Acute Dacryocystitis

Acute dacryocystitis

Acute dacryocystitis is an infection of the tear sac lacrimal sac. The reason for the infection could be a blocked tear duct (nasolacrimal duct). A lacrimal stone plugging the opening from the lacrimal sac into the tear duct could be another reason.

When the tear duct is blocked, tears and mucous will remain within the sac, forming a sludge that can easily become infected. A blocked tear duct can be the result of chronic inflammation, sinus disease, trauma and, rarely a tumour. Some diseases, such as Wegener’s, sarcoidosis or tuberculosis can also cause blockage of the tear duct.

The symptoms of acute dacryocystitis

• An acute onset of a painful red lump between the eye and the nose. In severe cases the swelling can be so prominent that the eyelids completely close, giving an orbital cellulitis.
• Sometimes acute dacryocystitis presents with general symptoms and a high temperature
  As the tears are full of bacteria, this can cause a conjunctivitis, and the eye is red, watering and uncomfortable.
• There may be a raised abscess arising from the sac that can be painful and then burst.
  If untreated, acute dacryocystitis will become chronic, with a discharge from the eye and even a fistula from the sac.

The definitive treatment of acute and chronic dacryocystitis is surgery, dacryocystorhinostomy (DCR).

Examination

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.

Treatment

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.

Our 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.

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