Dacryocystitis and Canaliculitis

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 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 which opens out into the inferior nasal meatus.

Dacryocystitis is an inflammation of the lacrimal 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.

Epidemiology¹

• Due to anatomical reasons, dacryocystitis is much less frequent in people of Afro-Caribbean origin compared to white individuals.
• It occurs more commonly in females.
• It tends to occur either in infants (uncommon) or in adults (much more commonly) over the age of 40, peak age 60-70 years old.

Presentation

Acute dacryocystitis

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

There may be complaints 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). There may be a fever and an elevated leukocyte count too. Mucopurulent discharge can be expressed from the punctum.

Chronic dacryocystitis

Patients may present with a history of epiphora and chronic or recurring unilateral conjunctivitis. There may be a painless swelling over the lacrimal sac and pressure over this will result in reflux of mucopurulent material through the lower punctum.

Differential diagnosis²

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

Investigations

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

Associated diseases²

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.

Management³

• 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:²
  • Children - co-amoxiclav (20-40 mg/kg/day) or cefaclor (20-40 mg/kg/day) in three divided doses
  • Adults - co-amoxiclav (500 mg 8 hourly) or cephalexin (500 mg 6 hourly)
  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.

Complications

These mainly lie in the risk of spread which can be superficial (e.g. cellulitis), deep (e.g. 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 DCRs 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.

This is an uncommon condition where the canaliculi become chronically infected. The most common pathogen is Actinomyces israeli.

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.

Differential diagnosis²

• Dacryocystitis
• Nasolacrimal duct obstruction
• Conjunctivitis

Management

Removal of the obstruction concretions (by expressing them through the punctum) and topical antibiotics (e.g. ciprofloxacin qds for 10 days) may have a temporary effect but ultimately, a canaliculectomy is often performed. A linear incision is made on the conjunctival side of the canaliculus and the concretions expressed. The canaliculus is irrigated with antibiotics or an iodine solution. Occasionally, more extensive surgery is needed.