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Dacryocystitis

Dacryocystitides

The lacrimal excretory system functions by draining tears into the nasal cavity. The lacrimal duct is continuous with the nasal and conjunctival mucosa and is normally colonized with microorganisms. When the lacrimal duct drainage system gets obstructed, the resulting stagnation of tears leads to dacryocystitis.


Presentation

Dacryocystitis may present with:

  • Sudden onset of pain
  • Conjunctival congestion
  • Erythema
  • Edema in the lacrimal sac region
  • Tenderness along the medial canthal area
  • Epiphora may be obvious
  • Fever
  • If the lacrimal sac is ruptured, it may fistualize through the skin
  • Cellulitis may be obvious around the eye
  • Mattering of eyelashes
  • Diminished visual acuity may be due to abnormal tearing, mattering or eyelids
  • Irregularities on corneal surface
  • Altered pupillary reaction
  • If orbital cellulitis developed, diplopia may be present
  • Loss of vision is rare with dacryocystitis alone but can be present with orbital cellulitis

Complications

Excessive Tearing
  • The hallmark symptom of both forms of dacryocystitis is epiphora (ie, excessive tearing). An obstruction of the lacrimal duct also can cause dacryocystitis.[ncbi.nlm.nih.gov]
  • Between episodes of acute infection, there may still be excessive tearing or cloudy drainage from block tear ducts. In infants, the obstruction that causes an infection is commonly outgrown by the age of 9 to 12 months.[drugs.com]
  • If abnormal tear production is ruled out, then obstructions in tear drainage is the most likely cause of the excessive tearing.[encyclopedia.com]
  • The main symptoms are excessive tearing or watering of the eye, even when the child is not crying (this is called epiphora ).[m.rossa-editorial.kidshealth.org]
Blepharitis
  • Diagnostic Pearls Subscription Required Differential Diagnosis & Pitfalls Orbital cellulitis Preseptal cellulitis Hordeolum and chalazion Cavernous sinus thrombosis Basal cell carcinoma of the eyelid Squamous cell carcinoma of the eyelid Actinomycosis Blepharitis[visualdx.com]
  • Meibomitis and blepharitis are usually bilateral associated with irritation of the lid margins and burning sensation.[speciality.medicaldialogues.in]

Workup

The diagnosis of dacryocystitis is most often made clinically.

Investigations

  • Lacrimal secretions should be obtained for culture.
  • Complete blood count if infection is suspected.
  • Imaging is very rarely done. MRI or CT scan is necessary if a mass or obstruction of the lacrimal duct is suspected.
  • Dcaryocystography and dacryoscitigraphy are often used to detect congenital abnormalities.
  • The Jones test is useful to differentiate a functional block from an anatomical block.
  • Nasal endoscopy can be performed to evaluate for presence of a mass, inferior turbinate hypertrophy, septal deviation and inferior meatal narrowing.
  • Some patients may require investigation to rule out sarcoidosis, Wegener granuolomatosis, lymphoma and leukemia.
Gram-Positive Bacteria
  • The majority of microorganisms in our study were gram-positive bacteria, 75% of the overall microorganisms cultured were gram-positive bacteria, with a predominance of staphylococcus species.[ncbi.nlm.nih.gov]
  • The majority of microorganisms in our study were Gram-positive bacteria, representing 53.7% of the overall microorganisms cultured with a predominance of Staphylococcus species.[ncbi.nlm.nih.gov]
  • There was an increase in the percentage of gram-positive bacteria over time. The sensitivity of gram-positive isolates to tested antibiotics is relatively low compared with that of gram-negative isolates.[ncbi.nlm.nih.gov]
  • An average of 1.07 organisms/patient (standard deviation 0.49 organisms/patient) were recovered from microbiologic cultures, and Gram-positive bacteria represented the majority of cultured organisms.[ncbi.nlm.nih.gov]

Treatment

  • All patients with dacryocystitis, especially with the acute form, need hospital admission until the symptoms subside and the cause has been treated.
  • The treatment of dacryocystitis depends upon the clinical manifestations of the disease.
  • Acute dacryocystitis is treated with IV antibiotics. Once the patient is admitted, a CT scan or MRI should be obtained to ensure that this is no abscess that will require surgical drainage.
  • The initial IV antibiotic must cover Staphylococcus, including Methicillin-resistant Staphylococcus.
  • In patients not acutely ill, oral antibiotics may be used.
  • When discharged, topical antibiotics tobramycin or gentamicin can be used.
  • If allergic rhinitis is suspected as cause of inflammation of the nasolacrimal duct, topical steroids may be beneficial.

Other treatments

  • Nasal decongestants for short periods.
  • Post-surgery, intranasal saline can be used to keep the ostium open, clean and moist.
  • Warm compress may help decrease the edema and swelling.
  • Congenital dacryocystitis tends to resolve with conservative measures like massage of the sac and warm compresses. This is first line of management before any probing is done. The massage breaks up any potential obstruction.

Surgery

  • If there is a fluctuant swelling, a stab incision can be made to release the collection.
  • Most patients with dacryocystitis require dacryocystorhinostomy (DCR) whether the patient is symptomatic or not [6] [7] [8].
  • Surgery is done after the infection and inflammation has subsided.
  • DCR may be performed via an endonasal approach or an open approach. Laser may be used to recanalize the duct [9] [10].
  • Balloon dacryoplasty is now used in patients who fail DCR. It is most successful in patients with localized narrowing of the duct. It may be combined with stenting of the duct.

Complications

DCR is a relatively safe procedure but complications can occur which include:

  • Hemorrhage which may require nasal packing, cauterization or thrombin.
  • Infection may occur in diabetics and patients on steroids. Hence, post-procedure antibiotics is recommended.
  • Most serious complication of DCR is CSF leak. Damage to the cribriform plate can easily occur during osteotomy of the lacrimal duct.
  • Failure of DCR to work because of an inadequate procedure or fibrosis.

Prognosis

Acute dacryocystitis is a painful disorder that can affect the quality of life. The morbidity is primarily related to the lacrimal abscess and potential spread to the eye. Chronic dacryocystitis can also lead to a poor quality of life because the constant tearing, mattering and pain.

Congenital dacryocystitis has the highest morbidity and can quickly lead to spread to the eye. Newborns can quickly develop orbital cellulitis, meningitis, brain abscess and sepsis. Even when treated, congenital dacryocystitis can lead to failure to thrive.

Acute dacryocystitis can cause a lacrimal sac abscess and spread of infection. This is a serious condition. Chronic dacryocystitis causes predominantly chronic tearing and watering and is rarely associated with severe morbidity. After surgery, there is a 70-90% success rate, depending on whether the procedure was done open or laser assisted.

Etiology

Dacryocystitis tended to be more common on the left rather than the right side. It is believed that this may be because the nasolacrimal duct and lacrimal fossa form a wider angle on the right side than on the left side [4].

Other common causes of lacrimal duct obstruction include:

In congenital cases, there is failure of the duct to canalize and thus the nasolacrimal duct is obstructed. In infants and children, anatomical defects of the mid face should be investigated.

Organisms that cause dacryocystitis include:

  • Staphylococcus epidermidis [5]
  • Staphylococcus aureus. Methicillin-resistant Staphylococcus aureus (MRSA) is more common in patients with acute dacryocystitis than with chronic dacryocystitis.
  • Haemophilus influenzae
  • Streptococcus
  • Pneumococcus
  • Anaerobic organisms like Propionibacterium, Peptostreptococcus, and Prevotella
  • Gram negative bacteria like Escherichia coli

Epidemiology

Dacryocystitis is not a very common disorder. The exact incidence is not known. The disorder occurs in both gender and is seen at all ages. Infants with congenital facial defects are quite prone to dacryocystitis. In general, the disorder is rare in African Americans because the nasolacrimal ostium is large, straight and less prone to obstruction.

In adults, dacryocystitis is much more common in females than males. Whereas congenital dacryocystitis occurs with equal frequency in both genders. Dacryocystitis has a bimodal age of presentation; it can present in infants and in patients aged 50 or older.

Sex distribution
Age distribution

Pathophysiology

In congenital cases, there appears to be some type of anatomical defect in the facial area that leads to blockage of the nasolacrimal duct. In other congenital cases, there is failure of the lacrimal duct to recanalize.

Over the years, many anatomical variations in the nasolacrimal duct have been observed. Tears generally drain into the lacrimal duct via puncta located in the upper and lower eyelid on the medial side of the eyes. The puncta open up into the nasolacrimal duct which has various folds and valves. The entire lacrimal duct is lined with pseudostratified columnar epithelium. The nasolacrimal duct opens just under the inferior turbinate in the nasal cavity. Any anatomical defect, mass, swelling, edema or trauma along this anatomical route can lead to obstruction and dacryocystitis.

Prevention

Dacryocystitis is not a preventable disorder. But once it has occurred, the individual can take precautions to keep the disorder from getting worse. This includes applying warm compresses, maintaining good eyelid hygiene and rinsing the eyes and debris regularly. Regular nasal hygiene and irrigation may also help removed any temporary distal obstructions in the lacrimal duct. At the first sign of epiphora, patients should be urged to seek medical assistance.

Summary

The nasolacrimal duct plays a role in regulating the flow of tears into the nose. This excretory system when blocked is easily prone to infection and inflammation because the mucosal membrane is normally colonized with microorganism. The blockage of the nasolacrimal duct usually leads to excess overflow of tears (epiphora). The failure to excrete tears in the nasolacrimal duct leads to overgrowth of bacteria in the mucosal lining, eventually causing dacryocystitis.

Dacryocystitis may be acute or chronic. In the acute scenario, there is sudden onset of redness and pain in the medial canthal area. At the same time, the patient complains of an overflow of tears. It has been observed that dacryocystitis is more common the left side. This is believed to be due to the nasolacrimal duct and lacrimal fossa forming a greater angle on the right side than on the left side, which creates an obstruction to tear flow [1] [2] [3].

Patient Information

Dacryocystitis is a disorder of the duct which drains tears. The lacrimal duct is located in the corner of the eye where it meets the nose. The duct can be obstructed for many reasons and this can quickly result in an infection. The features of dacryocystitis include excess tearing, pain around the nose and eye, and redness. The diagnosis is made with a clinical exam. The condition needs to be treated otherwise the infection can spread to the eye or brain. Patients need a short admission to the hospital for antibiotics. Use of warm compress and irrigation of the nose also help with the recovery. All patients need a surgical procedure to ensure that the lacrimal duct is open. Once treated, the results are satisfying.

References

Article

  1. Ali MJ. Pediatric Acute Dacryocystitis. Ophthal Plast Reconstr Surg. 2015 Apr 8 
  2. Sielicka D, Mrugacz M, Bakunowicz-Łazarczyk A. Nasolacrimal duct disorders in children. Part I. Anatomy, physiology and clinical signs]. Klin Oczna. 2010;112(10-12):342-5
  3. Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar B, Hernandez JL. Dacryocystitis: Systematic Approach to Diagnosis and Therapy. Curr Infect Dis Rep. 2012 Jan 29.
  4. Repp DJ, Burkat CN, Lucarelli MJ. Lacrimal excretory system concretions: canalicular and lacrimal sac. Ophthalmology. 2009 Nov;116(11):2230-5.
  5. Goold LA, Madge SN, Au A, Leibovitch I, McNab A, Tumuluri K, Selva D. acute suppurative bacterial dacryoadenitis: a case series. Br J Ophthalmol. 2013 Jun;97(6):735-8
  6. Yakopson VS, Flanagan JC, Ahn D, Luo BP. Dacryocystorhinostomy: History, evolution and future directions Saudi J Ophthalmol. 2011 Jan;25(1):37-49.
  7. Meister EF, Otto M, Rohrwacher F, Mozet C. Current recommendations of dacryocystorhinostomy. Laryngorhinootologie. 2010 Jun;89(6):338-44.
  8. Strong EB. Endoscopic dacryocystorhinostomy. Craniomaxillofac Trauma Reconstr. 2013 Jun;6(2):67-74.
  9. Huang J, Malek J, Chin D, Snidvongs K, Wilcsek G, Tumuluri K, Sacks R, Harvey RJ. Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy. Orbit. 2014 Apr;33(2):81-90.
  10. Al-Nuaimi D, Inkster C, Lobo C. Paediatric powered endonasal dacryocystorhinostomy. Eur Arch Otorhinolaryngol. 2011 Dec;268(12):1823-8

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Last updated: 2018-06-22 11:09