Evan Sussenbach
Junior Medical Student
Medical College of Georgia, Augusta

Massimo Federico, MD
Resident, Department of Emergency Medicine
Medical College of Georgia, Augusta

Pearl: In patients with the sudden onset of pain, erythema, and edema overlying the lacrimal sac region, treatment should be instituted for acute dacryocystitis before this disease process predisposes the patient to more severe consequences, including orbital cellulitis, cavernous sinus thrombosis, or even blindness.

Case: A 33-year-old woman presented to the emergency department with the acute onset of pain, erythema, and edema in the skin overlying the lacrimal sac. (Figures 1, 2) The patient described signs consistent with epiphora, the overflow of tears secondary to blockage of the nasolacrimal duct. She denied purulent drainage, conjunctivitis, diplopia, or any changes in vision. On examination, she was afebrile and otherwise well-appearing. She had a palpable mass underneath the medial canthal tendon. Laboratory evaluation revealed a white blood cell count of 5,600 per cubic millimeter. The initial differential diagnosis list was limited to acute dacryocystitis, periorbital cellulitis, orbital cellulitis, anterior blepharitis, and chalazion. With the patient not manifesting signs of conjunctivitis, vision changes, eye pain, papillary dysfunction, or fever, orbital cellulitis was not suspected. Cultures were obtained from purulence around the medial canthus, and the patient was discharged home with a prescription for amoxicillin/clavulanate.

Figure 1

Figure 2

Figure 3

Diagnosis: Acute dacryocystitis

Discussion: The nasolacrimal system can be thought of as a series of three pools with channels between each.¹ Those three pools are the eye, the lacrimal sac, and the nose.¹ The nasolacrimal system drains tears pooling on the surface of the eye through a series of ducts and into the nasal cavity. The medial canthus has two ostia, both of which drain into canaliculi, which eventually empty into the lacrimal sac and lacrimal duct. (Figure 3) Since the lacrimal duct empties into the inferior meatus in the nose, which is colonized with bacteria, the nasolacrimal system is prone to infection and inflammation.² Blockage of the nasolacrimal drainage system can result in decreased tear flow, overgrowth of bacteria, and dacryocystitis. Acquired dacryocystitis can be broken into two categories — acute and chronic.³ Acute dacryocystitis typically presents with the sudden onset of pain, erythema, and edema in the region overlying the lacrimal sac. In contrast, chronic dacryocystitis has a more insidious onset with swelling and epiphora but less inflammation and pain.⁴ Congenital dacryocystitis forms from a failure in canalization of the nasolacrimal system, a process that normally occurs during the third month of intrauterine gestation.
People with an increased tendency toward developing acute dacryocystitis include those with a longer, narrower osseous nasolacrimal canal.¹ Whites, who have a longer, narrower nasolacrimal canal, develop dacryocystitis more commonly than African-Americans, who have a larger nasolacrimal ostia and a shorter, wider lacrimal canal.¹ Acquired dacryocystitis is more common in women than men by a 3:1 ratio.¹ Dacryocystitis has a peak incidence in two age groups. Two to four percent of newborns develop dacryocystitis secondary to congenital stenosis of the nasolacrimal duct.⁴ In adults, the peak incidence is in the fifth and sixth decades.¹ Dacryocystitis occurs more frequently on the left side than on the right side because often the nasolacrimal duct and lacrimal fossa form a greater angle on the right side than on the left side.⁵

Symptoms
A patient with acute dacryocystitis may present with a spectrum of symptoms. The mildest dacryocystitis presents with clear epiphora. More severe dacryocystitis involves conjunctival injection, periorbital cellulitis of the nose, cheek, teeth, and face, orbital cellulitis, cavernous sinus thrombosis, purulent epiphora, meningitis, brain abscess, or sepsis.⁶ The most common presentation, however, is the patient with sudden onset of pain, erythema, and edema overlying the lacrimal sac region. The lacrimal sac may rupture and create a fistula through the skin, producing drainage in a process called mattering. This fistula, however, commonly closes after a few days of drainage.⁸ Excessive tearing is almost always present, and it is not uncommon for a palpable mass to be noted inferiorly to the medial canthal tendon.⁷ A very small percentage of patients present very ill with fever and an elevated white blood cell count. 

Diagnosis
The differential diagnosis list can be extensive – to include adult blepharitis, periorbital cellulitis, chalazion, dacryoadenitis, hordeolum (stye), bacterial conjunctivitis, episcleritis, and sarcoidosis.^6,7 The most pressing concern is to rule out orbital cellulitis – the most serious sequela of acute dacryocystitis.  Orbital cellulitis – an abscess within the orbit itself – manifests as eye pain, impairment of extraocular eye motility, loss of visual acuity, and edema of the bulbar conjunctivae.² When this occurs, it may lead to blindness, cavernous sinus thrombosis, and death.⁴

Acute dacryocystitis is a clinical diagnosis in most cases, but the use of imaging can help rule out other causes in abnormal presentations or demonstrate the reason for the nasolacrimal obstruction. Dacryocystography, the first method used for visualizing the nasolacrimal system, involves irrigating the lacrimal ducts with contrast and taking serial radiographs.⁸ Dacryocystography may reveal nasolacrimal duct stenosis, fistulae, mucoceles, foreign bodies, mass lesions, or lacrimal system stones that may be the cause of the lacrimal disorder.⁸ Dacryoscintigraphy involves instilling Technetium-99m pertechnetate solution into each eye and has been found to be as sensitive as dacryocystogaphy while being easier for children to tolerate.⁸ Ultrasound, although not ideal for visualizing the nasolacrimal system, can demonstrate enlargement of the lacrimal sac or a dacryocystocele.⁸ CT scans are useful for demonstrating patency of the lacrimal drainage system, as well as revealing issues in the adjacent bony and soft-tissue structures.⁸ If orbital cellulitis is suspected, a CT scan with contrast is essential.⁸ MRI is adequate for identifying obstruction of the lacrimal system and can differentiate mucoceles, neoplasms, and papillomas.⁸ MRI should be used as a secondary imaging modality, however, because of its cost and because it cannot be used emergently the way a CT can.

Treatment
The treatment of dacryocystitis depends upon the clinical presentation. Simple infection of the lacrimal sac and skin without orbital cellulitis does not require hospitalization unless the patient is febrile or appears toxic.⁹ Cultures should be drawn, and then treatment may be initiated with an oral antibiotic, such as amoxicillin/clavulanate.⁹ Cool compresses may aid in resolution of the disease.⁷

Acute dacryocystitis with orbital cellulitis requires inpatient intravenous (IV) antibiotics against likely pathogens, including Staphylococcus aureus, Streptococcus pneumoniae, other Streptococcus species, and Hemophilus influenzae.⁴ An ophthalmological consult should be requested, with appropriate neuroimaging studies and surgical exploration and drainage. Blood cultures and cultures of the lacrimal secretions should be obtained immediately.¹⁰ Antibiotic therapy with intravenous nafcillin or cefazolin should be initiated for penicillin-resistant Staphylococcus, with consideration for treatment of MRSA with vancomycin or clindamycin.²

Acute congenital dacryocystitis is a serious condition, as an infant’s nasolacrimal system and orbital floor are not yet completely formed, predisposing to bacterial facial cellulitis and cavernous sinus thrombosis.² Acute congenital dacryocystitis should be treated promptly and aggressively with parenteral antibiotics, as newborn infants can experience orbital cellulitis, brain abscess, meningitis, sepsis, and death. Blood cultures should be obtained before antibiotics are begun.⁹

References:

1. Mills DM, Meyer DR. Acquired nasolacrimal duct obstruction. Otolaryngologic Clin North Am 2006;39:979-999.
2. Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am  2007;21:393–408.
3. Mills DM, Bodman MG, Meyer DR, et al. The microbiologic spectrum of dacryocystitis: A national study of acute versus chronic infection. Ophthal Plast Reconstr Surg 2007;23:302-6.
4. Pasternak A, Irish B. Ophthalmologic Infections in Primary Care  2004;6:19-33.
5. Agarwal, S, Agarwal A, Apple DJ, et al.  Dacryocystitis.  Textbook of Ophthalmology, Volume 1. Jaypee Brothers Medical Publishers;New Delhi:2002.
6. Prentiss KA, Dorfman DH. Pediatric ophthalmology in the emergency department.  Emerg Med Clin North Am  2008;26:181–198.
7. Naradzay J, Barish RA. Approach to ophthalmologic emergencies. Med Clin North Am  2006;90:305–328.
8. Ansari SA, Pak J, Shields M. Pathology and imaging of the lacrimal drainage system.  Neuroimaging Clin North Am  2005;15:221–237.
9. Sowka JW, Gurwood AS, Kabat AG. Dacryocystitis.  Handbook of Ocular Disease Management.  Jobson Publishing;2001.
10. Baskin DE, Reddy AK, Chu YI, et al. The timing of antibiotic administration in the management of infant dacryocystitis. J AAPOS 2008;12:456-9.
11. Boulos PR. A lacrimal sac abscess incision and drainage technique. Arch Ophthalmol. 2008;126:1297-1300.
12. Morgan S, Austin M, Whittet H. The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy. Br J Ophthalmol 2004;88:139–141.
13. Asheim J, Spickler E. CT demonstration of dacryolithiasis complicated by dacryocystitis.  Am J Neuroradiology 2005;26:2640-2641.

Online Resources:

1.  http://emedicine.medscape.com/article/909213-overview
2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2083007/pdf/981.pdf

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