Bilateral Nasolacrimal Duct Obstruction with Unilateral Acute Dacryocystitis
You have bilateral nasolacrimal duct obstruction (dacryostenosis) with acute dacryocystitis affecting one eye, which explains the asymmetric swelling and pain despite bilateral duct involvement.
Understanding Your Condition
Your provider correctly identified that both eyes have duct issues (bilateral dacryostenosis), but only one eye has progressed to active infection and inflammation (acute dacryocystitis). This asymmetric presentation is common—having blocked tear ducts bilaterally doesn't mean both will become infected simultaneously 1.
Why One Eye Is Worse
The painful, swollen eye has developed acute dacryocystitis, which occurs when bacteria colonize the stagnant tears trapped behind the blocked duct 1. The most common culprit is Staphylococcus aureus, though other bacteria including MRSA can be responsible 1.
Immediate Management Required
Critical Warning Signs to Monitor
You must watch for these danger signs that require emergency evaluation 1:
- Proptosis (eye bulging forward)
- Restricted eye movement
- Decreased vision
- Orbital pain with eye movement
These indicate potential orbital cellulitis, which requires urgent imaging and possible surgical drainage 1, 2.
Treatment Approach
For the acutely infected eye:
- Obtain cultures before starting antibiotics to guide therapy, especially given increasing MRSA prevalence 1
- Systemic antibiotics targeting gram-positive bacteria (particularly S. aureus) are essential
- Warm compresses applied to the affected area
- Avoid nasolacrimal massage during acute infection
Given your severe fluconazole reaction history:
- Your documented hypersensitivity to fluconazole (which can cause drug rash with eosinophilia and systemic symptoms syndrome) 3 is irrelevant here—dacryocystitis is a bacterial infection, not fungal
- Antifungals have no role in treating this condition
- Standard antibiotics for dacryocystitis do not cross-react with azole antifungals
Definitive Treatment
Once the acute infection resolves, you will likely need dacryocystorhinostomy (DCR) surgery to create a new drainage pathway, as medical management alone rarely resolves chronic nasolacrimal duct obstruction 1. The asymptomatic eye may eventually require the same intervention if it becomes symptomatic.
Common Pitfall
The key mistake would be delaying treatment while the infection worsens. Acute dacryocystitis can progress to orbital cellulitis, which is sight-threatening and potentially life-threatening 1, 2. Your pain and swelling indicate active infection requiring prompt antibiotic therapy, not just observation.