What is the treatment for an infected tear duct (dacryocystitis)?

Treatment of Infected Tear Duct (Dacryocystitis)

For acute dacryocystitis in adults, initiate broad-spectrum systemic antibiotics covering both gram-positive organisms (S. aureus, S. pneumoniae, S. epidermidis) and gram-negative bacteria (H. influenzae, P. aeruginosa), with amoxicillin-clavulanic acid or a combination of gentamicin plus amoxicillin-clavulanic acid being the most effective empiric choices. 1

Initial Medical Management

Antibiotic Selection

• Start oral amoxicillin-clavulanic acid as first-line therapy in adults with acute dacryocystitis, as this provides coverage against the most commonly implicated pathogens 1
• Add gentamicin for enhanced gram-negative coverage, particularly if the infection appears severe or is not responding to initial therapy 1
• Consider that 58.3% of dacryocystitis cases involve gram-negative rods, with 50% of isolates resistant to most oral antibiotics, making culture-directed therapy essential for non-responders 2

Pediatric Considerations

• Admit pediatric patients with acute dacryocystitis for intravenous antibiotic administration rather than oral therapy 1, 3
• Monitor hospitalized children closely for progression to periorbital cellulitis or orbital abscess formation 3

Surgical Intervention Algorithm

When to Perform Immediate Incision and Drainage

• Proceed with incision and drainage of the lacrimal sac if the patient has severe pain or a lacrimal sac abscess, as this provides almost immediate pain resolution and rapid infection control 2
• Obtain culture material directly from inside the infected sac during drainage to guide definitive antibiotic therapy 2
• Apply antibiotics directly inside the drained sac for optimal local control 2

Timing of Definitive Surgery (Dacryocystorhinostomy)

• Perform dacryocystorhinostomy (DCR) after acute infection resolves to prevent clinical relapse, as the underlying nasolacrimal duct obstruction must be corrected 1, 4
• In pediatric acute dacryocystitis, perform nasolacrimal duct probing within 1-2 days after starting intravenous antibiotics 3
• For neonates with acute dacryocystitis, combine nasolacrimal duct probing with nasal endoscopy to excise any intranasal duct cysts 3

Management of Treatment-Resistant Cases

Culture-Directed Therapy

• Obtain cultures of ocular discharge in all cases that fail to respond to empiric antibiotics within 48-72 hours 4, 5
• Consider atypical organisms including Proteus mirabilis (common in catheterized patients) and Stenotrophomonas maltophilia (resistant to β-lactams) in refractory cases 4, 5
• Switch to trimethoprim-sulfamethoxazole if cultures reveal S. maltophilia, as this organism is resistant to first-line β-lactam antibiotics 5

Chronic Recurrent Dacryocystitis

• Perform external DCR for patients with multiple recurrences despite appropriate antibiotic treatment to maintain nasolacrimal system patency 4
• Chronic low-grade dacryocystitis (67% of pediatric cases) can be managed with outpatient nasolacrimal duct probing 3

Special Clinical Scenarios

Dacryocystitis with Periorbital Cellulitis

• Admit for intravenous antibiotics and perform nasolacrimal duct probing as inpatient procedure 3
• Monitor closely for progression to orbital involvement 3

Dacryocystitis with Orbital Abscess

• Perform urgent inferior orbitotomy for orbital abscess drainage, combined with simultaneous nasolacrimal duct probing and stent placement 3
• This represents a surgical emergency requiring immediate intervention 3

Post-Traumatic Dacryocystitis

• Treat with DCR and stent placement rather than simple probing 3

Common Pitfalls to Avoid

• Do not rely solely on oral antibiotics without considering surgical drainage in patients with severe pain or abscess formation, as this delays resolution and prolongs suffering 2
• Avoid assuming all cases are caused by typical ocular flora; failure to culture resistant cases leads to prolonged ineffective treatment 2, 5
• Do not discharge pediatric patients with acute dacryocystitis on oral antibiotics alone; intravenous therapy with inpatient monitoring is required 1, 3
• Recognize that treating only the acute infection without addressing the underlying nasolacrimal duct obstruction will result in recurrence 1, 4