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Acute Dacryocystitis - Complete Guide

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Clinical Photo

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1. ETIOLOGY (Causes)

Primary Cause

• Nasolacrimal duct obstruction (NLDO) - by far the most common underlying cause. Obstruction blocks tear drainage, creating a stagnant pool in the lacrimal sac that gets infected.

Uncommon Causes

• Lacrimal sac diverticula
• Dacryoliths (stones inside the lacrimal sac)
• Nasal or sinus surgery (post-operative scarring)
• Facial trauma
• Rarely, lacrimal sac tumors

Causative Organisms

Predisposing Factors

• Middle-aged to older adults (more common in women due to narrower nasolacrimal anatomy)
• History of previous episodes (recurrent NLDO)
• Concomitant sinus disease
• Prior nasal/sinus surgery or facial trauma
• Diabetes mellitus (impairs immunity, increases atypical organisms)

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2. CLINICAL FEATURES

Symptoms

• Pain at the inner corner of the eye (medial canthal area) - subacute onset
• Swelling - tense, tender red swelling just below the medial canthal tendon
• Epiphora (excessive tearing / watering eye)
• Discharge - mucoid or purulent
• Fever and chills (in moderate-severe cases)
• Symptoms may be recurrent

Signs (What You See on Examination)

• Erythematous (red), tender, tense swelling over the nasal aspect of the lower eyelid
• Swelling extends around the periorbital area
• Mucoid or purulent discharge expressed from the punctum when gentle pressure is applied over the lacrimal sac - this is the key diagnostic sign
• Important landmark: Swelling is BELOW the medial canthal tendon (if above, suspect lacrimal sac tumor)

• Possible preseptal (periorbital) cellulitis
• Skin fistula may form below the medial canthal tendon in severe/untreated cases
• Abscess formation (fluctuant mass that may point to skin)

Key Diagnostic Maneuver

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3. DIFFERENTIAL DIAGNOSIS

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4. INVESTIGATIONS / WORKUP

1. History - Ask about previous episodes, sinus disease, trauma, surgery
2. Clinical examination - Express discharge from the punctum by pressing the lacrimal sac
3. Gram stain + culture of expressed discharge (use chocolate agar in children for H. influenzae)
4. Blood cultures if patient is febrile and systemically unwell
5. CT scan of orbits and paranasal sinuses - in atypical, severe, or antibiotic-unresponsive cases (to rule out abscess, orbital cellulitis, or sinus pathology)
6. Evaluate extraocular motility and pupillary response to rule out concurrent orbital cellulitis

Do NOT probe or irrigate the lacrimal system during the acute infection - this can spread infection.

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5. COMPLICATIONS

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6. MEDICAL MANAGEMENT

General Measures (All Patients)

• Warm compresses to the inner canthal area for 5-10 minutes, 4 times daily (promotes drainage)
• Gentle massage over the lacrimal sac area
• Pain relief - acetaminophen (paracetamol) ± codeine as needed
• Topical antibiotic drops (e.g., trimethoprim/polymyxin B 4 times daily) - adjunct only; topical therapy alone is NOT adequate

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7. TREATMENT ALGORITHM

┌─────────────────────────────────────────────────────────────────┐
│              ACUTE DACRYOCYSTITIS - TREATMENT ALGORITHM         │
└─────────────────────────────────────────────────────────────────┘
                              │
                    CONFIRM DIAGNOSIS
              (Swelling below medial canthal tendon
               + pus expressed from punctum on pressure)
                              │
              ┌───────────────┴───────────────┐
              ▼                               ▼
     ADULT PATIENT                     CHILD PATIENT
              │                               │
    ┌─────────┴──────────┐         ┌──────────┴──────────┐
    ▼                    ▼         ▼                     ▼
 MILD CASE           SEVERE      MILD                 SEVERE
(Afebrile,          CASE         (Afebrile,           (Febrile,
systemically        (Febrile /   well, reliable       acutely ill)
well)               acutely ill) parent)
    │                    │             │                    │
    ▼                    ▼             ▼                    ▼
ORAL ANTIBIOTICS     IV ANTIBIOTICS  ORAL ANTIBIOTICS   IV ANTIBIOTICS
                                                        + HOSPITALIZE
• Cephalexin         • Cefazolin     • Amoxicillin/     • Cefuroxime
  500mg PO q6h         1g IV q8h       clavulanate        50-100mg/kg/d
  OR                   OR              25-45mg/kg/d       IV in 3 doses
• Amoxicillin/       • Cefuroxime      PO in 2 doses      (consult
  clavulanate          50-100mg/       (max 90mg/         ID specialist)
  500/125mg            kg/d IV         kg/d)             OR
  TID or                               OR               • Cefazolin
  875/125mg BID                      • Cefpodoxime        33mg/kg IV q8h
                                       10mg/kg/d
                                       PO in 2 doses
              │                    │             │                    │
              └──────────┬─────────┘             └─────────┬─────────┘
                         │                                  │
              ┌──────────▼─────────────────────────────────▼──────────┐
              │  IF MRSA SUSPECTED (exposure history, treatment        │
              │  failure, immunocompromised, nursing home patient):    │
              │  Adults: TMP-SMX 160/800mg PO q12h OR                 │
              │          Clindamycin 300mg PO TID                     │
              │  Children: TMP-SMX or Clindamycin IV                  │
              └─────────────────────────────────────────────────────── ┘
                                       │
                                       ▼
                        + ADJUNCT MEASURES (ALL PATIENTS)
                    • Warm compresses 5-10 min, 4x daily
                    • Topical antibiotics (e.g., TMP/Polymyxin B QID)
                    • Pain relief (acetaminophen ± codeine)
                                       │
                                       ▼
                          ABSCESS PRESENT? (Pointing pus)
                    ┌──────────────────────────────────────┐
                    │                                      │
                   YES                                    NO
                    │                                      │
                    ▼                                      ▼
        INCISION AND DRAINAGE                    CONTINUE ANTIBIOTICS
        (alleviate pain, hasten                  (FULL 10-14 DAY COURSE)
        healing; risk: persistent
        skin-sac fistula)
                    │                                      │
                    └────────────────┬─────────────────────┘
                                     │
                                     ▼
                             DAILY FOLLOW-UP
                    (until improvement confirmed)
                    If worsens → HOSPITALIZE + IV antibiotics
                                     │
                                     ▼
              AFTER ACUTE INFECTION RESOLVES:
              Probe and irrigate lacrimal system to assess patency
                                     │
                    ┌────────────────┴─────────────────┐
                    │                                  │
             OBSTRUCTION                         NO OBSTRUCTION
             CONFIRMED                              FOUND
                    │                                  │
                    ▼                                  ▼
        SURGICAL CORRECTION                    Monitor; treat
        (DCR - Dacryocystorhinostomy)          underlying cause
        ± silicone intubation
        Especially for recurrent/
        chronic dacryocystitis

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8. ANTIBIOTIC SUMMARY TABLE

Antibiotic course: Minimum 10-14 days total (IV switched to oral once improving)

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9. SURGICAL MANAGEMENT (Post-acute Phase)

• Creates a new drainage pathway between the lacrimal sac and the nasal mucosa, bypassing the blocked nasolacrimal duct
• Recommended after the acute infection resolves
• Indicated for: recurrent dacryocystitis, confirmed NLDO, and to close persistent skin fistulae
• Can be done externally (incision on skin) or endoscopically (endonasal approach)

Important tip: Do not perform intraocular surgery (e.g., cataract surgery) if there are any signs of active lacrimal system infection - risk of endophthalmitis.

---

• Wills Eye Manual, 6th/7th ed. (Section 6.9, pp. 399-402)
• Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed. (pp. 124-125)
• Tintinalli's Emergency Medicine: A Comprehensive Study (p. 421-427)

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Acute vs. Chronic Dacryocystitis - Comparison Chart

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Quick Memory Summary

ACUTE = RED + PAINFUL + FEVER + PUS → ANTIBIOTICS FIRST, then DCR later
CHRONIC = WATERY EYE + PAINLESS SWELLING + MUCUS → DCR is the cure

• Kanski's Clinical Ophthalmology, 10th ed., pp. 124-125
• Wills Eye Manual, pp. 399-402
• Textbook of Family Medicine, 9th ed., p. 350

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What Was Already Covered Above:

1. Etiology - Nasolacrimal duct obstruction as primary cause, uncommon causes (dacryoliths, trauma, surgery, tumors), and causative organisms by patient group (Staph, Strep, H. influenzae, MRSA in special populations)
2. Clinical Features - Symptoms (pain, swelling, epiphora, fever, purulent discharge) and Signs (tense erythematous swelling BELOW medial canthal tendon, pus expressed on pressure, preseptal cellulitis)
3. Complications - Lacrimal sac abscess, preseptal cellulitis, orbital cellulitis, skin fistula, mucocele, meningitis (rare), endophthalmitis, recurrence
4. Medical Management with Treatment Algorithm Chart - Full decision tree covering:
   • Mild vs. severe cases
   • Adult vs. child dosing
   • MRSA coverage
   • Incision & drainage for abscess
   • Warm compresses, topical antibiotics, pain relief
   • Follow-up and surgical planning (DCR)

---

---

Chronic Dacryocystitis - Complete Guide

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Clinical Photo

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1. ETIOLOGY (Causes)

Primary Cause

• Chronic nasolacrimal duct obstruction (NLDO) - the sac fills with stagnant tears and mucus, which gets secondarily infected or inflamed over time

Causes of NLDO Leading to Chronic Dacryocystitis

Predisposing Factors

• Female sex - narrower bony nasolacrimal canal
• Middle age to elderly adults (most common group)
• History of sinusitis or chronic nasal disease
• Previous acute dacryocystitis that was incompletely treated
• Infants with congenital NLDO (usually resolves spontaneously by 12 months)

Organisms (when infection is present)

• Staphylococcus epidermidis (most common in chronic form)
• Actinomyces species (associated with dacryolith formation)
• Mixed flora, Candida, Aspergillus (in immunocompromised patients)
• Often no active infection - just sterile obstruction with mucus accumulation

---

2. CLINICAL FEATURES

Symptoms

1. Epiphora (watering eye) - the PRIMARY and most common complaint; constant or intermittent tearing that runs down the cheek
2. Mucoid or mucopurulent discharge - especially in the morning (crusting of lashes)
3. Painless swelling at the inner corner of the eye (medial canthus) - the mucocele
4. Recurrent conjunctivitis - same eye, keeps coming back despite treatment
5. Blurred vision - from tear film disturbance
6. No pain, no fever - key difference from acute form
7. Episodes may worsen during upper respiratory tract infections

Signs on Examination

• Painless soft swelling at the medial canthus (mucocele) - smooth, compressible, non-inflamed, normal skin color
• Swelling is BELOW the medial canthal tendon (if above - suspect tumor)
• Mucopurulent reflux from punctum when gentle pressure applied to lacrimal sac - classic diagnostic sign
• Chronic or recurrent unilateral conjunctivitis on the same side
• If no obvious swelling, pressure over sac still commonly causes mucoid reflux through the canaliculus

• Constant tearing and crusting of lashes from birth or shortly after
• Yellow-green discharge
• Mucus reflux on pressing the sac
• Normal visual function (check red reflex)

---

3. INVESTIGATIONS / WORKUP

1. Clinical examination - compress the lacrimal sac to express discharge; examine both eyes
2. Fluorescein dye disappearance test - place fluorescein in conjunctival sac; if dye remains at 5-10 minutes under blue light, drainage is impaired (highly specific)
3. Lacrimal syringing/irrigation - inject saline through punctum; obstruction confirmed if fluid does not flow into nose; also localizes the site of blockage
4. Lacrimal probing - fine wire passed through canaliculus to locate and confirm obstruction (safe in chronic, unlike acute phase)
5. Dacryocystography (DCG) - contrast X-ray to visualize the anatomy and site of blockage (especially before surgery)
6. CT scan / MRI - if tumor, sinusitis, or trauma suspected
7. Nasal endoscopy - to assess intranasal anatomy before DCR planning
8. Culture of expressed discharge - to guide antibiotic choice if recurrent infection

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4. COMPLICATIONS

Important: Always rule out and correct chronic dacryocystitis BEFORE any planned intraocular surgery to prevent endophthalmitis.

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5. MEDICAL MANAGEMENT

Conservative (Non-Surgical) Measures

1. Lacrimal sac massage (Crigler's massage)
   • Press finger over the common canaliculus first (to block reflux)
   • Then roll finger downward over the sac to apply hydrostatic pressure
   • This may rupture a membranous obstruction (especially in infants)
   • Teach parents to do this 4-6 times daily in infants
2. Topical antibiotics
   • Fluoroquinolone drops (e.g., ciprofloxacin, ofloxacin) 4 times daily
   • For recurrent conjunctivitis episodes
   • Reduces bacterial load but does NOT cure obstruction
3. Warm compresses
   • Promotes drainage, reduces mild discomfort
4. Treat underlying cause
   • Manage chronic sinusitis, rhinitis, or systemic disease if present

Important: Medical treatment alone is NOT curative in chronic dacryocystitis. It only provides temporary relief. Definitive treatment is SURGICAL.

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6. TREATMENT ALGORITHM

┌──────────────────────────────────────────────────────────────────────┐
│           CHRONIC DACRYOCYSTITIS - TREATMENT ALGORITHM               │
└──────────────────────────────────────────────────────────────────────┘
                               │
                 CONFIRM DIAGNOSIS
         (Painless mucocele + epiphora +
          mucoid reflux on sac compression
          + recurrent conjunctivitis)
                               │
               ┌───────────────┴────────────────┐
               ▼                                ▼
          INFANT / CHILD                     ADULT
     (Congenital NLDO)
               │                                │
    ┌──────────┴──────────┐         ┌───────────┴───────────┐
    ▼                     ▼         ▼                       ▼
 AGE < 12 MONTHS      AGE 12-14    RULE OUT               SYSTEMIC
                        MONTHS     TUMOR FIRST            CAUSE?
    │                     │        (CT/MRI if             (Wegener's,
    ▼                     ▼         mass above             sarcoidosis,
CONSERVATIVE          PROBING       medial                 lymphoma)
MANAGEMENT            (single       canthal                    │
• Lacrimal sac         probe         tendon)                   ▼
  massage              curative                          TREAT UNDERLYING
  4-6x daily           in ~90%)                          CONDITION FIRST
• Topical antibiotics         │
  (fluoroquinolone QID)       │
• Wait for spontaneous        │
  resolution                  │
  (~80-90% resolve            │
  by 12 months)               │
    │                         │
    ▼                         │
IF NOT RESOLVED               │
by 12-14 months:              │
Refer for probing             │
± irrigation                  │
    │                         │
    └──────────┬──────────────┘
               │
               ▼
     IF PROBING FAILS or ADULT WITH CONFIRMED NLDO
               │
               ▼
    ┌──────────────────────────────────────┐
    │   DACRYOCYSTORHINOSTOMY (DCR)        │
    │   (DEFINITIVE SURGICAL TREATMENT)   │
    └──────────────────────────────────────┘
               │
    ┌──────────┴─────────┐
    ▼                    ▼
EXTERNAL DCR        ENDOSCOPIC DCR
(Traditional        (Endonasal approach
 skin incision)      - no external scar)
    │                    │
    └──────────┬─────────┘
               │
               ▼
    ± SILICONE TUBE INTUBATION
    (Bicanalicular tube placed to stent
     the new opening; removed after 3-6 months)
               │
               ▼
    POST-DCR CARE:
    • Topical antibiotics + steroids post-op
    • Nasal decongestants to reduce swelling
    • Avoid nose blowing for 2 weeks
    • Silicone tube removal at 3-6 months
    • Follow-up to confirm patency
               │
               ▼
    IF DCR FAILS (Recurrent symptoms):
    → REVISION DCR
    → Investigate for dacryolith, canalicular
      stenosis, or tumor
    → Consider Jones tube (bypass procedure)

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7. DACRYOCYSTORHINOSTOMY (DCR) - Explained Simply

• DCR = Dacryocysto-Rhino-Stomy
• "Dacryocysto" = lacrimal sac | "Rhino" = nose | "Stomy" = new opening
• A new drainage hole is made directly between the lacrimal sac and the nose, bypassing the blocked nasolacrimal duct

• Tears can now bypass the blocked duct and drain directly into the nasal cavity
• Eliminates the stagnant pool of tears/mucus in the lacrimal sac
• Cures epiphora, mucocele, and recurrent conjunctivitis

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8. MEDICAL TREATMENT SUMMARY TABLE

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Quick Memory Summary

CHRONIC DACRYOCYSTITIS = PAINLESS WATERY EYE + MUCUS ON PRESSURE
                                    ↓
               CONSERVATIVE (massage, drops) = temporary only
                                    ↓
              DEFINITIVE CURE = DCR (new hole into nose)

• Kanski's Clinical Ophthalmology, 10th ed., pp. 124-125
• Wills Eye Manual, 7th ed., pp. 399-402
• Cummings Otolaryngology: Head and Neck Surgery (Endoscopic DCR chapter, p. 965)
• Textbook of Family Medicine, 9th ed., p. 350

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Dacryocystorhinostomy (DCR) - Complete Surgical Guide

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Anatomy Relevant to DCR

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1. INDICATIONS

Primary Indications (Do DCR for these)

1. Chronic dacryocystitis with confirmed nasolacrimal duct obstruction (NLDO) - the main indication
2. Recurrent acute dacryocystitis - to prevent further episodes
3. Mucocele of the lacrimal sac
4. Symptomatic epiphora (persistent watering eye) due to NLDO causing significant distress
5. Lacrimal sac fistula - DCR closes the fistula by restoring normal drainage
6. Dacryolithiasis (lacrimal stones) with obstruction
7. Before planned intraocular surgery (e.g., cataract) when chronic dacryocystitis/NLDO is present - to prevent endophthalmitis
8. Failed probing in children (after second probing failure)
9. Post-traumatic NLDO - after nasal/facial fractures
10. Iatrogenic NLDO - after nasal/sinus surgery

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2. CONTRAINDICATIONS

Absolute Contraindications

1. Active acute dacryocystitis - infection must be fully treated first with antibiotics before any surgery
2. Lacrimal sac tumor - DCR alone is not appropriate; requires tumor excision
3. Bleeding disorders not corrected preoperatively
4. Obstruction proximal to common canaliculus (canalicular block) - DCR bypasses the duct but not a canalicular blockage; requires canaliculoplasty or Jones tube instead

Relative Contraindications

1. Nasal pathology - severe septal deviation, polyps, or active rhinitis may complicate surgery (septal correction may be done at same time)
2. Previous DCR failure with scarred sac - small scarred residual sac may limit marsupialization; outcomes compromised
3. Systemic conditions - uncontrolled diabetes, anticoagulant therapy, severe hypertension (must be optimized before surgery)
4. Wegener's granulomatosis, sarcoidosis - underlying disease must be controlled first
5. Medial canthal tumor above the medial canthal tendon - suspect lacrimal sac neoplasm; biopsy first

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3. TYPE OF ANAESTHESIA

External DCR

• Infiltration: 1% lidocaine with 1:100,000 epinephrine injected at the medial canthal area and around the lacrimal sac
• Nerve blocks: Infratrochlear nerve block and anterior ethmoidal nerve block
• Nasal packing: Ribbon gauze soaked in 4% cocaine or xylometazoline + lidocaine placed in nasal cavity for mucosal vasoconstriction and anaesthesia
• Advantage of LA: Avoids general anaesthesia risks; patient can cooperate; better vasoconstriction

Endoscopic DCR

• General anaesthesia is standard and preferred
• Controlled hypotension is used intraoperatively (reduces cardiac output to minimize bleeding)
• Local injections (1% lidocaine with 1:100,000 epinephrine) into nasal mucosa supplemented
• Head elevated 30 degrees to reduce venous congestion
• Topical vasoconstrictors (1:1000 epinephrine neuropatties) placed periodically during surgery

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4. MAJOR SURGICAL STEPS

A. EXTERNAL DCR (Traditional Open Approach)

STEP 1: SKIN INCISION
• Curvilinear incision ~11mm long, 2-3mm medial to inner canthus
• Incision over lacrimal sac area, parallel to medial orbital rim
• Avoids angular vessels and medial canthal tendon

STEP 2: DISSECTION TO LACRIMAL SAC
• Divide orbicularis oculi muscle
• Retract medial canthal tendon (may be reflected or cut and repaired)
• Expose the periosteum of the lacrimal fossa

STEP 3: LACRIMAL SAC EXPOSURE
• Incise periosteum along lacrimal fossa
• Elevate periosteum with Freer elevator
• Expose the lacrimal sac in the lacrimal fossa

STEP 4: OSTEOTOMY (Bone Removal)
• Create a bony window in the medial wall of lacrimal fossa
• Remove the lacrimal bone and frontal process of maxilla
  using bone punch (Kerrison punch) or hammer and gouge
• Window size: ~15mm x 15mm (minimum)
• Expose the nasal mucosa beneath

STEP 5: NASAL MUCOSAL FLAPS
• Incise the nasal mucosa to create anterior and posterior flaps

STEP 6: LACRIMAL SAC OPENING
• Dilate the punctum with punctum dilator
• Pass Bowman probe through canaliculus to tent the sac
• Incise the lacrimal sac vertically to create anterior (H-flap) 
  and posterior flaps

STEP 7: ANASTOMOSIS (Flap Suturing)
• Suture posterior flap of lacrimal sac to posterior nasal mucosal flap
  (2-3 absorbable sutures, e.g., 5-0 Vicryl)
• Anterior flap anastomosis performed similarly
• This creates the new drainage ostium

STEP 8: SILICONE INTUBATION (if needed)
• Pass silicone bicanalicular tube (O'Donoghue tubes) through
  superior and inferior canaliculi into the new opening
• Secure in nasal cavity without tension (prevents cheese-wiring)
• Left in for 3-6 months (up to 9 months if canalicular stenosis)

STEP 9: WOUND CLOSURE
• Close periosteum and orbicularis muscle in layers
• Skin closed with interrupted 6-0 nylon or absorbable sutures
• Light pressure dressing applied

B. ENDOSCOPIC DCR (Endonasal Approach - No External Scar)

STEP 1: PREPARATION
• Patient under GA, head raised 30°, controlled hypotension
• 4% cocaine/xylometazoline nasal packing for decongestion
• 1% lidocaine + epinephrine injected into nasal mucosa
• Septoplasty performed if septum obstructs visualization (~50% cases)

STEP 2: MUCOSAL FLAP ELEVATION
• 30° endoscope introduced into nasal cavity
• Posteriorly pedicled mucoperiosteal flap raised using 
  No.15 blade + Freer elevator
• Flap elevated from lacrimal bone up to axilla of middle turbinate

STEP 3: BONE REMOVAL (Critical step)
• Frontal process of maxilla removed with forward-biting bone 
  punch (Hajek-Koeffler or Kerrison rongeur)
• DCR drill bit used to "saucerize" remaining bone
• Entire lacrimal sac must be exposed - it should sit 
  "proud" (protruding) over saucerized bone
• Posterior lacrimal bone removed with round knife

STEP 4: CANNULATION
• Punctum dilated; Bowman probe (size 00) passed through 
  inferior canaliculus into lacrimal sac
• Probe tip must be clearly VISIBLE tenting the medial sac wall
  (if entire sac moves without tip visible = probe in canaliculus, NOT sac)

STEP 5: MARSUPIALIZATION (Opening the sac)
• Spear knife used to incise sac vertically top to bottom
• Anterior and posterior sac flaps created and laid flat
• Flaps should lie open without tension - confirms adequate bone removal

STEP 6: FLAP REINSERTION
• Nasal mucosal flap trimmed to fit opened lacrimal sac
• Flaps apposed to provide mucosal-to-mucosal healing
• Minimizes granulation tissue formation

STEP 7: SILICONE INTUBATION (if canalicular stenosis)
• O'Donoghue tubes passed if common canaliculus is tight
• Secured with GelFoam + silicone tubing + titanium clips
• Left in situ 4-6 weeks (or 6-9 months if canalicular stenosis)

STEP 8: NASAL PACK
• Light absorbable nasal pack or gel foam placed
• Standard nasal pack removed at 24-48 hours

---

5. COMPARISON: EXTERNAL vs. ENDOSCOPIC DCR

---

6. POST-OPERATIVE CARE

Immediate (Day 0-1)

1. Ice pack to medial canthal area - reduces swelling and bruising
2. Nasal pack removal at 24-48 hours (if non-absorbable pack used)
3. Head elevated 30-45 degrees - reduces oedema
4. Observe for bleeding - nasal bleeding is the most common early complication

Medications (Post-op Routine)

1. Topical antibiotic-steroid drops (e.g., chloramphenicol + dexamethasone) 4 times daily for 2-4 weeks - reduces infection and scarring
2. Nasal decongestant drops/spray (e.g., xylometazoline) twice daily for 1-2 weeks - reduces mucosal oedema around new ostium
3. Oral antibiotics - broad spectrum for 5-7 days (e.g., amoxicillin/clavulanate or cephalexin)
4. Oral analgesics (paracetamol/ibuprofen) for pain
5. Topical nasal steroid spray after 2 weeks - reduces scarring and synechiae

Activity Restrictions

1. No nose blowing for 2 weeks - risk of surgical emphysema, dislodging clots
2. Avoid swimming for 2-4 weeks
3. Avoid heavy lifting and strenuous activity for 2 weeks
4. Sleep with head elevated for 1-2 weeks

Silicone Tube Care

1. Check tubes are in correct position at first follow-up
2. Tubes removed at 3-6 months (up to 9 months if canalicular stenosis was present)
3. Tube removal is a quick, painless outpatient procedure
4. Instruct patient: if tube extrudes prematurely, do NOT pull - seek review urgently

Follow-Up Schedule

1. 1 week - check wound healing, skin suture removal (external DCR), assess bleeding
2. 4-6 weeks - nasal endoscopy to check ostium patency, remove crusts/synechiae
3. 3-6 months - silicone tube removal + lacrimal irrigation to confirm patency
4. 6-12 months - final assessment; fluorescein dye disappearance test

---

7. COMPLICATIONS AND MANAGEMENT

INTRAOPERATIVE COMPLICATIONS

---

EARLY POST-OPERATIVE COMPLICATIONS (Days-Weeks)

---

LATE / LONG-TERM COMPLICATIONS

---

REVISION DCR - When and How

• Symptomatic recurrence after initially successful DCR
• Failed primary DCR (persistent epiphora from day 1)

1. Review original DCG to assess residual sac size
2. Nasal endoscopy to identify cause of failure (ostium closed, scarred, granuloma)
3. If sac tissue is adequate - revision with wider marsupialization
4. If sac is small/scarred - outcomes are poorer; tailored nasal flap approach
5. Jones tube (bypass tube) - if canalicular system is also compromised; glass tube inserted from medial canthus directly into nose, bypassing entire lacrimal system

---

8. SUCCESS RATES SUMMARY

Anatomic obstruction (like chronic dacryocystitis/NLDO) achieves 95-97% success with proper technique. Functional obstruction has similar anatomical success but only ~81% are symptom-free (lacrimal pump anomalies persist).

---

QUICK SURGERY SUMMARY FLOWCHART

CHRONIC DACRYOCYSTITIS WITH CONFIRMED NLDO
              ↓
   Treat any active infection first
              ↓
   Pre-op workup: DCG, nasal endoscopy, 
   Jones tests, CT if needed
              ↓
   Choose approach:
   ┌──────────────┬────────────────────┐
   │ External DCR │  Endoscopic DCR    │
   │ (LA/sedation)│  (GA preferred)    │
   └──────────────┴────────────────────┘
              ↓
   Surgery: Bone removal → Sac exposure 
   → Open sac → Anastomose to nasal mucosa 
   → Silicone tube if needed
              ↓
   Post-op: Antibiotic-steroid drops + 
   nasal decongestant + no nose blowing
              ↓
   Follow-up: Tube removal at 3-6 months
              ↓
   Check patency: Irrigation + fluorescein test
              ↓
   SUCCESS (~92-97%) or REVISION DCR

---

• Cummings Otolaryngology: Head and Neck Surgery, 7th ed. (Chapter 49 - Endoscopic DCR, pp. 964-970)
• Kanski's Clinical Ophthalmology, 10th ed., pp. 124-125
• Wills Eye Manual, 7th ed., pp. 399-402

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Dacryocystectomy (DCT) - Complete Surgical Guide

What is Dacryocystectomy?

Key difference from DCR: DCR bypasses the blocked duct and preserves the sac to create a new drainage path. DCT removes the sac entirely. After DCT, there is no lacrimal sac - tears still drain partly through canalicular capillary action and evaporation, and epiphora (watering) may persist to a variable degree.

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1. INDICATIONS

Primary Indication

1. Lacrimal sac tumor (neoplasm) - the most important and classic indication; complete sac excision with histopathology is required

Indications Specific to Chronic Dacryocystitis

1. Recurrent dacryocystitis - more than 2 episodes in 6 months or more than 3 in one year, especially when DCR is not feasible
2. Chronic dacryocystitis with failed or refused DCR - patients unfit or unwilling for DCR
3. Frail elderly patients (75 years and older) with high anaesthetic/bleeding risk who cannot tolerate DCR
4. Patients on long-term anticoagulant therapy where DCR carries high haemorrhagic risk
5. Chronic discharging lacrimal sac fistula - fistulous tract and sac excised together
6. Lacrimal sac mucocele that is large, expanding, or secondarily infected and unfit for DCR
7. Nasal or facial malformations that make intranasal access for DCR technically impossible (e.g., severe septal deformity, absent nasal anatomy)
8. Risk of post-DCR nasocutaneous fistula (e.g., in irradiated tissue)
9. Wegener's granulomatosis / vasculitis with NLDO - DCR fails due to disease recurrence; DCT removes the infected sac
10. NLDO with dry eye, ocular cicatricial pemphigoid, Crohn's disease, systemic lupus - DCT is a viable alternative when DCR is inadvisable
11. Patients with recurrent dacryocystitis after failed DCR - DCT removes residual infected sac tissue
12. Anxious or medically unfit patients unable to tolerate prolonged surgery in supine position

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2. CONTRAINDICATIONS

Absolute Contraindications

1. Active acute dacryocystitis - acute infection must be treated with antibiotics first; surgery only after infection settles
2. Uncorrected bleeding diathesis (coagulation disorders not optimized)
3. Unfit for any surgery due to extreme systemic illness

Relative Contraindications

1. Bilateral NLDO - removing both lacrimal sacs leads to severe, permanent bilateral epiphora; consider DCR instead
2. Young patients who desire tear drainage - DCT eliminates the lacrimal sac permanently; epiphora will persist; DCR is strongly preferred in younger patients
3. Isolated canalicular block without sac disease - sac is healthy; no indication to excise it
4. Patient preference for drainage restoration - DCT does NOT restore lacrimal drainage; patients must be counselled that watering may continue
5. Lacrimal sac tumor with orbital extension - DCT alone is not sufficient; orbital exenteration may be required

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3. PRE-OPERATIVE ASSESSMENT

1. Full history and slit-lamp examination
2. Dacryocystography (DCG) or CT scan to assess sac anatomy
3. Rule out lacrimal sac tumor - note if mass is above medial canthal tendon
4. Routine bloods: CBC, coagulation profile, blood glucose
5. Stop anticoagulants as per protocol (discuss with physician)
6. Consent patient: inform that epiphora will likely persist as no new drainage pathway is created; also discuss scar

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4. TYPE OF ANAESTHESIA

Standard for Most Cases

• Shorter procedure than DCR, so LA is well tolerated
• Especially preferred in elderly/frail patients (main target group for DCT)

Local Anaesthesia Technique

1. Infiltration anaesthesia:
   • 1-2 mL of 2% lidocaine with 1:100,000 adrenaline (epinephrine) injected into the medial canthal area, over the lacrimal sac, and along the planned incision line
   • Adrenaline provides vasoconstriction, reducing bleeding
2. Nerve blocks:
   • Infratrochlear nerve block (superomedial orbital rim)
   • Anterior ethmoidal nerve block if needed
3. No nasal packing needed (unlike DCR - the nasal cavity is NOT entered during DCT)

General Anaesthesia - Used when:

• Patient request / high anxiety
• Children
• Planned additional procedures simultaneously
• Suspected lacrimal sac tumor (wider dissection may be needed)

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5. MAJOR SURGICAL STEPS

PRE-OPERATIVE SETUP
• Patient supine, head slightly elevated
• Skin prepped and draped
• Puncta dilated with punctum dilator
• LA infiltrated as described above
• Monitor vital signs throughout (especially in elderly)

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STEP 1: SKIN INCISION
• Curvilinear incision approximately 10-15 mm long
• Placed 2-3 mm medial to the inner canthus
  (same position as external DCR incision)
• Direction: parallel to medial orbital rim
• Depth: through skin and subcutaneous tissue only
• AVOID: angular vessels (lie 8mm medial to inner canthus)

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STEP 2: DISSECTION TO LACRIMAL SAC
• Divide orbicularis oculi muscle in line with the incision
• Identify and protect the angular vessels
  (ligate or cauterise if encountered)
• Incise and reflect the periosteum (periorbita)
  over the anterior lacrimal crest
• Expose the lacrimal sac lying in the lacrimal fossa

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STEP 3: CANALICULAR IDENTIFICATION
• Pass a Bowman probe (size 0 or 00) through the
  inferior or superior canaliculus into the lacrimal sac
• This tents the medial wall of the sac and helps identify it
• The probe also guides safe canalicular division

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STEP 4: LACRIMAL SAC DISSECTION
• Using fine scissors (Westcott or Stevens tenotomy scissors)
  and fine-toothed forceps, carefully dissect the lacrimal sac
  free from its attachments on all sides
• Dissect medially (lacrimal fossa bone), laterally 
  (periorbita), superiorly (fundus of sac), and inferiorly 
  (neck of sac at nasolacrimal duct junction)
• Keep dissection close to sac wall to protect periorbita

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STEP 5: DIVISION OF CANALICULI
• Divide the common canaliculus (or superior and inferior
  canaliculi separately if they enter separately) as close
  to the sac as possible
• Preserve maximum canalicular length for patient comfort
  and possible future Jones tube if needed

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STEP 6: DIVISION OF NASOLACRIMAL DUCT
• At the inferior end of the sac (neck), divide and
  ligate / cauterise the nasolacrimal duct stump
• The nasal mucosa is NOT opened (this is the 
  critical difference from DCR - nasal cavity not entered)
• Haemostasis secured with bipolar cautery

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STEP 7: COMPLETE SAC EXCISION
• Entire lacrimal sac is now completely freed and excised
• The sac is removed as a single specimen
• If tumor suspected: send for FROZEN SECTION
  and HISTOPATHOLOGY (routine in all cases)
• If fistula present: excise the fistulous tract in continuity
  with the sac (en bloc excision)

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STEP 8: HAEMOSTASIS AND DEAD SPACE
• Thorough haemostasis with bipolar cautery
• Bone wax applied to exposed lacrimal fossa bone edge
  if oozing
• Dead space obliterated by approximating soft tissues

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STEP 9: OPTIONAL - SILICONE TUBE INTUBATION
• In selected cases (recurrent dacryocystitis + epiphora),
  permanent silicone intubation of residual canaliculi
  can be performed (as per recent DCT + intubation technique)
• This provides some residual drainage via the canaliculi

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STEP 10: WOUND CLOSURE
• Periosteum closed with 5-0 absorbable suture (Vicryl)
• Orbicularis muscle closed with interrupted 5-0 Vicryl
• Skin closed with interrupted 6-0 nylon or fast-absorbing
  Vicryl sutures
• Light pressure dressing applied
• Total operative time: approximately 20-45 minutes
  (shorter than DCR)

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6. COMPARISON: DCT vs. DCR

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7. POST-OPERATIVE CARE

Immediate (Day 0-1)

1. Pressure dressing over the medial canthal area - reduces haematoma and oedema; removed at 24-48 hours
2. Ice pack applied intermittently for first 24 hours - reduces swelling and bruising
3. Observe for bleeding - most common early complication
4. Head elevated 30-45 degrees when resting

Medications

1. Topical antibiotic eye drops (e.g., chloramphenicol 0.5% or moxifloxacin) 4 times daily for 1-2 weeks
2. Topical antibiotic-steroid ointment on wound (e.g., chloramphenicol ointment) to prevent infection and reduce scarring
3. Oral antibiotics for 5-7 days (e.g., cefalexin 500mg QID or amoxicillin/clavulanate 625mg BD) - especially important in infected/chronic cases
4. Oral analgesics - paracetamol ± ibuprofen for pain (usually mild)
5. No nasal decongestants needed (nasal cavity not entered, unlike DCR)

Activity and Wound Care

1. Keep wound dry for 48 hours
2. No nose blowing vigorously for 1-2 weeks (prevents subcutaneous emphysema)
3. No swimming for 2 weeks
4. Skin suture removal at 5-7 days (if non-absorbable sutures used)
5. Avoid heavy lifting for 1-2 weeks

Histopathology

1. Review histopathology result at first follow-up (1 week) - MANDATORY to exclude tumor

Follow-Up Schedule

1. 1 week - wound check, suture removal, histopathology review
2. 4-6 weeks - assess healing, residual epiphora level
3. 3 months - long-term review; counsel patient regarding persistent epiphora
4. If silicone tube placed - review tube position at 6 months

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8. COMPLICATIONS AND MANAGEMENT

INTRAOPERATIVE COMPLICATIONS

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EARLY POST-OPERATIVE COMPLICATIONS (Days-Weeks)

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LATE / LONG-TERM COMPLICATIONS

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9. OUTCOME AND PATIENT COUNSELLING

What to tell patients BEFORE DCT:

1. Epiphora (watering eye) will persist after surgery - this is expected and permanent, because no new drainage pathway is created. Patients must clearly understand this before consenting.
2. Surgery aims to cure recurrent infection and discharge - NOT to cure watering
3. Small scar will be present at the medial canthal area (same as DCR scar)
4. If epiphora is severe and intolerable after recovery, a Jones tube (glass bypass tube) can be considered as a salvage procedure

Success of DCT in Chronic Dacryocystitis:

• Excellent at eliminating recurrent infection (primary goal)
• Epiphora reduction: satisfactory in most patients (tear drainage partly maintained through canalicular capillary action and evaporation)
• Overall well-tolerated, especially in elderly/frail patients
• Complication rate lower than DCR in high-risk patients

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10. DCT TREATMENT ALGORITHM (CHRONIC DACRYOCYSTITIS CONTEXT)

CHRONIC DACRYOCYSTITIS
         │
         ▼
IS DCR FEASIBLE AND APPROPRIATE?
         │
    ┌────┴──────────────┐
    │ YES               │ NO (any of below)
    ▼                   ▼
  DO DCR          CONSIDER DCT IF:
(preferred)       • Lacrimal sac TUMOR
                  • Frail/elderly (>75 yrs), high surgical risk
                  • On anticoagulants, high bleeding risk
                  • Recurrent dacryocystitis (>2/6mths) post-DCR
                  • Nasal malformation preventing DCR
                  • Wegener's/vasculitis with NLDO
                  • Chronic skin fistula
                  • Patient refuses DCR
                         │
                         ▼
               TREAT ACTIVE INFECTION FIRST
               (Antibiotics until infection settles)
                         │
                         ▼
                  PRE-OP WORKUP
               (CT/DCG, bloods, consent)
                         │
                         ▼
              ANAESTHESIA: LA + sedation
              (GA for frail/anxious/tumor cases)
                         │
                         ▼
               DCT SURGERY:
            Incision → Expose sac →
            Identify canaliculi →
            Dissect sac free →
            Divide canaliculi + duct →
            Excise sac completely →
            Send for histopathology →
            ± Silicone intubation →
            Close wound
                         │
                         ▼
                POST-OP CARE:
            Pressure dressing + antibiotics
            + topical drops + wound care
                         │
                         ▼
              FOLLOW-UP AT 1 WEEK:
            Check wound + review histopathology
                         │
              ┌──────────┴──────────┐
              ▼                     ▼
          TUMOR on           BENIGN chronic
          histology          dacryocystitis
              │                     │
              ▼                     ▼
         ONCOLOGY             Monitor epiphora
         REFERRAL             If intolerable:
         (Wide excision /     → Consider Jones tube
          radiotherapy)

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• Open Ophthalmology Journal: Dacryocystectomy with Lacrimal Silicone Intubation in Challenging Patients (Vol.14, p.25)
• Dacryocystectomy as treatment of chronic dacryocystitis in frail elderly patients - Nature Eye Journal
• eMedscape: Dacryocystitis Treatment & Management
• Kanski's Clinical Ophthalmology, 10th ed.
• Wills Eye Manual, 7th ed.