Ophthalmology · Lacrimal System Disorders
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Dacryocystitis is an infection of the lacrimal sac caused by nasolacrimal duct obstruction.
Patients present with unilateral pain, swelling, tenderness, and erythema in the medial canthal region.
Physical examination reveals purulent discharge from the puncta upon application of pressure to the lacrimal sac.
The most common causative pathogens in adults are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, and Pseudomonas aeruginosa; beta-hemolytic streptococci are more characteristic of pediatric dacryocystitis than the adult pattern.
Acute uncomplicated dacryocystitis is treated with oral antibiotics with gram-positive coverage, such as cephalexin or amoxicillin-clavulanate; IV antibiotics (e.g., vancomycin plus ceftriaxone) are reserved for cases with orbital cellulitis, systemic toxicity, or progression despite oral therapy.
Incision and drainage is indicated only if a lacrimal sac abscess has formed.
Definitive treatment for chronic or recurrent cases is a dacryocystorhinostomy to create a new drainage pathway.
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A 52-year-old woman presents to the urgent care clinic with a 2-day history of increasing pain and swelling near the inner corner of her left eye. On physical exam, there is marked erythema and tenderness over the medial canthal region. When the physician applies gentle pressure to the area, a small amount of purulent material is expressed through the puncta. The patient has no history of trauma or recent ocular surgery.
What is the most likely diagnosis?
Dacryocystitis
The clinical presentation of medial canthal swelling, tenderness, and purulent discharge from the puncta is pathognomonic for dacryocystitis, which results from obstruction of the nasolacrimal duct.
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Etiology / Epidemiology
Infection of the lacrimal sac due to nasolacrimal duct obstruction. Common in infants and adults >40.
Clinical Manifestations
Unilateral tearing, tenderness, and purulent discharge at the medial canthus.
Diagnosis
Primarily clinical diagnosis. Avoid lacrimal irrigation during acute infection.
Treatment
Oral cephalexin or amoxicillin-clavulanate for uncomplicated cases; IV vancomycin/ceftriaxone if orbital cellulitis/systemic toxicity. No probing during acute phase.
Prognosis
Risk of orbital cellulitis. Surgical dacryocystorhinostomy for chronic cases.
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Epidemiology & Etiology
Most commonly caused by Staphylococcus aureus or Streptococcus species. Obstruction is often idiopathic in adults but may result from dacryoliths. In infants, it is frequently due to failure of the Valve of Hasner to canalize.
Pertinent Anatomy
The lacrimal sac resides in the lacrimal fossa between the anterior and posterior lacrimal crests. Obstruction of the nasolacrimal duct leads to stasis of tears and subsequent bacterial overgrowth.
Pathophysiology
Stasis within the lacrimal sac creates a nidus for bacterial proliferation. Inflammation leads to edema, further occluding the duct and creating a closed-loop system. This progression can lead to abscess formation and potential extension into the orbit.
Clinical Manifestations
Patients present with acute onset of pain, erythema, and edema localized to the medial canthal region. Gentle pressure over the sac often produces purulent reflux through the puncta. Red flags include fever, proptosis, or ophthalmoplegia, suggesting progression to orbital cellulitis.
Diagnosis
Diagnosis is clinical. Lacrimal sac irrigation is the gold standard for identifying the site of obstruction but is strictly contraindicated during the acute infectious phase due to the risk of spreading infection.
Treatment
Acute uncomplicated dacryocystitis is managed with oral antibiotics with gram-positive coverage, such as cephalexin or amoxicillin-clavulanate. IV antibiotics (e.g., vancomycin plus ceftriaxone) are reserved for cases with orbital cellulitis, systemic toxicity, or progression despite oral therapy. Warm compresses and topical antibiotics are adjunctive. Do not perform probing or irrigation while the area is acutely inflamed to prevent systemic seeding.
Prognosis
Most cases resolve with appropriate antibiotics. Chronic or recurrent cases require dacryocystorhinostomy to create a new drainage pathway. Failure to treat can lead to orbital cellulitis or cavernous sinus thrombosis.
Differential Diagnosis
Dacryoadenitis: inflammation of the lacrimal gland (lateral, not medial)
Preseptal cellulitis: diffuse eyelid swelling without focal lacrimal sac tenderness
Orbital cellulitis: presence of pain with eye movement and ophthalmoplegia
Conjunctivitis: diffuse injection without focal medial canthal mass
Mucocele: non-tender, non-inflamed swelling of the lacrimal sac