You are called to the postnatal ward to review a 22-hour-old infant with feeding difficulties.
On examination, two bluish, soft swellings are located medially to the inner canthus on both eyes. The infant is unsettled but has a mild fever.
What do you do?
What is dacryocystitis?
Dacryocystitis is an inflammation of the lacrimal sac. This oval-shaped structure receives tear drainage from the eye and sits in a groove formed by the lacrimal bone and frontal process of the maxilla. The lacrimal sac is not the same as the lacrimal gland. This exocrine gland produces tears and is located within the lateral orbit.
Congenital dacryocystitis arises from the incomplete canalisation of the nasolacrimal duct during fetal development. Normally, the nasolacrimal ducts undergo canalisation by birth, allowing for proper tear drainage from the eyes into the nasal cavity.
This process is incomplete in some infants, resulting in a blockage that can lead to dacryocystitis. The condition is often identified in the neonatal period due to tear duct obstruction, manifesting as excessive tearing, discharge, and sometimes, a palpable mass over the lacrimal sac area. As the fluid builds up in the lacrimal drainage system, the lacrimal sac balloons, leading to cyst formation (dacryocoele) or inflammation (dacryocystitis)
What are the symptoms of dacryocystitis?
Swelling, redness and discharge overlying the lacrimal sac and nasolacrimal canal area suggest dacryocystitis.
With pressure, you might be able to express purulent material through the lacrimal punctum. Rarely, patients may have systemic symptoms such as fever. This should trigger urgent management.
It most commonly affects children aged 3 to 4 but can present from birth to adolescence. The mean age of presentation is 30-40 days in infants.
The causal microorganisms differ from those in the adult population, who experience a wide range of gram-positive and gram-negative organisms. Gram-positive organisms make up around 60% of pathogens in children and infants.
How do you diagnose dacryocystitis?
In most cases, the diagnosis is clinical.
You could perform Crigler tear duct massage, massaging the lacrimal sac to produce purulent material. This can then be sent for culture and sensitivity.
Nasal endoscopy or dacryocystography can evaluate the anatomy of the lacrimal duct. In dacryocystography, contrast is injected into the lacrimal punctum. Lacrimal scintigraphy is a nuclear medicine technique that uses radio-isotopes to delineate lacrimal flow.
Lacrimal scintigraphy showing the lacrimal duct system bilaterally, Public Demain, Wikimedia
What is the differential diagnosis for dacryocystitis?
Dacryocystitis presents with distinctive symptoms such as tearing, discharge, and inflammation near the lacrimal sac. However, several other conditions can mimic these signs, making accurate diagnosis crucial for effective treatment. Understanding the differential diagnosis of dacryocystitis helps clinicians understand other potential causes of the patient’s symptoms.
Preseptal and Orbital Cellulitis
Preseptal cellulitis, an eyelid and periocular tissue infection, does not affect the orbit or eye. In contrast, orbital cellulitis is an infection involving the fat and muscle around the eye, potentially leading to vision loss or eye movement restrictions. Unlike dacryocystitis, these conditions often cause more generalized swelling and systemic symptoms but may coexist with dacryocystitis.
Conjunctivitis
Conjunctivitis is characterized by redness, itching, and discharge from the eye. While it shares the symptom of discharge with dacryocystitis, conjunctivitis typically involves more diffuse redness across the conjunctiva and lacks the localized swelling over the lacrimal sac evident in dacryocystitis.
Acute Sinusitis
Acute sinusitis, an infection of the paranasal sinuses, can cause facial pain, nasal congestion, and discharge, sometimes leading to confusion with dacryocystitis. However, sinusitis symptoms are more centred around the nasal passages and sinuses, without the specific signs of lacrimal sac inflammation.
Chalazion and Hordeolum (Stye)
A chalazion or a stye, which are eyelid gland blockages leading to localized swellings, may occasionally be confused with dacryocystitis. However, these conditions typically present as lid margin swellings, unlike the lacrimal sac swelling seen in dacryocystitis.
Lacrimal Duct Obstruction
Though not an infection, lacrimal duct obstruction can mimic the early stages of dacryocystitis, primarily presenting with excessive tearing. The absence of infection signs helps distinguish simple obstruction from dacryocystitis.
How do we treat acute dacryocystitis?
Management depends on the underlying cause.
Congenital nasolacrimal duct obstruction is highly likely to self-resolve in children, so we often take a conservative approach. This means antibiotics to cover gram-positive organisms alongside warm compresses and Crigler massage.
If these conservative measures do not work, specialists may try lacrimal probing. After applying a topical anaesthetic, a small probe is inserted into the lower punctum of the lacrimal canal to relieve the obstruction.
Occasionally, lacrimal probing does not work, and an operation is needed. This might be balloon dacryoplasty, stenting, or dacryocystorhinostomy (DCR).
In dacryocystorhinostomy, surgeons create an alternative passage for tears to flow, bypassing the lacrimal sac. This is done endoscopically or externally.
What are the complications of dacryocystitis?
While dacryocystitis is primarily an inflammatory condition of the lacrimal sac, it can lead to several complications if left untreated or inadequately managed. These complications range from localised issues within the eye and lacrimal system to more serious systemic infections.
Local Complications
Chronic Infection: Persistent dacryocystitis can lead to a chronic lacrimal sac infection, causing continuous discomfort and recurrent episodes of acute inflammation.
Periorbital Cellulitis: The infection can spread to the tissues surrounding the eye, leading to periorbital cellulitis. This condition is characterized by eyelid swelling, redness, and pain, requiring urgent medical treatment to prevent further spread.
Lacrimal Sac Abscess: If the infection progresses, it can lead to an abscess in the lacrimal sac. This presents as a painful, swollen mass and might necessitate surgical intervention for drainage.
Dacryolith Formation: Chronic inflammation can lead to dacryoliths (lacrimal stones) forming within the lacrimal sac or nasolacrimal duct, further obstructing tear drainage.
Systemic complications
Orbital Cellulitis: A more severe spread of infection can lead to orbital cellulitis, an infection of the fat and muscles around the eye. This serious condition can cause eye movement restriction and vision loss and may require intravenous antibiotics or surgical intervention.
Meningitis: In rare cases, the infection can spread to the central nervous system, leading to meningitis, a life-threatening infection of the membranes surrounding the brain and spinal cord.
Sepsis: The spread of infection through the bloodstream, known as sepsis, is a critical condition that can lead to organ failure and death if not promptly treated.
Ophthalmologic Complications
Vision Impairment: Although less common, chronic dacryocystitis and its complications can affect visual acuity indirectly through recurrent infections and inflammation.
Conjunctivitis: Repeated episodes of dacryocystitis can predispose individuals to conjunctivitis, given the proximity of the lacrimal sac to the conjunctival surface.
References
Alaboudi A, Al-Shaikh O, Fatani D, Alsuhaibani AH. Acute dacryocystitis in pediatric patients and frequency of nasolacrimal duct patency. Orbit. 2021 Jan 2;40(1):18-23.
Isaza G, Arora S. Probing without irrigation in children with congenital nasolacrimal duct obstruction. Clinical and Investigative Medicine. 2013 Jun 1:E158-62.
Luo B, Li M, Xiang N, Hu W, Liu R, Yan X. The microbiologic spectrum of dacryocystitis. BMC ophthalmology. 2021 Dec;21(1):1-7.
Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar B, Hernandez JL. Dacryocystitis: systematic approach to diagnosis and therapy. Current Infectious Disease Reports. 2012 Apr;14:137-46.
Prat D, Magoon K, Revere KE, Katowitz JA, Katowitz WR. Management of pediatric acute dacryocystitis. Ophthalmic Plastic and Reconstructive Surgery. 2021 Feb 15;37(5):482-7.
