The lacrimal drainage system consists of the puncta (upper and lower within the eyelids) which are the opening to the upper and lower canaliculus. These meet at the common canaliculus and open into the lacrimal (tear) sac. This runs parallel to the nose and is separated from the middle meatus of the nasal cavity by two thin plates of bone. It continues down to become the nasolacrimal duct (tear duct) which opens out into the inferior nasal meatus.

Dacryocystitis

Dacryocystitis is an inflammation of the lacrimal (tear) sac, often as a result of infection. It may be acute or chronic. For anatomical reasons, it occurs more frequently on the left side. An ocular origin for inflammation of the lacrimal system is less common than a nasal origin.

Rarely, congenital dacryocystitis can occur (<1% of newborns).¹ This is a serious condition because the orbital septum is poorly formed in infants and there is a significant risk of spread (orbital cellulitis and its complications).

Epidemiology²

It is more common in females. It tends to occur either in infants (uncommon) or in adults (much more common) over the age of 40, peak age 60-70 years old.

Presentation

Acute dacryocystitis:²

• Symptoms and signs are over the region of the lacrimal sac (but may spread to nose and face with teeth pain being experienced by some). Therefore, look just lateral and below the bridge of the nose for:
  • Excess tears (epiphora) - almost invariably
  • Pain
  • Redness
  • Swelling

The patient may complain of decreased visual acuity owing to the excess tears and an abnormal tear composition.¹

Examination will reveal a tender, tense, red swelling (± preseptal cellulitis in severe cases). Mucopurulent discharge can be expressed from the punctum. There may be a fever and an elevated leukocyte count too.

Chronic dacryocystitis:³
This may present with a history of chronic or recurring epiphora and may have persistent redness of the medial canthus. There may be a painless or recurring swelling over the lacrimal sac, and pressure over this will result in reflux of mucopurulent material through the lower punctum.

Differential diagnosis^2,4

• Orbital or facial cellulitis (discharge cannot be expressed from the punctum).
• Acute ethmoid or frontal sinusitis.
• Dacryocystocele (mild enlargement of a non-inflamed lacrimal sac in an infant).

Investigations

• In severe or atypical cases (e.g. non-responsive to antibiotics), culture the expressed contents of the sac.
• CT scan of the orbit and the paranasal sinuses can be useful.
• A dacryocystography (DCG) may be performed where structural abnormalities are suspected.

Associated diseases⁴

This is most commonly associated with nasolacrimal duct obstruction which results in stasis of the lacrimal sac contents. Less commonly, it is associated with anatomical abnormalities of the lacrimal sac or with nasal or sinus surgery. Nasal disease may be found in a number of these patients, e.g. various forms of rhinitis, trauma or the presence of a foreign body.¹ Rarely, there may be a lacrimal sac tumour.

Management⁵

Acute dacryocystitis management:

• Patients tend to be managed on an outpatient basis unless they are systemically unwell.
• Initially, treatment of acute dacryocystitis is with oral antibiotics and analgesia. Examples include:⁴
  • Children - co-amoxiclav or cefaclor.
  • Adults - co-amoxiclav or cefalexin.
  The regime is guided by clinical response but typically, a 10- to 14-day course is required.
• Incision and drainage may be considered if the infection extends outside the sac and a superficial skin abscess is formed. However, this carries the risk of forming a fistula, resulting in tears draining directly to the skin surface.
• Once the infection has settled and in chronic cases, a dacryocystorhinostomy (DCR) is performed.

• Nonsurgical treatment involves warm compresses, massage and probing of the nasolacrimal duct.
• Probing involves inserting a fine metal probe via the punctum and canalicular system and passing it into the nasolacrimal sac, past the obstruction. This can often be done without a general anaesthetic. If there is acute infection, the procedure is usually deferred for a few days, until antibiotics have taken effect.⁷
• If this is not effective, surgical treatment is a DCR (see box below).
• Balloon dacryoplasty has become popular in the last few years, but may have lower success rates in the long-term. It is suitable for patients with focal stenoses or occlusions of the nasolacrimal duct.^1,8

• Conservative management, involving gentle massage over the lacrimal sac, warm compresses ± prophylactic antibiotic drops, was reported as effective in 76% of cases.
• Probing and irrigation may resolve the obstruction.
• Be aware that serious infection can develop rapidly.

See also the separate article Congenital Nasolacrimal Duct Obstruction.

Complications

These lie mainly in the risk of spread which can be superficial (e.g. cellulitis), deep (e.g. orbital cellulitis, orbital abscess⁹, meningitis) or generalised (e.g. sepsis). These complications are rare and tend to be seen in the immunocompromised individuals and in cases of congenital dacryocystitis.

Intraocular surgery - such as cataract surgery - should be postponed until the dacrocystitis (whether acute or chronic) has been treated, as there is a significant risk of ensuing endophthalmitis. However, there are complications associated with DCR too:

• Failed procedure.
• Cutaneous scarring.
• Epistaxis.
• Cellulitis.
• Cerebrospinal fluid rhinorrhoea (if the subarachnoid space is inadvertently entered).

Prognosis

This is good if managed promptly and surgery is not delayed once the acute phase has resolved. However, congenital dacryocystitis can be very serious and is associated with significant morbidity and mortality if not treated promptly and aggressively.

Chronic canaliculitis

This is an uncommon condition where the canaliculi become chronically infected. Common pathogens reported are Staphylococcus spp., Streptococcus spp., Actinomyces spp. and Propionibacterium spp.¹⁰

Presentation

• Symptoms:
  • Unilateral epiphora.
  • Chronic mucopurulent conjunctivitis (refractory to usual treatment).
• Signs:
  • Oedema of the canaliculus: look for a swelling at the medial end of the upper or the lower lid.
  • 'Pouting' punctum: this is turned out and is prominent.
  • Gentle compression of the canaliculi results in expression of concretions: solid, pale-yellow fatty material.

Investigation

High-frequency ultrasound may be helpful.¹¹

Differential diagnosis⁴

• Dacryocystitis.
• Nasolacrimal duct obstruction.
• Conjunctivitis.

Management¹⁰

• Removal of the obstruction concretions (by expressing them through the punctum) and topical antibiotics (e.g. ciprofloxacin qds for 10 days) may be effective in some cases.
• Surgery (canaliculectomy or punctoplasty) is often performed, often with expression of 'concretions' from the duct and irrigation with antibiotics or an iodine solution. Occasionally, more extensive surgery is needed.
• One study suggested that intracanalicular antibiotics can be helpful as an alternative to surgery.¹²

Canalicular obstruction^13,14

Obstruction of the lacrimal canaliculi may be congenital (see separate Congenital Nasolacrimal Duct Obstruction article) or acquired. Acquired causes include trauma, scarring, inflammatory conditions, local tumours, Bell's palsy, radiotherapy and certain drugs, e.g. docetaxel.

Presenting features are excess tearing ± sticky discharge and irritation.

Investigations:

• Syringing and probing to identify the site of obstruction.
• The Jones' fluorescein dye test

• Treat infection if present.
• Syringing and probing may be used, but they risk trauma to the duct and may aggravate the condition.
• Surgical treatment - there are various treatment methods, including punctoplasty, insertion of a silicone tube, trephination, balloon canaliculoplasty, endocanalicular laser surgery, conjunctivodacryocystorhinostomy (CDCR) and canalicodacryocystorhinostomy (canaliculo-DCR).¹⁵ One review suggests that laser or ballon canaliculoplasty may be well tolerated and a good alternative to CDCR.¹⁴

Document references

1. Gilliland GD; Dacryocystitis, eMedicine, Aug 2009
2. Dacryocystitis (acute) - clinical management guidelines, College of Optometrists, September 2008
3. Dacryocystitis (chronic) - clinical management guidelines, College of Optometrists, September 2008
4. Kunimoto DY, Kanitkar KD, Makar MS; The Wills Eye Manual, 4th Edition, 2004, Lippincott, Williams and Wilkins
5. Kanski J. Clinical Ophthalmology, A Systematic Approach, 5th Ed, 2003, Butterworth Heinemann
6. Endoscopic dacryocystorhinostomy, NICE (2005)
7. Wong RK, VanderVeen DK; Presentation and management of congenital dacryocystocele. Pediatrics. 2008 Nov;122(5):e1108-12. Epub 2008 Oct 27. [abstract]
8. Konuk O, Ilgit E, Erdinc A, et al; Long-term results of balloon dacryocystoplasty: success rates according to the Eye (Lond). 2008 Dec;22(12):1483-7. Epub 2007 Aug 24. [abstract]
9. Martins MC, Ricardo JR, Akaishi PM, et al; Orbital abscess secondary to acute dacryocystitis: case report. Arq Bras Oftalmol. 2008 Jul-Aug;71(4):576-8. [abstract]
10. Zaldivar RA, Bradley EA; Primary canaliculitis. Ophthal Plast Reconstr Surg. 2009 Nov-Dec;25(6):481-4. [abstract]
11. Tost F, Bruder R, Ostendorf M; (High-frequency ultrasonography applied to disorders of the lacrimal canaliculi J Fr Ophtalmol. 2003 Dec;26(10):1035-8. [abstract]
12. Mohan ER, Kabra S, Udhay P, et al; Intracanalicular antibiotics may obviate the need for surgical management of Indian J Ophthalmol. 2008 Jul-Aug;56(4):338-40. [abstract]
13. Nasolacrimal duct obstruction - clinical management guidelines, College of Optometrists, January 2009
14. Liarakos VS, Boboridis KG, Mavrikakis E, et al; Management of canalicular obstructions. Curr Opin Ophthalmol. 2009 Sep;20(5):395-400. [abstract]
15. Athanasiov PA, Prabhakaran VC, Mannor G, et al; Transcanalicular approach to adult lacrimal duct obstruction: a review of Ophthalmic Surg Lasers Imaging. 2009 Mar-Apr;40(2):149-59. [abstract]

Internet and further reading

• Cavazza S, Laffi GL, Lodi L, et al; Congenital dacryocystocele: diagnosis and treatment. Acta Otorhinolaryngol Ital. 2008 Dec;28(6):298-301. [abstract]

Acknowledgements