The lacrimal excretory system is prone to infection and inflammation for various reasons. This mucous membrane-lined tract is contiguous with 2 surfaces (conjunctival and nasal mucosal) that are normally colonized with bacteria. The functional purpose of the lacrimal excretory system is to drain tears from the eye into the nasal cavity. Stagnation of tears in a pathologically closed lacrimal drainage system can result in dacryocystitis.
Acquired dacryocystitis can be acute or chronic. Acute dacryocystitis is heralded by the sudden onset of pain and redness in the medial canthal region. An insidious onset of epiphora is characteristic of chronic inflammation or infection of the lacrimal sac.
See the image below.
A special form of inflammation of the lacrimal sac is that of congenital dacryocystitis, the pathophysiology of which is intimately related to the lacrimal excretory system embryogenesis.
Dacryocystitis has long been noted to occur more frequently on the left side than on the right side. In many instances, the nasolacrimal duct and lacrimal fossa formed a greater angle on the right side than on the left side.
Individuals with brachycephalic heads have a higher incidence of dacryocystitis than dolichocephalic or mesocephalic skulls. This is because brachycephalic skulls demonstrate a narrower diameter of inlet into the nasolacrimal duct, the nasolacrimal duct is longer, and the lacrimal fossa is narrower. Furthermore, patients with a flat nose and narrow face are at a higher risk for developing dacryocystitis, presumably because of the narrow osseous nasolacrimal canal.
In 1883, Nieden noted a 9% incidence of hereditary lacrimal excretory system inflammation. This is significantly higher than what has been found by the author in studies.
Dacryocystitis occurs in the following 3 forms: acute, chronic, and congenital.
In acute dacryocystitis, patients can experience severe morbidity and rarely mortality. Morbidity is related primarily to the lacrimal sac abscess and spread of the infection.
Chronic dacryocystitis is rarely associated with severe morbidity unless caused by a systemic disease. The primary morbidity is associated with chronic tearing, mattering, and conjunctival inflammation and infection.
Congenital dacryocystitis is a very serious disease associated with significant morbidity and mortality. If not treated promptly and aggressively, newborn infants can experience orbital cellulitis (because the orbital septum is formed poorly in infants), brain abscess, meningitis, sepsis, and death. Congenital dacryocystitis can be associated with an amniotocele, which, in severe cases, can lead to airway obstruction. More indolent forms of congenital dacryocystitis can be difficult to diagnose and can be associated with chronic tearing, mattering, amblyopia, and failure to thrive.
Blacks rarely develop dacryocystitis because the nasolacrimal ostium into the nose is large. In addition, the lacrimal canal is shorter and straighter in blacks than in whites.
In adults, females are afflicted more commonly by dacryocystitis. Most studies demonstrate that 70-83% of cases of dacryocystitis occur in females. Congenital dacryocystitis occurs with equal frequency in both sexes.
Lacrimal sac infections and inflammations commonly occur in 2 discrete age categories, infants and adults older than 40 years. Acute dacryocystitis in newborns is rare, occurring in fewer than 1% of all newborns. Acquired dacryocystitis is primarily a disease of females and is most common in patients older than 40 years, with a peak in patients aged 60-70 years.
The naso-optic fissure is the source of origin of the lacrimal drainage system. The ectoderm in this region thickens and becomes embedded in the mesenchyme between the lateral nasal and maxillary processes. This cord of ectoderm subsequently canalizes and opens into the conjunctival fornix prior to opening into the nasal vestibule. Frequently, this opening into the nasal cavity is incomplete at birth. Canalization of the lacrimal excretory system begins in the superior portion first and is segmental, only later coalescing to form a continuous lumen. The canaliculi, which develop as outpouchings from the solid cord of ectodermal tissue prior to canalization, also canalize prior to the vertical portions of the nasolacrimal duct.
Many variations in the anatomy of the lacrimal drainage system have been noted. Normally, tears drain into the lacrimal system through two puncta, one present in the upper lid and the other in the lower lid. More commonly, the lower punctum lies slightly temporal to the upper punctum.
The connections from the puncta to the lacrimal sac are called canaliculi. These canaliculi have a short vertical segment, averaging 2 mm in length, and a longer horizontal segment, averaging 10-12 mm in length.
An ampulla connects the vertical and horizontal segments. The individual canalicular horizontal segments join to form a common canaliculus in 90% of patients. This common canaliculus dilates, forming the sinus of Maier just lateral to the lacrimal sac.
A fold of mucosa known as the valve of Rosenmüller marks the junction of the lacrimal sac and the common canaliculus. The lacrimal sac lies in the bony lacrimal fossa derived from the lacrimal and maxillary bones. The average width of the sac is approximately 6-7 mm and the length varies from 12-15 mm. The mucosa of the sac is lined by pseudostratified columnar epithelium with substantial amounts of lymphoid and elastic tissue interposed within the connective tissue layer. The sac is normally irregular and flat in shape with a collapsed lumen.
The lacrimal sac is covered on its outer surface by the lacrimal fascia of the periorbita. This fascia splits to envelop the lacrimal sac between the attachments of the lacrimal fascia to the anterior and posterior lacrimal crests. The lacrimal sac mucosa only loosely adheres to the lacrimal fascia. However, posterior to the sac are the deep heads of the pretarsal and preseptal orbicularis muscles. Anteriorly, the medial canthal tendon covers the upper two fifths of the lacrimal sac.
The nasolacrimal duct averages 18 mm in length and 4.5-5 mm in diameter. Multiple valves are present in the nasolacrimal duct, representing analog from the segmental canalization of the ectodermal cord that develops into the nasolacrimal duct. Of these, the most prominent valves are the valve of Taillefer, the valve of Krause, and the valve of Hasner (located at the junction of the duct with the nasal mucosa). Like the lacrimal sac, the nasolacrimal duct is lined by pseudostratified columnar epithelium.
The lacrimal, maxillary, and ethmoid bones form the bony nasolacrimal canal. The bulk of the duct is contributed by the maxilla, anteriorly, laterally, and posteriorly. The lacrimal bone forms the medial wall superiorly, and the inferior concha of the ethmoid bone forms the medial wall of the canal inferiorly. The mucosal opening of the nasolacrimal duct under the inferior turbinate lies 5-8 mm from the anterior tip of the inferior turbinate. The lacrimal bone and the nasal process of the maxilla make up the lacrimal fossa equally. The anterior and posterior lacrimal crests form the anterior and posterior borders of the lacrimal fossa, respectively.
The dimensions of the lacrimal fossa are 4-8 mm in width, 15 mm in height, and 2 mm in depth. Ethmoid air cells in approximately 40-60% of patients separate the lacrimal fossa from the nasal cavity, although considerable variability exists in the number and location of these air cells. The lacrimal sac fossa lies at the level of the anterior tip of the middle turbinate.
Acute dacryocystitis is manifested by the sudden onset of pain, erythema, and edema overlying the lacrimal sac region.
The tenderness is characteristically localized in the medial canthal region but may extend to the nose, cheek, teeth, and face.
Thermography has demonstrated an intensive hemifacial reaction in patients with acute dacryocystitis. Frequently, a purulent discharge is noted from the puncta.
It is not uncommon for the sac to rupture and fistulize through the skin; this fistula commonly closes after a few days of drainage.
Conjunctival injection and preseptal cellulitis often occur in conjunction with acute dacryocystitis.
Epiphora is invariably present, and it is not uncommon for a palpable mass to be noted inferior to the medial canthal tendon.
A few patients present with fever, prostration, and an elevated leukocyte count.
More serious sequelae of acute dacryocystitis include extension into the orbit with formation of an abscess and development of orbital cellulitis. When this occurs, it may lead to blindness, cavernous sinus thrombosis, and death.
Tearing is the most common presentation of chronic dacryocystitis and is related to the obstruction of the outflow of tears, debris, and epithelial cells from the surface of the eye.
This is caused by the obstruction of drainage of the mucous layer of the tear film with collection of debris and denuded epithelial cells from the surface of the eye.
Frequently, it may be associated with conjunctivitis. This is attributed to the toxic nature of the debris to the surface of the eye or because of exotoxins produced by staphylococcal organisms, which normally reside on the external surface of the eye and are not cleared by the normal tear outflow.
Cellulitis is seen predominately in acute dacryocystitis and is due to bacterial overgrowth with rupture through the wall of the lacrimal sac into surrounding soft tissue.
This is a rare, but serious, complication of dacryocystitis. It is associated most commonly with acute dacryocystitis and congenital acute dacryocystitis.
Commonly, orbital cellulitis presents as an inflamed painful eye with abnormal motility, abnormal pupil examination, and decreased visual acuity.
Massive periorbital edema and erythema is not uncommon.
A commonly observed complaint, it is primarily due to the increased tear film on the surface of the eye. This increased tear film abnormally refracts light and is associated with fluctuating visual acuity.
In addition, the standard 3 layers of the tear film, mucus, aqueous, and oil, are abnormal and are present in abnormal proportions.
This usually is related to the inflammation associated with the buildup of toxic debris on the surface of the eye and exotoxins secreted by staphylococcal organisms living on the surface of the eye.
Periorbital edema is most pronounced in the morning and subsides late in the day because of repeated contractures of the orbicularis muscle milking the edema from the soft tissues around the eye.
Fever results from a fulminant bacterial or fungal infection in the lacrimal sac, which spreads to the surrounding tissues. This is not uncommonly associated with significant sinus disease.
Leukocytosis also is common in acute dacryocystitis.
Cellulitis surrounding the affected lacrimal sac is common in patients with acute dacryocystitis. This can spread to involve the orbit and cause orbital cellulitis.
Altered visual acuity most frequently is caused by an abnormal tear film with abnormal refraction of light at the air-tear film interface. It also can be due to corneal surface irregularities resulting from chronic surface inflammation.
Altered pupillary reaction is only seen in severe cases of dacryocystitis associated with an orbital cellulitis. This is due to increased intraorbital pressure and necrosis of the pupillomotor fibers in the orbit.
Diplopia is also rare and is seen in patients with orbital cellulitis resulting from acute dacryocystitis. These patients have orbital inflammation involving the extraocular muscles, which causes the muscles to dysfunction, resulting in diplopia.
Loss of peripheral vision is also rare and caused by orbital cellulitis secondary to acute dacryocystitis. This results in an optic neuropathy with loss of peripheral vision. Many times, this can be subtle and can be detected on perimetry testing.
Conjunctivitis frequently is associated with acute and chronic dacryocystitis. It is primarily due to the buildup of toxic debris on the surface of the eye, including the exotoxin produced by staphylococcal organisms, which normally inhabit the surface of the eye.
Medial canthal fullness and tenderness are common in both acute dacryocystitis and chronic dacryocystitis, which is due to distention of the lacrimal sac and resultant infection of the lacrimal sac. Dacryocystitis usually does not extend above the medial canthal tendon, and the medial canthal swelling should not be pulsatile. Rarely, an occult tumor or cyst can be the cause of the medial canthal fullness.
Tearing is most commonly due to obstructed outflow of the tear system but may be exacerbated by conjunctivitis. Rarely, patients with acute or chronic dacryocystitis have no complaints of tearing but have other sequelae of tear sac infection, including redness, cellulitis, pain, fullness, and purulent discharge.
In congenital dacryocystitis, incomplete canalization of the nasolacrimal duct (specifically at the valve of Hasner) is clearly important in the pathogenesis. However, since the incidence of congenital dacryocystitis is much lower than the incidence of incomplete canalization, factors other than developmental ones appear to play a role in the pathogenesis. Neonatal infection is another important factor in the development of congenital dacryocystitis.
Both aerobic bacteria and anaerobic bacteria have been cultured from pediatric and adult patients with dacryocystitis. The most common organisms isolated from the lacrimal sacs of children with dacryocystitis include Staphylococcus aureus, Haemophilus influenzae, beta-hemolytic streptococci, mycobacterial species, and pneumococci. Methicillin-resistant Staphylococcus aureus (MRSA) is more common in patients with acute dacryocystitis than with chronic dacryocystitis.
Structural abnormalities of the midface also should be considered.
Nasal pathology that can predispose to dacryocystitis includes the following: hypertrophied inferior turbinate, deviated nasal septum, nasal polyp, and allergic rhinitis.
Obstruction of the nasolacrimal duct by a tight inferior meatus has been noted in many infants.
The etiology of dacryocystitis includes nasal disease and ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome, as outlined below.
Causes of nasal disease include the following:
Causes of EEC syndrome may include the following:
In acquired dacryocystitis, obstruction of the lower part of the nasolacrimal system frequently is present. Because of the intimate relationship of the nasolacrimal duct with the nose and paranasal sinuses, these structures are commonly associated as an etiologic factor in the pathogenesis of dacryocystitis.
One of the more common associations, if not a factor in the etiology of dacryocystitis, is ethmoidal inflammation. Because only a very thin lamina of bone is present between the ethmoid air cells and the lacrimal sac, it is not uncommon for inflammation of the ethmoid sinuses to cause dacryocystitis.
An ocular origin for inflammation of the lacrimal system is less common than a nasal origin.
Several cases of obstruction of the nasolacrimal duct by impacted cilia have been described.
Profuse secretion and stagnation of tears in the lacrimal sac, which may occur in uncorrected astigmatism and hypermetropia, may contribute to the development of dacryocystitis.
Most cases of dacryocystitis in adults are caused by stenosis of the lacrimal duct with resultant stagnation of lacrimal fluid and subsequent infection.
Approximately 50% of patients undergoing surgery for dacryocystitis have positive culture results; of these, pure cultures are obtained in 71% of them, with mixed cultures in the remaining 29% of patients.
The bacteriology of dacryocystitis mimics normal conjunctival flora in most instances, as follows:
Dacryolith formation has been noted in 14-16% of patients with dacryocystitis. Patients with a history of acute dacryocystitis have a higher incidence of dacryolith formation than those with chronic dacryocystitis.
When a tumor is present in the lacrimal sac, most are epithelial (ie, carcinomas, papillomas). The most common nonepithelial malignancy is a lymphoma. Epithelial tumors tend to be more common in men than in women, and nonepithelial tumors tend to be more common in women than in men.
In most cases, dacryocystitis is a clinical diagnosis.
Supportive laboratory analysis includes a complete blood count to assess the degree of leukocytosis; however, this rarely may assist in the determination of leukemia as an etiology of the lacrimal sac infection.
Blood cultures and cultures of the ocular surface, nose, and lacrimal sac discharge may prove useful in determining the appropriate antibiotic therapy.
Antineutrophil cytoplasmic antibody testing may be useful in ruling out granulomatosis with polyangiitis (Wegener granulomatosis) as a cause of dacryocystitis and nasolacrimal duct obstruction.
Antinuclear antibody (ANA) testing may be useful in the very rare cases of dacryocystitis caused by lupus involvement of the lacrimal drainage system with resultant obstruction and infection.
Plain films may be useful in elucidating facial skeletal anomalies or foreign bodies as the cause of the lacrimal disorder. In addition, occasionally, posttraumatic etiologies and mass lesions are noted on plain films as the cause of dacryocystitis.
Echography rarely is used. In most cases, it demonstrates enlargement and engorgement of the lacrimal sac. Rarely, lacrimal sac foreign bodies or masses are noted on echography.
CT scans are useful in patients suspected of harboring an occult malignancy or mass as a cause of dacryocystitis. In addition, posttraumatic causes of dacryocystitis usually are noted with CT scans.
MRIs are not as useful as CT scans but can be helpful in differentiating cystic lesions from solid mass lesions. MRIs can be useful in identifying patients with lacrimal sac diverticuli, which can cause recurrent dacryocystitis without epiphora and failure of surgical correction.
Dacryocystography (DCG) and dacryoscintigraphy are useful adjunctive diagnostic modalities when anatomical abnormalities of the nasolacrimal drainage system are suspected. Subtraction DCG with CT scan is also very sensitive to study the anatomy of the lacrimal sac and surrounding structures.
Ensure that epiphora is not related to hypersecretion or abnormal lid function or position.
Baseline tear secretion can be measured with the Schirmer basic secretor test.
A somewhat subjective test, it is used to assess the disappearance of fluorescein dye when placed in the eye. The ocular surface is evaluated at the slit lamp to determine disappearance of the fluorescein dye. This test is useful in children.
With the Jones I dye test, functional and anatomical obstruction of the nasolacrimal system can be assessed.
A positive result indicates no anatomical or functional blockage to tear flow.
A negative result indicates a lacrimal drainage system problem (ie, anatomical or functional blockage).
A Jones II dye test is used to determine the presence or absence of anatomical obstruction of the nasolacrimal outflow system.
A positive Jones II dye test (colored fluid from the nose) indicates a patent system anatomically.
In light of a negative Jones I dye test, a positive Jones II dye test indicates either partial obstruction of the nasolacrimal system or a false-negative Jones I test.
A negative Jones II eye test (clear fluid from the nose) indicates functional blockage of the nasolacrimal system. This is common with horizontal laxity of the lower eyelid or flaccidity of the canalicular system.
If no fluid can be irrigated with the Jones II test, complete nasolacrimal obstruction is present.
Nasal endoscopy is frequently useful in assessing the etiology of dacryocystitis. Tumors, papillomas, hypertrophy of the inferior turbinate, nasal septal deviation, and inferior meatal narrowing may be noted as causes of dacryocystitis.
Pathologic changes found in the lacrimal drainage system are related primarily to the etiology of the disease.
Because the most common underlying pathogenic factor is distal obstruction of the lacrimal drainage system with subsequent stagnation and infection, the most common pathologic finding in the lacrimal drainage system is inflammatory change. Chronic inflammation and fibrosis of the lacrimal sac are present in varying degrees in most patients.
Focal ulceration and loss of goblet cells are not uncommon.
Focal abscesses and granuloma formation also have been noted in the lacrimal sac.
The pathologic changes in the nasolacrimal duct and nasal mucosa follow closely to those in the lacrimal sac.
Chronic inflammation and fibrosis are the most common histologic changes noted in both the nasal mucosa and the nasolacrimal duct.
The treatment of dacryocystitis depends upon the clinical manifestations of the disease.
Acute dacryocystitis with orbital cellulitis necessitates hospitalization with intravenous (IV) antibiotics.
Appropriate neuroimaging studies should be obtained, and surgical exploration and drainage should be performed for focal collections of pus.
IV empiric antimicrobial therapy for penicillin-resistant Staphylococcus (nafcillin or cloxacillin) should be initiated immediately.
Blood cultures and cultures of the lacrimal secretions should be obtained prior to antibiotic therapy.
Treatment with warm compresses may aid in resolution of the disease.
Impending perforation should be treated with a stab incision of the skin.
Purulent infection of the lacrimal sac and skin should be treated similarly. Hospitalization is not mandatory unless the patient's condition appears serious.
Treatment with oral antibiotics (eg, amoxicillin-clavulanate) is appropriate.
Cultures of the lacrimal fluid may be helpful. The presence of a lacrimal sac mucocele in adults mandates treatment even if asymptomatic.
The treatment of choice is a dacryocystorhinostomy whether the patient is symptomatic or not. Probing should not be performed because mucoceles often are not sterile and probing may incite a cellulitis.
Patients with chronic dacryocystitis caused by a partial or intermittent nasolacrimal duct obstruction may benefit from topical steroid drop treatment.
Congenital chronic dacryocystitis may resolve with lacrimal sac massage, warm compresses, and topical and/or oral antibiotics.
See the list below:
See the list below:
Oral and topical antibiotics are the mainstay of medical therapy.
Clinical Context: Provides useful coverage for most organisms associated with dacryocystitis.
Clinical Context: Provides useful coverage for most organisms associated with dacryocystitis.
Clinical Context: Provides useful coverage for most organisms associated with dacryocystitis.
Clinical Context: For ocular infections, involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic. Available as a solution and ointment.
Clinical Context: Aminoglycoside antibiotic used for gram-negative bacterial coverage.
Clinical Context: Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane.
Clinical Context: Tobramycin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane. Dexamethasone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Used to treat systemic infections, including periorbital cellulitis, orbital cellulitis, and sinusitis.
Most patients are treated surgically on an outpatient basis.
Admission to the hospital is required for the following:
Definitive surgical therapy should be performed; in most cases, this involves dacryocystorhinostomy.
Topical antibiotics include Polytrim, gentamicin, tobramycin, and TobraDex (antibiotic/steroid combination drop).
Occasionally, nasal decongestants (eg, Afrin) are used on a short-term basis.
Oral antibiotics are useful in patients with acute dacryocystitis who are not acutely ill.
Intranasal saline may be useful postoperatively to keep the surgical ostium clean and open.
Patients may require transfer for diagnostic evaluation of associated systemic illnesses, such as Wegener granulomatosis, sarcoidosis, leukemia, lymphoma, and melanoma.
Proper eyelid hygiene, including warm compresses and eyelid scrubs, may prevent some cases of dacryocystitis.
Nasal hygiene with saline spray may help prevent distal lacrimal outflow obstruction.
Dacryocystorhinostomy, when properly performed, is a very safe and effective procedure. However, as with all surgical procedures, severe complications can occur.
Hemorrhage is the most notable complication and has been reported to occur in approximately 3% of patients. Considerations are as follows:
Infection is also a serious concern with dacryocystorhinostomy. Almost routinely, patients with diabetes and children who undergo dacryocystorhinostomy are on postoperative oral antibiotics. Some surgeons advocate spraying antibiotic drops into the nose postoperatively. More commonly, a suture abscess is noted, which can be treated with removal of the offending suture, hot compresses, and oral and topical antibiotics.
Cerebrospinal fluid (CSF) leakage is the most dreaded complication of dacryocystorhinostomy. Because the cribriform plate lies just above the medial canthal tendon, tears in the bony plate with resultant CSF leakage can occur during creation of the osteotomy. Variations in anatomy are frequently responsible for the above complication. The author has observed a CSF leakage from dacryocystorhinostomy in a patient who had an arachnoid cyst extending from the anterior cranial fossa into the nasal vestibule just under the surface of the skin.
Failure of the dacryocystorhinostomy is most commonly due to an inadequate osteotomy or a fibrous closure at the surgical ostium. Most cases of the latter can be treated with dilation of the ostium with successively larger Bowman probes. Balloon dacryocystoplasty has been shown to be effective in patients who fail dacryocystorhinostomy surgery.
Rarely, a papilloma, which is occluding the ostium, can be seen intranasally. This can be removed during intranasal revision of the osteotomy.
Fortunately, few patients fail dacryocystorhinostomy; those patients who do most often necessitate placement of a Jones tube.
The success rate of external dacryocystorhinostomy has traditionally been regarded as approximately 95%.
Premature stent loss (prior to 2 months in one study ) resulted in a success rate of 90%.
Intranasal dacryocystorhinostomy has a slightly lower success rate, presumably due to the inability to create as large an ostium.
Laser-assisted dacryocystorhinostomy is promising in that less morbidity is seen with the procedure; however, the success rate appears to be approximately 80-85%.
A 2014 meta-analysis suggests lower success rates with nasolacrimal surgery than the figures that are traditionally quoted above.
Balloon dacryoplasty is also a useful procedure in select patients and in patients who fail primary dacryocystorhinostomy. The author offers balloon dacryoplasty to patients with focal partial stenosis.
The conjunctival flora has been shown to normalize a few weeks after dacryocystorhinostomy.