Dacryocystitis and Its Management

Abstract

The lacrimal apparatus drains into the inferior meatus of the nose via the nasolacrimal duct. Blockage of this drainage pathway leads to a consistent and continuous epiphora which tends to become sticky and thick over time. Thus, it can lead to recurrent episodes of acute infections which present with a swelling in the medial canthal region (acute dacryocystitis). Dacryocystorhinostomy (DCR) is recognized as the most suitable treatment for patients with obstruction of the lacrimal system at the level of the sac or the nasolacrimal duct. This operation aims to create a bypass between the lacrimal sac and the nasal cavity. Traditionally, this was achieved by performing an external DCR using an external skin incision. But over the past two decades, we have seen advances in rigid endoscopic equipment, which have led to the development of a safer and less-invasive technique, namely, endoscopic DCR for treating symptomatic lacrimal apparatus disorders. This chapter provides a comprehensive overview of the lacrimal system, dacryocystitis etiology and management. It delves into the indications for surgical intervention and compares traditional external DCR with the less-invasive endoscopic DCR technique. By detailing postoperative care, this chapter aims to offer a streamlined approach to understanding and treating symptomatic lacrimal apparatus disorders.

1. Introduction

Dacryocystitis, an inflammation of the nasolacrimal sac, often stems from an obstruction within the nasolacrimal duct (NLDO), resulting in tear stagnation and the hallmark symptom of epiphora. Additionally, it may manifest as a tender swelling near the eye’s inferomedial canthus, periorbital cellulitis, erythema and purulent discharge. Timely diagnosis and effective management are pivotal in averting potential complications. Treatment typically encompasses antibiotics, wound care and addressing the underlying obstruction, often requiring surgical intervention such as dacryorhinocystostomy in chronic cases [1].

Collaborative efforts amongst ophthalmologists, otorhinolaryngologists, nurses, physicians and pharmacists are indispensable for comprehensive patient care and favorable outcomes.

2. Anatomy of the lacrimal system and its drainage pathway

The lacrimal sac, nestled within the lacrimal fossa, drains into the nasolacrimal duct. Lacrimal puncta, situated at the medial ends of the upper and lower eyelids, connect to the lacrimal sac via the upper and lower canaliculi. These canaliculi converge to form the common canaliculus, which opens high on the lateral wall of the lacrimal sac. It extends about 9 mm above the axilla of the middle turbinate. The thick anterior limb of the medial canthal tendon wraps along the anterior upper half of the lacrimal sac to insert onto the anterior lacrimal crest, and then the posterior limb passes behind the sac to insert onto the posterior lacrimal crest. The nasolacrimal duct travels within a bony canal formed by the maxillary and lacrimal bones, terminating at the inferior meatus of the nose.

Tear production by the lacrimal gland, along with accessory glands of Wolfring and Krause, nourishes and lubricates the eye. Tears flow through the puncta, ampullae, canaliculi and, finally, the lacrimal sac, before descending through the nasolacrimal duct and reaching the nasal cavity (Figure 1) [2, 3].

Figure 1.

Anatomy of the lacrimal apparatus and its drainage pathway.

3. Classification and etiology

Dacryocystitis, resulting from obstruction in the lacrimal drainage pathway, manifests as either acute or chronic, congenital, or acquired.

Acute dacryocystitis, an infectious state, can be caused by various Gram-positive and Gram-negative bacteria including Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Serratia marcescens and Pseudomonas aeruginosa [1].

Chronic dacryocystitis ensues from persistent obstruction, attributed to recurrent infections, dacryoliths, or systemic diseases like sarcoidosis and systemic lupus erythematosus.

Congenital dacryocystitis may stem from infection, failure of membrane rupture at the valve of Hasner, or persistent epithelial plugs [4].

Acquired dacryocystitis may be primary, characterized by chronic inflammation and fibrosis of the NLDO, or secondary, resulting from trauma, dacryolithiasis, tumors, or certain medications such as timolol, flourouracil and docetaxel.

4. Epidemiology

Dacryocystitis exhibits a bimodal distribution, with most cases occurring shortly after birth (congenital) or beyond 40 years of age. Predominantly affecting white individuals, over 75% of cases occur in females [1].

5. Pathophysiology

Obstruction within the nasolacrimal drainage system sets the stage for dacryocystitis, leading to the accumulation of tears in the lacrimal sac. Subsequent bacterial colonization incites infection, characterized by erythema, swelling and tenderness over the lacrimal sac. Untreated, it can progress to complications such as orbital abscess, cellulitis, necrotizing fasciitis and even meningitis [5].

6. Risk factors

Various factors contribute to the development of dacryocystitis, including gender (females have narrower ducts), older age (due to narrowed punctual openings and slower tear drainage), dacryoliths, nasal septal deviation, rhinitis, turbinate hypertrophy, idiopathic or iatrogenic trauma to the nasolacrimal system, systemic disorders and certain medications.

7. Clinical features

Acute dacryocystitis presents with sudden pain, erythema, fever and edema around the medial canthus and orbit. Symptoms progress over hours to days, often accompanied by purulent discharge. Chronic dacryocystitis typically manifests as epiphora, sometimes accompanied by conjunctival chemosis and changes in visual acuity due to altered tear film production (Figure 2).

Figure 2.

Acute dacryocystitis with swelling and erythema at the inferomedial aspect of the eye.

8. Complications

Without intervention, dacryocystitis can extend to adjacent orbital tissues, leading to preseptal cellulitis, orbital cellulitis, orbital abscess, optic nerve compression and eventual vision loss.

9. Evaluation and investigations

Diagnosis of dacryocystitis relies primarily on clinical assessment and patient history. Imaging and blood work are reserved for acutely ill patients. Diagnostic procedures include tear duct massage for microbiological evaluation, serologic testing for systemic diseases suspicion and various tests like syringing, diagnostic probing and nasal endoscopy for surgical planning. In recurrent cases, additional tests such as the Jones test, fluorescein dye disappearance test, dacryocystography and imaging modalities like CT/MRI may be employed. Secretory tests like Schirmer’s test may also be performed occasionally to rule out dry eye syndromes.

The following diagnostic tests are performed routinely if a surgical intervention is being planned:

• Syringing: used to check for the presence of any pre-sacral obstruction. Sterile saline solution is injected into the punctum, and if after 15–30 seconds, there was no regurgitation and if the patient appreciates a salty taste with awakening of the swallowing reflex, then the lacrimal passage is considered to be fully patent. If some saline regurgitated from either puncta and some saline passed into the nose, then the lacrimal passage is partially obstructed. A functional blockage is said to be present if there is no regurgitation of saline but a swelling developed in the lacrimal sac region (Figure 3) [6].

• Diagnostic probing: a lacrimal probe is passed through the punctum towards the canaliculus. If the common canaliculus is patent, the probe touches the medial wall of the sac and its underlying bone, giving a hard and bony feel (Hard stop). Hard stops are usually amenable to surgical correction. If there is a blocked common canaliculus, we encounter a soft, spongy feel.

• Diagnostic nasal endoscopy: is used to assess the nasal septum for deviation, middle meatus for any sinus disorders, osteomeatal complex and turbinates. It helps to exclude any rhinological pathology as the underlying etiology for dacryocystitis as well as helps in surgical planning.

Figure 3.

Lacrimal syringing which shows regurgitation and an incomplete canalicular block.

Additionally, in recurrent cases, the following additional tests may be required to rule out any other causes for excessive tearing:

• Jones Test: Primary Jones Test—2% fluorescence dye is instilled in the conjunctival sac, and a cotton tip applicator moistened with 4% lignocaine is inserted into the inferior meatus. If the applicator is stained with the dye, then the nasolacrimal passage is patent. Secondary Jones Test—it is only performed if the primary test is suggestive of an obstructed nasolacrimal passage. After 5 minutes, the conjunctival sac is flushed with normal saline to remove any residual dye, and then clear normal saline is injected into the sac. If the dye appeared in the nose after injecting, then it is suggestive of a partial blockage of the passage. If no dye was recovered from the nose, then it is suggestive of a canaliculus block. If no fluid is recovered from the nose, then it is suggestive of a complete blockage of the nasolacrimal passage.

• Fluorescein dye disappearance test: a drop of 2% fluorescence dye is instilled into the conjunctival cul de sac. After 5 minutes, if all the dye had disappeared, then there is no obstruction. However, if there is presence of residual dye, it indicates an obstruction.

• Dacryocystography: it is a relatively simple, inexpensive and straightforward procedure in which a radiographic contrast material (either water based or oil based) is injected into the lower lid canalicular system using a lacrimal cannula. Serial postero-anterior and lateral X-ray films of the orbit are obtained immediately after the injection and also after 30 minutes. A delay in emptying time, or failure of the dye to appear in the nasal cavity or nasopharynx, is indicative of an obstruction (Figure 4).

• CT/MRI: is usually reserved of traumatic cases or if there is extensive infection with a suspicion of orbital cellulitis. It helps in surgical planning especially if an endonasal and endoscopic intervention is being planned. These are very useful in evaluating infants with congenital dacryocystitis as they delineate the potential aetiologies of a medial canthal mass such as congenital encephaloceles or vascular malformations [7].

• Secretory tests: are occasionally performed to rule out dry eye syndromes. Schrimer’s test, Bengal rose staining test and lysozyme lysis tests are some examples of secretory tests which are occasionally performed.

Figure 4.

Dacryocystogram showing left lacrimal dacryolithiasis.

10. Management

Dacryocystitis necessitates a combined approach of medical and surgical interventions. While acute cases typically respond well to conservative management, surgical intervention becomes more favorable for chronic cases.

Congenital dacryocystitis often resolves spontaneously within the first year of life in about 80–100% cases, with a significant percentage achieving resolution within the initial 6 months [8]. For symptomatic cases not showing spontaneous resolution, lacrimal sac massage with high-pressure irrigation can be attempted. Probing, once considered the primary intervention, is now reserved for children over 1 year of age, after failed spontaneous resolution, with a success rate of approximately 70%. However, it carries risks of creating false passages and epithelial injury leading to fibrosis and scarring, thus reserved for children older than 1 year [9]. If primary probing fails, alternative surgical interventions such as silicone tube intubation, dacryocystorhinostomy, balloon catheter dilation and inferior turbinate fracture may be explored. Topical antibiotics are usually reserved for any acute flare ups.

Acute dacryocystitis is managed with oral antibiotics covering both Gram-positive and Gram-negative organisms (preferably with antistaphylococcal activity), warm compresses and Crigler massage. Lacrimal probing is discouraged during acute episodes. Unresponsive cases are managed with incision and drainage with direct antibiotic application to the lacrimal sac, to provide immediate pain relief and rapid infection control [10, 11].

Chronic dacryocystitis typically necessitates surgical management, with probing often performed initially in outpatient settings. However, most cases eventually require surgical intervention to prevent disease progression. Techniques such as balloon dilation, silicone tube intubation and nasolacrimal stenting may be attempted. However, the primary management remains dacryocystorhinostomy (DCR), either through external or endoscopic endonasal approaches.

11. Dacryocystorhinostomy (DCR)

DCR creates an anastomosis between the lacrimal sac and nasal mucosa, bypassing the obstructed drainage pathway. External DCR, described by Adeo Toti in 1904, historically served as the standard surgical approach until the late twentieth century. But was associated with external scarring and a failure rate of 3–15% [12]. In pursuit of a less invasive, more physiological and more effective technique, endoscopic endonasal DCR (EE-DCR) emerged. Initially described by Rice in 1988 [13] and first performed on live patients by McDonough and Meiring in 1989 [14], EE-DCR offers a more physiological approach with potentially higher success rates compared to traditional external DCR.

• Indications: persistent congenital dacryocystitis not responding to conservative measures, congenital lacrimal duct obstruction associated with mucocele, dacryocystitis, acquired nasolacrimal duct obstruction

• Contraindications: acute dacryocystitis, malignant lacrimal sac mass, dry eye syndromes, bleeding dycrasias

• Surgical prerequisites: confirmation of diagnosis and clinical features, blood investigations like a complete hemogram, serological evaluation for HIV, HBV and HCV, coagulation profile, additional anesthetic investigations such as blood pressure measurement and random blood sugars based on the patient’s age and comorbidities.

• Equipment and instruments: toothed forceps, needle holder, punctual dilator, Bowman’s probe, Freer’s periosteal elevator, blades (number 15, crescent knife), Kerrison punch, sutures (6-0 vicryl and 6-0 silk) and lacrimal (Crawford) stents.

• Anesthesia: can be performed under local or general anesthesia, but usually local anesthesia is preferred. Local infiltration to block the infratrochlear nerve in conjunction with topical anesthesia of the nasal mucosa is the preferred technique.

• Steps:

  1. A curvilinear incision, measuring about 1 cm in length, is given along the anterior lacrimal crest, 3–4 mm short of the medial canthus (Figure 5).

  2. Blunt subcutaneous dissection is done to expose the periosteum overlying the lacrimal fossa. Care is taken to avoid injury to the medial canthal tendon (Figure 6).

  3. Bone punches are made at the junction of the lamina payracea and the lacrimal bone to create a bony ostium which is then sequentially enlarged (Figure 7).

  4. Sac flaps are then created anteriorly and posteriorly using a Bowma’s probe.

  5. H-shaped incision is then made across the sac funds till the nasolacrimal duct. The flaps are then raised, and the posterior one is cut.

  6. Nasal mucosal flaps are then fashioned using an 11 blade along the bony ostium (Figure 8).

  7. The nasal mucosal and the sac flaps are then anastomosed edge to edge.

  8. Once the anastomosis is secure, the orbicularis is sutured back with 6-0 vicryl followed by skin with 6-0 silk (Figure 9).

  9. Additionally, if there are adhesions within the lacrimal sac, 0.04% Mitomycin C can be applied intraoperatively. Intubation can be done simultaneously especially in case of inadequate flaps [15, 16, 17].

  10. Nasal packing is optional, but may be required at times to achieve hemostasis.

• Postoperative care: postoperatively, the patient is prescribed analgesics, topical and oral antibiotics. Nasal decongestants and saline nasal drops are prescribed as well for wound care. The sutures are removed after 1 week, and the patient is regularly followed up in the clinic at 6 weeks, 12 weeks and 6 months.

• Complications:

  1. Early (1–4 weeks): wound dehiscence, infection, tube displacement, nasal crusting and intranasal synechiae.

  2. Intermediate (1–3 months): granulomas, tube displacement (Figure 10), synechiae, punctual cheese wiring, facial scar and nonfunctional DCR

  3. Late (>3 months): rhinostomy fibrosis, webbed facial scar, medial canthal distortion and failed DCR

Figure 5.

Curvilinear incision used for ExDCR.

Figure 6.

Dissection of the lacrimal sac to expose the bony lacrimal fossa.

Figure 7.

Creation of bony ostium using a Kerrison punch.

Figure 8.

Raising the nasal mucosal flap after making an incision in the sac.

Figure 9.

Wound closure with sutures showing an external facial scar.

Figure 10.

Postoperative complication showing tube displacement.

11.1 Endoscopic endonasal DCR

• Indications: epiphora caused by anatomic or functional obstruction of the lacrimal sac or the nasolacrimal duct, chronic relapsing dacryocystitis with purulent discharge, active infection of the lacrimal sac with infection of the overlying skin, acute dacryocystitis, nasolacrimal duct injury, dacryolithiasis, dacryocele and benign lacrimal sac mass

• Contraindications: dry eye syndromes, chronic epiphora due to presaccal obstruction, lagophthalmos with facial nerve palsy, ectropion of the lower lid, malignancy of the lacrimal system, extensive synechiae between the nasal septum and lateral nasal wall, sinonasal malignancy, Wegener’s granulomatosis, significant collapse of the nasal dorsal due to trauma, bleeding dycrasias

• Surgical prerequistes: confirmation of diagnosis and clinical features, syringing and diagnostic probing, diagnostic nasal endoscopy, blood investigations like a complete hemogram, serological evaluation for HIV, HBV and HCV, coagulation profile, additional anesthetic investigations such as blood pressure measurement and random blood sugars based on the patient’s age and comorbidities.

• Equipment and instruments: endoscopic camera system, video monitor, suction apparatus, antifog solution, light source and cable, 0^∘ and 30^∘ rigid nasal endoscopes, Blakesley forceps, endoscopic scissors, through cut forceps, Freer’s elevator, ball probe, sickle knife, suction cannulas, Kerrison rongeur and burr tips (optional).

• Anesthesia: general anesthesia is the preferred modality for performing an endoscopic end-nasal DCR as it facilitates correction of any simultaneous nasal pathology which contributes to NLDO. However, in cases of severe and uncontrolled comorbidities, it can be performed under local anesthesia as well.

• Steps:

  1. Nasal cavity is packed with cottonwoods soaked in 4% lignocaine with 1 in 10,000 adrenaline for about 5–10 minutes to decongest the nasal mucosa. If required, a septoplasty is then done to improve surgical exposure.

  2. Lateral wall of the nose is infiltrated with 2% lignocaine with adrenaline, just anterior to the uncinate process.

  3. A C-shaped mucosal flap measuring about 1.5 × 1 cm is then fashioned using a 15 number surgical knife. The first incision starts 1 cm above the axilla of the middle turbinate and runs forward by 1 cm, the blade is then turned vertically, a 1.5 cm incision is made downwards, the blade is then turned posteriorly and a 1 cm horizontal incision is made to create a posteriorly bases mucosal flap (Figure 11).

  4. The mucosal flap is then elevated and is then reflected or excised, to expose the underlying lacrimal bone and the frontal process of the maxilla.

  5. The thin lacrimal bone is elevated with a Freer elevator and removed with a forceps.

  6. Kerrison rongeur is then used to take off the frontal process of the maxilla (some surgeons prefer to drill it out with microdrills and burr attachments, especially if the bone is very thick)

  7. This exposes the medial wall of the lacrimal sac in its entirety.

  8. The medial wall of the sac is incised with a sickle knife and excised with a Blakesly forceps or a through cut forceps.

  9. Patency confirmed with saline irrigation via the inferior canaliculus.

  10. The mucosal flap is then repositioned to cover any exposed bone. Care should be taken to prevent the flap from covering the sac incision.

  11. Silicone stents can then be inserted, particularly in revision cases, from the upper and lower canaliculus. Once both the ends are visible inside the nasal cavity, they are held together using a Watzke sleeve or are gently tied together. The excess length of the tube is then excised intranasally.

  12. 0.04% Mitomycin C can then be applied to prevent granuloma formation.

  13. Nasal packs can be inserted to ensure hemostasis.

• Postoperative care: the patient is usually prescribed oral antibiotics, analgesics and saline nasal drops for 1 week in conjunction with topic antibiotic eye drops. Lacrimal syringing is performed twice daily on first and second postoperative days, and then the patients are discharged. They are followed up in the outpatient clinic at 1 week, 3 weeks and 3 months after the surgery. Nasal endoscopy is usually performed in the follow-up visits to ensure lacrimal passage latency and to remove any excessive crusting. In such cases, it is worthwhile to give saline nasal rinses and douches as well.

• Complications:

  1. Early (1–4 weeks): hemorrhage and bleeding into the orbit (in 5–10% cases), ecchymosis of the lower lid, emphysema of the lower lid or cheek, injury to lamina papyracea exposing the orbital fat, medial rectus injury leading to diplopia

  2. Intermediate (1–3 months): granulations, granulomas, synechiaea, stent migration, cheese wiring (excessively tight stent cuts through the canaliculus and the skin between them at the medial canthus) (Figure 12)

  3. Late (>3 months): synechiaea, granuloma formation, stent migration and cheese wiring, lacrimal sump syndrome (block of the common canaliculus intranasally due to mucus accumulation and accompanying sac inflammation, usually responds to external sac massage which helps to clear the accumulated mucus)

Figure 11.

Endoscopic view of the left lateral nasal wall showing the maxillary line and uncinate process (A) and a diagrammatic illustration demonstrating relationship of lacrimal sac to uncinate process and middle turbinate (B).

Figure 12.

Postoperative complication showing cheese wiring.

11.2 Ex-DCR vs. EE-DCR

EE-DCR has got several advantages over an Ex-DCR. It is a more physiological procedure as it avoids injury to the orbicularis oculi muscle, thereby preserving its pumping function. It avoids an external facial scar and any concomitant nasal pathologies can be corrected in a single procedure. However, it does require specialized training for performing procedures with endoscopic assistance, and moreover, the endoscopic equipment is expensive as well.

The major differences between the two procedures are summarized below in a tabular manner (Table 1).

Aspect	EX-DCR	EE-DCR
Approach	External	Endoscopic, endonasal
Physiological consideration	Less physiological as orbicularis oculi gets severed	More physiological as orbicularis oculi and its pumping mechanism are preserved
Scar	External facial scar present	Avoids a facial scar
Correction of nasal pathologies	Cannot be corrected	Can be corrected in a single procedure
Anesthesia	Local anesthesia is preferred	General anesthesia is preferred
Training requirement	No additional training	Requires specialized training for using endoscopes
Equipment	Inexpensive	Relatively expensive
Active infection	Cannot be done in cases of active infection	Active infection is not a contraindication

Table 1.

Comparison between external and endoscopic DCR.

12. Balloon catheter dilation of NLD/balloon dacryoplasty

It is a minimally invasive procedure to establish lacrimal system patency in patients with congenital NLDO [18]. It is typically performed in children above 12 months of age.

• Indications: failed probing, restenosis after failed silicone intubation

• Anesthesia: performed under general anesthesia

• Steps:

  1. Superior and inferior puncta are dilated using a punctual dilator

  2. The balloon catheter is lubricated and inserted into the upper lacrimal system till the 15 mm mark. It is slowly advanced towards the nose and can be grasped via the nostril once it is in place.

  3. The balloon is then inflated to 8 atmospheres for 90 seconds, then deflated, and then reinflated to 8 atmospheres for 60 seconds.

  4. It is then gently retracted 5 mm where the same steps are repeated.

  5. It is then removed by twisting in an anticlockwise manner.

• Postoperative care: topical antibiotic eye drops are prescribed for a week after the procedure. Usually analgesics are not required.

13. Recent advances

A new, novel lacrimal ostium stent (LOS) is currently being evaluated for use in patients with a small lacrimal sac, who are undergoing EE-DCR. Most cases of EE-DCR with a failed result, are attributed to the closure of the nasal ostium. In such cases, LOS comes in handy as it prevents the closure of the nasal ostium and thus, can enhance the success rate of the procedure.

The LOS is a tripartite structure composed of silicone. It has a smooth surface and has a central hollow tube which facilitates lacrimal drainage. It has also got an elliptical repositioning plate and four buckles which facilitate a strong fixation [19].

14. Conclusion

Dacryocystitis stands as a primary culprit behind epiphora and periorbital swelling, stemming from either nasolacrimal duct obstruction or lacrimal passage blockage, culminating in infection. It presents as either congenital or acquired, with the latter further categorized into primary or secondary forms. A comprehensive assessment involving physical examination and diagnostic tests is imperative for accurate diagnosis, emphasizing collaborative efforts between ophthalmologists and otorhinolaryngologists for optimal patient care. While acute cases typically receive conservative management, surgical intervention emerges as the cornerstone for chronic cases. Although external DCR (Ex-DCR) historically served as the gold standard surgical intervention, the tide is shifting towards Endoscopic Endonasal DCR (EE-DCR) owing to its myriad advantages.

Acknowledgments

I would like to express my sincere gratitude to my professors who have always been a beacon of wisdom and support in my professional journey. I would also like to thank my senior colleagues and coworkers, with whom I have had the pleasure to learn and grown both personally and professionally.

I want to thank authors Mohammed Javed Ali et al., Balwant Singh Gendeh and Roger S Taylor et al. whose wonderful illustrations have helped me gain a deeper understanding into the topic and hopefully, by using some of their illustrations, I will be able to reach out to a wider audience who will greatly benefit and learn, just like I had.

Conflict of interest

None.

Notes

I would like to express my gratitude to my family and friends who have always supported me and encouraged me to keep going, especially when things got tough. I want to humbly thank my teachers and professors, who have always motivated me and instilled in me a sense of curiosity which enables me to embark on new academic ventures. Lastly, I want to thank my pets—Taco and Jordan—for always giving me love and keeping stress at bay.