What is the treatment for dacryocystitis?

Treatment for Dacryocystitis

The treatment of dacryocystitis requires a combination of appropriate antibiotic therapy targeting common pathogens (Staphylococcus aureus, Streptococcus pneumoniae, and gram-negative bacteria) and addressing the underlying nasolacrimal duct obstruction through surgical intervention when indicated. 1

Initial Management

Acute Dacryocystitis

• Antibiotic Therapy:

  • Adults: Oral antibiotics effective against both gram-positive and gram-negative bacteria
    • First-line: Amoxicillin-clavulanic acid 1
    • Alternative: Fluoroquinolones for broader gram-negative coverage
  • Children: Intravenous antibiotics for severe cases 2
    • Hospitalization may be necessary for pediatric patients with acute presentation

• Warm Compresses:

  • Apply for 10-15 minutes, 3-4 times daily to improve local circulation and promote drainage

• Incision and Drainage:

  • For fluctuant abscesses or cases with severe pain
  • Provides immediate pain relief and allows direct application of antibiotics inside the infected sac 3
  • Enables collection of optimal culture material to guide targeted antibiotic therapy

Chronic Dacryocystitis

• Antibiotic Therapy:
  • Topical antibiotic drops/ointment (e.g., erythromycin, bacitracin)
  • Oral antibiotics for more persistent cases

Definitive Management

Surgical Intervention

• Nasolacrimal Duct Probing:

  • First-line surgical approach for children with chronic or acute dacryocystitis 2
  • Often combined with nasal endoscopy in neonates to excise intranasal duct cysts

• Dacryocystorhinostomy (DCR):

  • Indicated for:
    • Adults with persistent or recurrent dacryocystitis
    • Cases where the underlying cause is nasolacrimal duct obstruction
    • Failed conservative management
  • Creates a new drainage pathway between the lacrimal sac and nasal cavity
  • High success rate (>90%) for resolving symptoms and preventing recurrence 1

Special Considerations

Microbiology and Culture

• Obtain cultures before starting antibiotics when possible
• Common pathogens:
  • Gram-positive: S. aureus, S. pneumoniae, S. epidermidis
  • Gram-negative: H. influenzae, P. aeruginosa 1
• Consider atypical pathogens (including mycobacteria) in cases unresponsive to standard therapy 4

Complications

• Orbital Cellulitis:

  • Requires aggressive intravenous antibiotic therapy
  • May need imaging (CT scan) to evaluate extent of infection
  • Surgical drainage if abscess formation occurs

• Periorbital Cellulitis:

  • More common in children
  • Requires prompt treatment with antibiotics and nasolacrimal duct probing 2

Follow-up Care

• Monitor for resolution of symptoms
• Evaluate for recurrence which may indicate incomplete treatment of underlying obstruction
• Consider replacement of contact lenses after resolution if the patient is a contact lens wearer

Treatment Algorithm

1. Diagnosis: Confirm dacryocystitis based on symptoms (epiphora, pain, swelling over lacrimal sac)
2. Assess severity: Acute vs. chronic, presence of abscess or cellulitis
3. Initial treatment: Antibiotics (oral/IV) + warm compresses
4. For abscess: Consider incision and drainage with culture
5. For persistent cases: Surgical intervention with nasolacrimal duct probing (children) or dacryocystorhinostomy (adults)
6. Follow-up: Ensure resolution and address any underlying conditions

Remember that addressing the underlying nasolacrimal duct obstruction is essential for preventing recurrence of dacryocystitis 1.