Acute Dacryocystitis : Clinical review

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