Dacryocystitis : Introduction, Symptoms, Causes, Diagnosis, Management and Prevention - www.genericdrugscan.com

Dacryocystitis : Information

Dacryocystitis is an inflammation affecting lacrimal sac.

Lacrimal excretory system drain tears from eye to the nasal cavity. Stagnation of tears due to blockage of lacrimal drainage system can result in dacryocystitis.

Lacrimal drainage system consists of:-

Punctum (plural puncta): Punctum is located near the medial (inner) end of each eyelid and it joins vertical canaliculus.

Vertical canaliculus (plural canaliculi): Vertical canaliculus, also known as ampulla (plural ampulae) is about 2mm in length and it continues with horizontal canaliculus.

Horizontal canaliculus: Horizontal canaliculus is about 8mm in length. Canaliculus from upper and lower eyelid joins to form common canaliculus in about 90% of cases. A small flap of mucosa (valve of Rosenmuller) overhangs at the opening of common canaliculus into the lateral wall of lacrimal sac.

Lacrimal sac: Lacrimal sac is about 10mm long and lies in lacrimal fossa near medial canthus (where upper and lower lid meet internally) of the eye. It continues as nasolacrimal duct.

Nasolacrimal duct: Nasolacrimal duct is about 12mm long and joins lacrimal sac with the nasal cavity (nasolacrimal duct opens into the inferior meatus of the nose). The opening of the duct is partially covered by a mucosal fold known as valve of Hasner.

The contraction and expansion of lacrimal sac with each blink (being governed by action of orbicularis muscle) results in movement of tears from eyes to the nose.

Excessive watering from the eyes may be due to:-

- Lacrimation: Lacrimation is caused by reflex overproduction of tears due to irritation of the cornea or conjunctiva.

- Obstructive epiphora: Obstructive epiphora is due to mechanical obstruction of the drainage of tears.

- Lacrimal pump failure: Lacrimal pump failure is due to lax lower lid or weakness of orbicularis muscle.

Dacryocystitis may be congenital or acquired.

Congenital dacryocystitis is usually due to non-canalisation of the nasolacrimal duct.

Acquired dacryocystitis may be acute or chronic.

Acute dacryocystitis is characterised by sudden onset of acute pain and redness in the medial canthal area.

Chronic dacryocystitis is characterised by chronic inflammation or infection of the lacrimal sac resulting in epiphora (watering from the eye).

References:

http://emedicine.medscape.com/article/1210688-overview

http://eyewiki.aao.org/Dacryocystitis

http://eyewiki.aao.org/Dacryocystorhinostomy

http://www.ncbi.nlm.nih.gov/pubmed/7091274

Kanski,Jack J. Clinical Ophthalmology, A Systematic Approach .Third Edition.UK. Butterworth Heinemann, 1994.

The patient usually present with:-

Congenital dacryocystitis: The lower end of nasolacrimal duct may be non-canalised at birth. It gets canalised on its own in most of the cases during first few weeks of life. During non-canalised period, child may have symptoms like:-

- Watering from the eye.

- Mucopurulent discharge from the eyes, if there is superadded infection due to blockage.

Besides non-canalisation, neonatal infection may also cause congenital dacryocystitis.

Acute dacryocystitis: It may be associated with one or more of following features:-

- Pain of sudden onset, redness and swelling overlying lacrimal sac area.

- Watering from the eyes.

- Discharging wound overlying lacrimal sac area.

- Conjunctival redness.

- Lid swelling.

Patient may have systemic features like fever and general prostration.

Chronic dacryocystitis: It may be associated with:-

- Watering from the eyes.

- Mucopurulent discharge from the eyes, if there is associated infection.

- Conjunctival redness.

- Swelling in the region of lacrimal sac.

The causative agents for dacryocystitis may be:-

In children:-

- Staphylococcus aureus.

- -haemolytic streptococcus.

- Pneumococcus.

- Haemophilus influenzae.

In adults:-

- Staphylococcus epidermidis.

- Staphylococcus aureus.

- Pneumococcus.

- Pseudomonas aeruginosa.

- Fusobacterium

Dacryocystitis usually occurs due to obstruction of the nasolacrimal duct which leads to stagnation of tears.

Dacryoliths or concretions may also block lacrimal drainage system. Dacryoliths may be associated with Fungal infection.

Nasal diseases like rhinitis, deviated nasal septum, nasal polyp or hypertrophy of inferior turbinate may block the opening of nasolacrimal duct in the nose, thereby leading to stagnation of tears.

Abnormalities of midface should also be considered as contributory factor.

Occult malignancy or mass may present as dacryocystitis.

The diagnosis depends upon clinical presentation and tests conducted thereof:-

Congenital dacryocystitis: Child may present with:-

- Watering from the eye.

- Mucopurulent discharge from the eyes, if there is superadded infection due to blockage.

- Regurgitation of discharge from the punctum on applying pressure over lacrimal sac area.

- Congenital lacrimal sac mucocele (also called congenital dacryocele or amniontocele). This is a collection of amniotic fluid or mucus secretion in lacrimal sac, caused due to imperforate valve of Hasner. It present as a bluish cystic swelling at or below medial canthal area. It should be differentiated from encephalocele which present as pulsatile swelling lying above medial canthal area.

Congenital dacryocystitis should be differentiated from conditions like neonatal conjunctivitis, punctual atresia and congenital glaucoma which also cause watering from the eyes.

Acute dacryocystitis: It may be associated with one or more of following features:-

- Pain/ tenderness, erythema and oedema over lacrimal sac area.

- Epiphora or watering from the eyes.

- Discharging fistula from lacrimal sac through the skin.

- Associated conjunctivitis.

- Preseptal cellulitis.

- Orbital cellulitis.

There may be associated fever and general prostration.

Chronic dacryocystitis: It may be associated with:-

- Watering from the eyes.

- Mucopurulent discharge from the eyes, if there is associated infection.

- Chronic or recurrent conjunctivitis.

- Mucocele in the region of lacrimal sac.

- Regurgitation of discharge from punctum on applying pressure over mucocele.

Dacryocystitis should be differentiated from conditions like:-

- Acute ethmoidal sinusitis.

- Punctal ectropion.

- Eyelid ectropion.

- Infected sebaceous cyst.

- Cellulitis.

- Allergic rhinitis.

Laboratory diagnosis: Following tests may be conducted for dacryocystitis:-

- Examination of smear of discharge from the eye.

- Culture and sensitivity of the discharge from the eye.

- Blood culture.

Imaging studies:

- Plain X-ray: Plain X-ray may help in diagnosing skeletal abnormality or any foreign body as a causative factor.

- CT scan: CT scan is useful in suspected cases of occult malignancy or mass.

- Dacryocystography (DCG): Radiographs are taken after injecting contrast medium into canaliculi.

- Subtraction DCG with CT scan: DCG is done by obtaining bone-free images by subtraction for better delineation.

- Lacrimal Scintillography: Tears are labelled with technetium-99m and its progress is monitored through drainage system to look for any abnormality.

Other tests:

- Fluorescein dye disappearance test: This is performed by instilling fluorescein dye in conjunctival sac. Prolonged retention of dye usually more than 5 minutes indicate delayed drainage.

- Primary Jones dye test: It differentiates partial obstruction of lacrimal passages from primary hypersecretion of tears. Fluorescein dye is instilled in conjunctival sac and its recovery from nose is assessed. Fluorescein may be recovered from nose in primary hypersecretion. Non recovery of fluorescein from nose may be due to partial obstruction or failure of lacrimal pump.

- Secondary Jones dye test: It identifies the probable site of partial obstruction. Topical anaesthetic drops are instilled and residual fluorescein is washed out from conjunctival sac. The drainage system is then irrigated using normal saline. Recovery of fluorescein stained saline from nose indicates partial obstruction of the nasolacrimal duct. If unstained saline is obtained from the nose, it may be due to partial obstruction of the upper drainage system (punctum, canaliculus or common canaliculus) or may be due to defective lacrimal pump.

- Nasal endoscopy: This may help in ruling out hypertrophy of inferior turbinate, any deviation of nasal septum or narrowing of inferior meatus.

Histological examination:

There may be chronic inflammation and fibrosis in lacrimal sac.

Lacrimal sac may also show loss of goblet cells, focal ulceration, abscess or granuloma formation.

Nasolacrimal duct and nasal mucosa may also show signs of chronic inflammation and fibrosis.

Management should be carried out under medical supervision.

Congenital dacryocystitis:

- Local massage over lacrimal sac: This is carried out by blocking the common canaliculus with finger and then stroking downward to increase hydrostatic pressure within lacrimal sac, which may open the membranous obstruction in the nasolacrimal duct.

- Topical and/or systemic antibiotics for superadded infection.

- Probing and syringing: Probing is done to open obstructive membrane near lower end of nasolacrimal duct in cases in which the duct does not open spontaneously. Syringing is performed after probing. Antibiotic drops are prescribed after syringing. Probing may be repeated in cases which do not improve.

- Dacryocystorhinostomy (DCR): DCR is a surgical procedure (external approach done through skin) in which a communication is made between medial wall of lacrimal sac and the nasal cavity, for drainage. This is done in failed cases of probing.

Acute dacryocystitis:

- Systemic broad spectrum antibiotics are prescribed.

- Warm compresses may help in resolution of the disease.

- Stab incision of the skin: Impending perforation is treated with stab incision of the lacrimal sac through the skin. Stab incision may lead to fistula formation, but it is rare.

- Dacryocystorhinostomy (DCR): When the acute infection has been controlled, a DCR may be needed to relieve any permanent obstruction.

Chronic dacryocystitis:

- Dacryocystorhinostomy (DCR): This is the procedure done in patients having longstanding epiphora or mucocele, to relieve obstruction.

- Endoscopic DCR: This is an endonasal procedure (through the nose) which may be done with or without laser.