Dacryocystitis

Acute dacryocystitis showing the classic tense, erythematous swelling at the nasal aspect of the lower eyelid (Wills Eye Manual)

Anatomy Recap

Etiology

• Primary cause: Nasolacrimal duct obstruction (NLDO) - the vast majority of cases
• Less common: Lacrimal sac diverticula, dacryoliths, nasal/sinus surgery, trauma, lacrimal sac tumors
• Pathogens (acute): Staphylococci, Streptococcus pneumoniae, Haemophilus influenzae (especially in children)
• Special populations: Gram-negative organisms and atypical bacteria are more common in diabetics, immunocompromised patients, and nursing home residents
• MRSA should be considered in appropriate epidemiological contexts

Classification

Acute Dacryocystitis

• Symptoms: Subacute onset of pain at the medial canthal area, epiphora, fever/chills
• Signs:
  • Erythematous, tender, tense swelling below the medial canthal tendon (this is the key anatomical landmark)
  • Mucoid or purulent discharge expressible from the punctum on pressure over the sac
  • May progress to abscess formation and preseptal cellulitis
  • Fistula formation from skin (below medial canthal tendon) is a known complication

Key sign: Swelling in dacryocystitis is always below the medial canthal tendon. A mass above the tendon suggests a lacrimal sac tumor (rare) - Wills Eye Manual

Chronic Dacryocystitis

• Symptoms: Chronic epiphora, recurrent unilateral conjunctivitis
• Signs: Painless swelling at the inner canthus (mucocele), or pressure over sac elicits mucopurulent canalicular reflux even without obvious swelling
• Can progress to lacrimal sac abscess; rarely orbital or facial cellulitis

Differential Diagnosis

Workup

1. History: Prior episodes, ENT infections, sinus disease, trauma, surgery
2. External exam: Gentle pressure over the lacrimal sac with cotton-tipped swab to express discharge from punctum - do bilaterally
3. Orbital assessment: Pupillary response, extraocular motility, globe position (rule out concurrent orbital cellulitis)
4. Microbiology: Gram stain and blood agar culture of expressed discharge; use chocolate agar in children (for H. influenzae)
5. Imaging (CT orbits + paranasal sinuses): In atypical, severe, or antibiotic-unresponsive cases

Do NOT attempt to probe or irrigate the lacrimal system during acute infection - Kanski's & Wills Eye Manual

Treatment

Acute Dacryocystitis

• Warm compresses + gentle massage q.i.d.
• Topical antibiotics (e.g., trimethoprim/polymyxin B q.i.d.) as adjunct - topical alone is NOT adequate

• Adjust based on culture/sensitivity
• Total course: 10-14 days

• Incision and drainage (I&D): Reserved for a pointing, fluctuant abscess about to spontaneously drain - carries risk of persistent sac-skin fistula
• Dacryocystorhinostomy (DCR): Definitive surgery after acute infection resolves; creates anastomosis between lacrimal sac and nasal mucosa, bypassing NLD obstruction; indicated for recurrent or chronic dacryocystitis

Chronic Dacryocystitis

• Definitive treatment: Dacryocystorhinostomy (DCR)
• A 2025 meta-analysis (PMID 39762863) comparing transcanalicular laser-assisted vs. external DCR for primary acquired NLDO confirms external DCR remains the gold standard for anatomical and functional success

Follow-Up

• Acute: Daily until improvement confirmed; hospitalize and start IV antibiotics if outpatient condition worsens
• Post-resolution: Probing and irrigation to assess NLD patency; refer for DCR if obstruction confirmed or recurrence occurs

Important Clinical Pearls

• Postpone intraocular surgery if any signs of lacrimal drainage system infection - risk of endophthalmitis (Kanski's Clinical Ophthalmology)
• In children, dacryocystitis is usually a secondary bacterial infection following viral upper respiratory infection
• Improperly treated dacryocystitis can lead to periorbital/orbital cellulitis - children often require hospitalization

Endonasal (Endoscopic) DCR - Indications & Complications

Indications

Primary Indications

What Endonasal DCR Cannot Treat

• Obstruction proximal to the common canaliculus (canalicular disease) - DCR alone is insufficient; Lester Jones tube may be required
• Lesions at the punctum or canalicular level require separate management

Contraindications / When Endonasal Is Less Preferred

• Lacrimal sac tumor - requires combined external + endonasal extirpation, not DCR alone
• Extensive medial canthal scarring or trauma distorting anatomy (external approach may be easier)
• Active acute dacryocystitis - surgery deferred until infection resolves
• Surgeon without established rhinologic/endoscopic proficiency - inexperience causes most severe complications; ideally performed as a team with an oculoplastic surgeon and endoscopic otolaryngologist

Complications

Perioperative Complications (Overall ~5% complication rate)

1. Hemorrhage - Most common; usually managed with topical 1:1000 epinephrine and spot bipolar cautery; rarely requires abandoning the procedure
2. Orbital fat exposure - Occurs if dissection goes posterior to the uncinate process; the exposed fat re-mucosalizes spontaneously - do not attempt repair; patient must avoid nose-blowing until healed
3. Orbital hematoma - Rare but serious; can cause compartment syndrome and vision loss
4. Synechiae / granulation tissue obstruction of the ostium - Leading cause of late failure

Surgical Failure

• Primary causes of endoscopic DCR failure:
  • Inadequate bony removal (most common) - any remaining unopened lacrimal sac creates a fluid meniscus and increases lacrimal resistance, causing pump failure
  • Insufficient sac marsupialization
  • Cicatricial closure of the ostium
• Silicone stent ("cheese-wiring") - stents placed under too much tension can tear through the lacrimal puncta, causing iatrogenic functional epiphora; reported in ~0.1% of cases
• Ostial granulomas - 47% form at the ostium edge; most respond to topical steroids; surgical excision or intralesional triamcinolone for obstructing ones; recurrence <5%
• Lacrimal sac tumor (missed diagnosis) - approximately 1/3 of lacrimal sac tumors present with persistent or recurrent epiphora after DCR; suspect when bloody nasal discharge, medial canthal swelling, or proptosis develop post-operatively

Rare but Serious Complications

Success Rates (Comparison)

• For anatomic obstruction: 95-97% success expected
• For functional obstruction: ~81% complete symptom relief (technical patency similar, but underlying pump failure persists in some)
• Laser-assisted DCR has poor long-term results and should generally be avoided as definitive treatment

Key Principles

"Failures in endoscopic DCR are primarily due to inadequate marsupialization of the lacrimal sac mucosa." - Cummings Otolaryngology

"Endonasal DCR has the advantage of creating no external incision, having similar outcomes to external DCR, and being an ideal option for revision cases." - Cummings Otolaryngology