Acute Dacryocystitis

Condition

Acute dacryocystitis is an infection in the lacrimal sac caused by either a blocked tearduct (nasolacrimal duct) or a lacrimal stone plugging the opening to the tearduct. When the opening of the duct is blocked, tears and mucous will remain within the sac, forming a deposit that can easily become infected. A blocked tearduct can be the result of various causes, such as chronic inflammation, sinus disease, trauma, and very rarely, tumour. Other rare causes include systemic conditions such as Wegeners, sarcoid or tuburculosis.

The symptoms of acute dacryocystitis are:

  • An acute onset of a painful, red lump between the eye and the nose
  • In severe cases, swelling can be so prominent that the eyelids completely close
  • Sometimes acute dacryocystitis presents with general symptoms and a high temperature
  • As tears are full of bacteria and can cause conjunctivitis, the eye is usually red, watering and uncomfortable
  • A raised absess that may burst
If untreated, acute dacryocystitis can become chronic with a discharge from the eye and even from the fistula over the sac. 
The definitive treatment of acute and chronic dacryocystitis is surgery.  


Examination

The symptoms and overall look of the area around the lacrimal sac are quite specific so diagnosis is simple. The oculoplastic surgeon will take a careful history regarding previous watering eye, infections, nasal disease and general medical conditions. 

The oculoplastic surgeon will examine the eyelids, the small openings to the tearducts (puncta), the inner corner of the eye (medial canthus) and often carry out a nasal endoscopic examination.

Typically the elevation is just below the inner corner of the eye and the surface appears red, tender or even acutely painful to the touch. The lump feels smooth and warm and may have an area of palpable absess within it. The skin over an acute dacryocystitis is often thinned and reddish blue in colour. Frequently the patient has an associated watering eye, but not in all cases. 

If the acute dacryocystitis is very severe, the appearance can be similar to that of an orbital cellulitis, with the orbit and eyelid swelled, the patient feverish and unwell. 

In contrast, chronic dacryocystitis has less redness and pain, and the elevation is more likely to have chronic discharging from the lacrimal sac via a fistula.

Treatment

The definitive treatment of acute dacryocystitis is surgery.

Initially, it can be treated with systemic antibiotics in order to reduce the infection; but if the cause is a blocked tearduct, this will have to be bypassed surgically (DCR). 

Acute dacryocystitis can be treated using two methods:

 1. Urgent drainage of dacryocystitis via the skin. This relieves the pain and pressure, but does not treat the underlying cause, therefore the dacryocystitis may return and become chronic. The definitive treatment is a dacryocystorhinostomy (DCR) which should be done within six weeks of the absess drainage.

 2. A primary DCR can be performed to treat both the infected absess and the tearduct obstruction at the same time. The endoscopic endonasal DCR is preferred because it avoids a skin incision near to the absess. However, an external DCR is possible by varying the position of the skin incision. The lacrimal sac has formed an absess in the soft tissue anterior to it and by draining the lacrimal sac conents directly into the nose, the absess is drained. At the DCR, it is possible to check within the sac for any possible tumours or other pathology and a biopsy can be obtained if necessary.

The oculoplastic surgeon will advise about the best option depending on the case. In a small number of patients in whom the origin of their acute dacryocystitis is a lacrimal sac stone, the patient can spontaneously pass the stone through the duct (similar to a kidney stone) and the dacryocystitis will be resolved.