What is the recommended approach to diagnose nasolacrimal duct obstruction, its common etiologies, and the acute management of dacryocystitis?

Diagnosis and Management of Nasolacrimal Duct Obstruction and Dacryocystitis

For acute dacryocystitis in adults, initiate systemic antibiotics targeting both Gram-positive (S. aureus, S. pneumoniae) and Gram-negative organisms (H. influenzae, P. aeruginosa), with gentamicin and amoxicillin-clavulanic acid being first-line choices; if severe or not rapidly improving, perform incision and drainage with direct intra-sac antibiotic application for immediate pain relief and infection control. 1, 2

Diagnostic Approach to Nasolacrimal Duct Obstruction

Clinical Presentation

• Epiphora (tearing) is the cardinal symptom of nasolacrimal duct obstruction 3
• Mucopurulent discharge from the punctum indicates more advanced obstruction, particularly when the stenosis is at or distal to the lacrimal sac 3
• Symptoms cause optical system alterations and can progress to acute phlegmonous dacryocystitis if untreated 3

Essential Diagnostic Steps

• Patient history focusing on duration of tearing, presence of discharge, and previous episodes of infection 3
• Inspection (both macroscopic and microscopic) of the lacrimal region and ocular surface 3
• Palpation of the lacrimal sac area—pressure over a distended sac that expresses mucopurulent material through the punctum confirms the diagnosis 4
• Functional testing to determine patency: irrigation of the lacrimal system distinguishes patent from obstructed ducts 5
• Anatomical classification determines the grade (incomplete vs. complete), type (functional vs. mechanical), and localization (pre-saccal, intra-saccal, or post-saccal) 3

Mandatory Pre-Surgical Evaluation

• ENT consultation is obligatory before any lacrimal surgery to rule out sinonasal pathology that may contribute to or mimic lacrimal obstruction 3
• CT imaging may reveal ethmoiditis or sinusitis masquerading as dacryocystitis—these conditions can cause pseudodacryocystitis and even progress to true nasolacrimal duct obstruction if untreated 5

Common Etiologies of Nasolacrimal Duct Obstruction

Primary Causes

• Distal nasolacrimal duct obstruction is the most common anatomical finding in dacryocystitis and must be addressed to prevent clinical relapse 1
• Congenital obstruction in infants and children presents with tearing, crusting, and boggy swelling over the inner canthus 4

Secondary Causes

• Chronic rhinosinusitis with nasolacrimal duct involvement—many patients with giant fornix syndrome have concomitant nasolacrimal duct obstruction requiring surgical correction 6
• Anterior ethmoiditis can cause localized infection mimicking dacryocystitis; recurrent sinus infections may progress to complete nasolacrimal duct obstruction 5

Acute Management of Dacryocystitis

Immediate Antibiotic Therapy

• Oral antibiotics in adults: gentamicin and amoxicillin-clavulanic acid are effective against the bacteria commonly implicated (S. aureus, S. pneumoniae, S. epidermidis, H. influenzae, P. aeruginosa) 1
• Intravenous antibiotics in pediatric patients prior to any surgical intervention 1
• Coverage must address both Gram-positive and Gram-negative organisms, as 58.3% of acute dacryocystitis cases involve Gram-negative rods, with 50% resistant to most oral antibiotics 2

Surgical Drainage for Severe Cases

• Incision and drainage with direct intra-sac antibiotic application results in almost immediate pain resolution and rapid infection control 2
• This approach provides optimal culture material to guide antibiotic selection 2
• In a series of 12 consecutive patients, this technique achieved rapid control of acute infection, with all 8 patients subsequently undergoing dacryocystorhinostomy achieving full cure 2

Definitive Treatment

• Dacryocystorhinostomy (DCR) is the definitive surgical treatment after acute infection is controlled 2, 1
• Timing of surgery depends on clinical signs, symptoms, patient age, and general status 1
• Minimally invasive transcanalicular procedures or anastomosing surgeries can be selected based on clinical findings 3
• For recurrent infections with underlying ethmoiditis, combined external DCR and anterior ethmoidectomy prevents recurrence 5

Management of Congenital Nasolacrimal Duct Obstruction

Conservative Management

• Antibiotic eye drops five times daily for one week after manual expression of discharge from the sac area is effective in only 3.43% of cases 4

Probing Protocol

• First probing achieves 98.10% cure rate across all age groups 4
• Timing matters: success rates are 100% for ages 1-12 months, 99.40% for 12-18 months, 98% for 18-24 months, 95.24% for 24-36 months, and 89.87% for 36-48 months 4
• Repeat probing at 1-week intervals if first attempt fails: second probing achieves 99.64% cure, third probing achieves 100% 4
• Early probing repeated two to three times is highly effective at all ages and should be performed before considering more invasive procedures 4

Critical Pitfalls to Avoid

• Do not assume all lacrimal sac swelling is dacryocystitis—ethmoiditis can cause pseudodacryocystitis with a patent lacrimal system; always irrigate to confirm obstruction 5
• Do not delay ENT evaluation—unrecognized sinonasal disease will cause treatment failure and recurrence 3, 5
• Do not rely solely on oral antibiotics for severe acute dacryocystitis—incision and drainage dramatically accelerates resolution and prevents complications 2
• Do not culture before drainage—direct intra-sac cultures obtained during drainage provide superior specimens compared to external swabs 2
• Do not perform definitive DCR during acute infection—control the acute process first, then proceed with definitive surgery 1
• Do not delay probing in congenital cases beyond 12 months—success rates decline with age, though repeated probing remains effective even up to 48 months 4