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Definition

• Infection of the lacrimal sac usually due to obstruction of the nasolacrimal systems

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Anatomy

The lacrimal apparatus is responsible for tear production and drainage of the eye and consists of 3 main structures:

• Lacrimal gland
  • Serous gland located in the superiorlateral corner of the orbit in the lacrimal fossa
  • Responsible for tear secretion onto the globe
• Lacrimal canaliculi
  • Drainage ducts located in the medial corner of the eye and drain into the nasolacrimal duct
• Nasolacrimal duct
  • Drains into the inferior nasal meatus of the nasal cavity

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Pathophysiology

• The most common cause of dacryocystitis is obstruction of the nasolacrimal duct
• Adults
  • Chronic inflammation leading to fibrosis/stenosis of the duct
  • Most commonly in postmenopausal women

• Infants/Children
  • Persistent membrane covering the Valve of Hasner
    • Occurs in up to 90% of newborns
      • Becomes patent by the end of the first month of life in 90%

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Microbiology

• Pediatric
  • Streptococcus pneumoniae
  • Staphylococcus species
  • Haemophilus influenza
  • Entrobacteriaceae species
• Adults
  • Staphylococcus aureus
  • Staphylococcus epidermidius
  • Pseudomonas aeruginosa
  • Propionibacterium species

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Clinical Findings

• The main clinical finding is tearing and discharge
• Acute
  • Inflammation, pain, swelling, and tenderness beneath the medial canthal tendon around the lacrimal sac
    • Purulence can be expressed through the lacrimal puncta with direct pressure on the lacrimal sac

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• Chronic
  • Tearing and matting of the eyelashes is most common
  • Mucoid material can be expressed occasionally

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Diagnostic Studies

• Although this is clearly a clinical diagnosis and the majority do not need further studies, you can do a bedside test called “Dye Disappearance Test”
  • Apply a drop of topical anesthetic
  • Place a drop of fluorescein stained saline in the inferior cul-de-sac of each of the patient’s eyes
  • Wipe away excess tears from eyelids
  • Observe patient for 5 minutes with careful instructions that the eye should not be rubbed and cheeks should not be wiped
  • After 5 minutes inspect eye, nose, and cheek
    • All of the fluorescein should have drained into the nose within 5 minutes if there is no obstruction
    • If any fluorescein remains in eye or drained down the cheek, then the test is positive

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Treatment

• Most cases respond to appropriate systemic antibiotic therapy
  • Culture expressed purulence to aid in antibiotic selection
  • Acute (7-10 days of therapy)
    • Mild cases – Clindamycin
    • Severe – Vancomycin + 3^rd generation cephalosporin

• For infants:
  • External digital massage of the lacrimal sac is first line
    • Increases the hydrostatic pressure to force open the obstructed membrane

• Nasolacrimal probing is indicated in acute cases and cases persisting for > 6 months
  • Some cases require balloon dilation, silicone stent placement, or inferior turbinate fracture

• For adults:
  • Chronic topical antibiotic drops can help keep patent, but this is only symptomatic relief
    • Fluoroquinolones – moxifloxacin, ciprofloxacin, ofloxacin
    • Aminoglycoside – tobramycin, gentamicin
  • Dacryocystorhinostomy is required to prevent recurrence
    • Permanent fistula formed between lacrimal sac and the nose

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The Cottage Physician (1893)

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References

1. Duncan JL, Parikh NB, Seitzman GD, Riordan-Eva P. Disorders of the Lids & Lacrimal Apparatus. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020. New York, NY: McGraw-Hill
2. Orbit. In: Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy, 2e New York, NY: McGraw-Hill;
3. Vagefi M. Lids & Lacrimal Apparatus. In: Riordan-Eva P, Augsburger JJ. eds. Vaughan & Asbury’s General Ophthalmology, 19e New York, NY: McGraw-Hill
4. Horton JC. Disorders of the Eye. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e New York, NY: McGraw-Hill
5. Hoffmann J, Lipsett S. Acute Dacryocystitis. The New England journal of medicine. 2018; 379(5):474. [pubmed]
6. Campolattaro BN, Lueder GT, Tychsen L. Spectrum of pediatric dacryocystitis: medical and surgical management of 54 cases. Journal of pediatric ophthalmology and strabismus. ; 34(3):143-53; quiz 186-7. [pubmed]
7. Qian Y, Traboulsi EI. Lacrimal sac compression, not massage. Journal of pediatric ophthalmology and strabismus. ; 46(4):252. [pubmed]
8. Örge FH, Boente CS. The lacrimal system. Pediatric clinics of North America. 2014; 61(3):529-39. [pubmed]