Dacryocystitis

Anatomy

The Lacrimal Apparatus

Component	Description
Lacrimal gland	Has two parts: a larger orbital part and a smaller palpebral part; both lie around the levator palpebrae superioris muscle and posterior to the orbital septum.
Ducts	~12 ducts open into the lateral superior fornix of the conjunctiva.
Tear drainage	Tears flow across the cornea to the lacus lacrimalis, enter the lacrimal puncta, then drain via the lacrimal canaliculi to the lacrimal sac, and through the nasolacrimal duct into the inferior nasal meatus.
Lacrimal fold	A mucosal fold at the distal duct opening prevents air from entering during nose blowing.
Nerve supply	Parasympathetic secretomotor fibres are via the lacrimal nerve (from the maxillary branch of CN V).

Pathology

Common organisms:

Organism	Notes
Staphylococcus aureus	Most common
Streptococcus pneumoniae	Common
Streptococcus pyogenes	May cause rapid progression
Haemophilus influenzae	Especially in children
Pseudomonas aeruginosa	Consider in chronic/recurrent infections

Causes:

Group	Cause
Neonates/Children	Congenital nasolacrimal duct obstruction (up to 20% of newborns; 90% resolve by 6 months) Craniofacial abnormalities (may cause more severe infections e.g. orbital cellulitis)
Adults	Chronic allergic rhinitis Chronic sinusitis Facial trauma Faciomaxillary tumours

Clinical Assessment

Dacryocystitis may present in acute or chronic forms.

Symptoms and Signs

• Inflammation over lacrimal sac/duct
  • Swelling
  • Redness
  • Tenderness
  • Warmth
• Epiphora
  • Excessive tearing
• Purulent discharge
  • Expressed from punctum on pressure
• Eyelash matting/crusting
• Abscess formation

Complications

Complication	Description
Conjunctivitis	Local spread of infection
Fistula formation	Rupture through skin with drainage
Periorbital/orbital cellulitis	Serious local extension
Spreading facial cellulitis	May obscure the diagnosis of dacryocystitis
Meningitis	Rare but serious

Investigations

Test	Purpose
Swab for M/C/S	Culture purulent discharge when possible
CT scan	Identifies abscesses, soft tissue inflammation, and bony involvement
Dacryocystography (DCG)	Contrast study to assess duct patency; may be done with fluoroscopy, CT, or MRI

Management

Intervention	Notes
Analgesia	Paracetamol, aspirin, NSAIDs, opioids if severe
Warm compresses	Aid drainage of pus
Antibiotics	Oral: flucloxacillin or clindamycin for 7–10 days IV: vancomycin + third-gen cephalosporin if febrile/unwell
Crigler massage	Downward massage of lacrimal sac 2–3 times/day (especially in infants)
Surgery	Drain abscesses if present Dacryocystorhinostomy (DCR) for chronic or recurrent cases (can be done endoscopically to avoid scarring)

Disposition

• Refer all suspected cases to Ophthalmology.
• Urgent referral if signs of orbital cellulitis or other serious complications.

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Appendix 1

Appendix 2

Appendix 3

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References

FOAMed

• Bell DJ. Dacryocystography. Radiopaedia

Publications

• The Eye Emergency Manual, NSW Department of Health, 3rd ed. 2023