Inflammatory state of the nasolacrimal sac caused by an obstruction within the nasolacrimal duct and subsequent stagnation of tears in the lacrimal sac.
Aetiology
Acute dacryocystitis:
Usually due to an acute infectious state
- Staphylococcus aureus (M/C)
- Streptococcus pyogenes (M/C)
- Haemophilus influenza
- Pseudomonas aeruginosa
Chronic dacryocystitis:
Result of chronic obstruction due to systemic disease, repeated infection, dacryoliths, and chronic inflammatory debris of the nasolacrimal system.
- Wegener’s granulomatosis
- Sarcoidosis
- Systemic lupus erythematosus (SLE)
- Traumatic causes:
- Nasoethmoid fractures
- Iatrogenic causes:
- Endonasal and endoscopic sinus procedures
- Topical medications: Timolol, pilocarpine, dorzolamide, idoxuridine, and trifluridine
- Systemic medications: Fluorouracil and docetaxel
- Neoplasms:
- Primary lacrimal sac tumors
- Benign papillomas
Congenital forms:
Due to a membranous obstruction at the valve of Hasner in the distal nasolacrimal duct.
Before delivery, the nasolacrimal system is filled with amniotic fluid. When the amniotic fluid fails to be expressed from the nasolacrimal system, it becomes purulent within a few days of delivery and becomes pathologic.
Anatomy
The flow of tears will usually begin with tear production by the lacrimal gland. The tears will lubricate the eye until they are collected into the superior and inferior puncta and drained into the superior and inferior canaliculi. From there, tears will drain into the common canaliculus. At this point, they will then pass through the valve of Rosenmuller into the lacrimal sac. The lacrimal sac will then collect the tears and flow down the nasolacrimal duct, pass through the distal valve of Hasner, and finally pass into the nasal cavity.
Pathophysiology
Dacryocystitis, regardless of etiology, is almost always caused by an obstruction in the nasolacrimal system with the resultant stagnation of tears.
Obstructions
(at any level of the nasolacrimal system)
↓
Stagnation of tears will
(provide a favorable environment for infectious organisms to propagate and proteinaceous debris to form)
↓
Lacrimal sac inflammation
↓
Characteristic swelling in the inferomedial portion of the orbit
Clinical features
Acute dacryocystitis
Symptoms may occur over several hours to several days
- Medial canthus overlying the lacrimal space will appear erythematous, tender, and edematous
- Mucopurulent material can be expressed from the superior and inferior puncta
- Increased tears
Chronic dacryocystitis:
- Excessive tearing (may be the only symptom)
Diagnosis
Diagnosis of dacryocystitis is primarily clinical based on history and physical exam findings.
CT scan:
If orbital cellulitis or extensive infection is suspected
Plain-film dacryocystogram (DCG):
For anatomical considerations
Differential diagnosis:
- Preseptal/periorbital cellulitis
- Orbital cellulitis
- Sebaceous cyst
- Frontal, ethmoid, or maxillary sinusitis
- Neoplasm
- Ectropion of lower eyelid
- Dacryoadenitis
Management
Acute dacryocystitis
Managed conservatively
- Warm compresses and attempts of Crigler massage
- Oral antibiotics (empirical)
Chronic dacryocystitis:
Almost always managed surgically with high success rates
- Nasolacrimal probing (first-line management)
- Balloon dacryoplasty, nasolacrimal intubation, or nasolacrimal stenting (for recurrence)
- If above therapies fail:
- Percutaneous dacryocystorhinostomy (DCR)
- Endonasal dacryocystorhinostomy (EN-DCR)
Congenital dacryocystitis
About 90% of congenital dacryocystitis will resolve by six months to one year of age with conservative measures
- Crigler massage taught to parents or caregivers to perform at home.
- Topical antibiotics (for acute flares)
- Nasolacrimal probing (if conservative measures fail)
- Balloon dacryoplasty, nasolacrimal intubation, or nasolacrimal stenting (for recurrence)
- If above therapies fail:
- Percutaneous dacryocystorhinostomy (DCR)
- Endonasal dacryocystorhinostomy (EN-DCR)