#54 – Dacryocystitis



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Definition

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

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

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%

Microbiology

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

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

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

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 + 3rd 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

The Cottage Physician (1893)



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]

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