Dacryocystitis and canaliculitis

The lacrimal drainage system consists of the puncta - upper and lower within the eyelids and which are the opening to the upper and lower canaliculus. These meet at the common canaliculus and open into the lacrimal (tear) sac. This runs parallel to the nose and is separated from the middle meatus of the nasal cavity by two thin plates of bone. It continues down to become the nasolacrimal duct (tear duct) which opens out into the inferior nasal meatus.

Close-up view

Dacryocystitis¹

Dacryocystitis is an inflammation of the lacrimal sac, often as a result of infection. It may be acute or chronic. For anatomical reasons, it occurs more frequently on the left side. An ocular origin for inflammation of the lacrimal system is less common than a nasal origin.

Rarely, congenital dacryocystocele can occur as part of the picture of nasolacrimal duct obstruction. The incidence of congenital dacryocystocele varies from 1% to 12%² This is a serious condition because the orbital septum is poorly formed in infants and there is a significant risk of spread (orbital cellulitis and its complications).

Epidemiology

It is more common in females. It tends to occur either in infants (uncommon) or in adults (much more common) over the age of 40 years, peak age 60-70 years.

Presentation

Acute dacryocystitis

• Symptoms and signs are over the region of the lacrimal sac (but may spread to the nose and face with teeth pain being experienced by some). Therefore, look just lateral and below the bridge of the nose for:
  

  • Excess tears (epiphora) - almost invariably.

  • Pain.

  • Redness.

  • Swelling.

The patient may complain of decreased visual acuity owing to the excess tears and an abnormal tear composition³ .

Examination will reveal a tender, tense, red swelling (± preseptal cellulitis in severe cases). Mucopurulent discharge can be expressed from the punctum. There may be a fever and an elevated leukocyte count too.

Chronic dacryocystitis⁴
This may present with a history of chronic or recurring epiphora and may have persistent redness of the medial canthus. There may be a painless or recurring swelling over the lacrimal sac, and pressure over this will result in reflux of mucopurulent material through the lower punctum.

Differential diagnosis

• Orbital or facial cellulitis (discharge cannot be expressed from the punctum).

• Acute ethmoid or frontal sinusitis.

• Dacryocystocele (mild enlargement of a non-inflamed lacrimal sac in an infant).

Investigations

• In severe or atypical cases (eg, non-responsive to antibiotics), culture the expressed contents of the sac.

• CT scan of the orbit and the paranasal sinuses can be useful.

• A dacryocystography (DCG) may be performed where structural abnormalities are suspected.

Associated diseases

This is most commonly associated with nasolacrimal duct obstruction which results in stasis of the lacrimal sac contents. Less commonly, it is associated with anatomical abnormalities of the lacrimal sac or with nasal or sinus surgery. Nasal disease may be found in a number of these patients - eg, various forms of rhinitis, trauma or the presence of a foreign body. Some common systemic diseases associated with chronic dacryocystitis include granulomatosis with polyangiitis, sarcoidosis, and systemic lupus erythematosus. Rarely, there may be a lacrimal sac tumour.

Management

Acute dacryocystitis management

• Patients tend to be managed on an outpatient basis unless they are systemically unwell.

• Initially, treatment of acute dacryocystitis is with oral antibiotics and analgesia. Empiric antibiotics should include Gram-positive and Gram-negative coverage³ .

• The regime is guided by clinical response but, typically, a 10- to 14-day course is required.

• Incision and drainage may be considered if the infection extends outside the sac and a superficial skin abscess is formed. This carries the risk of forming a fistula, resulting in tears draining directly to the skin surface⁵ . However, a study found that early surgery produced faster resolution of the condition than surgery which was deferred until the infection had been treated conservatively⁶ .

Chronic dacryocystitis management^{7 8}

• Non-surgical treatment involves warm compresses, massage and probing of the nasolacrimal duct.

• Probing involves inserting a fine metal probe via the punctum and canalicular system and passing it into the nasolacrimal sac, past the obstruction. This can often be done without a general anaesthetic. If there is acute infection, the procedure is usually deferred for a few days, until antibiotics have taken effect⁹ .

• If this is not effective, surgical treatment is a DCR (see box below).

• Balloon dacryoplasty, nasolacrimal intubation and nasolacrimal stenting have all been attempted with varying degrees of success³ .

Congenital dacryocystocele management¹⁰

• One study reported that conservative management, involving gentle massage over the lacrimal sac, warm compresses ± topical and systemic antibiotics, was effective in all cases.

• Probing and irrigation may resolve the obstruction.

• Be aware that serious infection can develop rapidly.

See also the separate Congenital Nasolacrimal Duct Obstruction article.

Complications

These lie mainly in the risk of spread which can be superficial (eg, cellulitis), deep (eg, orbital cellulitis, orbital abscess, meningitis) or generalised (eg, sepsis)¹¹ . These complications are rare and tend to be seen in the immunocompromised individuals and in cases of congenital dacryocystitis.

Intraocular surgery - such as cataract surgery - should be postponed until the dacrocystitis (whether acute or chronic) has been treated, as there is a significant risk of ensuing endophthalmitis. However, there are complications associated with DCR too:

• Failed procedure.

• Cutaneous scarring.

• Epistaxis.

• Cellulitis.

• Cerebrospinal fluid rhinorrhoea (if the subarachnoid space is inadvertently entered).

Prognosis

This is good if managed promptly and surgery is not delayed once the acute phase has resolved. However, congenital dacryocystitis can be very serious and is associated with significant morbidity and mortality if not treated promptly and aggressively.

Chronic canaliculitis

This is an uncommon condition where the canaliculi become chronically infected. Common pathogens reported are Staphylococcus spp., Streptococcus spp., Actinomyces spp. and Propionibacterium spp.¹² .

Presentation

Symptoms

• Unilateral epiphora.

• Chronic mucopurulent conjunctivitis (refractory to usual treatment).

Signs

• Oedema of the canaliculus: look for a swelling at the medial end of the upper or the lower lid.

• 'Pouting' punctum: this is turned out and is prominent.

• Gentle compression of the canaliculi results in expression of concretions: solid, pale-yellow fatty material.

Investigation

High-resolution ultrasound biomicroscopy may be helpful¹³ .

Differential diagnosis

• Dacryocystitis.

• Nasolacrimal duct obstruction.

• Conjunctivitis.

Management¹⁴

• Removal of the obstruction concretions (by expressing them through the punctum) and topical antibiotics (eg, ciprofloxacin qds for 10 days) may be effective in some cases.

• Surgery (canaliculectomy or punctoplasty) is often performed, often with expression of concretions from the duct and irrigation with antibiotics or an iodine solution. Occasionally, more extensive surgery is needed.

• One study suggested that intracanalicular antibiotics can be helpful as an alternative to surgery.

Canalicular obstruction^{15 16}

Obstruction of the lacrimal canaliculi may be congenital (see the separate Congenital Nasolacrimal Duct Obstruction article) or acquired. Acquired causes include trauma, scarring, inflammatory conditions, local tumours, Bell's palsy, radiotherapy and certain drugs - eg, docetaxel.

Presenting features are excess tearing ± sticky discharge and irritation.

Investigations

• Syringing and probing to identify the site of obstruction.

• The Jones' fluorescein dye test.

Management

• Treat infection if present.

• Syringing and probing may be used but they risk trauma to the duct and may aggravate the condition.

• Surgical treatment - there are various treatment methods, including punctoplasty, insertion of a silicone tube, trephination, balloon canaliculoplasty, endocanalicular laser surgery, conjunctivodacryocystorhinostomy (CDCR) and canalicodacryocystorhinostomy (canaliculo-DCR)¹⁷ . Laser or balloon canaliculoplasty may be well tolerated and a good alternative to CDCR¹⁸ .