Janet was a 47-year-old woman who had been seeing an ophthalmologist for a blocked main lower tear duct in her right eye. She had been advised that she was going to require probing of the duct and this was to be arranged in the near future. However, Janet was forced to see her GP on the weekend because she developed tenderness that was maximum just lateral to her mid nose. Her eye was mildly red and more watery than usual. The GP put Janet on oral antibiotics and reviewed her the next day. By this time, Janet had developed pain and swelling below the eye and the GP referred her urgently to hospital for a presumptive dacryocystitis.
Dacryocystitis is inflammation of the lacrimal sac that sits below the eye and drains into the back of the nasal cavity. Interestingly, almost three-quarters of cases occur in females. Because of anatomical reasons, it is more common on the left side, and in people with brachycephalic-shaped heads (as the lacrimal duct is longer and the osseous nasolacrimal canal narrower in people with flat noses and thin faces). Dacryocystitis maybe acute, chronic and congenital. The acute and chronic forms are typically associated with sinus disease, especially affecting the ethmoids (mainly allergy, viral and bacterial infections). Rare causes include lupus, granulomatosis, sclerosis, radiation, trauma, cysts and tumours.
In Janet’s case, the acute infection can result in abscess formation in the lacrimal sac that may form a fistula and drain directly through the skin. This usually spontaneously closes after several days. Any significant infection in this region can result in orbital cellulitis, cavernous sinus thrombosis and extension of infection into the brain.
Chronic dacryocystitis is related mostly to chronic conjunctivitis and is generally less serious. Congenital dacryocystitis may be very dangerous, resulting in neonatal meningitis from abscess formation. The commonest bacterial infections responsible for these conditions include Pneumococcus, Staphylococcus, Pseudomonas and Streptococcus.
The diagnosis is usually based on clinical suspicion: a watery, red eye with tenderness over the lacrimal sac, and sometimes debris or pus may be expressed into medial eye via the tear duct. Later presentation includes swelling and redness over the lacrimal duct. Fever and leucocytosis may be present. Vision may be affected in relatively uncomplicated cases due to the altered tear film, or from chronic irritation of the corneal surface. Vision loss may also be due to orbital cellulitis, manifesting as diplopia from spasm of the eye muscles, and if the vision loss is peripheral, this may be due to the cellulitis causing optic neuropathy.
CT scanning may be indicated to diagnose abscess formation and CT subtraction dacryocystography (DCG) and dacryoscintigraphy are particularly useful to delineate anatomical abnormalities of the nasolacrimal region. Dye tests and nasal endoscopy are also commonly used as diagnostic aids.
Acute dacryocystitis may require hospitalisation for intravenous antibiotics and stabilisation of the infection prior to surgery. Chronic dacryocystitis and congenital dacryocystitis also usually require surgery.
Gilliland GD. Dacryocystitis. Medscape. 2016 Feb.