What is more effective for treating dacryocystitis, ROPLAS (Rapid Office Procedure for Lacrimal Stenosis) or syringing?

ROPLAS is Superior to Syringing for Dacryocystitis Diagnosis

ROPLAS (Regurgitation On Pressure over the Lacrimal Sac) is superior to syringing for diagnosing dacryocystitis due to its high sensitivity (93.2%) and specificity (99.3%), while avoiding the invasiveness and potential complications of syringing.

Comparison of ROPLAS vs. Syringing

ROPLAS Advantages

• Non-invasive diagnostic technique
• High sensitivity (93.2%) and specificity (99.3%) 1
• Excellent negative predictive value (99.5%) 1
• No risk of introducing infection or trauma
• Can be performed quickly in office setting
• Does not require specialized equipment

Syringing Disadvantages

• Invasive procedure with risk of:
  • Trauma to nasolacrimal system
  • Potential introduction of infection
  • Patient discomfort
  • Requires specialized equipment and training
  • More time-consuming

Diagnostic Algorithm for Dacryocystitis

1. Initial Assessment: Perform ROPLAS test

   • If positive (regurgitation observed): Confirms chronic dacryocystitis
   • If negative: Dacryocystitis unlikely (99.5% negative predictive value)

2. When to Consider Syringing:

   • Only when ROPLAS findings are equivocal
   • When index of suspicion remains high despite negative ROPLAS
   • For therapeutic purposes (not just diagnostic)

Treatment Considerations

The treatment approach should be based on whether the dacryocystitis is acute or chronic:

Acute Dacryocystitis

• Systemic antibiotics based on local resistance patterns
• Consider levofloxacin or amoxicillin/clavulanate as empiric therapy 2
• In severe cases, consider incision and drainage with direct application of antibiotics inside the infected sac 3
• Obtain cultures to guide antibiotic therapy, as up to one-third of cases may have resistant organisms 2

Chronic Dacryocystitis

• Surgical intervention often required (dacryocystorhinostomy)
• Medical management with warm compresses and eyelid hygiene may provide symptomatic relief 4

Special Considerations for Pediatric Patients

For pediatric patients with dacryocystitis:

• Not all cases require hospitalization (31% resolve without admission) 5
• Not all cases require early surgical intervention (56% resolve without it) 5
• Tailor treatment individually based on severity and presentation 5

Clinical Pearls and Pitfalls

• Pearl: ROPLAS is a simple, cost-effective screening test that can reduce unnecessary syringing procedures
• Pitfall: Relying solely on syringing without considering ROPLAS exposes patients to unnecessary risks
• Pearl: Obtaining cultures at the time of empiric antibiotic initiation is valuable due to high rates of antibiotic resistance 2
• Pitfall: Assuming a specific antibiotic will be effective without culture data may lead to treatment failure in up to one-third of patients 2

In conclusion, ROPLAS should be the first-line diagnostic approach for suspected dacryocystitis, with syringing reserved for specific indications when ROPLAS is inconclusive or when therapeutic intervention is needed.