Dacryocystitis is infection of the lacrimal sac usually due to congenital or acquired obstruction of the nasolacrimal system. It may be acute or chronic and occurs most often in infants and in persons over 40 years. It is usually unilateral. The usual infectious organisms are Staphylococcus aureus and streptococci in acute dacryocystitis and Staphylococcus epidermidis, streptococci, or gram-negative bacilli in chronic dacryocystitis.
Acute dacryocystitis is characterized by pain, swelling, tenderness, and redness in the tear sac area; purulent material may be expressed. In chronic dacryocystitis, tearing and discharge are the principal signs, and mucus or pus may also be expressed.
Tears are produced by the lacrimal glands; paired almond shaped exocrine glands which sit in the upper lateral portion of each orbit in the lacrimal fossa, an area found within the frontal bone. The tears lubricate the eye and are then collected into the superior and inferior puncta and then drain into the inferior and superior canaliculi. From the canaliculi, the tears pass through the valve of Rosenmuller into the lacrimal sac where they then flow down the nasolacrimal duct, through the Valve of Hasner, and finally drain into the nasal cavity
The risk factors for dacryocystitis are varied but are almost always related to nasolacrimal duct obstruction.
- Females are at greater risk due to their narrower duct diameter as compared to males
- Older age leads to narrowing of the punctual openings, slowing tear drainage
- Dacryoliths; often idiopathic, a collection of shed epithelial cells, lipids, and amorphous debris within the nasolacrimal system
- Nasal septum deviation, rhinitis and turbinate hypertrophy
- Damage to the nasolacrimal system due to trauma of the nasoethmoid region or endoscopic/endonasal procedures
- Neoplasm within the nasolacrimal system
- Systemic disease such as Wegener’s granulomatosis, sarcoidosis, and Systemic Lupus Erythematosus (SLE), or lacrimal sac tumors
- Medications such as timolol, pilocarpine,idoxuridine, and trifluridine
The etiology of dacryocystitis is typically due to a nasolacrimal duct obstruction (NLDO). This can further be categorized into duration (acute versus chronic) and onset (congenital and acquired causes).
Acute and chronic refer to the duration of current symptoms, with acute usually being a time frame less than three months.
Acute dacryocystitis usually requires systemic antibiotic therapy prior to intervention for the NLDO. In the United States, likely culprits are Staphylococcus aureus, B hemolytic Streptococcus and Pneumococcus and Haemophilus influenzae in children, whereas in adults it is more likely Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus pneumoniae and Pseudomonas aeruginosa.
Chronic dacryocystitis typically presents with less inflammatory signs and requires surgical therapy for the underlying cause.
Congenital forms of dacryocystitis are typically due to obstruction of the valve of Hasner, located in the distal portion of the nasolacrimal duct. If amniotic fluid is not expelled from the nasolacrimal system a few days following delivery, it can become purulent, leading to neonatal dacryocystitis.
Acquired causes of dacryocystitis include involutional changes (aging), systemic disorders (like sarcoidosis), trauma (such as nasoethmoid fractures), surgeries (such an endonasal procedures), neoplasms, and certain medications (such as timolol, pilocarpine, idoxuridine, and trifluridine).
Diagnosing dacryocystitis is relatively simple. During an exam, a doctor may ask for a person’s medical history and then access the eye for visible signs of dacryocystitis, such as swelling or redness.
A doctor may press on the lacrimal sac to see if pus comes out. If it does, the doctor may collect a sample of the pus to test for bacteria.
In some cases, a doctor may do a dye disappearance test. During this test, the doctor will place yellow dye in the corner of the eye. In a healthy eye, the yellow dye will disappear after a few minutes. If there is a blockage, the dye will linger in the eye for much longer.
The dye disappearance test can also indicate whether the tear ducts are partially or entirely blocked.
To check the level of blockage, a doctor will then swab inside the person’s nose on the side with the suspected blockage. If dye has passed through to the inside of the nose, it is likely to be a partial blockage.
Acute dacryocystitis responds well to systemic antibiotic therapy. To relieve the underlying obstruction, surgery is usually done electively but may be performed urgently in acute cases. The chronic form may be kept latent with antibiotics, but relief of the obstruction is the only cure.
In adults, the standard procedure is dacryocystorhinostomy, which involves surgical exploration of the lacrimal sac and formation of a fistula into the nasal cavity and, if necessary, supplemented by nasolacrimal intubation.
Congenital nasolacrimal duct obstruction is common and often resolves spontaneously. It can be treated by probing the nasolacrimal system, supplemented by nasolacrimal intubation or balloon catheter dilation, if necessary. Dacryocystorhinostomy is rarely required.