Dacryocystitis · What Is It, Causes, Symptoms, and More

Dacryocystitis is an infection or inflammation of the tear sac (i.e., lacrimal sac), a small chamber into which tears drain as they leave the eye. The lacrimal system begins with tear production by the lacrimal gland located beneath the upper eyelids. The tears coat the surface of the eye, keeping them hydrated and free of debris, viruses, and bacteria. They then flow through small holes, called puncta, located in the corners of the upper and lower eyelids, into the lacrimal sac, through the tear duct (lacrimal duct) and the nasal cavity.  

Dacryocystitis is most common in infants; however, adults over the age of 40 are at risk of developing dacryocystitis. Common causes include sinusitis (i.e., infection of the sinuses), nasal pus collections, lacrimal sac tumors, nasal septum deviation, trauma to the nasolacrimal area, and use of specific ophthalmic and oral medications.  

Forms of dacryocystitis include acute, chronic, acquired, and congenital dacryocystitis.  

Acute dacryocystitis is a sudden infection or inflammation of the tear sac, with an abrupt onset of symptoms, such as eye pain, redness, and swelling. Acute dacryocystitis is often caused by a bacterial infection.  

Chronic dacryocystitis is an infection or inflammation of the tear sac that occurs gradually over time and persists for a long period of time. A common cause includes chronic nasolacrimal duct obstruction, which 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.  Autoimmune diseases, such as Wegener’s granulomatosis, sarcoidosis, and systemic lupus erythematosus (SLE) can predispose to chronic dacryocystitis. 

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, caused by high-impact anterior force to the nose. Endonasal and endoscopic sinus procedures can very rarely cause damage to the lacrimal sac. 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 include lacrimal sac tumors and benign papillomas, or overgrowth of epithelial tissue. 

Congenital dacryocystitis is typically due to membranous obstruction in the distal nasolacrimal duct. Prior to birth, the nasolacrimal system is filled with amniotic fluid, and if the amniotic fluid fails to drain from the nasolacrimal system, it can become infected within a few days, resulting in dacryocystitis. 

Signs and symptoms of dacryocystitis 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. 

Signs and symptoms of chronic dacryocystitis are usually milder and typically consist of watery discharge from the eyes and minimal swelling of the skin overlying the tear sac. There may be minimal pain and pus when pressure is applied to the tear sac. Many individuals with chronic dacryocystitis may also concurrently have chronic conjunctivitis, or pink eye, as well as long lasting discomfort in the affected eye(s).  

Diagnosis begins with a thorough patient history and physical exam. Physical examination typically shows an increase in the size of the tear meniscus (i.e., crescent-shaped pool of tears that forms at the margin of the lower eyelid). 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 cases of severe acute dacryocystitis involving visual changes, fever, and orbital cellulitis, imaging of the eye using CT scans and blood tests may be performed to assess the extent of infection, screen for other diseases such as orbital cellulitis, and identify sources of lacrimal system obstruction. In cases of extensive and severe infection, an emergent ophthalmological consultation may be considered to prevent future vision loss. 

Blood tests, such as antineutrophilic cytoplasmic antibody and antinuclear antibody, may be performed to screen for underlying diseases (e.g., granulomatosis with polyangiitis and systemic lupus erythematosus) that are associated with chronic dacryocystitis.  

Dacryocystography or plain film dacrosystogram can be performed if a structural abnormality is suspected. A nasal endoscopy may also be used to rule out underlying structural abnormalities, such as septal deviation.  

The fluorescein dye disappearance test is another diagnostic procedure used to test the functionality of the lacrimal drainage system. A clinician places sterile dye in the corner of the eye and observes for drainage. After 5 minutes, if the dye remains stagnant in the eye or has overflowed onto the lower eyelid and down the cheek, it may indicate an obstruction in the lacrimal system. 

The treatment for dacryocystitis depends on the underlying cause. To treat symptoms, analgesics (e.g., NSAIDS, acetaminophen) and heat packs may be used. Commonly, 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 the individual’s age, severity of infection, and the presence of any complications. A sample of the eye discharge may be taken and sent to the lab for culturing. Depending on these results, antibiotic therapy may be adjusted.  

The abscess is often drained, to remove the source of infection. In certain cases, a surgical procedure called a dacryocystorhinostomy (DCR) may be required to bypass the blockage in the lacrimal system, allowing 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. 

If not treated promptly the infection may spread, causing orbital cellulitis, which is an infection of the soft tissues and fat surrounding the eye. This can spread to the brain, spinal cord, and blood which can be lethal.