Dacryocystitis

Back

Background

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.[1] 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.


View Image

Acute dacryocystitis.

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.

Pathophysiology

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.

Epidemiology

Frequency

United States

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.

Mortality/Morbidity

Dacryocystitis occurs in the following 3 forms: acute, chronic, and congenital.

Race

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.

Sex

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.

Age

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.

History

Physical

Causes

Laboratory Studies

Imaging Studies

Other Tests

Procedures

Histologic Findings

Pathologic changes found in the lacrimal drainage system are related primarily to the etiology of the disease.

Medical Care

The treatment of dacryocystitis depends upon the clinical manifestations of the disease.

Surgical Care

Consultations

Medication Summary

Oral and topical antibiotics are the mainstay of medical therapy.[13]

Amoxicillin and clavulanate (Augmentin)

Clinical Context:  Provides useful coverage for most organisms associated with dacryocystitis.

Ampicillin and sulbactam (Unasyn)

Clinical Context:  Provides useful coverage for most organisms associated with dacryocystitis.

Levofloxacin (Levaquin)

Clinical Context:  Provides useful coverage for most organisms associated with dacryocystitis.

Trimethoprim sulfate and polymyxin B sulfate (Polytrim)

Clinical Context:  For ocular infections, involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic. Available as a solution and ointment.

Gentamicin (Genoptic, Ocumycin)

Clinical Context:  Aminoglycoside antibiotic used for gram-negative bacterial coverage.

Tobramycin ophthalmic (AKTob, Tobrex)

Clinical Context:  Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, which results in a defective bacterial cell membrane.

Dexamethasone/tobramycin (TobraDex)

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.

Class Summary

Used to treat systemic infections, including periorbital cellulitis, orbital cellulitis, and sinusitis.

Further Inpatient Care

Further Outpatient Care

Inpatient & Outpatient Medications

Transfer

Deterrence/Prevention

Complications

Prognosis

Author

Grant D Gilliland, MD, Private Practice, Texas Ophthalmic Plastic, Reconstructive and Orbital Surgery Associates

Disclosure: Nothing to disclose.

Specialty Editors

Jorge G Camara, MD, Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD, Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Disclosure: Nothing to disclose.

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Disclosure: Allergan - Botox Cosmetic Honoraria Speaking and teaching

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

References

  1. Mills DM, Bodman MG, Meyer DR, Morton AD 3rd. The microbiologic spectrum of dacryocystitis: a national study of acute versus chronic infection. Ophthal Plast Reconstr Surg. Jul-Aug 2007;23(4):302-6. [View Abstract]
  2. Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar B, et al. Dacryocystitis: Systematic Approach to Diagnosis and Therapy. Curr Infect Dis Rep. Jan 29 2012;[View Abstract]
  3. Burduk PK, Dalke K, Olejarz E. [Dacryocystitis as a complication of maxillofacial fracture repair with reconstruction]. Otolaryngol Pol. 2008;62(5):536-9. [View Abstract]
  4. Batra R, Mudhar HS, Sandramouli S. A unique case of IgG4 sclerosing dacryocystitis. Ophthal Plast Reconstr Surg. May-Jun 2012;28(3):e70-2. [View Abstract]
  5. Mazow ML, McCall T, Prager TC. Lodged intracanalicular plugs as a cause of lacrimal obstruction. Ophthal Plast Reconstr Surg. Mar-Apr 2007;23(2):138-42. [View Abstract]
  6. Ghose S, Chhabra MS, Thakar A, et al. Nasal endoscopy in congenital dacryocystitis. J Pediatr Ophthalmol Strabismus. Nov-Dec 2006;43(6):341-5. [View Abstract]
  7. Baskin DE, Reddy AK, Chu YI, Coats DK. The timing of antibiotic administration in the management of infant dacryocystitis. J AAPOS. Oct 2008;12(5):456-9. [View Abstract]
  8. Spielmann PM, Hathorn I, Ahsan F, Cain AJ, White PS. The impact of endonasal dacryocystorhinostomy (DCR), on patient health status as assessed by the Glasgow benefit inventory. Rhinology. Mar 2009;47(1):48-50. [View Abstract]
  9. Konuk O, Ilgit E, Erdinc A, Onal B, Unal M. Long-term results of balloon dacryocystoplasty: success rates according to the site and severity of the obstruction. Eye. Dec 2008;22(12):1483-7. [View Abstract]
  10. Merkonidis C, Brewis C, Yung M, Nussbaumer M. Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review. Br J Ophthalmol. Dec 2005;89(12):1589-91. [View Abstract]
  11. Wu W, Yan W, MacCallum JK, et al. Primary treatment of acute dacryocystitis by endoscopic dacryocystorhinostomy with silicone intubation guided by a soft probe. Ophthalmology. Jan 2009;116(1):116-22. [View Abstract]
  12. Liang WH, Liang YQ, Deng XY, Yuan HZ. Spherical Headed Silicone Intubation in the Treatment of 26 Cases (31 eyes) of Chronic Dacryocystitis under Nasal Endoscopy. Yan Ke Xue Bao. Dec 2011;26(4):217-20. [View Abstract]
  13. Miquel T, Abad S, Badelon I, et al. Successful treatment of idiopathic orbital inflammation with infliximab: an alternative to conventional steroid-sparing agents. Ophthal Plast Reconstr Surg. Sep-Oct 2008;24(5):415-7. [View Abstract]
  14. Barmettler A, Ehrlich JR, Erlich J, Lelli G Jr. Current preferences and reported success rates in dacryocystorhinostomy amongst ASOPRS members. Orbit. Feb 2013;32(1):20-6. [View Abstract]
  15. Vicinanzo MG, McGwin G, Boyle M, Long JA. The consequence of premature silicone stent loss after external dacryocystorhinostomy. Ophthalmology. Jul 2008;115(7):1241-4. [View Abstract]
  16. Owji N, Khalili MR. Normalization of conjunctival flora after dacryocystorhinostomy. Ophthal Plast Reconstr Surg. Mar-Apr 2009;25(2):136-8. [View Abstract]
  17. Artenstein AW, Eiseman AS, Campbell GC. Chronic dacryocystitis caused by Mycobacterium fortuitum. Ophthalmology. May 1993;100(5):666-8. [View Abstract]
  18. Asiyo MN, Stefani FH. Pyogenic granulomas of the lacrimal sac. Eye. 1992;6 (Pt 1):97-101. [View Abstract]
  19. Atkinson PL, Ansons AM, Patterson A. Infectious mononucleosis presenting as bilateral acute dacryocystitis. Br J Ophthalmol. Dec 1990;74(12):750. [View Abstract]
  20. Avasthi P, Misra RN, Sood AK. Clinical and anatomical considerations of dacryocystitis. Int Surg. Mar 1971;55(3):200-3. [View Abstract]
  21. Bareja U, Ghose S. Clinicobacteriological correlates of congenital dacryocystitis. Indian J Ophthalmol. Apr-Jun 1990;38(2):66-9. [View Abstract]
  22. Berkefeld J, Kirchner J, Muller HM, Fries U, Kollath J. Balloon dacryocystoplasty: indications and contraindications. Radiology. Dec 1997;205(3):785-90. [View Abstract]
  23. Berlin AJ, Rath R, Rich L. Lacrimal system dacryoliths. Ophthalmic Surg. Jul 1980;11(7):435-6. [View Abstract]
  24. Brook I, Frazier EH. Aerobic and anaerobic microbiology of dacryocystitis. Am J Ophthalmol. Apr 1998;125(4):552-4. [View Abstract]
  25. Cassady JV. Developmental anatomy of nasolacrimal duct. Arch Ophthalmol. 1952.
  26. Cernea P, Talea L. [Congenital bilateral dacryocystitis and craniofacial dysraphia]. Oftalmologia. Apr-Jun 1992;36(2):135-9. [View Abstract]
  27. Coden DJ, Hornblass A, Haas BD. Clinical bacteriology of dacryocystitis in adults. Ophthal Plast Reconstr Surg. Jun 1993;9(2):125-31. [View Abstract]
  28. Dryden RM, Wulc AE. Lacrimal inflammations and infections. In: Oculoplastic, Orbital and Reconstructive Surgery. Vol. 2. 1417-23.
  29. Ducasse A, Hannion X, Adam R, Segal A. [Neonatal dacryocystitis. A case report]. Bull Soc Ophtalmol Fr. Jun-Jul 1990;90(6-7):595-7. [View Abstract]
  30. Dutton JJ. Standardized echography in the diagnosis of lacrimal drainage dysfunction. Arch Ophthalmol. Jul 1989;107(7):1010-2. [View Abstract]
  31. Eshraghy B, Raygan F, Tabatabaie SZ, Tari AS, Kasaee A, Rajabi MT. Effect of mitomycin C on success rate in dacryocystorhinostomy with silicone tube intubation and improper flaps. Eur J Ophthalmol. May-Jun 2012;22(3):326-9. [View Abstract]
  32. Ffooks OO. Dacryocystitis in Infancy. Br J Ophthalmol. Jul 1962;46(7):422-34. [View Abstract]
  33. Filipowicz-Banachowa A. [Pathological changes found in the lacrimal sac during nasolacrimal duct surgery]. Klin Oczna. Feb-Mar 1991;93(2-3):89-90. [View Abstract]
  34. Flanagan JC, Stokes DP. Lacrimal sac tumors. Ophthalmology. Dec 1978;85(12):1282-7. [View Abstract]
  35. Garfin SW. Etiology of dacryocystitis and epiphora. Arch Ophthalmol. 1942;27:167-88.
  36. Ghose S, Mahajan VM. Fungal flora in congenital dacryocystitis. Indian J Ophthalmol. Oct-Dec 1990;38(4):189-90. [View Abstract]
  37. Goldberg SH, Fedok FG, Botek AA. Acute dacryocystitis secondary to exudative rhinitis. Ophthal Plast Reconstr Surg. 1993;9(1):51-2. [View Abstract]
  38. Harley RD. Diseases of the lacrimal apparatus. Pediatr Clin North Am. Dec 1983;30(6):1159-66. [View Abstract]
  39. Hartikainen J, Lehtonen OP, Saari KM. Bacteriology of lacrimal duct obstruction in adults. Br J Ophthalmol. Jan 1997;81(1):37-40. [View Abstract]
  40. Hawes MJ. The dacryolithiasis syndrome. Ophthal Plast Reconstr Surg. 1988;4(2):87-90. [View Abstract]
  41. Heirbaut AM, Colla B, Missotten L. Silicone intubation for congenital obstruction of nasolacrimal ducts. Bull Soc Belge Ophtalmol. 1990;238:87-93. [View Abstract]
  42. Hurwitz JJ, Rodgers KJ. Management of acquired dacryocystitis. Can J Ophthalmol. Aug 1983;18(5):213-6. [View Abstract]
  43. Karesh JW, Perman KI, Rodrigues MM. Dacryocystitis associated with malignant lymphoma of the lacrimal sac. Ophthalmology. May 1993;100(5):669-73. [View Abstract]
  44. Lieb WE, Mohr A, Bruhl K. [The value of digital subtraction dacryocystography]. Fortschr Ophthalmol. 1989;86(6):679-81. [View Abstract]
  45. Liu X. [Culture of anaerobic bacteria and antibiotic sensitivity test in ocular infectious diseases]. Zhonghua Yan Ke Za Zhi. Mar 1991;27(2):80-3. [View Abstract]
  46. Mainville N, Jordan DR. Etiology of tearing: a retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthal Plast Reconstr Surg. May-Jun 2011;27(3):155-7. [View Abstract]
  47. Mandal R, Banerjee AR, Biswas MC, Mondal A, Kundu PK, Sasmal NK. Clinicobacteriological study of chronic dacryocystitis in adults. J Indian Med Assoc. May 2008;106(5):296-8. [View Abstract]
  48. Marx JL, Hillman DS, Hinshaw KD, Olson JJ, Putterman AM, Lam S. Bilateral dacryocystitis after punctal occlusion with thermal cautery. Ophthalmic Surg. Aug 1992;23(8):560-1. [View Abstract]
  49. Mauriello JA Jr, Palydowycz S, DeLuca J. Clinicopathologic study of lacrimal sac and nasal mucosa in 44 patients with complete acquired nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 1992;8(1):13-21. [View Abstract]
  50. McNab AA, Potts MJ, Welham RA. The EEC syndrome and its ocular manifestations. Br J Ophthalmol. Apr 1989;73(4):261-4. [View Abstract]
  51. Morgan S, Austin M, Whittet H. The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy. Br J Ophthalmol. Jan 2004;88(1):139-41. [View Abstract]
  52. Rosen N, Sharir M, Moverman DC, Rosner M. Dacryocystorhinostomy with silicone tubes: evaluation of 253 cases. Ophthalmic Surg. Feb 1989;20(2):115-9. [View Abstract]
  53. Schenck NL, Ogura JH, Pratt LL. Cancer of the lacrimal sac. Presentation of five cases and review of the literature. Ann Otol Rhinol Laryngol. Mar-Apr 1973;82(2):153-61. [View Abstract]
  54. Singh M, Jain V, Singh SP, Gupta SC. Endoscopic dacryocystorhinostomy in cases of dacryocystitis due to atrophic rhinitis. J Laryngol Otol. Jun 2004;118(6):426-8. [View Abstract]
  55. Sodhi PK. Early and late assessment of internal drainage of chronic dacryocystitis. Ophthalmologica. Jul-Aug 2004;218(4):288; author reply 289. [View Abstract]
  56. Stefanescu-Dima A, Petria I, Craitoiu S. [Carcinoma of the lacrimal sac]. Rev Chir Oncol Radiol O R L Oftalmol Stomatol Ser Oftalmol. Jul-Sep 1989;33(3):231-4. [View Abstract]
  57. Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology. Jul 1995;102(7):1065-70. [View Abstract]
  58. Udovicki J. [Rhinolithiasis complicated by purulent dacryocystitis]. Med Pregl. 1989;42(9-10):329-31. [View Abstract]
  59. Valenzuela AA, McNab AA, Selva D, O'Donnell BA, Whitehead KJ, Sullivan TJ. Clinical features and management of tumors affecting the lacrimal drainage apparatus. Ophthal Plast Reconstr Surg. Mar-Apr 2006;22(2):96-101. [View Abstract]
  60. van Bijsterveld OP, Klaassen-Broekema N. Lacrimal conjunctivitis. Bull Soc Belge Ophtalmol. 1990;238:61-9; discussion 69-70. [View Abstract]
  61. Vegh M, Nemeth J. [Ultrasound diagnosis of the lacrimal sack]. Fortschr Ophthalmol. 1990;87(6):638-40. [View Abstract]
  62. Viers R. Lacrimal disorders. In: Diagnosis and Treatment. St. Louis: CV Mosby; 1976:72-88.
  63. Wong SC, Healy V, Olver JM. An unusual case of tuberculous dacryocystitis. Eye. Sep 2004;18(9):940-2. [View Abstract]
  64. Zapala J, Bartkowski AM, Bartkowski SB. Lacrimal drainage system obstruction: management and results obtained in 70 patients. J Craniomaxillofac Surg. May-Jun 1992;20(4):178-83. [View Abstract]

Acute dacryocystitis.

A 2-week-old infant with life-threatening amniotocele causing airway compromise.

Postoperative image of same patient as in Media file 2, 1 year after drainage of amniotocele.

Acute dacryocystitis.

A 2-week-old infant with life-threatening amniotocele causing airway compromise.

Postoperative image of same patient as in Media file 2, 1 year after drainage of amniotocele.