Dacryocystitis

Dacryocystitis is an infection or inflammation of the tear sac (i.e., lacrimal sac), which is a small chamber into which tears drain as they leave the eye. Tears function to keep the eyes hydrated and free of debris, viruses, and bacteria. The flow of tears through the lacrimal system begins with tear production by the lacrimal gland beneath the upper eyelids. As fresh tears enter onto the surface of the eye, older tears will flow through small holes, called puncta, in the corners of the upper and lower eyelids into the nasolacrimal sac followed by the tear duct (lacrimal duct) and nasal cavity. 

Dacryocystitis is most common in infants; however, adults over the age of 40 also have a higher risk of developing dacryocystitis. Common causes in older children and adults may include sinusitis or infection of the sinuses, nasal pus collections, nasal septum deviation, trauma to the nasolacrimal area, and specific ophthalmic and oral medications. Other risk factors include being assigned female at birth, advanced age, and lacrimal sac tumors.

Acute dacryocystitis, one of the classifications of dacryocystitis, is a sudden infection or inflammation of the tear sac, typically caused by a bacterial infection, that results in an abrupt onset of symptoms (e.g., eye pain, redness, and swelling). Dacryocystitis can also be classified as chronic, acquired, and congenital dacryocystitis.

Chronic dacryocystitis is an infection or inflammation of the tear sac, typically due to chronic nasolacrimal duct obstruction, that occurs gradually over time, persists for a long period of time, and may lead to an overgrowth of bacteria. Chronic nasolacrimal duct obstruction may be due to repeated infection; chronic inflammatory debris in the lacrimal system; dacryoliths, or stones, that form in the inner part of the tear duct; and diseases, such as Wegener’s granulomatosis, sarcoidosis, and systemic lupus erythematosus (i.e. SLE).

Acquired dacryocystitis typically results from repeated trauma; surgeries; medications; and neoplasms, or abnormal masses of tissue. The most common traumas resulting in nasolacrimal duct obstruction are nasoethmoid fractures and endonasal and endoscopic sinus procedures. Ophthalmic medications commonly associated with acquired dacryocystitis are timolol, pilocarpine, dorzolamide, idoxuridine, and trifluridine. Oral medications that are commonly associated with acquired dacryocystitis are fluorouracil and docetaxel. The most commonly associated neoplasms, or abnormal growth of tissue, include lacrimal sac tumors and benign papillomas, or overgrowth of epithelial tissue.

General signs and symptoms of dacryocystitis may include pain and redness and swelling in the inner corner of the eye around the tear sac. Other symptoms may include watery pus or mucus discharge from the eyes, and in more severe cases, a fever may present and/or a collection of pus may rupture through the skin. 

Symptoms of acute dacryocystitis may present fairly quickly (i.e. within hours to a couple of days) and are generally more severe, involving pain, redness, swelling, oozing pus, and fever. When slight pressure is applied to the tear sac, pain may present alongside oozing pus through the punctum.

The systematic approach to diagnosis and therapy generally begins with a thorough patient history and physical exam conducted by a healthcare provider. Physical examination typically shows an increase in the size of the tear meniscus. Crigler massages, or tear duct massages, can be performed to release any infectious discharge from the tear sac in order to obtain a sample and send it to a laboratory to test for pathogens. 

In severely acute dacryocystitis involving visual changes, fever, and orbital cellulitis, imaging of the eye using CT scans and blood tests may be performed to screen for underlying diseases and lacrimal system obstructions. In such cases, an emergent ophthalmological consultation may be considered.

In chronic dacryocystitis, blood tests, such as antineutrophilic cytoplasmic antibody testing and antinuclear antibody testing, may be performed to screen for underlying diseases (e.g., granulomatosis with polyangiitis and systemic lupus erythematosus). Imaging may not be required in these cases unless trauma is suspected.

The treatment for dacryocystitis depends on the underlying cause of the illness. The most common treatment of acute dacryocystitis involves oral antibiotics, such as cephalexin, amoxicillin-clavulanate, and ciprofloxacin for 7-10 days to eradicate the underlying bacterial infection. In very mild cases or for small flare ups, antibiotic eye drops or ointments may be considered. However, in more severe cases involving fever or spreading infection, intravenous antibiotics, such as ceftriaxone and ciprofloxacin, may be used. The choice of initial antibiotic therapy depends on age, severity of infection, and the presence of any complications. A sample of the eye discharge may be taken and sent to the lab to determine if any pathogens are causing an infection. Depending on these results, antibiotic therapy may be adjusted. Once the infection is resolved, a surgical procedure called a dacryocystorhinostomy (DCR) may be required to bypass the blockage in the lacrimal system, allow tears to drain directly from the lacrimal sac into the nose, and prevent recurrent infections. DCR is also the main treatment for chronic dacryocystitis.

In both acute and chronic dacryocystitis, crigler massages may be attempted and warm compresses may be applied a few times daily to the affected eye(s) to relieve pain and swelling.