Inflammation of the lacrimal sac (acute dacryocystitis) is usually due to complete NLDO, which prevents normal drainage from the lacrimal sac into the nose. Chronic tear retention and stasis lead to secondary infection. Clinical findings include edema and erythema with distention of the lacrimal sac (Fig 15-25). The degree of discomfort ranges from none to severe pain. Complications include dacryocystocele formation, chronic conjunctivitis, and spread to adjacent structures (orbital or facial cellulitis).
Figure 15-24 Chronic canaliculitis. A, Superior and inferior pouting puncta. B, Vertical canaliculotomy. C, Expression of canaliculi with cotton-tip applicators. D, Sulfur granules expressed from canaliculi seen with Actinomyces israelii.
(Parts A–C courtesy of Bobby S. Korn, MD, PhD; part D courtesy of Eric A. Steele, MD.)
The following steps may be used in the treatment of 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 it is extremely painful for patients with active infection.
Probing of the NLD is not indicated in adults with acute dacryocystitis.
Topical antibiotics are of limited value. They do not reach the site of the infection because of stasis within the lacrimal drainage system. They also do not penetrate sufficiently within the adjacent soft tissue.
Oral antibiotics are effective for most infections. Gram-positive bacteria are the most common cause of acute dacryocystitis. However, the clinician should suspect gram-negative organisms in patients who have diabetes mellitus or are immunocompromised and in those who have been exposed to atypical pathogens (eg, individuals residing in nursing homes).
Parenteral antibiotics may be 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 pyocele or mucocele is localized and approaching the skin. Smears and cultures of the aspirate may inform the selection of systemic antibiotic therapy.
A localized abscess involving the lacrimal sac and adjacent soft tissues may require incision and drainage but should be reserved for cases that do not respond to more conservative measures or for patients in severe discomfort.
Figure 15-25 Acute dacryocystitis of the right side associated with NLDO.
(Courtesy of Bobby S. Korn, MD, PhD.)
Dacryocystitis indicating total NLDO requires a DCR in most cases because of inevitable persistent epiphora and recurrence. In general, external surgery is deferred until the acute inflammation is resolved. However, endonasal DCR can be safely performed for acute infection. Some patients, however, continue to have a subacute infection until definitive drainage surgery is performed.
Chronic dacryocystitis, a smoldering low-grade infection, may develop in some individuals. It may result in distention of the lacrimal sac, and massage may reflux mucoid material through the canalicular system onto the surface of the eye. If a tumor is not suspected, no further diagnostic evaluation is indicated to confirm the diagnosis of total NLDO. Chronic dacryocystitis is treated before elective intraocular surgery.
Meireles MN, Viveiros MM, Meneghin RL, Galindo-Ferreiro A, Marques ME, Schellini SA. Dacryocystorhinostomy as a treatment of chronic dacryocystitis in the elderly. Orbit. 2017;36(6):419–421.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.