Acute Dacryocystitis Requiring Immediate Systemic Antibiotics
This 7-month-old has developed acute dacryocystitis (infected lacrimal sac) complicating the congenital nasolacrimal duct obstruction, and requires immediate treatment with oral antibiotics plus topical antibiotic drops—this is NOT simple conjunctivitis. 1, 2
Critical Red Flags Present
Your infant displays several concerning features that distinguish this from routine tearing:
- Red and swollen lower lid indicates preseptal cellulitis or dacryocystitis, not just blocked duct 1
- Yellow purulent discharge from puncta suggests active bacterial infection of the lacrimal sac 2
- "Looks worse than normal" progression requires urgent evaluation to rule out serious complications 1
Immediate Actions Required
1. Rule Out Life-Threatening Conditions
Examine the cornea immediately with fluorescein staining to detect any corneal involvement, which would require emergency ophthalmology referral 1, 2. Any corneal opacity, infiltrate, or ulceration mandates same-day specialist evaluation 3.
Assess for orbital involvement by checking for:
If any of these are present, obtain immediate contrast-enhanced CT scan and ophthalmology consultation, as this could represent orbital cellulitis requiring IV antibiotics 1.
2. Initiate Antibiotic Therapy
Start dual antibiotic therapy immediately:
- Oral antibiotics (amoxicillin-clavulanate is preferred for dacryocystitis coverage of Staphylococcus aureus and typical nasopharyngeal pathogens) 3
- Topical fluoroquinolone drops (ofloxacin or ciprofloxacin-dexamethasone) applied to the eye 2-3 times daily 3, 2
The combination addresses both the lacrimal sac infection and any secondary conjunctivitis 2. Topical therapy alone is insufficient for dacryocystitis, unlike simple conjunctivitis where drops would suffice 3.
3. Supportive Measures
Discontinue lacrimal sac massage temporarily during acute infection, as this can spread bacteria 4, 5. Resume only after infection resolves.
Apply warm compresses to the affected area 3-4 times daily to promote drainage 4.
Gently clean discharge from the puncta and lid margin using cotton swabs dipped in warm water 3, 2.
Expected Clinical Course
Improvement should occur within 48-72 hours of starting antibiotics 2. If the eyelid swelling, redness, or discharge worsens or fails to improve after 3-4 days, immediate pediatric ophthalmology referral is mandatory 2.
The infant remains contagious for 24-48 hours after starting antibiotics and should avoid close contact with other children during this period 2.
Definitive Management After Infection Resolves
Once the acute infection clears (typically 7-10 days of antibiotics), probing of the nasolacrimal duct should be considered 6, 4. At 7 months of age:
- Spontaneous resolution rate is declining (most spontaneous resolution occurs by 6 months) 6, 4
- Office-based probing has 90% success rate at this age 7
- Delaying beyond 12 months may decrease success rates and prolong symptoms 6, 4
Children with unilateral obstruction benefit more from earlier probing than those with bilateral disease 6.
Common Pitfalls to Avoid
Do not mistake this for simple conjunctivitis. The combination of lid swelling, purulent discharge from the puncta (not just the eye surface), and worsening symptoms indicates lacrimal sac infection requiring systemic antibiotics 1, 2.
Do not use aminoglycoside-containing drops (like neomycin-polymyxin-gramicidin), as these are potentially ototoxic if they reach the middle ear through the nasolacrimal system 3. Only fluoroquinolones are safe 3.
Do not delay referral if no improvement occurs within 3-4 days, as this could indicate MRSA infection, abscess formation, or progression to orbital cellulitis 3, 1.