Dacryocystitis: Types, Causes, Symptoms, Diagnosis, Treatment and Complications

Stagnant tears due to blockage of the tear drainage system can lead to this infection.

It is an infection of the lacrimal sac in the inner corner of the eye. Tears help keep your eyes hydrated, clean, and bacteria-free.

The tear glands under the upper eyelids produce tears, which travel through small openings in the front of the eye. Every time you blink, tears roll down your eyes.

To make way for new tears, the fluid drains into your eyes through tiny holes, called points, at the corners of the upper and lower eyelids.

It then drains through the nasolacrimal sac into the tear duct and down the back of the nose.

Parts of the tear drainage system

The tear drainage system consists of:

  • Tip : It is located near the medial (inner) end of each eyelid and is attached to the vertical canaliculus.
  • Canaliculus vertica l: the canaliculus vertical, also known as the ampulla, is approximately 2 mm long and continues with a horizontal canaliculus.
  • Horizontal canaliculus : measures approximately 8 mm in length. The canaliculus of the upper and lower eyelid join to form a common canaliculus in approximately 90% of cases.
  • Lacrimal Sac : The lacrimal sac is approximately 10 mm long and is located in the lacrimal fossa near the medial canthus of the eye, where the upper and lower eyelids meet internally.
  • Nasolacrimal Duct : The nasolacrimal duct is approximately 12mm long and joins the lacrimal sac with the nasal cavity, the nasolacrimal duct opens into the lower meatus of the nose. The opening of this duct is partially covered by a fold of mucosa called the Hasner valve.

Functioning of the lacrimal system

The contraction and expansion of the lacrimal sac with each blink, which is governed by the action of the orbicularis oculi muscle, results in the movement of tears from the eyes to the nose.

Excessive watering of the eyes can be due to:

  • Lacrimation: which is caused by the reflex overproduction of tears due to irritation of the cornea or conjunctiva.
  • The obstructive epiphora: it is due to the mechanical obstruction of the drainage of the tears.
  • Lacrimal pump failure: It is due to a lax lower eyelid or orbicularis muscle weakness.

Types of dacryocystitis

Dacryocystitis can be:

  1. Congenital: Congenital dacryocystitis is usually due to non-canalization of the nasolacrimal duct.
  2. Acquired: Acquired dacryocystitis can be acute or chronic.

Acute dacryocystitis: Acute dacryocystitis is characterized by the sudden onset of sharp pain and redness in the medial canthal area.

Chronic Dacryocystitis : Chronic dacryocystitis lasts for a long period of time and is characterized by chronic inflammation or infection of the lacrimal sac resulting in epiphora.

Causes

Infections are usually caused by a blockage in the nasolacrimal duct that leads to stagnant tears and allows bacteria to accumulate within the lacrimal sac.

The infection usually begins due to this blockage in the tear duct.

Possible causes of this blockage include:

  • Injury to the nose or eye.
  • Growths inside the nose called nasal polyps.
  • Sinus inflammation.
  • Nasal or sinus surgery.
  • Presence of a foreign object in the duct.
  • Cancer.

Dacryocystitis is more common in babies, who can be born with a blocked tear duct. This is called congenital dacryocystitis.

Middle-aged women are more likely than men to have a blockage because their duct is naturally narrower.

The condition becomes more common as you get older.

Other risk factors for dacryocystitis include:

  • The deviated septum, when the septum, a thin wall between the nostrils, is off-center, making one nostril smaller than the other.
  • The rhinitis or inflammation of the mucous membrane in the nose.
  • Hypertrophy of the inferior turbinate or swelling of one of the bony structures of the nose that helps filter and humidify the air that is breathed.
  • The abnormalities of the midface.

The causative agents of dacryocystitis can be:

In children

  1. Staphylococcus aureus.
  2. Β-hemolytic streptococcus.
  3. Pneumococcus.
  4. Haemophilus influenzae.

In adults

  1. Staphylococcus epidermidis.
  2. Staphylococcus aureus.
  3. Pneumococcus.
  4. Pseudomonas aeruginosa.
  5. Fusobacterium.

Symptoms

Symptoms of chronic dacryocystitis include:

  • Pain, redness, and swelling in the inner corner of the eye.
  • Watery eye
  • Swelling in the corner of the eye next to the nose.
  • Red eyes
  • Pus or mucus in the corner of the eye
  • Fever.

Symptoms of acute dacryocystitis are generally milder.

You may notice watering and some discharge from your eye, but little or no swelling.

Diagnosis

The diagnosis depends on the clinical presentation and the tests performed on them. In congenital dacryocystitis the child may present:

  • Lacrimation of the eye.
  • Mucopurulent discharge from the eyes, if there is a super-seasoned infection due to a blockage.
  • Regurgitation of the punctum discharge when pressure is applied to the lacrimal sac area.
  • Congenital lacrimal sac mucocele (also called congenital dacryocele or amniontocele), caused by the imperforate valve of Hasner. It presents as a bluish cystic swelling in or below the medial canthus area.

Congenital dacryocystitis must be differentiated from conditions such as neonatal conjunctivitis, point atresia, and congenital glaucoma that also cause tearing of the eyes.

Dacryocystitis must be differentiated from conditions such as:

The following tests may be performed for dacryocystitis at diagnosis:

Laboratory

  • Eye discharge smear exam.
  • Blood test.
Imaging studies
  • Plain X-ray: Plain X- ray can help diagnose skeletal abnormalities or any foreign body as a causative factor.
  • Computed tomography: Computed tomography is useful in suspected cases of malignancy or occult mass.
  • Dacryocystography: X-rays are taken after contrast dye is injected into the canaliculi.
  • Dacryocystography with computed tomography: This is done by obtaining images without bone by subtraction for better delineation.
  • Tear scintigraphy: Tears are marked with technetium-99m and their progress is monitored through the drainage system to detect any abnormalities.
Other tests

Fluorescein dye disappearance test: performed by instilling fluorescein dye into the conjunctival sac. Prolonged retention of dye generally more than 5 minutes indicates delayed drainage.

Jones stain primary test: differentiates partial obstruction of the tear passages from primary tear hypersecretion. The fluorescein dye is infiltrated into the conjunctival sac and its recovery from the nose is assessed.

Fluorescein can be recovered from the nose in primary hypersecretion. Non-recovery of fluorescein from the nose may be due to partial obstruction or failure of the tear pump.

Jones Dye Secondary Test – Identifies the likely site of partial obstruction. Topical anesthetic drops are infiltrated and residual fluorescein is removed from the conjunctival sac. The drainage system is flushed with normal saline.

Recovery of fluorescein-stained saline from the nose indicates a partial obstruction of the nasolacrimal duct.

If unstained saline is drawn from the nose, it may be due to a partial obstruction of the upper drainage system (puncture, canaliculus, or common canaliculus) or it may be due to a faulty tear pump.

Nasal endoscopy: This can help rule out hypertrophy of the inferior turbinate, any deviation of the nasal septum, or narrowing of the inferior meatus.

Histological examination

There may be chronic inflammation and fibrosis in the lacrimal sac.

The lacrimal sac may also show goblet cell loss, focal ulceration, abscess, or granuloma formation.

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

Treatment

The main treatment for dacryocystitis is oral antibiotic eye drops and ointments. To relieve pain and inflammation from the infection, hold warm compresses to the eye several times a day.

After the infection clears, you may need a procedure called a dacryocystorhinostomy . This surgery is to clear the blocked canal, usually by removing a nearby bone.

Allows tears to drain directly from the lacrimal sac into the nose. The widening of the duct prevents infections in the future.

Surgery can be done endoscopically through very small incisions.

Local massage on the lacrimal sac is also recommended, it is performed by blocking the common canaliculus with the finger and then stroking down to increase the hydrostatic pressure within the lacrimal sac, which can open the membranous obstruction in the nasolacrimal duct.

Complications

An acute infection can become chronic if you don’t treat it quickly enough.

In babies with congenital dacryocystitis, the infection can spread to the eye socket.

This can lead to life-threatening complications such as:

  • Brain abscess, a collection of pus in the brain.
  • Meningitis or inflammation of the membranes that surround the brain and spinal cord .
  • Sepsis , an inflammatory response throughout the body caused by an infection.