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

• If the infection has extended into the orbital cavity, there may be orbital cellulitis and orbital abscess.
• It may present with a painful eye with limited mobility, abnormal pupils and diminished visual acuity. If orbital cellulitis is missed diagnosed, it can lead to blindness and cavernous sinus thrombosis and even death.

• Pallor

  A residual left afferent pupillary defect was present with slight pallor of the left optic nerve. A 51-year-old, otherwise healthy man sought care because of a 2-day history of right-sided medial canthal swelling, pain, redness, and tearing. [jamanetwork.com]

• Pathologist

  Histological specimens of CD are not commonly found in practice of pathologists, but when the histological sections are analyzed they reflect a multitude of aspects that need to be known in order to guide ophthalmologists in their practice. [ncbi.nlm.nih.gov]

• Overeating

  Abstract To evaluate the dacryocystectomy (DCT) outcomes for chronic dacryocystitis in an elderly population over 70 years old. [ncbi.nlm.nih.gov]

  There was also mucopurulent discharge from a fistula over the lacrimal sac and acute dacryocystitis. [nature.com]

  Pain, swelling, redness over the lacrimal sac at medial canthus Tearing, crusting, fever Digital pressure over the lacrimal sac may extrude pus through the punctum In chronic cases, tearing may be the only symptom A variety of causes may lead to dacryocystitis [en.wikipedia.org]

  – Regurgitation of discharge from the punctum on applying pressure over lacrimal sac area. – Congenital lacrimal sac mucocele (also called congenital dacryocele or amniontocele). [aimu.us]

  - Regurgitation of discharge from the punctum on applying pressure over lacrimal sac area. - Congenital lacrimal sac mucocele (also called congenital dacryocele or amniontocele). [nhp.gov.in]

• Hematochezia

  Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself [nejm.org]

• Ulcer

  Acute dacryocystitis: Acute conjunctivitis Corneal abrasion/ulcer Lid abscess Osteomyelitis of lacrimal bone Orbital cellulitis Rarely, Cavernous sinus thrombosis and septicemia B. [epomedicine.com]

  CONCLUSION: The possibility of a fungal infection should be considered in the evaluation of "routine" chronic dacryocystitis, particularly in the presence of corneal ulceration or postoperative endophthalmitis, as prompt initiation of appropriate therapy [ncbi.nlm.nih.gov]

  The most common complication is corneal ulceration, frequently in association with S. pneumoniae. The mainstays of treatment are oral antibiotics, warm compresses, and relief of nasolacrimal duct obstruction by dacryocystorhinostomy. [en.wikipedia.org]

• 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]

  The tear drainage system can get infected if it becomes blocked and bacteria collect in the ducts or the lacrimal sac. A blockage near the nose also can cause excessive tearing from the eye. [drugs.com]

  Chronic dacryocystitis most commonly manifests as the insidious onset of epiphora (excessing tearing). [visualdx.com]

  If abnormal tear production is ruled out, then obstructions in tear drainage is the most likely cause of the excessive tearing. [encyclopedia.com]

• Strabismus

  J Pediatr Ophthalmol Strabismus. 2006 Nov-Dec. 43(6):341-5. [Medline]. Sara E. Cosgrove, Edina Avdic, Kate Dzintars, Janessa Smith. 2015-2016 Treatment Recommendations For Adult Inpatients. Johns Hopkins Medicine. [emedicine.medscape.com]

  J Pediatr Ophthalmol Strabismus. 2010; 47 (4):214–219. [ PubMed ] [ncbi.nlm.nih.gov]

  J Pediatr Ophthalmol Strabismus. 1997;34143- 153 Google Scholar 4. Lawless MMartin F Orbital cellulitis and preseptal cellulitis in childhood. Aust N Z J Ophthalmol. 1986;14211- 219 Google Scholar Crossref 5. [jamanetwork.com]

• 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]

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.

• Staphylococcus Aureus

  Staphylococcus aureus is predominantly found in mixed growth. Chloramphenicol is the most effective drug of choice for chronic dacryocystitis. © Nepal Ophthalmic Society. [ncbi.nlm.nih.gov]

  Staphylococcus aureus is a common bacterial pathogen causing infectious dacrocystitis. [en.wikipedia.org]

• Streptococcus Pneumoniae

  The five most common isolates were Streptococcus pneumoniae (23%), Streptococcus pyogens (14.3%), Staphylococcus aureus (12.1%), Streptococcus viridans (9.9%) and Haemophilus influenzae (9.9%). [ncbi.nlm.nih.gov]

  It is most commonly caused by Staphylococcus aureus and Streptococcus pneumoniae. The most common complication is corneal ulceration, frequently in association with S. pneumoniae. [en.wikipedia.org]

  pneumoniae, Candida albicans Etiology of Acute Dacryocystitis: 1. [epomedicine.com]

• 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.

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.

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:

• Tight or narrowed inferior meatus
• Hypertrophied inferior turbinate
• Deviated nasal septum
• Nasal polyp, nasal tumors (lymphoma)
• Allergic rhinitis, hypertrophic rhinitis
• Nasal trauma
• Structural abnormalities of the midface should also be considered as a potential cause.

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

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.

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.

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.

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].

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.

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