What is the treatment for dacryocystitis?

Treatment of Dacryocystitis

The treatment of dacryocystitis requires a combination of appropriate antibiotic therapy targeting common causative organisms (Staphylococcus aureus, Streptococcus species, and Pseudomonas) and surgical intervention to address the underlying nasolacrimal duct obstruction that causes this condition.

Classification and Initial Assessment

• Acute dacryocystitis: Characterized by painful swelling in the medial canthal area, erythema, and purulent discharge
• Chronic dacryocystitis: Presents with persistent tearing, discharge, and recurrent episodes of inflammation

Medical Management

Antibiotic Therapy

1. For acute dacryocystitis in adults:

   • Initial empiric therapy should cover both gram-positive and gram-negative organisms
   • First-line oral options:
     • Amoxicillin-clavulanate (most effective broad coverage) 1
     • Levofloxacin (alternative with good coverage) 2
   • For severe cases requiring hospitalization:
     • Intravenous antibiotics with broad-spectrum coverage 3

2. For acute dacryocystitis in children:

   • Hospitalization for intravenous antibiotics is recommended for acute cases 3
   • Duration typically 24-48 hours before surgical intervention

3. Important considerations:

   • Up to one-third of cases may have resistant organisms 2
   • Obtain cultures at the time of initial treatment to guide therapy if empiric treatment fails
   • Adjust antibiotics based on culture results when available

Supportive Measures

• Warm compresses to the affected area (10-15 minutes, 3-4 times daily)
• Pain management with appropriate analgesics
• Avoid manipulation of the inflamed lacrimal sac

Surgical Management

Timing of Surgery

1. Acute dacryocystitis:

   • In adults: Incision and drainage of the lacrimal sac abscess provides rapid pain relief and infection control 4
   • In children with acute presentation: Nasolacrimal duct probing after initial control with IV antibiotics 3

2. Chronic dacryocystitis:

   • Definitive treatment requires addressing the nasolacrimal duct obstruction 5
   • Dacryocystorhinostomy (DCR) is the procedure of choice for adults

Surgical Procedures

1. Nasolacrimal duct probing:

   • Primary approach for children
   • May be combined with nasal endoscopy to excise intranasal duct cysts in neonates 3

2. Dacryocystorhinostomy (DCR):

   • Creates a new drainage pathway between the lacrimal sac and nasal cavity
   • Indicated for adults with chronic dacryocystitis
   • Can be performed via external or endoscopic approach
   • May include stent placement in complex cases 3

3. Special situations:

   • Orbital abscess complication: Requires inferior orbitotomy for drainage plus nasolacrimal duct intervention 3
   • Trauma-related cases: DCR with stent placement 3

Follow-up and Monitoring

• Assess response to treatment within 48-72 hours
• Complete resolution of acute infection should occur within 7-10 days with appropriate therapy
• Long-term follow-up to ensure patency of the nasolacrimal system

Special Considerations

• Atypical pathogens: Consider in refractory cases; may require extended antibiotic courses (e.g., Mycobacterium abscessus) 6
• Methicillin-resistant S. aureus: Increasing incidence requires consideration in empiric therapy 2
• Pediatric cases: Often require a combined medical-surgical approach with age-appropriate interventions 3

Pitfalls to Avoid

1. Treating with antibiotics alone without addressing the underlying nasolacrimal duct obstruction
2. Using narrow-spectrum antibiotics that don't cover both gram-positive and gram-negative organisms
3. Delaying surgical intervention in acute cases that don't respond promptly to antibiotics
4. Failing to obtain cultures, especially in recurrent or refractory cases

Remember that dacryocystitis has a high rate of recurrence if the underlying nasolacrimal duct obstruction is not addressed surgically, particularly in adults with chronic disease.