Dacryocystitis

Inflammatory and infectious condition of the lacrimal sac, most commonly resulting from obstruction of the nasolacrimal duct

Aetiology

Primary Etiology

  • Nasolacrimal duct obstruction (NLDO)
    • Idiopathic (most common in adults)
    • Congenital (in infants)
    • Inflammatory stenosis
    • Age-related involutional changes

Secondary Causes

  • Chronic rhinosinusitis
  • Nasal trauma or surgery
  • Nasal or sinus tumors
  • Facial fractures
  • Iatrogenic causes (e.g., radiotherapy)

Microbiological Agents

  1. Acute dacryocystitis
      • Staphylococcus aureus
      • Streptococcus pneumoniae
      • Streptococcus pyogenes
      • Haemophilus influenzae
  1. Chronic dacryocystitis
      • Staphylococcus epidermidis
      • Gram-negative bacilli
      • Anaerobic organisms

Clinical presentation

Acute Dacryocystitis

Symptoms
  • Sudden onset pain and swelling over the medial canthus
  • Redness and warmth of overlying skin
  • Epiphora
  • Fever and malaise (in severe cases)
Signs
  • Tender, erythematous swelling over the lacrimal sac
  • Fluctuance if abscess has formed
  • Purulent discharge expressed from puncta on pressure (regurgitation test positive)
notion image

Chronic Dacryocystitis

Symptoms
  • Chronic epiphora
  • Recurrent conjunctivitis
  • Intermittent mucopurulent discharge
Signs
  • Non-tender swelling or fullness over the lacrimal sac
  • Regurgitation of mucopurulent material on pressure
  • Minimal skin inflammation

Investigations

Clinical Evaluation

  • Detailed history (onset, systemic symptoms, recurrence)
  • Complete ophthalmic examination including visual acuity and ocular motility
  • Anel Test negative

Laboratory Studies

  • Complete blood count (CBC)
  • Inflammatory markers (ESR, CRP)
  • Viral serology (e.g., EBV) when indicated
  • Autoimmune markers (ANA, ANCA, serum IgG4) in chronic or bilateral cases

Imaging

CT or MRI of the orbit to assess gland enlargement, abscess formation, or orbital involvement

Biopsy

  • Indicated in:
    • Chronic or recurrent dacryoadenitis
    • Atypical presentations
    • Suspected neoplastic or IgG4-related disease

Management

Acute Dacryocystitis

  • Systemic broad-spectrum antibiotics (covering Gram-positive and Gram-negative organisms)
  • Analgesics and anti-inflammatory agents
  • Warm compresses
  • Incision and drainage if abscess formation is present (avoid syringing during acute infection)

Chronic Dacryocystitis

  • Definitive management with dacryocystorhinostomy (DCR):
    • External or endoscopic approach
  • Topical antibiotics for associated conjunctivitis
  • Management of underlying nasal pathology if present