Dacryocystitis

SIGNS AND SYMPTOMS
Pain, redness and swelling over the inner aspect of the lower eyelid and epiphora may signify aggravated blepharitis, meibomianitis or canaliculitis. However, suspect dacryocystitis if the problem recurs and is associated with fever and severe erythematous swelling around the nasal aspect of the lower lid; or if it involves the lacrimal sac such that mucopurulent discharge can be expressed from the inferior punctum. Older patients are predisposed to the condition as the lacrimal drainage system loses its elasticity and thins, and tears fail to flush debris through the complex. Patients with poor hygiene are at greater risk.


PATHOPHYSIOLOGY
The primary etiology of dacryocystitis is nasolacrimal obstruction secondary to mucocele of the lacrimal sac, which is precipitated by chronic blockage of the interosseous or intermembranous nasolacrimal duct. Most cases of nasolacrimal duct obstruction are found in the older population, and result from chronic mucosal degeneration, ductile stenosis, stagnation of tears, and bacterial overgrowth. Infantile dacryocystitis is uncommon but presents with the same signs and symptoms.

Lacrimal sac obstructions often produce signs and symptoms similar to dacryocystitis but not as severe. They are collectively known as canaliculitis. These infections are differentiated by solid concretions called dacryoliths, which can be expressed from the infected lacrimal sac. Dacryoliths can result from bacterial, fungal or viral infections.

MANAGEMENT
Management of an afebrile child with dacryocystitis includes oral amoxicillin/clavulanate (Augmentin) 20-40mgs/kg/day, PO, TID, or oral cefaclor 20-40mgs/kg/day, PO, TID, along with topical antibiotic drops QID (e.g. Polytrim, Tobrex, Ocuflox), ointments BID, warm compresses and acetaminophen. Management of an adult afebrile patient includes cephalexin (Keflex) or Augmentin 500mgs PO, QID along with topical antibiotic drops, ointments, warm compresses and aspirin or ibuprofen for pain and inflammation, as needed. Manage febrile patients with extreme caution. Patients who are acutely ill should be hospitalized and placed on IV cefazolin (Ancef), Q8H along with the other modalities. Consider neuroimaging (CT or MRI) when the etiology is in question.

Dacryoliths should be removed with curettage or canaliculotomy, cultured and treated accordingly with both topical and oral antibiotic, antiviral or antifungal preparations.

CLINICAL PEARLS

Obstruction of the tear drainage system can occur at any age. Punctal or canalicular stenosis may develop from a myriad of conditions. Punctal stenosis may result from conjunctival diseases such as Steven's-Johnson syndrome (dry eye and dry mouth secondary to reaction to sulfa medicine), ocular cicatricial pemphigoid, and mechanical, thermal or chemical injury. In the young, congenital anomalies of the nasolacrimal system include dacryostenosis, dacryocystocele and canalicular fistula
Bloody tears with a history of medial canthal mass should heighten suspicion for space occupying lesions. Facial cellulitis and acute ethmoidal or frontal sinusitis are among the important differential diagnoses.
Prompt, decisive and aggressive management is essential. Hospitalization with intravenous antibiotics should be considered in severe, febrile or recalcitrant presentations. Punctal dilation and nasolacrimal irrigation is always contraindicated in the acute stages. In fact, following the resolution of the acute infection, most cases remain with symptomatic epiphora, requiring dacryocystorhinostomy.