Acute v/s Chronic Dacryocystitis
What is Dacryocystitis ?
Inflammation/ infection of the lacrimal sac is known as dacryocystitis
CONGENITAL DACRYOCYSTITIS Â is a condition that manifests at birth .This obstruction can occur due to membranous obstruction in the distal NLD, hindering the normal drainage of tears from the eyes.
ACQUIRED DACRYOCYSTITIS :Â
Results from infection, trauma, surgeries , medications , neoplasms and masses and stones .Acquired dacryocystitis can be classified into ACUTE or CHRONIC dacryocystitis.
- Acute dacryocystitis is characterized by a sudden infection or inflammation of the lacrimal sac, primarily caused by bacterial infection. This condition leads to the abrupt onset of symptoms and requires prompt attention and intervention.
- Chronic Dacryocystitis occurs because of chronic nasolacrimal duct obstruction, occurs gradually over time and persists for a long period of time.
We shall discuss chronic dacryocystitis first as it is more common than the acute dacryocystitisÂ
Who is at Risk?
- PANDO (Primary Acquired Nasolacrimal Duct Obstruction): Individuals Over 65 demonstrates increasing narrowing of the nasolacrimal duct with age.
- SANDO – (Secondary acquired nasolacrimal duct obstruction) : Risk factors include trauma and dacryolithiasis (stone formation in the lacrimal sac).
- Females: Higher susceptibility due to the narrow lumen of the bony canal.Â
- Socioeconomic Status:Low socioeconomic status is a contributing factor.
- Race: Caucasians are at a higher risk compared to colored races. Characteristics include longer , narrow, and more sinuous ducts in caucasians .
- Personal Hygiene:Poor personal hygiene may increase the risk.
Pathophysiology Of Dacryocystitis
- Chronic dacryocystitis, a persistent inflammation of the lacrimal sac, is primarily rooted in tears stasis and subsequent chronic infection. The pathophysiology involves various factors contributing to the obstruction of the nasolacrimal duct (NLD).
- Factors are causing tears stasis are as follows :-
Anatomical Factors:
- Narrow Canal: A narrow nasolacrimal duct can impede the smooth flow of tears.
- Sinuous Canal: The duct’s sinuosity can create obstacles to tear drainage.
- Partial Canalization of Membranous NLD: Incomplete development of the membranous portion of the duct can hinder fluid passage.
- Excessive Folds in NLD: Abnormal folds can disrupt the normal drainage process.
Nasal Disorders:
- Deviated Nasal Septum: Extreme deviation can affect the alignment with the lacrimal sac.
- Atrophic Rhinitis: Tissue degeneration in the nasal lining can contribute to obstruction.
- Inferior Turbinate Hypertrophy: Enlargement of the nasal turbinate can obstruct tear drainage.
- Saddle Nose Deformity: Structural deformities may interfere with the normal flow of tears.
Mild Grade Inflammation of Sac:
- Recurrent conjunctivitis can lead to inflammation and blockage of the NLD.
- Epithelial debris and mucus plugs, coupled with hyperlacrimation, contribute to stasis.
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The microbes can cause infection in the stagnated tear fluid within the lacrimal sac . These are namely:-Â
- Staphylococcus
- Pneumococcus
- Streptococcus
- Pseudomonas pyocyanea
- Rarely TB, syphilis, leprosy, Rhinosporidiosis
There are some drugs that an cause acquired dacryocystitis.
Clinical nugget : What is ROPLAS test?
- ROPLAS stands for Regurgitation On Pressure over LAcrimal Sac.Â
- Blockage of the nasolacrimal duct leads to stasis of the secretions inside the lacrimal sac .
- Pressure over the lacrimal sac area causes regurgitation of the discharge from the puncta into the eye.
- This is known as a positive ROPLAS test and indicates the presence of nasolacrimal duct obstructionÂ
- NOTE: A positive ROPLAS must be followed by a nasolacrimal syringing test. A negative syringing confirms the blockage and this is a contraindication of cataract surgery.
Chronic dacryocystitis and Stages
There are four key stages: chronic catarrhal dacryocystitis, stage of lacrimal mucocele, stage of chronic suppurative dacryocystitis( pyocele), and chronic fibrotic sac.
Chronic Catarrhal Dacryocystitis:
- Initial manifestation marked by mild inflammation of the lacrimal sac.
- Associated with nasolacrimal duct blockage.
- Common symptoms include watering and mild redness at the inner canthus.
- Diagnostic tool: Regurgitation on Pressure over the Lacrimal Sac (ROPLAS) test and syringing.
- ON SYRINGING :clear fluid or few fibrinous mucoid flakes regurgitate
- DACRYOCYSTOGRAPHY shows a blocked nasolacrimal duc with a normal size lacrimal Sac with healthy mucosa.
Stage of Lacrimal Mucocele
- Progression due to persistent obstruction and chronic stasis.
- Distension of the lacrimal sac leads to the formation of a swelling at the inner canthus known as a mucocele.
- Patients experience constant tearing.
- SYRINGING or ROPLAS TEST : Gelatinous Mucoid flakes  regurgitate from the puncta on pressing the sac.
- DACRYOCYSTOGRAPHY reveals Distended sac with blockage in the NLD.
Stage of Chronic Suppurative Dacryocystitis ( PYOCELE)
- As the infection persists for longer duration; a mucocele turns into purulent pyocele.
- Patients complain of recurrent conjunctivitis, swelling at the inner canthus, and mild erythema of overlying skin.
- The pyocele can be differentiated from a mucocele by greater signs of inflammation in pyocele.
- SYRINGING :Purulent discharge flows through the punctum during regurgitation tests(ROPLAS)
- DACRYOCYSTOGRAPHYÂ reveals Distended sac with blockage in the NLD.
Stage of Chronic Fibrotic Sac
- Persistent inflammation leads to fibrosis of the mucosa within the lacrimal sac.
- Despite experiencing epiphora, patients exhibit watery discharge as the sac loses its ability to produce mucoid or purulent fluids.
- SYRINGING may reveal minimal discharge.
- DACRYOCYSTOGRAPHY shows a small sac with irregular folds in the mucosa or a thickened mucosa.
Clinical nugget : What is an encysted Mucocele?
Encysted mucocele involves blockage of canaliculi along with the nasolacrimal duct. This produces a large fluctuant swelling at inner canthus with NEGATIVE ROPLAS test as there is no pathway for exit of tears and canaliculi are also blocked due to chronic inflammationÂ
Management/Treatment of Chronic Dacryocystitis
Medical ManagementÂ
- Antibiotics and warm compress for managing acute episodes of dacryocystitis.
Surgical intervention
- Incision and drainage for lacrimal abscessÂ
- It is the mainstay of treatment for chronic dacryocystitis, to deal with the obstruction of the nasolacrimal duct . Either DCR or a DCT surgery can be undertaken. For more on DCR you can check our article on Dacryocystorhinostomy or check our video on DCR steps .Â
DACRYOCYSTORHINOSTOMY (DCR) an anastomosis is created between the sac and the nasal mucosa to bypass an obstruction in the nasolacrimal duct.
For more on Dacryocystorhinostomy, you can read the post here.
Acute Dacryocystitis
- Acute suppurative inflammation of the lacrimal sac , characterised by presence of painful swelling of the region of the sac
Etiology Of Acute Dacryocystitis
- AN ACUTE EXACERBATION on Chronic Dacryocystitis
- ACUTE PERIDACROCYSTITIS : due to infection from neighbouring structures : paranasal sinuses, bones , dental abscess and caries teeth of upper jaw
- Organisms causing dacryocystitis : staphylococcus, streptococcus and pneumococcus.
Stages Of Acute Dacryocystitis
There are 3 stages of Acute dacryocystitis namely;Â cellulitis stage, abscess stage and the stage of fistula formation. Let us discuss each of these one by one.
Stage of Cellulitis
Symptoms:
- Red, hot, firm, tender swelling.
- Epiphora and constitutional symptoms such as fever and malaise.
- Redness and edema spreading to lids and cheeks.
Treatment:
- Systemic antibiotics (penicillins, cephalosporins, macrolides).
- Topical antibiotics eye drops directly applied.
- Systemic anti-inflammatory analgesics.
- Hot fomentation for pain and swelling relief.
Stage of Abscess Formation
Symptoms:
- Continued inflammation leads to infection with pyogenic organisms.
- Lacrimal sac filled with pus, develops a fluctuant swelling called lacrimal abscess.
- Pus points below due to gravitation and presence of medial palpebral ligament in the upper part.
Treatment: Incision and Drainage (I&D):
- Culture sensitivity test for identification.
- Fill incision tract with broad-spectrum antibiotic ointment.
- Betadine application.
- Continued hot compresses.
Stage of Fistula Formation
 Symptoms:
- Forms when abscess is left unattended, resulting in spontaneous discharge.
- External Fistula: Below the medial palpebral ligament (MPL).
- Internal Fistula: Rare, opening into the nasal cavity.
Treatment:
- Control acute infection first.
- Fistulectomy: Surgical removal of the fistulous tract.
- Dacryocystorhinostomy (DCR) with or without DCT.
Complications of Acute Dacryocystitis
Corneal Ulcer:A trivial corneal abrasion can get infected and develop a corneal ulcer.Common type: Ulcer serpens (caused by Streptococcus Pneumoniae).
Cellulitis:Untreated chronic dacryocystitis may result in the spread of infection to surrounding tissues. This leads to cellulitis, causing redness, swelling, and pain around the eye.
- Spread to Surrounding Tissues: Untreated acute dacryocystitis can lead to the spread of infection to surrounding tissues.It can cause lid abscess, preseptal cellulitis, orbital cellulitis, acute conjunctivitis and facial cellulitis as well .
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Conclusions
We hope you found this information on dacryocystitis insightful and valuable . If you enjoyed our content, don’t forget to share, comment, and subscribe to our channel on Insight Ophthalmology. For a visual walkthrough of these concepts, check out our detailed video on the Dacryocystitis on YouTube. Stay informed, and thank you for being a part of our community!
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