What is Dacryocystitis?
Dacryocystitis is a condition resulting from inflammation of the nasolacrimal sac, typically caused by a blockage in the nasolacrimal duct. This blockage makes tear flow stagnant in the lacrimal sac. You can tell if a person has Dacryocystitis when the lacrimal sac swells up at the inner corner of the eye due to inflammation. Knowing the structure of the eye and the way tears move helps us better understand this condition and how it can affect different levels of the eye.
So, how do tears flow? Well, they begin their journey in the lacrimal gland where they are produced. They then help to keep the eye moist, get collected into the top and bottom puncta (tiny openings), and are then drained into the top and bottom canaliculi (channels). From these channels, the tears flow into a common pool called the ‘common canaliculus’, before moving on through the valve of Rosenmuller into the lacrimal sac. These collected tears then go down the nasolacrimal duct, passing through the valve of Hasner, eventually making their way into the nasal cavity.
What Causes Dacryocystitis?
Dacryocystitis, an infection of the tear sac, can be divided into acute or chronic types, and those that are acquired or congenital (born with).
Acute dacryocystitis is usually caused by an infection. In the US, the most common culprit bacteria are variants of Staphylococcus and Streptococcus, along with Haemophilus influenzae and Pseudomonas aeruginosa.
Chronic dacryocystitis, on the other hand, is often the result of a long-term blockage caused by a systemic disease, repeat infections, hard lacrimal stones (dacryoliths), or chronic inflammation of the nasolacrimal system (which produces and drains tears). Diseases such as Wegener granulomatosis, sarcoidosis, and systemic lupus erythematosus are some common conditions that lead to this.
Acquired dacryocystitis is generally the result of repeated injuries, surgeries, medication use, or neoplasms (tumors). It’s important to note that fractures to the nose and ethmoid bone are the most common injuries leading to this kind of blockage. Sinus procedures specifically conducted through endonasal endoscopic surgery are the most associated surgeries. Topical medicines like timolol, pilocarpine, dorzolamide, idoxuridine, and trifluridine, and systemic drugs like fluorouracil and docetaxel, are known to cause acquired dacryocystitis. The most common tumors associated with this condition are primary lacrimal sac tumors and benign papillomas.
On the other hand, congenital forms of dacryocystitis occur due to a membrane blockage at the valve of Hasner (located in the tear duct). Before birth, the tear duct system is filled with amniotic fluid. If this fluid doesn’t get flushed out from the duct system, it turns infectious within a few days of birth and becomes a problem.
Risk Factors and Frequency for Dacryocystitis
Dacryocystitis is a condition that typically occurs just after birth or in adults who are over 40 years old. It is more common in white adults, with females making up almost 75% of all cases. This condition is seen in about 1 in 3884 live births. It’s important to know that while serious health problems and death rates are generally low with dacryocystitis, if it is not treated quickly and correctly in newborns, it can have significant consequences.
Signs and Symptoms of Dacryocystitis
Acute dacryocystitis is a condition that can develop over several hours to days and usually leads to certain eye irregularities. During an external eye exam, the area near the corner of the eye, the medial canthus, may look red, swollen, and feel tender. Swelling may also reach the bridge of the nose, but it’s rare for the upper part of the eye socket to be affected. Often, there are signs like a possibly pus-filled discharge seeping out from the upper and lower tear duct openings, and an increase in tears, a condition also known as epiphora.
Chronic dacryocystitis, on the other hand, might just cause excessive tearing. There could also be a gunky substance present due to a disrupted tear film. This condition might lead to redness in the lining of the eye and a slight decrease in vision clarity. Tests to measure visual acuity are crucial, and any sudden changes in vision that can’t be explained by a disrupted tear film should raise alarm bells for potentially more serious complications. In such cases, immediate consultation with an eye specialist is required. A red, swollen eye is not typically caused by dacryocystitis and should prompt the health professional to consider other diagnoses. Also, pain while moving the eyes should raise suspicion for other health conditions.
Testing for Dacryocystitis
The diagnosis of dacryocystitis, which is an inflammation of the tear sac, is largely dependent on the patient’s history and the doctor’s physical examination. If pus is present, it can be collected by a procedure called a Crigler massage for further laboratory tests, such as cultures and gram staining. If the patient is exhibiting signs of toxicity, such as fever or sudden changes in vision, then more extensive lab tests and blood cultures should be performed. In such severe cases, urgent consultation with an eye specialist is recommended.
If there’s a risk of orbital cellulitis or a widespread infection, a doctor might also order a CT scan. For situations where the physical structure of the tear sac is in question, a specific X-ray type called a dacryocystogram (DCG) can be done. Using a technique called subtraction DCG can help in obtaining clearer images.
For chronic cases of dacryocystitis, if doctors suspect the root cause is a systemic disease, further blood tests can be done. For instance, antineutrophilic cytoplasmic antibody testing can be performed if Wegener granulomatosis (a rare type of vasculitis) is suspected, and antinuclear antibody (ANA) testing can be ordered if they suspect systemic lupus erythematosus (an autoimmune disease).
Treatment Options for Dacryocystitis
Acute dacryocystitis, an infection of the tear duct, can be treated with simple home measures such as warm compresses and gentle massage around the eye, known as Crigler massage. If symptoms aren’t too severe, oral antibiotics that target gram-positive bacteria, especially bacteria that cause staph infections, can be considered. However, in more severe cases or when the patient is very unwell, intravenous antibiotics may be needed. These antibiotics should cover both gram-positive and gram-negative bacteria. It’s generally not advised to probe the tear duct during an active infection. If infections keep coming back, an eye specialist might need to assess the need for surgery.
Chronic dacryocystitis, a long-term inflammation of the tear sac, usually requires surgical treatment. Probing the tear duct is often the first step and can be done at a doctor’s office. Other options include balloon dacryoplasty (using a balloon to widen the tear duct), nasolacrimal intubation (inserting a small tube into the tear duct to keep it open), and nasolacrimal stenting (inserting a permanent tube). However, these measures might not always work the first time. If these treatments are unsuccessful, doctors may consider percutaneous or endonasal dacryocystorhinostomy (procedures to create a new tear duct).
If a baby has congenital dacryocystitis (tear duct infection present at birth), home treatments are usually tried first. Parents or caregivers can be taught to perform Crigler massage. Eye drops could be tried for sudden flare-ups. Most cases clear up on their own within 6 months to a year. If these measures don’t work, a referral can be made to an eye specialist to consider probing the tear duct, which works in over 70% of cases. Other options like balloon dacryoplasty, nasolacrimal intubation, or nasolacrimal stenting can be tried if symptoms return. In more stubborn cases, dacryocystorhinostomy may be the final solution.
What else can Dacryocystitis be?
When a doctor is trying to diagnose a certain condition, they often have to consider other conditions that have similar symptoms. These are known as differential diagnoses. For instance, if you have issues with your eye, the doctor might consider the following conditions:
- Preseptal cellulitis: an infection of the skin around the eye
- Orbital cellulitis: a serious infection behind the eye
- Sebaceous cyst: a small, painless lump under the skin
- Frontal, ethmoid, or maxillary sinusitis: inflammation of the sinuses in the face
- Neoplasm: an abnormal growth, which could be cancer or a benign tumor
- Ectropion of the lower eyelid: the lower eyelid turns or tilts outwards
- Dacryoadenitis: an inflammation of the tear-producing glands
It’s important for your physician to carefully evaluate your symptoms and possible underlying conditions to make the most accurate diagnosis.
What to expect with Dacryocystitis
In simple terms, dacryocystitis, a condition related to the tear ducts, usually has a positive outcome. Common treatments like probing are often very effective, and more complex procedures like DCR yield success rates of 93% to 97%. For newborns with the condition, around 90% of cases naturally get better by their first birthday with just basic care.
For people with a simple blockage in their tear ducts, the outlook is generally positive. However, those with more complicated blockages might face more challenges. These difficult cases can impact sight and quality of life.
Possible Complications When Diagnosed with Dacryocystitis
Dacryocystitis is a condition that can spread from the tear sac to the tissues around the eye socket. This may result in conditions like preseptal cellulitis, orbital cellulitis, and orbital abscess, which is a pocket of pus in the eye socket. Orbital cellulitis, in particular, could lead to the compression of the optic nerve and, subsequently, loss of vision. To prevent these complications, it’s crucial to start taking antibiotics as soon as possible.
Preventing Dacryocystitis
Parents should be vigilant if their child has unusual eye discharge, or if there’s redness and swelling near the inner corner of the eyes. If these symptoms are ignored, it may lead to a delayed diagnosis and potentially more complex treatments. Therefore, it’s crucial to seek medical help quickly if you notice these signs in your child.