Dacryocystitis

Etiology

Dacryocystitis can be classified as acute or chronic and acquired or congenital.

An acute infectious state typically causes acute dacryocystitis. In the United States, the most common organisms are Staphylococcus and Streptococcus species, followed by Haemophilus influenzae and Pseudomonas aeruginosa.

Chronic dacryocystitis results from chronic obstruction due to systemic disease, repeated infection, dacryoliths, and chronic inflammatory debris of the nasolacrimal system. Some common systemic diseases include Wegener granulomatosis, sarcoidosis, and systemic lupus erythematosus. 

Acquired states are typically due to repeated trauma, surgeries, medications, and neoplasms. Among traumatic causes of nasolacrimal obstruction, nasoethmoid fractures are the most common. Endonasal and endoscopic sinus procedures have the highest association among surgeries. Common topical medications associated with acquired states are timolol, pilocarpine, dorzolamide, idoxuridine, and trifluridine. The most common systemic medications are fluorouracil and docetaxel. Primary lacrimal sac tumors and benign papillomas are the most common neoplasms.

Congenital forms are 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 pathologic.

Epidemiology

Dacryocystitis has a bimodal distribution, with most cases occurring just after birth in congenital cases or in adults older than 40. Congenital dacryocystitis occurs in roughly 1 in 3884 live births. Dacrocystitis is found more often in adults of the white race, with females comprising nearly 75% of all cases.[5]

Serious morbidity and mortality are low with dacryocystitis. However, in congenital dacryocystitis, morbidity and mortality can be significant if not treated promptly and appropriately.

Pathophysiology

Regardless of etiology, dacryocystitis is almost always caused by an obstruction in the nasolacrimal system with the resultant stagnation of tears. Obstructions can occur at any level of the nasolacrimal system. Stagnation of tears provides a favorable environment for infectious organisms to propagate and proteinaceous debris to form. The lacrimal sac will then inflame, causing the characteristic swelling in the inferomedial portion of the orbit.

Histopathology

In chronic dacryocystitis, fibrosis and nongranulomatous inflammation are the most common findings. Sarcoidosis, lymphoma, and papilloma are other common findings.

History and Physical

In acute dacryocystitis, symptoms may occur over several hours to several days. A careful external eye exam must be performed. The medial canthus overlying the lacrimal space will appear erythematous, tender, and edematous. The bridge of the nose may also be involved; however, it is uncommon that the superomedial aspect of the orbit is involved. The mucopurulent material can frequently be expressed from the superior and inferior puncta. There may also be an increase in tears, also known as epiphora.

In chronic dacryocystitis, tearing may be the only symptom. Mattering may be present due to a tear film. Tear films typically cause conjunctival injection and a mild decrease in visual acuity. Visual acuity testing is imperative, and any acute changes not explained by tear filming should raise concern for more extensive involvement. Emergent ophthalmological consultation is warranted in this scenario. Furthermore, erythema involving the whole orbit is not characteristic of dacryocystitis and should lead the examiner to an alternative diagnosis. Any pain with extraocular movement should also raise suspicion for alternative diagnoses.

Evaluation

The diagnosis of dacryocystitis is primarily based on history and physical exam findings. Cultures and gram staining can be obtained by expressing purulent material via the Crigler massage. Laboratory studies and blood cultures should be considered in patients with suspected toxicity, particularly those with fever or acute visual changes. Emergent ophthalmological consultation is also advised in these cases. Strong consideration should be given to performing a CT scan if orbital cellulitis or extensive infection is suspected. If there are anatomical concerns, a plain-film dacryocystogram (DCG) can be performed by qualified personnel. A subtraction DCG technique will potentially help improve the viewing quality of the image.[3][6][7][8]

In chronic cases, appropriate serologic testing can be performed if systemic diseases are suspected as the underlying cause. Antineutrophilic cytoplasmic antibody testing can be performed if Wegener granulomatosis is suspected. Likewise, antinuclear antibody (ANA) testing can be pursued if systemic lupus erythematosus is suspected.

Treatment / Management

Treatment of acute dacryocystitis includes conservative measures such as warm compresses and Crigler massage. For uncomplicated cases, oral antibiotics should be considered. Coverage should be aimed at gram-positive organisms, particularly antistaphylococcal agents. In complicated cases or toxic patients, intravenous antibiotics should be administered. Empiric antibiotics should include gram-positive and gram-negative coverage. Lacrimal probing is discouraged in the acute phase. For recurrent infections, referral to ophthalmology for surgical evaluation is advised.[9][10][11](B2)

Chronic dacryocystitis is almost always managed surgically. Probing is accepted as first-line management in chronic cases and can be done in the outpatient setting. Inevitably, patients will progress to further surgical options to treat the condition. Balloon dacryoplasty, nasolacrimal intubation, and nasolacrimal stenting have all been attempted with variable first-time success rates. If these therapies fail, evaluation for percutaneous dacryocystorhinostomy (DCR) or endonasal dacryocystorhinostomy (EN-DCR) is then pursued.

Treatment of congenital dacryocystitis includes conservative measures first. Crigler massage should be taught to parents or caregivers to perform at home. Topical antibiotics can be considered for acute flares. About 90% of congenital dacryocystitis will resolve by 6 months to 1 year of age with conservative measures. If conservative measures fail, a referral is made to ophthalmology for nasolacrimal probing. Nasolacrimal probing is successful in more than 70% of cases. Balloon dacryoplasty, nasolacrimal intubation, or nasolacrimal stenting can be pursued if symptoms recur. If these measures fail, then DCR or EN-DCR will serve as the definitive treatment.

Differential Diagnosis

Differential diagnoses to consider include the following:

• Preseptal, or periorbital, cellulitis
• Orbital cellulitis
• Sebaceous cyst
• Frontal, ethmoid, or maxillary sinusitis
• Neoplasm
• Ectropion of the lower eyelid
• Dacryoadenitis

Prognosis

In general, the prognosis for dacryocystitis is good. Simple probing techniques are highly successful. DCR has been reported to be more than 93% to 97% successful.In congenital cases, approximately 90% will resolve with conservative measures alone by the age of 1.

The outlook for most patients with simple obstruction is good, but for those with complex obstruction, the outcomes are guarded and can interfere with vision and lifestyle.[12][13][14] 

Complications

Dacryocystitis can extend from the lacrimal sac to the surrounding orbital tissues. This can lead to preseptal cellulitis, orbital cellulitis, and orbital abscess.[15] Orbital cellulitis can lead to optic nerve compression and vision loss. Early administration of systemic antibiotics is the best way to prevent these complications.