Dacryocystitis - Clinical Features And Management.

Definition: Dacryocystitis is an inflammation of the lacrimal sac, positioned immediately distal to the canaliculi and proximal to the nasolacrimal duct.

Etiology: Inflammation is usually secondary to obstruction of the nasolacrimal duct.

Clinical findings include:

• swelling over the lacrimal sac, 
• redness, 
• tearing, 
• eyelash matting and crusting, 
• conjunctival redness. 

During examination tears and mucopurulence may be expressed from the punctum when pressure is applied over the lacrimal sac.

Dacryocystitis. Swelling and erythema over the medial lower lid and lacrimal sac developed in this 10-year-old patient with streptococcal pharyngitis.

Complications include:

• conjunctivitis and 
• orbital or preseptal cellulitis.

Up to 20% of normal newborns have a closed nasolacrimal passage, and 90% spontaneously open within the first 6 months.


Management: 

• Ophthalmologic consultation is recommended. 
• The most common organisms isolated in children are S aureus, Staphylococcus epidermidis, and α-hemolytic Streptococci. 
• Oral clindamycin for 7 to 10 days is recommended for outpatient management.
• Febrile and acutely ill patients require IV vancomycin in combination with a third-generation cephalosporin.
• Treatment of nasolacrimal duct obstruction is managed initially with downward lacrimal sac massage (“Crigler” massage) 2 to 3 times a day. 
• Unresolved nasolacrimal duct obstruction requires lacrimal duct probing by the ophthalmologist.

Important Points To Remember:
1. Nasolacrimal duct obstruction is the most common cause of persistent tearing and ocular discharge in children.
2. Swelling is localized to the extreme nasal aspect of the lower lid and may be confused with a hordeolum. Occasionally, conjunctival redness may be present.
3. Dacryocystitis may be confirmed by pressure on the lacrimal sac and the reflux of tears and purulent material from the punctum. The lacrimal sac and lacrimal fossa lie in the inferior medial aspect of the orbit, not on the side of the nose.
4. Urgent referral should be made for any signs of orbital cellulitis. These include proptosis, limitation of extraocular movements, and loss of vision.