Dacryocystitis

Overview

Definition

Dacryocystitis is an inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the lacrimal sac due to nasolacrimal duct (NLD) obstruction and the subsequent stasis of tears.

Anatomy and physiology

• Lacrimal glands
  • Location: upper lateral aspect of orbit (lacrimal fossa)
  • Function: produce tears that protect and lubricate the outer portion of the eye
• Tear drainage system
  • Lacrimal canaliculi
  • Valve of Rosenmuller: mucosal fold between the canaliculi and lacrimal sac
  • Lacrimal sac: dilated portion of the NLD
  • NLD: drains into the inferior nasal meatus Nasal meatus Nose Anatomy (External & Internal)
  • Valve of Hasner: mucosal fold partially covering the NLD that opens into the nasal meatus Nasal meatus Nose Anatomy (External & Internal)
• Physiology
  • Released tears lubricate the eye → enter the lacrimal canaliculi (through puncta lacrimalia) at the medial eye corner → common canaliculus → lacrimal sac → drains into the NLD

Epidemiology

• Bimodal distribution Bimodal distribution Measures of Central Tendency and Dispersion:
  • After birth ( congenital Congenital Chorioretinitis cases)
  • In adults > 40 years of age
• Congenital Congenital Chorioretinitis NLD obstruction: affects 6% of newborns
• Women > men
• White individuals are more commonly affected.

Types of Dacryocystitis

Based on etiology

Nasolacrimal system obstruction is the main etiology.

• Congenital Congenital Chorioretinitis NLD obstruction
  • Most common cause: membranous obstruction at the valve of Hasner due to incomplete canalization of the nasolacrimal apparatus 
• Congenital Congenital Chorioretinitis dacryocystocele
  • Obstruction at both proximal and distal portions of nasolacrimal duct system
    • Proximal: block at the common canaliculus or the valve of Rosenmuller
    • Distal: block usually at the valve of Hasner
  • Seen as a swelling Swelling Inflammation inferior to the medial canthus, but can present as respiratory distress (from nasal obstruction) in newborns
• Acquired
  • Nasal pathology: deviated septum, nasal polyp, hypertrophied inferior turbinate
  • Tumors: primary lacrimal sac tumors and benign Benign Fibroadenoma papilloma Papilloma A circumscribed benign epithelial tumor projecting from the surrounding surface; more precisely, a benign epithelial neoplasm consisting of villous or arborescent outgrowths of fibrovascular stroma covered by neoplastic cells. Cowden Syndrome or malignancies
  • Trauma: nasal fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures and surgery
  • Dacryolith: stone within the lacrimal sac
  • Inflammatory disease: sarcoidosis Sarcoidosis Sarcoidosis is a multisystem inflammatory disease that causes noncaseating granulomas. The exact etiology is unknown. Sarcoidosis usually affects the lungs and thoracic lymph nodes, but it can also affect almost every system in the body, including the skin, heart, and eyes, most commonly. Sarcoidosis, granulomatosis with polyangiitis Granulomatosis with Polyangiitis A multisystemic disease of a complex genetic background. It is characterized by inflammation of the blood vessels (vasculitis) leading to damage in any number of organs. The common features include granulomatous inflammation of the respiratory tract and kidneys. Most patients have measurable autoantibodies (antineutrophil cytoplasmic antibodies) against myeloblastin. Granulomatosis with Polyangiitis
  • Sinusitis Sinusitis Sinusitis refers to inflammation of the mucosal lining of the paranasal sinuses. The condition usually occurs concurrently with inflammation of the nasal mucosa (rhinitis), a condition known as rhinosinusitis. Acute sinusitis is due to an upper respiratory infection caused by a viral, bacterial, or fungal agent. Sinusitis: maxillary and ethmoidal
  • Medications: timolol Timolol A beta-adrenergic antagonist that is similar in action to propranolol; the levo-isomer is more active. Timolol has been proposed as an anti-hypertensive, anti-arrhythmic, anti-angina, and anti-glaucoma agent. It is also used in the treatment of migraine disorders and tremor. Class 2 Antiarrhythmic Drugs (Beta Blockers), pilocarpine Pilocarpine A slowly hydrolyzed muscarinic agonist with no nicotinic effects. Pilocarpine is used as a miotic and in the treatment of glaucoma. Cholinomimetic Drugs, dorzolamide, idoxuridine, and trifluridine

Based on onset

• Acute dacryocystitis
  • Acute inflammation Acute Inflammation Inflammation of the lacrimal sac arising from obstruction of the lacrimal system
  • Obstruction leads to stagnation of tears, providing an environment for bacterial growth. 
  • Common organisms in local infection or abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease:
    • Staphylococcus epidermidis Staphylococcus epidermidis A species of staphylococcus that is a spherical, non-motile, gram-positive, chemoorganotrophic, facultative anaerobe. Mainly found on the skin and mucous membrane of warm-blooded animals, it can be primary pathogen or secondary invader. Staphylococcus and S. aureus S. aureus Potentially pathogenic bacteria found in nasal membranes, skin, hair follicles, and perineum of warm-blooded animals. They may cause a wide range of infections and intoxications. Staphylococcus
    • Alpha-hemolytic streptococci
    • Pseudomonas aeruginosa Pseudomonas aeruginosa A species of gram-negative, aerobic, rod-shaped bacteria commonly isolated from clinical specimens (wound, burn, and urinary tract infections). It is also found widely distributed in soil and water. P. Aeruginosa is a major agent of nosocomial infection. Pseudomonas
• Chronic dacryocystitis
  • Insidious onset
  • Chronic obstruction from:
    • Recurrent infections Recurrent infections Common Variable Immunodeficiency (CVID)
    • Dacryoliths
    • Systemic diseases 
    • Tumors

Clinical Presentation

• Acute dacryocystitis: Symptoms present within hours or days.
  • Redness Redness Inflammation
  • Swelling Swelling Inflammation in the medial canthus and inferomedial area of orbit
  • Tenderness below the medial canthus of the eye
  • Purulent discharge from the punctum
  • Mattering: debris and surface epithelial cells on the eyelashes
  • Epiphora: excessive tearing
• Chronic dacryocystitis symptoms include:
  • Epiphora: most common symptom
  • Fluctuating visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam: Increased tear film refracts light abnormally.
  • Mucocele:
    • Also called dacryocele or dacryocystocele
    • Palpable mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast (formed from trapped fluid) at the medial canthus

Complications

• Complications involving other ocular structures:
  • Preseptal cellulitis Preseptal cellulitis Orbital and preseptal cellulitis are infections differentiated by the anatomic sites affected in the orbit. Infection anterior to the orbital septum is preseptal cellulitis. Inoculation with the pathogen can occur through trauma or surgery. Cellulitis also occurs via extension from a nearby structure (such as from sinus infection or sinusitis). Orbital and Preseptal Cellulitis:
    • Infectious inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the structures anterior to the orbital septum Orbital Septum Orbital and Preseptal Cellulitis ( skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions and subcutaneous tissue Subcutaneous tissue Loose connective tissue lying under the dermis, which binds skin loosely to subjacent tissues. It may contain a pad of adipocytes, which vary in number according to the area of the body and vary in size according to the nutritional state. Soft Tissue Abscess) 
    • Presents with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, swelling Swelling Inflammation, redness Redness Inflammation, and discharge
  • Orbital cellulitis Orbital cellulitis Orbital and preseptal cellulitis are infections differentiated by the anatomic sites affected in the orbit. Infection posterior to the septum is orbital cellulitis. Inoculation with the pathogen can occur through trauma or surgery. Cellulitis also occurs via extension from a nearby structure (such as from sinus infection or sinusitis). Orbital and Preseptal Cellulitis:
    • Infectious inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the structures posterior to the orbital septum Orbital Septum Orbital and Preseptal Cellulitis (orbital fat, muscles, bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types)
    • Presents with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, redness Redness Inflammation, discharge, swelling Swelling Inflammation, proptosis Proptosis Retinoblastoma, diplopia Diplopia A visual symptom in which a single object is perceived by the visual cortex as two objects rather than one. Disorders associated with this condition include refractive errors; strabismus; oculomotor nerve diseases; trochlear nerve diseases; abducens nerve diseases; and diseases of the brain stem and occipital lobe. Myasthenia Gravis, and abnormal eye movement
• Complications beyond the eye:
  • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the meninges Meninges The brain and the spinal cord are enveloped by 3 overlapping layers of connective tissue called the meninges. The layers are, from the most external layer to the most internal layer, the dura mater, arachnoid mater, and pia mater. Between these layers are 3 potential spaces called the epidural, subdural, and subarachnoid spaces. Meninges: Anatomy 
  • Sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock: infection associated with life-threatening organ dysfunction
  • Cavernous sinus thrombosis Cavernous sinus thrombosis Formation or presence of a blood clot (thrombus) in the cavernous sinus of the brain. Infections of the paranasal sinuses and adjacent structures, craniocerebral trauma, and thrombophilia are associated conditions. Clinical manifestations include dysfunction of cranial nerves III, IV, V, and VI, marked periorbital swelling, chemosis, fever, and visual loss. Cranial Nerve Palsies: embolization Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding of infectious organism(s) causing thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus in the cavernous sinus

Diagnosis

• Clinical: based on signs and symptoms
• Laboratory tests: 
  • Culture of lacrimal sac discharge: guides antibiotic treatment 
  • Obtained if systemic diseases are considered as etiology
• Fluorescein dye Fluorescein Dye Ophthalmic Exam disappearance test:
  • Fluorescein dye Fluorescein Dye Ophthalmic Exam is placed into the patient’s eye and after 5 minutes, an evaluation is done (with cobalt blue filter of slit lamp Slit Lamp A microscope with a light source that can be projected into a linear beam. It allows cross-sectional viewing of the aqueous humor; conjuncteiva; cornea; eyelids; iris; and lens of the eye. Ophthalmic Exam).
  • Persistence of dye and asymmetric dye clearance: NLD obstruction confirmed
• Imaging:
  • Computed tomography (CT) scan:
    • To evaluate structures in cases of trauma/fractures
    • To assess mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast or tumor Tumor Inflammation involvement
    • To determine extent of infection/ abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
  • Dacryocystography:
    • Helps in assessment of anatomical abnormalities of the duct
• Nasal endoscopy Endoscopy Procedures of applying endoscopes for disease diagnosis and treatment. Endoscopy involves passing an optical instrument through a small incision in the skin i.e., percutaneous; or through a natural orifice and along natural body pathways such as the digestive tract; and/or through an incision in the wall of a tubular structure or organ, i.e. Transluminal, to examine or perform surgery on the interior parts of the body. Gastroesophageal Reflux Disease (GERD):
  • Evaluates intranasal pathology such as septal deviation, inferior meatal narrowing, and inferior turbinate hypertrophy Hypertrophy General increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia). Cellular Adaptation

Management

• Acute dacryocystitis from congenital Congenital Chorioretinitis NLD obstruction
  • NLD probing: contraindicated in acute dacryocystitis
  • Crigler massage:
    • Push index finger down on the lacrimal sac and slide the finger downward against the bony side of the nose Nose The nose is the human body’s primary organ of smell and functions as part of the upper respiratory system. The nose may be best known for inhaling oxygen and exhaling carbon dioxide, but it also contributes to other important functions, such as tasting. The anatomy of the nose can be divided into the external nose and the nasal cavity. Nose Anatomy (External & Internal).
    • 10 motions performed 3 times a day
    • Done until child is 1 year of age
    • 90% of NLD obstructions resolve by 6–12 months of age.
  • Warm compresses Warm Compresses Chalazion (10 minutes, 4 times a day) 
• Acute dacryocystitis with infection
  • Localized infection:
    • Conservative measures (massage, warm compress)
    • Oral antibiotics (coverage for gram-positive Gram-Positive Penicillins organisms)
  • Complicated cases with spread of infection: IV antibiotics (coverage for gram-positive Gram-Positive Penicillins and gram-negative organisms)
• Chronic dacryocystitis 
  • NLD probing:
    • Successful in 70% of cases
    • Done as an outpatient
  • Other options if probing fails:
    • Nasolacrimal stenting
    • Balloon dacryoplasty 
    • Nasolacrimal intubation Intubation Peritonsillar Abscess 
  • Percutaneous dacryocystorhinostomy (DCR) or endonasal dacryocystorhinostomy (EN-DCR)
    • Done when previous therapeutic measures fail
    • For complete NLD obstruction

Differential Diagnosis

• Conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the conjunctiva Conjunctiva The mucous membrane that covers the posterior surface of the eyelids and the anterior pericorneal surface of the eyeball. Eye: Anatomy, the outer lining of the eye. Etiology can be infectious or non-infectious. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with redness Redness Inflammation and discharge on one or both eyes Both Eyes Refractive Errors. Bacterial conjunctivitis Bacterial Conjunctivitis Conjunctivitis often has purulent discharge whereas viral causes have watery discharge.
• Hordeolum Hordeolum A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye) ( stye Stye A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye)): an abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease affecting the eyelash follicle or eyelid gland. Stye Stye A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye) usually presents as a locally painful, erythematous, swollen eyelid margin. Most lesions resolve spontaneously, but gentle warm compresses Warm Compresses Chalazion facilitate drainage. If the abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease does not resolve, incision and drainage Incision And Drainage Chalazion by an ophthalmologist are performed.
• Chalazion Chalazion A chalazion is one of the most common inflammatory lesions of the eyelid. It is caused by obstruction of the Meibomian or Zeis glands, leading to granulomatous inflammation and resulting in a firm, rubbery, slow-growing nodule that is typically non-tender. Chalazion: a firm, nontender mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast at the eyelid resulting from obstruction of the Zeis or meibomian glands. The condition is usually managed conservatively with warm compresses Warm Compresses Chalazion. Persistence of the lesion requires incision and curettage Curettage A scraping, usually of the interior of a cavity or tract, for removal of new growth or other abnormal tissue, or to obtain material for tissue diagnosis. It is performed with a curet (curette), a spoon-shaped instrument designed for that purpose. Benign Bone Tumors or glucocorticoid injection by an ophthalmologist.