A 13-year-old female came to clinic with a history of swelling medially on her left eye for the past 2 days. She said that it was painful but it improved after expressing some “pus” from the area when she pushed on it. She had had some facial trauma about 4 days prior to this when she was hit on the nose playing volleyball. She had some bruising but had not sought care. She endorsed increased tearing but had no redness or irritation of the eye. Her vision was normal and she had no problems moving her eyes. She denied any fever, chills, nausea, changes in mentation, rhinorrhea, facial or dental pain.
The past medical history was positive for a chalazion on the left eye about 2 years previously.
The pertinent physical exam revealed a well appearing female with normal vital signs. Along the lateral area of the nose/medial area of the left eye she had a 1 cm red/purplish mass. It was not warm but was just slightly tender. No pus could be seen after palpation of the area. The puncta looked clear. There was no conjunctival or scleral injection. Extraocular movements were normal and pupils were 3 mm and reacted briskly to light. Her nose had normal structures with some bruising at the bridge without abnormal discharge. Teeth had no pain with tapping.
The diagnosis of of dacrocystitis was made. Because this seemed mild but in an older child, ophthalmology was consulted by phone. They agreed to starting antibiotics and followed her up the next day. She continued to do well and this eventually resolved. It was felt this occurred because of swelling due to the nasal injury.
Tears are produced in the lacrimal gland which resides in the upper outer quadrant of the eye. The tears flow across the eye medially and are collected in the superior and inferior puncta which drain into their respective canaliculi, and these drain into a common canaliculus. Tears then pass through the valve of Rosenmuler into the lacrimal sac where they are collected. Tears then pass through the nasolacrimal duct, through the distal valve of Hasner and into the nasal cavity. Vascular connections are extensive in this anatomic area and veins do not have valves. Therefore infections can spread easily through direct or indirect spread from the nasolacrimal duct system to other adjacent systems.
Dacrocystitis is an inflammation of the nasolacrimal sac that is usually caused by obstruction, leading to tear stagnation which then provides a good environment for proteinaceous material to form and infectious organisms to propagate. Dacrocystitis can be acute or congenital or acquired and acute or chronic. Congenital dacrocystitis is usually due to obstruction or stenosis in the distal anatomy particular the valve of Hasner. “Before delivery [of an infant] the nasolacrimal system is filled with amniotic fluid. When the amniotic fluid fails to be expressed forom the nasolacrimal system, it becomes purulent with a few days of delivery and becomes pathologic.” Acquired disease is caused by trauma, surgery, foreign bodies, neoplasms or medications. Chronic disease is due to chronic obstruction due to a systemic disease such as sarcoidosis or lupus erythematosus. Acute disease is usually due to an acute infectious cause with Staphylococcus(most common) species, Streptococcus species, Haemophilus influenzae and Pseudomonas aeruginosa being the most common causes. Polymicrobial infections are also common.
Not surprisingly given the pathophysiology and causes of dacrocystitis, there is a bimodal distribution with cases occurring around birth (mainly congenital and more acute) and then again in adults > 40 years old (acquired and may be acute or chronic).
Diagnosis is usually clinical. Symptoms can occur over hours to days. The area around the medial canthus swells and is tender and usually erythematous or even more purple colored. Purulent material can sometimes be expressed from the puncta. There often is an increase in tears which may also cause conjunctival injection. Constitutional symptoms such as fever or elevated inflammatory markers may be present but aren’t necessary for diagnosis. A full examination of the ophthalmologic and nasal structures is important. Culture of purulent material may be helpful to identify an offending organism. Imaging of the anatomic area may be necessary if there is extensive disease or involvement of the posterior orbital structures or complications are suspected. Potential morbidities can be severe with mortality a possibility as well because of the number of important structures that lie adjacent to this area including orbital cellulitis, meningitis, brain abscess, cavernous sinus thrombosis, lacrimal duct fistulas, sinusitis, or permanent vision loss.
Acute dacrocystitis can be a very serious infection and especially younger patients may need more evaluation or treatment. All require close monitoring. Congenital dacrocystitis usually resolves by 6 months. Nasolacrimal duct probing or intubation or balloon dacroplasty or stenting may be necessary depending on the underlying cause and types of previous treatment. Sometimes a dacrocystorhinostomy may be necessary.
The differential diagnosis includes:
- Capillary hemangioma
- Cellulitis – preseptal or orbital
- Dacroadenitis – or inflammation of the nasolacrimal sac
- Dermoid cyst
- Ectropian or eversion of the lower lid
- Sebaceous cyst
- Severe acne or medical chalazion usually can be eliminated as possibilities but in the right circumstances can be considered.
Questions for Further Discussion
1. What causes general eyelid swelling? A review can be found here
2. What is the difference between a hordeolum, chalazion and stye? A review can be found here
3. List emergencies related to the eye.
- Disease: Dacrocystitis | Eye Infections
- Age: Teenager
To Learn More
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Ali MJ. Pediatric Acute Dacryocystitis. Ophthalmic Plast Reconstr Surg. 2015;31(5):341-347. doi:10.1097/IOP.0000000000000472.
Chung SY, Rafailov L, Turbin RE, Langer PD. The microbiologic profile of dacryocystitis. Orbit. 2019;38(1):72-78. doi:10.1080/01676830.2018.1466901.
Taylor RS, Ashurst JV. Dacryocystitis. In: StatPearls. StatPearls Publishing; 2021. Accessed April 5, 2021. http://www.ncbi.nlm.nih.gov/books/NBK470565/.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa