Dacryocystitis (acute)


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. In neonates (most common) and infants (less common) it may be associated with dacryocoele (distended lacrimal sac caused by accumulation of mucoid fluid), 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)
Acute dacryocystitis may be superimposed on chronic dacryocystitis

Symptoms of acute dacryocystitis

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

Signs of acute dacryocystitis

Red, tender swelling centred over lacrimal sac and extending around the infero-medial portion of 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)
Dacryocystitis may be associated with conjunctivitis and preseptal cellulitis. Rarely, the infection in dacryocystitis extends behind the septum, causing orbital cellulitis

Differential diagnosis

Facial cellulitis, preseptal cellulitis, orbital cellulitis (refer to Clinical Management Guideline on Cellulitis [preseptal and orbital])
Acute sinusitis
Infection following superficial trauma/abrasion of skin 
Lacrimal sac mucocoele (dacryocoele)
Chronic dacryocystitis 
(See Clinical Management Guideline on Dacryocystitis [chronic])

Management by optometrist

Practitioners should work within their scope of practice, 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

Non pharmacological

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

For mild cases (in adults), warm compresses, massage of lacrimal sac to encourage drainage of purulent material through puncta
(GRADE*: Level of evidence=low, Strength of recommendation=strong)


Mild and non-febrile cases in adults:

  • topical antibiotic: e.g. chloramphenicol drops and/or ointment for not less than 5 days
  • oral systemic antibiotic, e.g. co-amoxiclav or alternatives, where there is a penicillin allergy, e.g. erythromycin
    (GRADE*: Level of evidence=low, Strength of recommendation=strong)

For patients who do not respond well to antibiotic therapy within 24 to 36 hours consider urgent referral for further management e.g. dacryocystorhinostomy (DCR). 
(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 in adults not responsive to systemic antibiotic within 24-36 hours, 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 in secondary care or local primary/community pathways where available

Additional guidance may be available

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

Lilja M, Leivo T, Uusitalo M, Vento S, Virkkula P, Blomgren K. Acute versus late endoscopic dacryocystorhinostomy in treatment of acute dacryocystitis: A prospective randomised trial with an 18-month follow-up. Acta Ophthalmol. 2023 Sep 14. doi: 10.1111/aos.15752. Online ahead of print.

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

Yu B, Tu Y, Zhou G, Hong H, Wu W. Immediate endoscopic dacryocystorhinostomy in patients with new onset acute dacryocystitis. laryngoscope. 2022;132(2):278-283.


What is acute Dacryocystitis?

Dacryocystitis means infection of the tear sac, the small chamber in which the tear fluid collects as it drains from the eye surface, which is beneath the skin alongside the inner corner of the eye. It is commonest in infants and middle-aged women and is usually caused by an infection by commonly occurring bacteria. It starts suddenly with pain and tenderness over the tear sac and the patient may quickly develop a raised temperature. The infection may also cause conjunctivitis (infection of the transparent membrane over the white of the eye) and cellulitis (infection of the soft tissues surrounding the eye). Sometimes the sac bursts, releasing pus on to the skin surface.

How is Dacryocystitis managed?

It is important to try to distinguish between this condition and a serious infection of the eye socket (orbital cellulitis) itself, especially in children, who should be referred to hospital the same day for emergency treatment. Treatment includes antibiotics, which may have to be given via a needle into a vein, and surgery to encourage pus from the infection to drain away.

Dacryocystitis (acute)
Version 14
Date of search 1.11.23
Date of revision 21.12.23
Date of publication 05.03.24
Date for review 31.10.25
© College of Optometrists

Sign in to continue

Forgotten password?

Not already a member of the College?

Start enjoying the benefits of College membership today. Take a look at what the College can offer you and view our membership categories and rates.