Acute Dacryocystitis : Clinical review

Acute dacryocystitis

 

Definition: Acute dacryocystitis is the inflammation of the lacrimal sac which usually occurs in very young children or > 40 years

Microbiology of Acute Dacryocystitis:

  1. Congenital: Hemophilus influenzae (acute – rare), Others (chronic)
  2. Adults:
    • Acute: Staphylococcus aureus, Beta-hemolytic streptococci
    • Chronic: Streptococcus pneumoniae, Candida albicans

Etiology of Acute Dacryocystitis:

1. Congenital: Nasolacrimal duct obstruction –

  • Membranous: valve of Hasner
  • Epithelial debris
  • Complete non-canalization

2. Adult:

a. Acute:

  1. Exacerbation of chronic dacryocystitis
  2. Acute peridacryocystitis (neighboring structures): Paranasal sinus, bones, dental abscess, caries teeth

b. Chronic:

  1. Anatomical: narrow bony canal, partial canalization, excessive folds
  2. Foreign body
  3. Hyperlacrimation (stagnation of tears)
  4. Recurrent conjunctivitis
  5. Lower end Nasolacrimal duct obstruction: Polyps, Hypertrophied turbinates, Deviated nasal septum, tumors, atrophic rhinitis

Clinical features of Acute Dacryocystitis:

A. Congenital:

  1. Epiphora and Discharge (usually after 7 days of birth)
  2. Regurgitation test positive
  3. Swelling in lacrimal sac area

B. Acute:

  1. Stage of Cellulitis: Signs of inflammation in sac area, epiphora, fever, malaise
  2. Stage of Lacrimal abscess: Fluctuant swelling, pus point (below and outer side)
  3. Stage of Fistula formation: below medial palpebral ligament

C. Chronic:

  1. Catarrhal stage (mild inflammation): epiphora +/- mild redness in sac area
    • Regurgitation test: clear fluid or few fibrinous mucoid flakes
  2. Stage of lacrimal mucocele: epiphora + swelling in sac area
    • Regurgitation test: milky/gelatinous mucoid fluid
  3. Stage of Suppurative dacryocystitis (pyogenic infection): mucocele → pyocele, epiphora, recurrent conjunctivitis, swelling, redness
    • Regurgitation test: Frank purulent discharge
  4. Stage of fibrotic sac: persistent epiphora and discharge

Complications of Acute Dacryocystitis:

A. Acute dacryocystitis:

  1. Acute conjunctivitis
  2. Corneal abrasion/ulcer
  3. Lid abscess
  4. Osteomyelitis of lacrimal bone
  5. Orbital cellulitis
  6. Rarely, Cavernous sinus thrombosis and septicemia

B. Chronic dacryocystitis:

  1. Chronic conjunctivitis
  2. Simple corneal abrasion/ulcer
  3. Lid: Ectropion, Eczema, Maceration
  4. Acute on chronic dacryocystitis
  5. Endophthalmitis (Intraocular surgery)

Treatment of Acute Dacryocystitis:

A. Congenital:

  1. 6-8 weeks age: Massage over lacrimal sac + Topical antibiotics
  2. 2-4 months age: Lacrimal syringing with normal saline X 1 or 2 times per week + Antibiotics
  3. 4-6 months age: Probing of Nasolacrimal duct under GA with Bowman’s probe every month
  4. Probing failure: Silicone tube intubations
  5. > 4 years with failed probing: Dacryocystorhinostomy (DCR)

B. Acute adult:

  1. Cellulitis: Antibiotics (Systemic + Topical), NSAIDs, hot fomentation
  2. Lacrimal abscess: Incision and Drainage +/- Dacryocystorhinectomy (DCT) or DCR
  3. Fistula: Antibiotics, fistulectomy + DCT or DCR

C. Chronic adult:

  1. Conservative: repeated lacrimal syringing
  2. Surgical: DCR, DCT, conjunctivo-DCR

Criggler’s massage:

  • Indication: Congenital Nasolacrimal duct obstruction
  • Principle: Massaging lacrimal sac in an inferior direction to increase the hydrostatic pressure in nasolacrimal duct to force it open.
  • Frequency: 10 times in a episode X 3 times/day