The symptoms and overall appearance of the area around the lacrimal sac are specific, making diagnosis simple. The oculoplastic surgeon will take a careful history of previous watering eye, eye infections, nasal discharge and general medical conditions. The oculoplastic surgeon will then examine the eyelids, the area over the lacrimal sac, the small openings to the tear ducts (puncta), the inner corner of the eye (medial canthus) and carry out nasal endoscopic examination.
Typically, the elevation of the lacrimal sac is situated just below the inner corner of the eye. In dacryocystitis the surface of the elevation appears red and is tender, or even acutely painful to the touch. The lump feels smooth and warm and may have an area of palpable abscess 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 like that of an orbital cellulitis. The orbit and eyelid are swollen and the patient feverish and unwell. This is then an emergency.
In contrast, chronic dacryocystitis has less redness and pain. The elevation is more likely to have a chronic discharge from the lacrimal sac, either via a fistula or, if it is just a mucocele, back to the eye.
A mucocele is a collection of mucous within the lacrimal sac and predisposes to the risk of dacryocystitis.
The definitive treatment of acute dacryocystitis is surgery. Initially, we treat dacryocystitis with systemic antibiotics to reduce the infection. Since the cause is a blocked tear duct, this will have to be bypassed surgically by dacryocystorhinostomy (DCR).
Urgent management of acute dacryocystitis:
- Urgent drainage of the dacryocystitis via the skin under local anaesthetic. This relieves the pain and pressure, but does not treat the underlying cause. Therefore the dacryocystitis may return and risk becoming chronic. The definitive treatment is a dacryocystorhinostomy (DCR) which must be done within six weeks of the abscess draining.
- A primary DCR is performed which treats both the infected abscess and the tear duct obstruction simultaneously. We prefer the endoscopic endonasal DCR in acute dacryocystitis because it avoids a skin incision near to the abscess. However, an external DCR, carefully positioning the skin incision away from the abscess, can also be used with success. During the DCR the lacrimal sac contents are drained directly into the nose. The associated abscess in the soft tissue is also drained. And since there is no longer any stagnant tears or mucous (sludge) the dacryocystitis will not recur.
At DCR it is possible to check within the sac for any tumours, or other pathology and, if in doubt, a biopsy of the lacrimal sac can be done.
Jane Olver, as an oculoplastic surgeon, will tell you about the best option depending on your particular case. In a small number of patients, in whom the origin of the acute dacryocystitis is a lacrimal sac stone, the dacryocystitis can spontaneously resolve once the stone has passed through to the duct (like a kidney stone). But often the stones or sludge caught in the sac and blocking the top end of the duct cannot pass down, or recurs, and DCR is required.