Dacryocystitis - Complete Explanation

What is Dacryocystitis?

Part 1: Congenital Dacryocystitis

Cause (Etiology)

• Results from stasis (pooling) of secretions due to a blocked nasolacrimal duct (NLD) at birth.
• Up to 30% of newborns have NLD closure at birth.
• The most common cause is membranous occlusion at the valve of Hasner (the lower end of the duct).
• Other causes: epithelial debris, upper-end occlusion, incomplete canalization, or (rarely) bony occlusion.
• Common bacteria: Staphylococci, Pneumococci, Streptococci, Haemophilus influenzae, and Enterobacteriaceae.

Clinical Features

1. Epiphora (watering eye) - develops after ~7 days of birth, followed by mucopurulent discharge.
2. Regurgitation test positive - pressing over the lacrimal sac causes mucopurulent discharge to come out from the lower punctum.
3. Swelling in the sac area may eventually appear.

Differential Diagnosis

• Ophthalmia neonatorum
• Congenital glaucoma

Complications (if untreated)

• Recurrent conjunctivitis
• Acute-on-chronic dacryocystitis
• Lacrimal abscess
• Fistula formation

Treatment (Step-Wise, Age-Dependent)

Part 2: Adult Dacryocystitis

A. Chronic Dacryocystitis

Predisposing Factors

• Age: 40-60 years most affected.
• Sex: 80% female (due to comparatively narrower bony canal).
• Race: Rarer in Black individuals (shorter, wider, less sinuous lacrimal duct).
• Heredity: Affects facial configuration and canal dimensions.
• Socio-economic status: More common in lower socio-economic groups.
• Poor personal hygiene.

Causes of Stasis

• Narrow bony canal, partial canalization
• Foreign bodies in sac
• Excessive lacrimation (primary or reflex)
• Associated conjunctivitis causing mucus plugs
• Nasal diseases: polyps, hypertrophied inferior concha, deviated nasal septum, atrophic rhinitis

Sources of Infection

• Conjunctiva, nasal cavity (retrograde), or paranasal sinuses.

Causative Organisms

4 Stages of Chronic Dacryocystitis

• Mild inflammation + NLD blockage.
• Only symptom: watering eye ± mild redness at inner canthus.
• Syringing reveals clear fluid or fibrinous mucoid flakes.
• Dacryocystography: NLD block with normal-sized sac.

• Chronic stagnation causes distension of the sac.
• Constant epiphora + swelling just below inner canthus.
• Regurgitation: milky/gelatinous mucoid fluid.
• Dacryocystography: distended sac with NLD blockage.
• Encysted mucocele: both canalicular openings get blocked - large fluctuant swelling with negative regurgitation test.

• Pyogenic infection converts mucocele into pyocoele (pus-filled sac).
• Epiphora + recurrent conjunctivitis + swelling with mild skin erythema.
• Regurgitation yields frank purulent discharge.
• Encysted pyocoele if canalicular openings are also blocked.

• Prolonged repeated infections lead to a small, fibrosed sac.
• Persistent epiphora and discharge.
• Dacryocystography: very small sac with irregular mucosal folds.

Complications of Chronic Dacryocystitis

• Chronic intractable conjunctivitis
• Acute-on-chronic exacerbation
• Ectropion of lower lid, skin maceration and eczema
• Risk of corneal ulceration (infected abrasion)
• High risk of endophthalmitis if intraocular surgery is done - hence lacrimal syringing is mandatory before any intraocular surgery.

Treatment of Chronic Dacryocystitis

1. Conservative (probing + syringing): only useful in recent/early cases.
2. Balloon catheter dilation (dacryocystoplasty): for partial NLD obstruction; ~50% success in adults.
3. Dacryocystorhinostomy (DCR): operation of choice - re-establishes lacrimal drainage. Infection should be controlled first.
4. Dacryocystectomy (DCT): only when DCR is contraindicated (very old patient, markedly shrunken fibrosed sac, TB/syphilis/leprosy of sac, tumours, gross nasal disease).
5. Conjunctivodacryocystorhinostomy (CDCR): performed when canaliculi are blocked.

B. Acute Dacryocystitis

Etiology

1. Acute exacerbation of chronic dacryocystitis.
2. Acute peridacryocystitis - from neighbouring infected structures (paranasal sinuses, bone, dental abscess).

• Organisms: Streptococcus haemolyticus, Pneumococcus, Staphylococcus.

3 Stages of Acute Dacryocystitis

• Painful, red, hot, firm, tender swelling in lacrimal sac region.
• Epiphora + constitutional symptoms (fever, malaise).
• Redness/oedema spreads to lids and cheek.
• With treatment: resolution possible. Without treatment: self-resolution is rare.

• Oedema blocks the canaliculi; sac fills with pus and its anterior wall ruptures.
• Large fluctuant lacrimal abscess forms, pointing below and to the outer side of the sac (due to gravity and medial palpebral ligament above).

• Untreated abscess discharges spontaneously.
• Leaves an external fistula below the medial palpebral ligament.
• Rarely: internal fistula opening into the nasal cavity.

Complications of Acute Dacryocystitis

• Acute conjunctivitis
• Corneal ulceration
• Lid abscess
• Osteomyelitis of lacrimal bone
• Orbital cellulitis
• Facial cellulitis and acute ethmoiditis
• Rarely: cavernous sinus thrombosis or generalized septicaemia

Treatment of Acute Dacryocystitis

1. Cellulitis stage: Systemic + topical antibiotics, anti-inflammatory analgesics, hot fomentation.
2. Lacrimal abscess stage: Above + drain the pus when it points on skin (small incision, gentle squeeze, betadine dressing). Then DCT or DCR depending on sac condition.
3. External fistula: Control acute infection with antibiotics first, then fistulectomy + DCT or DCR.

Part 3: Surgical Procedures

Dacryocystorhinostomy (DCR)

Dacryocystectomy (DCT)

Part 4: Lacrimal Gland Conditions (Dacryoadenitis)

Acute Dacryoadenitis

• Inflammation of the lacrimal gland - primary or secondary to local/systemic infection.
• Local: trauma, erysipelas, gonococcal/staphylococcal conjunctivitis, orbital cellulitis.
• Systemic: mumps, influenza, infectious mononucleosis, measles.
• Features: painful swelling in lateral upper lid; classic S-shaped curve of upper lid margin.
• Treatment: systemic antibiotics + analgesics + hot fomentation; incision & drainage if pus forms.

Chronic Dacryoadenitis

• Painless swelling of lacrimal gland, ptosis, downward/inward eyeball displacement, diplopia.
• Causes: sequel to acute inflammation, chronic conjunctivitis, tuberculosis, syphilis, sarcoidosis.
• Diagnosis by FNAB or incisional biopsy; treat the underlying cause.

Mikulicz's Syndrome

Dacryops

Part 5: Tumours of the Lacrimal Gland

• Pleomorphic adenoma: Slow-growing, painless; displaces eyeball downward and inward; locally invasive; treatment - complete surgical removal with capsule (recurrence is common with incomplete removal).
• Lacrimal gland carcinoma: Painful mass of short duration; inferonasal dystopia; sensory loss; CT shows infiltrative tumour; treatment - complete excision + high-dose radiotherapy.

Key Clinical Pearls

• Always syringe the lacrimal sac before any intraocular surgery to rule out dacryocystitis (risk of post-op endophthalmitis).
• Regurgitation test is key to diagnosing lacrimal sac obstruction.
• DCR is the gold standard surgery for chronic dacryocystitis; external DCR has the highest success rate (95%).
• Membranous occlusion at the valve of Hasner is the most common cause of congenital NLD block.
• Balloon catheter dilation has only ~50% success in adults.