What Is Dacryocystitis?

Overview

Dacryocystitis refers to the inflammation and infection of the tear sac, which is also known as the lacrimal sac. This sac is connected to the tear duct, also called the nasolacrimal duct, and is a part of the tear system.

Under normal circumstances, tears flow from the eyes into the tear ducts and then drain into the nasal passages.

Dacryocystitis occurs when there is a blockage along this pathway. The blockage can be present in the tear sac itself, the passages that facilitate tear movement, or the nasolacrimal duct. When tears are unable to flow properly, the stagnant fluid becomes susceptible to infection, leading to inflammation and the development of dacryocystitis.¹

Types of dacryocystitis

Dacryocystitis can be categorised into two types: acute and chronic based on the duration of the condition, and congenital and acquired based on when it occurs.^1,Acute dacryocystitis typically presents suddenly and resolves within a relatively short period, usually under three months. On the other hand, chronic dacryocystitis persists for an extended period.

In addition to the difference in duration, chronic dacryocystitis is more frequently associated with systemic (whole-body) and autoimmune conditions. These conditions can include granulomatosis with polyangiitis, sarcoidosis, and lupus (systemic lupus erythematosus). Individuals with chronic dacryocystitis may also experience chronic conjunctivitis (pink eye).

Furthermore, the types of pathogens involved in acute and chronic dacryocystitis may vary. The causative agents, such as bacteria or viruses, can differ between the two types of the condition.

In addition to chronic and acute dacryocystitis, another classification of the condition is based on whether it is congenital (present at birth) or acquired.

Congenital dacryocystitis primarily occurs due to the incomplete drainage of amniotic fluid from the tear system after birth. It is commonly seen as neonatal dacryocystitis, where the retained fluid can become infected, leading to inflammation and infection of the tear sac.

Acquired dacryocystitis, on the other hand, develops due to various factors unrelated to birth. These factors can include traumatic injuries such as broken bones, previous surgeries affecting the tear system, the presence of tumours, or the use of certain medications.

The classification of dacryocystitis into congenital and acquired forms helps in understanding the different underlying causes and potential risk factors associated with the condition.

Causes of dacryocystitis

Dacryocystitis is caused by a blockage in the tear duct, which disrupts the normal flow of tears from the eyes into the nasal cavity.^1,4

In newborns, the blockage is often caused by a membrane obstructing the tear duct. In children and older individuals, there can be various factors contributing to the blockage.

For acquired dacryocystitis, the following factors can be involved:

• Ageing: Dacryocystitis is more common in adults over the age of 40
• Trauma: Traumatic injuries, such as those resulting from broken bones or surgeries on the nose, can lead to blockages in the tear duct
• Medical conditions: Other medical conditions, including immune system disorders, inflammations, infections like sinusitis, or unusual nasal structures, can contribute to acquired dacryocystitis
• Tumours: Presence of tumours in the tear duct or nearby structures can cause blockages and subsequent dacryocystitis
• Certain medications: Some medications, such as the blood pressure medication timolol, glaucoma drugs like dorzolamide and pilocarpine, antiviral drugs like trifluridine, and certain cancer treatments including fluorouracil, docetaxel, or radioactive iodine, may increase the risk of developing dacryocystitis
• Retained punctal plugs: The use of punctal plugs, which are small devices inserted into the tear ducts to treat dry eye, can occasionally lead to blockages and contribute to dacryocystitis

It's important to consult with a healthcare professional for an accurate diagnosis and appropriate management of dacryocystitis, as the underlying cause and contributing factors may vary from person to person.

Signs and symptoms of dacryocystitis

Acute dacryocystitis

Symptoms and signs of acute dacryocystitis typically manifest in the region of the lacrimal sac, although they may spread to the nose and face. When examining the patient, focus on the area just lateral and below the bridge of the nose. The following symptoms and signs are commonly observed:

• Excess tears (epiphora): Almost always present due to the obstruction of tear drainage
• Pain: The patient may experience pain in the affected area
• Redness: Redness and inflammation can be observed over the lacrimal sac and surrounding tissues
• Swelling: There may be swelling in the region of the lacrimal sac, and in severe cases, preseptal cellulitis (infection of the tissues in front of the orbital septum) may also be present

The patient may also complain of decreased visual acuity due to the excessive tearing and abnormal tear composition. Examination of the area will reveal a tender, tense, and red swelling. In some cases, there may be mucopurulent discharge that can be expressed from the punctum (the small opening in the eyelid for tear drainage). Additional findings may include fever and an elevated white blood cell count.

Chronic dacryocystitis

Chronic dacryocystitis typically presents with a history of chronic or recurring epiphora (excess tearing) and may exhibit persistent redness in the medial canthus (the inner corner of the eye). Other features of chronic dacryocystitis include:

• Painless or recurring swelling over the lacrimal sac: A swelling may be observed in the area of the lacrimal sac, which may come and go or persist over time
• Reflux of mucopurulent material: Applying pressure over the lacrimal sac can cause the reflux of mucopurulent material (a mixture of mucus and pus) through the lower punctum

It is important to consider these symptoms and signs when evaluating patients with suspected acute or chronic dacryocystitis.

Management and treatment for dacryocystitis

In cases of acute dacryocystitis caused by bacterial infection, healthcare providers typically prescribe oral or intravenous (IV) antibiotics.^3,6 Additionally, antibiotic ointment or drops may be recommended. Warm compresses can provide symptomatic relief, and gentle massaging of the affected area may also be beneficial. Improvement in symptoms is typically observed within a few days of starting antibiotic treatment.

Commonly used antibiotics for treating tear duct infections include:

• Amoxicillin-clavulanate
• Cephalexin
• Ciprofloxacin
• Clindamycin
• Trimethoprim-Sulfamethoxazole

For infants with neonatal dacryocystitis experiencing recurrent episodes, the condition often resolves within approximately one year as they outgrow it.

In some cases of acute dacryocystitis, after completing a course of antibiotics, healthcare providers may recommend a surgical procedure called dacryocystorhinostomy (DCR).² DCR is also the primary treatment for chronic dacryocystitis.^5,6 This surgical intervention involves creating a new pathway for tears to bypass the blocked tear duct, facilitating proper tear drainage.¹

Diagnosis

To diagnose dacryocystitis, your healthcare provider may rely on a combination of physical examination, medical history assessment, and specific tests.^1,4 These may include:

1. Eye exam: Your eyes will be examined to assess the extent of inflammation and any associated symptoms
2. Compression test: Gentle pressure may be applied to the swollen area, and if discharge comes out through the punctum (tear drainage opening), it can indicate the presence of dacryocystitis
3. Sample collection: A sample of the discharge may be taken and sent to the lab for culture and sensitivity testing. This helps identify the specific bacteria or pathogen causing the infection and guides appropriate antibiotic treatment
4. Blood tests: A blood sample may be taken to check the white blood cell count, which can indicate the presence of an infection. Blood tests can also be used to identify any underlying causes contributing to the eye condition
5. Dye test: A yellow dye may be placed in your eye to assess tear flow. If the dye takes a longer time to disappear, it suggests a tear duct blockage. If the dye appears on a swab placed in your nose, it indicates a partial blockage
6. Imaging tests: In some cases, additional imaging tests such as computed tomography (CT) or magnetic resonance imaging (MRI) may be ordered to evaluate the underlying causes of dacryocystitis

Further testing may be necessary if you have experienced blood in your tears (haemolacria) or vision problems, as these symptoms may indicate additional complications or associated conditions.

It's important to consult with a healthcare professional who can perform a thorough evaluation and recommend the appropriate tests for an accurate diagnosis and effective management of dacryocystitis.¹

Complications

Dacryocystitis carries the risk of various complications, primarily related to the spread of infection. These complications can include:

• Superficial spread: This can result in conditions such as cellulitis, which is an infection of the skin and underlying tissues
• Deep spread: In some cases, the infection can spread deeper, leading to conditions like orbital cellulitis (infection of the tissues around the eye), orbital abscess (collection of pus within the eye socket), or even more severe complications like meningitis
• Generalised spread: Rarely, dacryocystitis can lead to systemic infection, such as sepsis, which is a severe and potentially life-threatening condition involving widespread infection throughout the body. These complications are more commonly observed in immunocompromised individuals or cases of congenital dacryocystitis

In cases where intraocular surgery, such as cataract surgery, is planned, it is important to postpone the procedure until the dacryocystitis, whether acute or chronic, has been effectively treated. This is because there is a significant risk of developing endophthalmitis, which is an infection within the eye following surgery.

It is also important to be aware that dacryocystorhinostomy (DCR), a surgical procedure used to treat dacryocystitis, may have its own associated complications, including:⁵

• Failed procedure: In some cases, the DCR procedure may not successfully resolve the underlying issue
• Cutaneous scarring: Surgical incisions involved in DCR can lead to scarring of the skin
• Epistaxis: Nosebleeds can occur as a possible complication of DCR
• Cellulitis: In rare cases, cellulitis may develop as a complication following DCR
• Cerebrospinal fluid rhinorrhoea: If the surgeon accidentally enters the subarachnoid space during DCR, it can lead to the leakage of cerebrospinal fluid through the nose

It is essential to discuss potential complications and risks associated with any surgical procedure with a healthcare professional to ensure informed decision-making and appropriate management.

FAQs

How can I prevent dacryocystitis?

Most forms of dacryocystitis cannot be completely prevented, but you can take certain measures to reduce the risk of infection and minimise the chances of developing the condition. Here are some preventive steps you can follow:

1. Practise good hand hygiene: Wash your hands frequently with soap and water for at least 20 seconds, especially before touching your face, or eyes, or applying any eye medications. If soap and water are not available, use a hand sanitiser that contains at least 60% alcohol
2. Avoid touching your eyes: Refrain from touching or rubbing your eyes with unwashed hands, as this can introduce germs and increase the risk of infections
3. Maintain a clean environment: Keep your living and working spaces clean and free from dust, irritants, and potential sources of infection
4. Avoid crowded places and sick individuals: Minimise your exposure to crowded areas or close contact with people who have contagious illnesses, as this can help reduce the risk of acquiring infections
5. Follow proper contact lens hygiene: If you wear contact lenses, follow the recommended cleaning and disinfection guidelines provided by your eye care professional to prevent eye infections.
6. Protect your eyes from irritants: When participating in activities that may expose your eyes to irritants, such as swimming or dusty environments, use appropriate protective eyewear to minimise the risk of irritation or injury

While these preventive measures cannot guarantee the complete prevention of dacryocystitis, they can help reduce the likelihood of developing infections that may contribute to the condition. If you have specific concerns or risk factors, it's advisable to consult with a healthcare professional for personalised advice.

How common is dacryocystitis?

Congenital nasolacrimal duct obstruction (NLDO) is relatively common in newborns, affecting approximately 6% of babies. Dacryocystitis, which is inflammation and infection of the tear sac, occurs less frequently, with an incidence of about 1 in 3,884 live births.

The higher prevalence of NLDO in females compared to males is attributed to anatomical differences. Female infants tend to have narrower tear duct passageways, making them more susceptible to blockages and subsequent complications such as dacryocystitis.

It's important for parents and caregivers to be aware of the possibility of NLDO in newborns and seek appropriate medical evaluation and management if symptoms or signs of obstruction or infection arise. Early detection and treatment can help prevent complications and promote normal tear drainage and eye health in infants.

When should I see a doctor?

Always contact a healthcare provider if you have any of the signs or symptoms of dacryocystitis or if your child has any of these symptoms.

Summary

Timely and aggressive management is crucial, especially in cases of congenital dacryocystitis. Prompt treatment and appropriate surgical intervention are essential to prevent potential complications and mitigate the associated morbidity and mortality risks. Therefore, if there are concerns or suspicion of congenital dacryocystitis, it is of utmost importance to seek immediate medical attention to ensure timely and effective management.