Dacryocystitis

Dacryocystitis typically presents with a tender, red swelling near the inner corner of the eye. The infection involves the lacrimal sac, the tear-collection structure beside the nose. When the nasolacrimal duct below it is blocked, tears stagnate and bacteria can proliferate. The result is tenderness, swelling, redness, and sometimes purulent material from the tear drainage opening.

Anatomy of the Tear Drainage System

Tears made by the lacrimal gland and accessory glands wash across the eye, then drain through small openings (puncta) at the inner corner of the upper and lower lids. From there they pass through the canaliculi, enter the lacrimal sac, and continue down through the nasolacrimal duct into the nose, where they evaporate or are swallowed unnoticed.

When the duct below the sac is blocked, tears back up into the sac. The stagnant fluid is an ideal environment for bacterial overgrowth, and clinical infection is the result. The location of the lacrimal sac - just under the skin at the side of the nose, beneath the inner end of the lower eyelid - is what gives the visible lump its characteristic position.

Acute vs. Chronic Dacryocystitis

Acute Dacryocystitis

• Sudden onset of pain, redness, and swelling at the inner corner of the eye
• Tender lump, often with a fluctuant feel if an abscess has developed
• Tearing, sometimes with mucopurulent discharge from the punctum when pressure is applied to the sac
• Mild fever and malaise in some cases
• Risk of progression to preseptal cellulitis or, less commonly, orbital cellulitis if untreated

Chronic Dacryocystitis

• Persistent or recurrent excessive tearing (epiphora) is the dominant symptom
• Mild swelling at the inner canthus, sometimes with intermittent purulent discharge from the punctum on pressure
• Less acute pain than the acute form
• May flare up to acute dacryocystitis episodically
• Often the patient has had recurrent conjunctivitis-type episodes for years before the underlying problem is recognized

Symptoms

• Swollen, tender lump at the side of the nose, below the inner corner of the eye
• Redness of the overlying skin
• Increased tearing
• Discharge of mucus or pus from the eye, especially after pressure on the sac
• Pain in the inner corner of the eye, may radiate to the nose or cheek
• Eyelid swelling in moderate to severe cases
• Fever in some cases
• May develop red eye from associated conjunctivitis

Causes

Mechanical: Blocked Tear Duct

The fundamental problem is usually nasolacrimal duct obstruction. The block can be:

• Congenital - failure of the duct to fully canalize at birth; the most common cause in infants
• Primary acquired (PANDO) - idiopathic fibroinflammatory narrowing of the duct in adults, most common in women in their 50s-70s
• Acquired secondary - caused by:
  • Chronic sinusitis or nasal disease
  • Trauma involving the nose or mid-face
  • Prior nasal or sinus surgery
  • Tumors of the lacrimal sac, nose, or sinuses (rare but important)
  • Granulomatous disease (sarcoidosis, granulomatosis with polyangiitis)
  • Use of certain chemotherapy drugs (e.g., docetaxel, fluorouracil)
  • Punctal occlusion or canalicular stenosis

Common Pathogens

Acute dacryocystitis is dominated by gram-positive cocci - Staphylococcus aureus (including MRSA), coagulase-negative staphylococci, and Streptococcus species. Chronic dacryocystitis has a higher share of gram-negative organisms (including Pseudomonas aeruginosa and Haemophilus influenzae) and mixed flora; anaerobes are seen with dental or sinus sources. Fungal infection is rare and typically occurs in immunocompromised hosts. Neonatal acute dacryocystitis can additionally involve group B Streptococcus, Haemophilus, and gram-negatives.

Diagnosis

The diagnosis is usually clinical. The doctor will:

• Inspect the inner canthus for swelling, redness, and warmth
• Palpate gently - a tender, sometimes fluctuant mass over the sac supports acute dacryocystitis
• Apply pressure on the sac and watch the puncta for reflux of mucus or pus - a positive test strongly supports the diagnosis
• Test the tear film and look for conjunctivitis features
• Perform a slit lamp examination of the lid margin and ocular surface
• Test visual acuity - should be normal
• Consider imaging if there is concern for tumor, abscess, atypical features, or if surgery is being planned. CT-dacryocystography or MRI can demonstrate sac anatomy.

A culture of any expressed discharge is helpful in choosing antibiotic therapy, particularly when MRSA or unusual organisms are suspected.

Treatment

Acute Dacryocystitis

• Oral antibiotics with coverage for staphylococci and streptococci. Choices are similar to preseptal cellulitis: amoxicillin-clavulanate is common; cephalexin may fit selected low-risk cases; doxycycline or trimethoprim-sulfamethoxazole is usually added to beta-lactam coverage when MRSA is a concern; clindamycin may be used when a single agent with MRSA and streptococcal coverage is appropriate.
• Warm compresses applied to the lump several times daily
• Pain control with acetaminophen or NSAIDs
• Drainage of an abscess when fluctuant - usually performed in clinic or the operating room rather than at home
• Topical antibiotic drops for any associated conjunctivitis are an adjunct, not a substitute for systemic therapy
• IV antibiotics and admission for severe cases, particularly with cellulitis or systemic illness

Chronic Dacryocystitis and Nasolacrimal Duct Obstruction in Adults

The recurrent episodes of acute dacryocystitis will not stop until the underlying obstruction is bypassed. Surgical options include:

• Dacryocystorhinostomy (DCR) - the definitive procedure. A new drainage opening is created surgically between the lacrimal sac and the inside of the nose. Can be performed by an external (skin incision) or endonasal (through the nose) approach. Success rates are typically 85-95%.
• Balloon dacryoplasty - endoscopic balloon dilation of the duct. Lower success rates than DCR but less invasive; sometimes considered in selected patients.
• Silicone tube intubation - can be used to maintain a newly created or dilated drainage pathway.

Congenital Nasolacrimal Duct Obstruction in Infants

• Most cases of simple congenital NLDO (~90%) resolve spontaneously in the first year of life
• Lacrimal sac massage (Crigler massage) is recommended - gentle downward pressure to encourage opening of the membranous obstruction
• Topical antibiotic drops for any infectious flare-ups
• Probing of the nasolacrimal duct is considered when obstruction does not resolve. Some pediatric ophthalmologists perform in-office probing between 6 and 12 months of age; later probing is performed under general anesthesia
• Silicone tube intubation or balloon dacryoplasty may be needed for persistent or recurrent cases
• DCR is reserved for severe, refractory cases in children

Neonatal Acute Dacryocystitis (Distinct Urgent Entity)

A newborn with a tense, red, tender swelling at the lacrimal sac is not the same as simple congenital NLDO. Neonatal acute dacryocystitis requires admission, IV antibiotics covering staphylococci, streptococci (including group B Streptococcus), Haemophilus, and gram-negatives, and early probing rather than watchful waiting. Untreated, it can progress rapidly to orbital cellulitis, sepsis, or meningitis.

Complications

• Lacrimal sac abscess with skin breakdown and possible spontaneous fistula
• Preseptal cellulitis spreading from the sac
• Orbital cellulitis in rare severe cases
• Recurrent acute episodes until definitive treatment of the underlying obstruction
• Lacrimal sac mucocele - a non-infected cystic dilation of the sac
• Lacrimal sac tumor - uncommon but should be considered in atypical, persistent, or bloody discharge cases

Frequently Asked Questions

Is dacryocystitis the same as a stye?

No. A stye (hordeolum) is an infection of an oil gland or eyelash follicle on the eyelid margin. Dacryocystitis is an infection of the tear drainage sac, located between the eye and the nose. The position of the lump is the easiest visual clue.

Why do I keep getting this?

Recurrence often means the underlying tear duct obstruction has not been definitively treated. Antibiotics control individual flares but do not reliably correct the drainage problem. In adults with repeated episodes, dacryocystorhinostomy is the usual way to stop the cycle by creating an alternate drainage path.

Will it go away on its own?

A single episode of acute dacryocystitis usually responds within days to a week of oral antibiotics. In adults, the underlying duct obstruction often persists, so recurrent episodes are more likely without definitive drainage treatment. In infants, congenital obstruction often resolves on its own within the first year of life.

Is dacryocystorhinostomy a major surgery?

DCR is generally considered a moderate procedure performed under sedation or general anesthesia. The endonasal approach avoids a skin incision and has cosmetically excellent results. Recovery is typically 1-2 weeks of mild discomfort, with congestion or minor bleeding from the nose. Long-term success rates are 85-95% depending on technique and individual anatomy.

Should I press on the lump to drain it?

Clinicians may apply gentle pressure to express discharge for diagnosis or culture, but patients should not repeatedly squeeze the lump at home. Firm squeezing is not therapeutic and may worsen inflammation. If an abscess has formed, drainage should be performed in a clinical setting with appropriate sterile technique. The mainstay at home is warm compresses and the antibiotic course.

References