Dacryocystitis

Aka: Dacryocystitis

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II. Pathophysiology

  1. Nasolacrimal Duct Obstruction
  2. Obstruction predisposes to tear stasis and infection
  3. Bacterial Infection occurs from contiguous spread from colonized Conjunctiva or nasal mucosa
    1. Streptococcus Pneumoniae
    2. Staphylococcus aureus
    3. HaemophilusInfluenzae
    4. Streptococcus Pyogenes
    5. Enterobacteriaceae

III. Types

  1. Acute Dacryocystitis
    1. Presents with pain and erythema at the medial canthus
  2. Chronic dacrocystis
    1. Chronic inflammation at the lacrimal sac results in epiphora
  3. Congenital Dacryocystitis
    1. Distinguish from the typical minor Lacrimal Duct Obstruction common to many newborns (relieved with massage at medial canthus)
    2. Associated with craniofacial abnormalities
    3. Risk of Orbital Cellulitis

IV. Causes

  1. Infants
    1. Congenital Nasolacrimal Duct Obstruction
  2. Adults
    1. Chronic Rhinitis or Chronic Sinusitis
    2. Facial Trauma
    3. Maxillofacial tumor

V. Differential diagnosis

  1. Stye
  2. Internal Hordeolum
  3. Orbital Cellulitis

VI. Symptoms

  1. Eye Pain or irritation
  2. Epiphora (excessive tearing, spilling onto the face)

VII. Signs

  1. Acute
    1. Conjunctival injection
    2. Inflammation of the medial portion of lower Eyelid (at medial canthus)
      1. Affects the region of the lacrimal sac
      2. Localized pain, tenderness, swelling and redness
    3. Purulent discharge from the lacrimal puncta
      1. Drainage increases with pressure over the lacrimal sac
  2. Chronic
    1. Pressure on puncta expresses fluid
    2. Conjunctivitis
    3. Blepharitis

VIII. Lab

  1. Exudate culture and Gram Stain (identifies MRSA)

IX. Management: General

  1. Urgent ophthalmology referral (Incision and Drainage may be needed)

X. Management: Antibiotics in children

  1. Mild to moderate cases
    1. Amoxicillin-clavulanate (Augmentin)
  2. Severe cases
    1. Cefuroxime

XI. Management: Antibiotics in adults

  1. Mild to moderate
    1. Cephalexin
  2. Severe cases (2 Antibiotic regimens)
    1. Antibiotic 1 (choose one)
      1. Nafcillin or Oxacillin 2 grams IV every 4 hours
      2. Vancomycin 15-20 mg/kg IV every 8-12 hours (if MRSA suspected)
    2. Antibiotic 2 (choose one)
      1. Ceftriaxone 2 g IV every 24 hours
      2. Cefepime 2 g IV every 12 hours
      3. Levofloxacin 750 mg IV or oral every 24 hours (if Cephalosporin allergic)

XII. References

  1. Trobe (2012) Physician's Guide to Eye Care, AAO, San Francisco, p. 62-3
  2. Gilbert (2012) Sanford Guide

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