What is the management approach for dacrocystitis?

Dacryocystitis: Presentation and Management

Clinical Presentation

Dacryocystitis presents as inflammation of the lacrimal sac, typically manifesting with pain, swelling, and erythema over the medial canthal region, often accompanied by epiphora (tearing) and purulent discharge from the punctum. 1 The condition can present in acute or chronic forms, with acute dacryocystitis being particularly painful and potentially progressing to serious complications including preseptal or orbital cellulitis, orbital abscess formation, and even vision loss if left untreated. 2, 3

Key Clinical Features to Assess:

• Location and extent of inflammation: Determine if infection is localized to the lacrimal sac or has spread to preseptal/orbital spaces 3
• Visual acuity: Critical to assess, as intraconal abscess formation can cause vision loss 3
• Systemic signs: Fever, tachycardia, and general toxicity indicate severity 4
• Age of patient: Pediatric cases require more aggressive management with intravenous antibiotics 1, 4
• History of trauma or prior episodes: May indicate underlying structural abnormalities 4

Management Approach

Immediate Medical Management

For acute dacryocystitis, initiate empiric antibiotic therapy immediately while obtaining culture material, as the microbiology is diverse and resistance patterns are increasingly problematic. 5, 2

Antibiotic Selection:

Adults with acute dacryocystitis should receive oral levofloxacin or amoxicillin-clavulanate as first-line empiric therapy, as these provide the broadest coverage against the most common pathogens, though even these agents may encounter resistance in 16-32% of cases. 5 The most commonly isolated organisms are:

• Staphylococcus aureus (30% of cases) 5
• Pseudomonas species (12%) 5
• Propionibacterium acnes (10%) 5
• Gram-negative rods (58.3% in some series) 2

Gentamicin combined with amoxicillin-clavulanic acid provides effective coverage against both Gram-positive (S. aureus, S. pneumoniae, S. epidermidis) and Gram-negative bacteria (H. influenzae, P. aeruginosa) commonly implicated in dacryocystitis. 1

Pediatric patients require hospital admission for intravenous antibiotic administration, as the risk of progression to orbital complications is significant. 4 This allows for close monitoring to detect orbital cellulitis or abscess formation early. 4

Surgical Intervention

For acute dacryocystitis with severe pain or inadequate response to antibiotics, perform incision and drainage with direct application of antibiotics inside the infected sac, as this results in almost immediate pain resolution and rapid infection control. 2 This approach also provides optimal culture material for targeted antibiotic therapy. 2

Timing and Type of Surgery:

Chronic low-grade dacryocystitis (67% of pediatric cases) can be managed with outpatient nasolacrimal duct probing. 4

Acute dacryocystitis requires a combined medical-surgical strategy with surgery performed within 1-2 days of initiating intravenous antibiotics. 4 The specific surgical approach depends on clinical presentation:

• Neonatal acute dacryocystitis: Nasolacrimal duct probing with nasal endoscopy for excision of intranasal duct cyst 4
• Acute dacryocystitis with periorbital cellulitis: Nasolacrimal duct probing 4
• Post-traumatic dacryocystitis: Dacryocystorhinostomy (DCR) with stent placement 4
• Dacryocystitis complicated by orbital abscess: Inferior orbitotomy for abscess drainage, simultaneous nasolacrimal duct probing, and stent placement 4

External dacryocystorhinostomy should be performed as definitive treatment after acute infection is controlled, as the underlying nasolacrimal duct obstruction must be addressed to prevent clinical relapse. 1, 3 All eight patients who underwent DCR after acute infection control achieved complete cure in one series. 2

Culture-Guided Management

Obtain cultures at the time empiric antibiotic treatment is initiated, as routine treatment with any specific antibiotic may fail in up to one-third of patients given the broad range of causative organisms. 5 When culture results return:

• If infection is improving on empiric therapy, continue current regimen even if isolated organisms show in vitro resistance, as clinical response supersedes laboratory susceptibility. 6
• If infection is worsening despite susceptibility, consider surgical intervention or inadequate drug levels 6
• Modify antibiotics to cover all isolated organisms if clinical response is inadequate 6

Critical Complications Requiring Urgent Intervention

Patients with intraconal abscess formation require immediate surgical drainage, as both reported cases with intraconal involvement had visual loss on presentation. 3 In contrast, extraconal abscesses may preserve vision if treated promptly. 3

Monitor closely for progression to orbital cellulitis or abscess formation, particularly in pediatric patients, as this represents an ophthalmic emergency requiring immediate surgical drainage under general anesthesia. 3

Common Pitfalls to Avoid

• Do not rely solely on oral antibiotics for acute dacryocystitis in children—hospital admission for IV antibiotics is essential 4
• Do not assume standard oral antibiotics will be effective—50% of isolates may be resistant to most oral agents 2
• Do not delay surgical intervention in severe cases—prolonged conservative management leads to unnecessary pain and risk of complications 2
• Do not neglect definitive surgical treatment after acute infection resolves—the underlying obstruction must be corrected to prevent recurrence 1