Aetiology

Acute bacterial infection of lacrimal sac
Usually secondary to blockage of nasolacrimal duct
Most common in neonates (as a complication of congenital NLD obstruction) and adults >40 years of age (more common in females than males)

Paediatric acute dacryocystitis has features that are unique and distinct from those of adults.It may be associated with dacryocoele in neonates and infants, which tends to progress rapidly to lacrimal abscess, and if untreated can proceed to vision-and life-threatening complications such as orbital cellulitis, orbital abscess and meningitis

In adults, infection may be equally due to Gram positive or Gram-negative organisms:
Staphylococcus aureus and Streptococcus pneumoniae are the most common isolates amongst Gram-positive bacteria and Haemophilus influenzae, Serratia marcescens and Pseudomonas aeruginosa amongst Gram-negative bacteria
In paediatric acute dacryocystitis, Gram-positive infections predominate

Predisposing factors

Female:male ratio approximately 2:1
Maxillary sinusitis
Trauma to adjacent tissues
Nasal or sinus surgery
Congenital obstruction of nasolacrimal duct (see Clinical Management Guideline on Nasolacrimal Duct Obstruction)

Symptoms of acute dacryocystitis

Sudden onset
Pain
Tender swelling over lacrimal sac (anatomically located just below the medial palpebral ligament)
Epiphora
Fever (raised temperature)

Signs of acute dacryocystitis

Red, tender swelling centred over lacrimal sac and extending around the orbit
Purulent discharge expressible from one or both puncta when pressure is applied over the lacrimal sac (NB likely to be painful for patient)
Sac may discharge on to skin surface
(NB important to distinguish between acute dacryocystitis, in which sac is full of pus, and mucocoele in which sac is filled with mucoid material in the absence of infection)
Frequently, patients may present with conjunctivitis and preseptal cellulitis. Rarely, the infection extends behind the septum, causing orbital cellulitis

Differential diagnosis

Facial cellulitis, preseptal cellulitis, orbital cellulitis (check ocular motility and look for proptosis) (Refer to Clinical Management Guideline on Cellulitis [preseptal and orbital])
Acute frontal sinusitis (inflammation involves the upper eyelid)
Infection following superficial trauma/abrasion of skin 
Trigeminal neuralgia
Dacryocystitis (chronic)
(See also Clinical Management Guideline on Dacryocystitis [chronic])

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Do not attempt to probe the lacrimal system during acute infection (risk of spreading infection)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Topical antibiotic to prevent bacterial conjunctivitis: e.g. chloramphenicol drops and/or ointment for not less than 5 days
For mild and non-febrile cases, consider prescribing systemic antibiotic, e.g. co-amoxiclav or, where there is a penicillin allergy, erythromycin
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Management category

A2 (modified, as condition not sight-threatening): for severe cases and in all children, give first aid measures and refer as emergency (same day) to ophthalmologist or A&E Department. Cases are severe if patient has pyrexia and/or is systemically unwell or if an abscess has developed (i.e. pointing on surface)
A3 (modified, as condition not sight-threatening): for milder cases not responsive to systemic antibiotic within 7 days, refer urgently (within one week) to ophthalmologist (If treating, exercise low threshold for referral because of association with potentially serious complications)
B1: in mild cases responsive to systemic antibiotic treatment, monitor for obstruction of the nasolacrimal drainage system (see Clinical Management Guideline on Dacryocystitis [chronic])
B3: management to resolution if no long-term sequelae 

Possible management by ophthalmologist

Incision and drainage where appropriate
Systemic (including parenteral) antibiotics
Follow-up may include investigation and surgical intervention for nasolacrimal duct obstruction
Primary endoscopic dacryocystorhinostomy may result in earlier resolution than if the procedure is delayed
In neonates and infants, co-management with Paediatrician may be indicated

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradingworkinggroup.org)
 

Sources of evidence

Ali MJ. Pediatric Acute Dacryocystitis. Ophthalmic Plast Reconstr Surg. 2015;31(5):341-7

Ali MJ, Joshi SD, Naik MN, Honavar SG. Clinical profile and management outcome of acute dacryocystitis: two decades of experience in a tertiary eye care center. Semin Ophthalmol. 2015;30(2):118-23

Campolattaro BN, Lueder GT, Tychsen L. Spectrum of pediatricdacryocystitis: medical and surgical management of 54 cases. J Pediatr Ophthalmol Strabismus. 1997;34(3):143-53

Eshraghi B, Abdi P, Akbari M, Fard MA. Microbiologic spectrum of acute and chronic dacryocystitis. Int J Ophthalmol. 2014;7 (5): 864-7

Li EY, Wong ES, Wong AC, Yuen HK. Primary vs Secondary Endoscopic Dacryocystorhinostomy for Acute Dacryocystitis With Lacrimal Sac Abscess Formation: A Randomized Clinical Trial. JAMA Ophthalmol. 2017;135(12):1361-1366

Luo B, Li M, Xiang N, Hu W, Liu R, Yan X The microbiologic spectrum of dacryocystitis. BMC Ophthalmol. 2021;21(1):29

Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar B, Hernandez JL. Dacryocystitis: Systematic Approach to Diagnosis and Therapy. Curr Infect Dis Rep. 2012;14(2):137-46

Dacryocystitis (acute)
Version 13
Date of search 16.08.21
Date of revision 25.11.21
Date of publication 06.04.22
Date for review 15.08.23
© College of Optometrists