Dacryocystitis (acute)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

Bacterial infection of lacrimal sac
Usually secondary to blockage of nasolacrimal duct
Commonest in infants and post-menopausal women
Relatively rare in older children
Infection may be 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

Predisposing factors

Maxillary sinusitis
Trauma to adjacent tissues
Nasal or sinus surgery
Congenital obstruction of nasolacrimal duct (see Clinical Management Guideline on Nasolacrimal Duct Obstruction)

Symptoms

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

Signs

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
(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

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)

Pharmacological

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
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

Evidence base

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

Sources of evidence

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

Lay summary

Dacryocystitis means inflammation 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.

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 11
Date of search 17.07.17
Date of revision 19.12.17
Date of publication 06.04.18
Date for review 16.07.19
© College of Optometrists

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