Dacryocystitis: Exam-Oriented Summary
Definition and Clinical Presentation
Dacryocystitis is an acute or chronic inflammation of the lacrimal sac, typically caused by bacterial infection secondary to nasolacrimal duct obstruction, requiring prompt recognition and treatment to prevent orbital complications. 1
Key Clinical Features to Assess:
- Visual acuity measurement - critical as intraconal abscess formation can cause vision loss 1
- Pain, erythema, and swelling over the lacrimal sac area (medial canthal region) 2, 3
- Purulent discharge from the punctum with pressure over the lacrimal sac 2
- Epiphora (tearing) 2
- Fever and systemic signs in acute cases 4
- Potential progression to preseptal or orbital cellulitis 2, 4
Microbiology
The causative organisms have evolved beyond traditional teaching:
- Staphylococcus aureus remains most common (30% of cases) 5
- Gram-negative organisms (particularly Pseudomonas species) account for 58.3% in some series 6, 5
- Propionibacterium acnes (10% of cases) 5
- Streptococcus pneumoniae 2
- Uncommon pathogens like Proteus mirabilis can occur 2
Critical pitfall: Up to 50% of isolates are resistant to most oral antibiotics, and even optimal empiric choices (levofloxacin or amoxicillin/clavulanate) may encounter resistant organisms in 16-32% of patients 6, 5
Diagnostic Approach
Immediate Actions:
- Obtain cultures at the time empiric antibiotic treatment is initiated - this is essential given the broad range of organisms and high resistance rates 1, 5
- Assess for orbital involvement (proptosis, ophthalmoplegia, vision changes) 1, 4
- Consider imaging (CT or ultrasound) if orbital extension is suspected 4, 3
Management Algorithm
Acute Dacryocystitis in Adults:
For adults with acute dacryocystitis, initiate empiric oral antibiotics immediately while awaiting culture results, with levofloxacin or amoxicillin/clavulanate being the most effective choices based on current resistance patterns. 5
Initial Treatment:
- Start empiric oral antibiotics (levofloxacin or amoxicillin/clavulanate preferred) 5
- Warm compresses 2
- Avoid digital pressure/massage in acute phase 2
If Inadequate Response or Severe Presentation:
- Incision and drainage with direct antibiotic application inside the infected sac results in almost immediate pain resolution and rapid infection control 6
- This approach also provides optimal culture material 6
- Consider if patient has severe pain or slow resolution on systemic antibiotics 6
Antibiotic Modification Strategy:
- If infection is improving on empiric therapy, continue current regimen even if isolated organisms show in vitro resistance - clinical response supersedes laboratory susceptibility 1
- Modify antibiotics to cover all isolated organisms only if clinical response is inadequate 1
Definitive Management:
- Dacryocystorhinostomy (DCR) is required for definitive treatment in patients with underlying nasolacrimal duct obstruction to prevent recurrence 1, 2, 6
- Can be performed after acute infection resolves 2, 6
- 100% cure rate in patients undergoing DCR after acute infection control 6
Pediatric Dacryocystitis:
Pediatric patients require hospital admission for intravenous antibiotic administration due to significant risk of progression to orbital complications. 1, 4
Chronic Low-Grade Dacryocystitis (67% of pediatric cases):
- Outpatient nasolacrimal duct probing 4
Acute Dacryocystitis (33% of pediatric cases):
- Hospital admission for IV antibiotics 1, 4
- Inpatient surgery within 1-2 days tailored to clinical scenario: 4
- Neonates: nasolacrimal duct probing + nasal endoscopy for intranasal duct cyst excision 4
- With periorbital cellulitis: nasolacrimal duct probing 4
- Post-facial trauma: dacryocystorhinostomy with stent placement 4
- With orbital abscess: inferior orbitotomy for drainage + simultaneous nasolacrimal duct probing with stent 4
Infantile Dacryocystitis with Abscess:
- Modified decompression and probing approach: gentle abscess decompression followed by nasolacrimal duct probing 3
- May require repeat procedures 3
Follow-Up and Monitoring
- Monitor for resolution of pain, erythema, and discharge 6
- Assess for recurrence - chronic recurrences and epiphora are potential sequelae 2
- Educate patients that DCR surgical procedure may be needed to prevent future recurrences 2
- Average follow-up should extend 1.75 years to monitor for recurrence 4
Common Pitfalls
- Failing to obtain cultures before starting antibiotics - this leaves you without guidance when empiric therapy fails 1, 5
- Relying solely on traditional Gram-positive coverage - gram-negative organisms now predominate in many series 6, 5
- Changing antibiotics based on in vitro resistance when patient is clinically improving - clinical response is more important than laboratory data 1
- Underestimating risk in pediatric patients - always admit for IV antibiotics and close monitoring 1, 4
- Not counseling about definitive surgical management - medical therapy alone often results in recurrence without DCR 1, 2