DACRYOCYSTITIS

Oleh : Rizki Chusnaini

Definition
• Infection of the lacrimal sac is usually secondary to
obstruction of the nasolacrimal duct. It may be acute or
chronic and is most commonly staphylococcal or
streptococcal.

• Occurs in 3 form :
▫ Acute : patients experience severe morbidity dan rarely
mortality. Morbidity is related primarily to the lacrimal sac
abscess and spread of the infection
▫ Chronic : The primary morbidity is associated with chronic
tearing, mattering, and conjunctival inflammation and
infection
▫ Congenital : is a very serious disease associated with
significant morbidity and mortality. If not treated promptly
and aggressively, newborn infants can experience orbital
cellulitis (because the orbital septum is formed poorly in
infants), brain abscess, meningitis, sepsis, and death.
Lacrimal passages –consist of
Physiology
• Epiphora is defined as the sign of overflow of tears, and may
be caused by the following:
1 Hypersecretion secondary to ocular inflammation or surface
disease. In these cases watering is associated with symptoms of
the underlying cause and treatment is usually medical.
2 Defective drainage due to compromise of the lacrimal
drainage system. It may be caused by:
a Malposition of the lacrimal puncta (e.g. secondary to
ectropion).
b Obstruction along the lacrimal drainage system, from the
puncta to the nasolacrimal duct.
c Lacrimal pump failure, which may occur secondarily to
lower lid laxity or weakness of the orbicularis muscle (e.g. facial
nerve palsy).
Evaluation
• External examination
2. Lacrimal sac
1 The puncta and eyelids
• Fluorescent disappearance testing: A somewhat
subjective test, it is used to assess the
disappearance of fluorescein dye when placed in
the eye. The ocular surface is evaluated at the slit
lamp to determine disappearance of the
fluorescein dye. This test is useful in children.
• With the Jones I dye test, functional and anatomical
obstruction of the nasolacrimal system can be assessed.
▫ A positive result indicates no anatomical or functional
blockage to tear flow.
▫ A negative result indicates a lacrimal drainage system
problem (ie, anatomical or functional blockage).
• A Jones II dye test is used to determine the presence or
absence of anatomical obstruction of the nasolacrimal
outflow system. A positive Jones II dye test (colored fluid
from the nose) indicates a patent system anatomically.
• In light of a negative Jones I dye test, a positive Jones II
dye test indicates either partial obstruction of the
nasolacrimal system or a false-negative Jones I test.
• If no fluid can be irrigated with the Jones II test,
complete nasolacrimal obstruction is present.
Clinical findings
• Edema and erythema with
distension of the lacrimal sac
below the medial canthal
tendon
• The degree of discomfort
ranges none to severe pain
• it occurs more commonly in women.
• Age 40-60 years age group.
• There may be pooling of tears near the media
canthus.
• On pressure over the sac there may be a mucoid
or mucopurulent reguritation through the
puncta or more rarely it passes down the nose.
• There may be a non tender swelling
Radiographic feature
• CT scans are useful in patients
suspected of dacryocystitis.
• The typical finding is a
wellcircumscribed round
lesion that is centered at the
lacrimal fossa and that
demostrates peripheral
enhancement
• MRIs are not as useful as CT scans but can be
helpful in differentiating cystic lesions from solid
mass lesions
• Dacryocystography (DCG) and dacryoscintigraphy
are useful adjunctive diagnostic modalities when
anatomical abnormalities of the nasolacrimal
drainage system are suspected.
Dacryoscintigraphy

Scintigraphy is a sophisticated test which assesses tear drainage under more

physiological conditions than DCG. Although it does not provide the same
detailed anatomical visualization as DCG, it is more sensitive in assessing
incomplete blocks. It is also useful in assessing physiological obstruction
beyond the sac
Workup cont.....
• Nasal endoscopy is frequently useful in assessing
the etiology of dacryocystitis.[5] Tumors,
papillomas, hypertrophy of the inferior
turbinate, nasal septal deviation, and inferior
meatal narrowing may be noted as causes of
dacryocystitis.
• Laboratory Studies
• In most patients, physicians make a clinical
diagnosis of dacryocystitis.
• Supportive laboratory analysis includes a complete
blood count to assess the degree of leukocytosis;
however, this rarely may assist in the determination
of leukemia as an etiology of the lacrimal sac
infection.
• Blood cultures and cultures of the ocular surface,
nose, and lacrimal sac discharge may prove useful in
determining the appropriate antibiotic therapy.
Complications
• 1-chronic conjunctivitis
• 2-Acute dacryocystitis may arise.
• 3-Lacrimal abscess.
• 4-Lacrimal fistula- when the lacrimal abscess
ruptures or is drained.
• 5-Orbital cellulitis,facial cellulitis and rarely
cavernous sinus thrombosis
Treatment
• Acute dacryocystitis
a. Initial treatment involves the application of local warm
compresses and oral antibiotics such as flucloxacillin or co-
amoxiclav; irrigation and probing should not be performed.
b Incision and drainage may be considered if pus
points and an abscess is about to drain spontaneously.
However, this carries a risk of the development of a lacrimal
fistula, which may serve as a conduit for tears from the
lacrimal sac to the skin surface (Fig. 2.21C).
c DCR is usually necessary after the acute infection has
been controlled. Surgery should not be delayed in the
presence of persistent epiphora because of the risk of
recurrent infection.
• Chronic dacryocystitis  DCR
Dacryocystorhinostomy (DCR)
• DCR surgery is a procedure that aims to
eliminate fluid and mucus retention within the
lacrimal sac and to increase tear drainage for
relief of epiphora (water running down the face).
A DCR procedure involves removal of bone
adjacent to the nasolacrimal sac and
incorporating the lacrimal sac with the lateral
nasal mucosa in order to bypass the
nasolacrimal duct obstruction. allows tears to
drain direcctly into the nasal cavity from the
canaliculi via a new low resistance pathway
Thank you!
Guidelines for treating acute
dacryocystitis :
• Irrigation or probing of the canalicular system
should be avoided until the infection subsides. In
most cases, irrigation is not needed to establish the
diagnosis and is extremely painful in the setting of
active infection
• Diagnostic or therapeutic probing on the NLD is not
indicated in adults with acute dacryocystitis
• Topical antibiotics are of limited value.  they
dont’t reach the site of the infection because of statis
within the lacrimal drainage system and do not
penetrate sufficiently within the adjacent soft tissue
 • Oral antibiotics are effective in most infections
Guidelines
- gram positivecont.....
bacteria are the most common cause
of acute dacryocystitis.
We should suspect gram negative bacteria in
patients who are diabetic or immunocompromised
or in those who have been exposed to atypical
pathogens
• Parenteral antibiotics are necessary for the
treatment of severe cases, especially if cellulitis or
orbital extension is present
• Aspiration of the lacrimal sac may be performed if a
pyocelle –mucocele is localized and approaching the
skin. Information regarding appropiate systemic
antibiotic therapy may be obtained from smears and
cultures of the aspirated material
Dacrycystitis chronic
• Is a smoldering low grade infection, may develop in
some individuals
• Usually results in distension of the lacrimal sac
• Massage may reflux mucoid material through the
canalicular system onto the surface of the eye
• Diagnostic probing and irrigation should be confined to
the upper system in adults, because does not achieve
permanent patency in adults.
• If a tumor is not suspected, no further diagnostic
evaluation is indicated to confirm the diagnosis of a total
NLD obstruction
• Chronic dacryocystitis needs to be surgically resolved
before elective intraocular surgery.
• A localized abcess involving the lacrimal sac and
adjacent soft tissues requires incision and
drainage. The incised abcess is packed open and
allowed to heal by second intention. This
treatment should be reserved for severe cases
and those that do not respond to more
conservative measures, because a chronically
draining epithelialized fistula that
communicates with the lacrimal sac can form
• lacrimal puncta- one in each lid and situated near the
posterior border of the margin 6 mm from The medial
canthus.
• Canaliculi – one in each eyelid-it commences at the punctum
and carries tears to the lacrimal sac.
• Lacrimal sac =lies in the lacrimal fossa formed by the lacrimal
bone and frontal process of maxilla.It is covered by lacrimal
foscia.
• Anterior to the lacrimal foscia is the medial palpebral
ligament.
• The upper part of the sac is known as the fundus.The lower
end narrows as it open into the nasolacrimal duct
• D-Naso lacrimal duct is 3-4 in length and opens into the
inferior meatus of the nose. It is directed downwards,slightly
outwards and backwards.
• The tears which are secreted by the lacrimal glands into the
conjunctival sac are drained by the lacrimal passage into the
nose
Treatment and Management
• The treatment of dacryocystitis depends upon the
clinical manifestations of the disease.
▫ Acute dacryocystitis with orbital cellulitis necessitates
hospitalization with intravenous (IV) antibiotics.
Appropriate neuroimaging studies should be obtained,
and surgical exploration and drainage should be
performed for focal collections of pus.
 IV empiric antimicrobial therapy for penicillin-resistant
Staphylococcus (nafcillin or cloxacillin) should be
initiated immediately.
 Blood cultures and cultures of the lacrimal secretions
should be obtained prior to antibiotic therapy.
 Treatment with warm compresses may aid in resolution
of the disease.
 Impending perforation should be treated with a stab
incision of the skin.
• Purulent infection of the lacrimal sac and skin should be
treated similarly. Hospitalization is not mandatory
unless the patient's condition appears serious.
Treatment with oral antibiotics (eg, Augmentin) is
appropriate.
▫ Cultures of the lacrimal fluid should be obtained. The
presence of a lacrimal sac mucocele in adults mandates
treatment even if asymptomatic.
▫ The treatment of choice is a dacryocystorhinostomy
whether the patient is symptomatic or not. Probing should
not be performed because mucoceles often are not sterile
and probing may incite a cellulitis.
• Patients with chronic dacryocystitis caused by a partial
or intermittent nasolacrimal duct obstruction may
benefit from topical steroid drop treatment.
• Congenital chronic dacryocystitis may resolve with
lacrimal sac massage, warm compresses, and topical
and/or oral antibiotics.