What is the treatment for dacryocystitis?

Treatment of Dacryocystitis

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

Classification and Initial Management

Acute Dacryocystitis

1. Systemic Antibiotics

   • Adults: Oral antibiotics effective against gram-positive and gram-negative bacteria
     • First-line: Amoxicillin-clavulanic acid 1
     • Alternative: Anti-staphylococcal antibiotics
   • Children: Intravenous antibiotics for severe cases 2

2. Incision and Drainage

   • Indicated for lacrimal sac abscess
   • Provides immediate pain relief
   • Allows for direct application of antibiotics inside the infected sac
   • Provides optimal culture material 3

3. Timing of Surgical Intervention

   • Primary Endoscopic Dacryocystorhinostomy (EN-DCR): Can be performed within 2 weeks of presentation
     • Results in faster symptom resolution (13.8 days vs. 31.7 days with delayed surgery)
     • No difference in complication rates or success rates at 1 year 4
   • Secondary EN-DCR: Performed after acute infection resolves with medical management

Chronic Dacryocystitis

1. Medical Management

   • Topical antibiotics (bacitracin or erythromycin ointment)
   • Warm compresses to reduce inflammation

2. Definitive Treatment

   • Dacryocystorhinostomy (DCR) to create a new drainage pathway
   • Success rates of approximately 87.5% at one year 4

Special Considerations

Pediatric Dacryocystitis

• In infants and children, nasolacrimal duct probing is often effective 2
• For neonates with acute dacryocystitis: nasolacrimal duct probing and nasal endoscopy for excision of intranasal duct cyst
• For acute dacryocystitis with periorbital cellulitis: nasolacrimal duct probing after intravenous antibiotics
• For complicated cases (orbital abscess): drainage plus nasolacrimal duct probing and stent placement

Concomitant Conditions

• Many patients with giant fornix syndrome have concomitant nasolacrimal duct obstruction and chronic dacryocystitis, which may need to be addressed surgically 5
• Obtain cultures before starting antibiotics, especially given the increasing frequency of methicillin-resistant S. aureus (MRSA) 5

Microbiology and Antibiotic Selection

• 58.3% of dacryocystitis infections involve gram-negative rods 3
• 50% of isolates may be resistant to most oral antibiotics 3
• Common pathogens include:
  • Gram-positive: S. aureus, S. pneumoniae, S. epidermidis
  • Gram-negative: H. influenzae, P. aeruginosa 1
• Empiric therapy should cover both gram-positive and gram-negative organisms

Follow-up and Monitoring

• Monitor for resolution of symptoms (pain, swelling, discharge)
• Evaluate for recurrence within 3 months
• Assess for complications such as orbital cellulitis or abscess formation
• Long-term follow-up to ensure patency of the nasolacrimal drainage system

By addressing both the infection with appropriate antibiotics and the underlying nasolacrimal duct obstruction through surgical intervention, dacryocystitis can be effectively managed with good long-term outcomes.