Differentiating Dacryocystitis from Dacryostenosis
Dacryocystitis is an infection/inflammation of the lacrimal sac presenting with pain, swelling, erythema, and purulent discharge at the medial canthal region, while dacryostenosis is a chronic narrowing or obstruction of the nasolacrimal duct presenting primarily with epiphora (tearing) without acute inflammatory signs.
Clinical Presentation
Dacryocystitis
- Acute inflammatory signs: Pain, tenderness, erythema, and swelling over the lacrimal sac area (medial canthus below the medial canthal tendon) 1, 2
- Purulent discharge: Expressible from the punctum with pressure over the lacrimal sac 2
- Systemic symptoms: May include fever and malaise in acute cases 2
- Complications: Can progress to preseptal or orbital cellulitis, abscess formation, and rarely vision loss 3
- Microbiology: Predominantly gram-positive bacteria, especially Staphylococcus aureus, though gram-negative bacteria, anaerobes, and fungi can occur 4
Dacryostenosis (Nasolacrimal Duct Obstruction)
- Primary symptom: Chronic epiphora without acute inflammatory signs 5, 6
- Recurrent infections: History of repeated mild infections or chronic low-grade dacryocystitis 2
- No acute inflammation: Absence of pain, erythema, warmth, or purulent discharge in uncomplicated cases 6
- Functional obstruction: Patent canaliculi but obstructed nasolacrimal duct confirmed by irrigation 5
Key Differentiating Features
Physical Examination Findings
- Dacryocystitis: Tender, erythematous, fluctuant mass at medial canthus; purulent material expressible from punctum; possible preseptal cellulitis 1, 2
- Dacryostenosis: Non-tender lacrimal sac; clear tear lake; positive regurgitation test (reflux of clear or mucoid material with lacrimal sac compression) 5
Diagnostic Testing
- Lacrimal irrigation: In dacryostenosis, irrigation demonstrates obstruction with reflux through the opposite punctum; in acute dacryocystitis, irrigation should be deferred until infection resolves 5, 1
- Cultures: Indicated in dacryocystitis to guide antibiotic therapy, especially given increasing MRSA prevalence 4
- Imaging: CT or MRI may be needed in dacryocystitis complicated by orbital involvement to assess for abscess formation 3
Clinical Pitfalls
Critical warning: Acute dacryocystitis can rapidly progress to orbital cellulitis and abscess formation with risk of permanent vision loss 3. Monitor carefully for:
- Proptosis
- Restricted extraocular motility
- Decreased vision
- Orbital pain with eye movement
These signs mandate urgent imaging and possible surgical drainage 3.
Common mistake: Attempting nasolacrimal duct probing during acute dacryocystitis. The infection must be controlled with intravenous antibiotics first, followed by definitive surgical treatment 1-2 days later 2.
Management Implications
Dacryocystitis
- Acute cases: Hospital admission for intravenous antibiotics, monitoring for orbital complications, followed by surgical intervention (probing in children, dacryocystorhinostomy in adults with chronic disease) 1, 2
- Chronic/recurrent: Dacryocystorhinostomy is the definitive treatment 5, 6
Dacryostenosis
- Conservative management initially: Warm compresses, massage, topical antibiotics for secondary conjunctivitis 2
- Definitive treatment: Dacryocystorhinostomy when conservative measures fail and functional lacrimal pump is intact 5, 6
Age consideration: In pediatric patients, chronic low-grade dacryocystitis from dacryostenosis can be managed with outpatient probing, while acute dacryocystitis requires inpatient management 2. Success rates for dacryocystorhinostomy in children (83%) are comparable to adults when proper surgical technique is employed 6.