Lacrimal System Infections Lacrimal System Infections

M. Esaghi M.DM. Esaghi M.D

Oculoplastic FelowshipOculoplastic Felowship

Mazandaran University of Medical Mazandaran University of Medical Sciences Sciences

DacryosystitisDacryosystitis

DacryocystitisDacryocystitis

•• Dacryocystitis is usually the result of lacrimal Dacryocystitis is usually the result of lacrimal outflow obstruction and stasis of tears in the outflow obstruction and stasis of tears in the lacrimal saclacrimal sac

•• Outflow obstruction can be secondary to Outflow obstruction can be secondary to infection or anatomical anomalies. infection or anatomical anomalies.

•• Infection of the lacrimal sac is usually Infection of the lacrimal sac is usually bacterial and in only 1.2% of cases is a fungal bacterial and in only 1.2% of cases is a fungal organism the causative agens.organism the causative agens.

DacryocystitisDacryocystitis

•• The lacrimal excretory system is prone to infection The lacrimal excretory system is prone to infection and inflammation for various reasons:and inflammation for various reasons:

•• This mucous membraneThis mucous membrane--lined tract is contiguous with lined tract is contiguous with 2 surfaces (conjunctival and nasal mucosal) that are 2 surfaces (conjunctival and nasal mucosal) that are normally colonized with bacteria.normally colonized with bacteria.

•• The functional purpose of the lacrimal excretory The functional purpose of the lacrimal excretory system is to drain tears from the eye into the nasal system is to drain tears from the eye into the nasal cavity. Stagnation of tears in a pathologically closed cavity. Stagnation of tears in a pathologically closed lacrimal drainage system can result in dacryocystitis.lacrimal drainage system can result in dacryocystitis.

DacryocystitisDacryocystitis

•• Dacryocystitis can become a lifeDacryocystitis can become a life--threatening threatening

infection with the potential to progress to infection with the potential to progress to

orbital cellulitis and/or orbital abscess, orbital cellulitis and/or orbital abscess,

meningitis, or cavernous sinus thrombosis meningitis, or cavernous sinus thrombosis

•• Dacryocystitis has long been noted to occur Dacryocystitis has long been noted to occur

more frequently on the left side than on the more frequently on the left side than on the

right side. In many instances, the nasolacrimal right side. In many instances, the nasolacrimal

duct and lacrimal fossa formed a greater angle duct and lacrimal fossa formed a greater angle

on the right side than on the left side. on the right side than on the left side.

•• Acquired dacryocystitis can be acute or Acquired dacryocystitis can be acute or

chronic. Acute dacryocystitis is heralded by chronic. Acute dacryocystitis is heralded by

the sudden onset of pain and redness in the the sudden onset of pain and redness in the

medial canthal region. An insidious onset of medial canthal region. An insidious onset of

epiphora is characteristic of chronic epiphora is characteristic of chronic

inflammation or infection of the lacrimal sac.inflammation or infection of the lacrimal sac.

Dacryocystitis more common in:Dacryocystitis more common in:

•• Individuals with skull anomalies (brachycephalic)Individuals with skull anomalies (brachycephalic)

•• This is because brachycephalic skulls demonstrate a This is because brachycephalic skulls demonstrate a

narrower diameter of inlet into the nasolacrimal duct, narrower diameter of inlet into the nasolacrimal duct,

the nasolacrimal duct is longer, and the lacrimal fossa the nasolacrimal duct is longer, and the lacrimal fossa

is narrower is narrower

•• Furthermore, patients with a flat nose and narrow Furthermore, patients with a flat nose and narrow

face are at a higher risk for developing dacryocystitis, face are at a higher risk for developing dacryocystitis,

presumably because of the narrow osseous presumably because of the narrow osseous

nasolacrimal canal. nasolacrimal canal.

•• Race:Race:Blacks rarely develop dacryocystitis because Blacks rarely develop dacryocystitis because the nasolacrimal ostium into the nose is large. In the nasolacrimal ostium into the nose is large. In addition, the lacrimal canal is shorter and straighter in blacksaddition, the lacrimal canal is shorter and straighter in blacksthan in whites.than in whites.

•• Sex:Sex:In adults females are afflicted more commonly by In adults females are afflicted more commonly by dacryocystitis. Most studies demonstrate that 70dacryocystitis. Most studies demonstrate that 70--83% of cases 83% of cases of dacryocystitis occur in females. Congenital dacryocystitis of dacryocystitis occur in females. Congenital dacryocystitis occurs with equal frequency in both sexesoccurs with equal frequency in both sexes

•• Age:Age:Lacrimal sac infections and inflammations commonly Lacrimal sac infections and inflammations commonly occur in 2 discrete age categories, infants and adults older thaoccur in 2 discrete age categories, infants and adults older than n 40 years. Acute dacryocystitis in newborns is rare, occurring 40 years. Acute dacryocystitis in newborns is rare, occurring in fewer than 1% of all newborns..in fewer than 1% of all newborns..

CausesCauses

•• In congenital dacryocystitis, incomplete canalization of the In congenital dacryocystitis, incomplete canalization of the NLD. However, since the incidence of congenital NLD. However, since the incidence of congenital dacryocystitis is much lower than the incidence of incomplete dacryocystitis is much lower than the incidence of incomplete canalization, other factors than developmental ones appear to canalization, other factors than developmental ones appear to play a role in the pathogenesisplay a role in the pathogenesis

•• Both aerobic bacteria and anaerobic bacteria have been Both aerobic bacteria and anaerobic bacteria have been cultured from pediatric and adult patients with dacryocystitis cultured from pediatric and adult patients with dacryocystitis The most common organisms isolated from the lacrimal sacs The most common organisms isolated from the lacrimal sacs of children with dacryocystitis include of children with dacryocystitis include Staphylococcus aureus, Staphylococcus aureus, Haemophilus influenzae,Haemophilus influenzae, betabeta--hemolytic streptococci, and hemolytic streptococci, and pneumococci. pneumococci.

…………CausesCauses

•• Structural abnormalities of the midface also Structural abnormalities of the midface also should be considered. should be considered.

•• Obstruction of the nasolacrimal duct by a tight Obstruction of the nasolacrimal duct by a tight inferior meatus has been noted in many inferior meatus has been noted in many infants. infants.

•• The etiology of dacryocystitis includes nasal The etiology of dacryocystitis includes nasal disease and ectrodactylydisease and ectrodactyly--ectodermal dysplasiaectodermal dysplasia--clefting (EEC) syndromeclefting (EEC) syndrome

…………CausesCauses

•• In acquired dacryocystitis obstruction of the lower part of the In acquired dacryocystitis obstruction of the lower part of the nasolacrimal system frequently is present. Because of the nasolacrimal system frequently is present. Because of the intimate relationship of the nasolacrimal duct with the nose intimate relationship of the nasolacrimal duct with the nose and paranasal sinuses, these structures are commonly and paranasal sinuses, these structures are commonly associated as an etiologic factor in the pathogenesis of associated as an etiologic factor in the pathogenesis of dacryocystitis. dacryocystitis.

•• ethmoidal inflammation ethmoidal inflammation

•• ocular origin ocular origin

•• impacted cilia impacted cilia

•• Profuse secretion and stagnation of tears in the lacrimal sac, Profuse secretion and stagnation of tears in the lacrimal sac, which may occur in uncorrected astigmatism and which may occur in uncorrected astigmatism and hypermetropia, may contribute to the development of hypermetropia, may contribute to the development of dacryocystitis. dacryocystitis.

Nasal diseaseNasal disease

•• Sinusitis (maxillary, ethmoidal) Sinusitis (maxillary, ethmoidal)

•• Hypertrophic rhinitis Hypertrophic rhinitis

•• Vasomotor rhinitis Vasomotor rhinitis

•• Syphilitic rhinitis Syphilitic rhinitis

•• Rhinitis ozaenosa Rhinitis ozaenosa

•• Adenoids Adenoids

•• Eczema of nares Eczema of nares

•• Purulent rhinitis Purulent rhinitis

•• Nasal trauma Nasal trauma

•• Ethmoidal tumor Ethmoidal tumor

•• Nasal tumor Nasal tumor

•• Atrophic rhinitis sicca Atrophic rhinitis sicca

•• Rhinitis fibrinosa Rhinitis fibrinosa

•• Enlarged inferior turbinate Enlarged inferior turbinate

•• Foreign body in the nose Foreign body in the nose

•• Septal deviation Septal deviation

•• Frontal sinus neoplasm Frontal sinus neoplasm

•• Nasal mucosal infection Nasal mucosal infection

•• Diphtheria Diphtheria

•• Measles Measles

•• Scarlatina Scarlatina

•• Nasal septal abscess Nasal septal abscess

•• Ethmoidal mucocele Ethmoidal mucocele

•• Rhinolithiasis Rhinolithiasis

•• Bacterial:, Bacterial:, Staphylococcus Staphylococcus

epidermidisepidermidis (most (most

common), common), Staphylococcus Staphylococcus

aureus, Pseudomonas aureus, Pseudomonas

aeruginosa, Escherichia aeruginosa, Escherichia

coli, Pneumococcus, coli, Pneumococcus,

Propionibacterium acnes, Propionibacterium acnes,

Mycobacterium fortuitumMycobacterium fortuitum

•• -- Tuberculosis, syphilis, Tuberculosis, syphilis,

trachomatrachoma

•• Viral Infectious: Viral Infectious:

mononucleosis mononucleosis

•• Fungal Fungal -- Candida albicans, Candida albicans,

Aspergillus nigerAspergillus niger

Fungal DacryocystitisFungal Dacryocystitis

•• Silicone Punctal Plug Migration Resulting in Silicone Punctal Plug Migration Resulting in

DacryocystitisDacryocystitis and Canaliculitis and Canaliculitis

Lacrimal TumorsLacrimal Tumors

•• Acquired nasolacrimal duct obstruction and Acquired nasolacrimal duct obstruction and

dacryocystitis may occasionally result from tumors of dacryocystitis may occasionally result from tumors of

the nasolacrimal sac, inflammatory diseases such as the nasolacrimal sac, inflammatory diseases such as

Wegener granulomatosis and sarcoidosisWegener granulomatosis and sarcoidosis

•• mechanical causes such as compression of the mechanical causes such as compression of the

excretory system from external tumors. Nasolacrimal excretory system from external tumors. Nasolacrimal

Metastasis From Heptocellular Carcinoma Metastasis From Heptocellular Carcinoma

Masquerading as Dacryocystitis Masquerading as Dacryocystitis

Dacryocystitis FormsDacryocystitis Forms

•• Congenital Congenital

dacryocystitisdacryocystitis

•• Acute dacryocystitisAcute dacryocystitis

•• chronic dacryocystitis chronic dacryocystitis

Congenital dacryocystitisCongenital dacryocystitis

•• is a very serious disease is a very serious disease

associated with significant associated with significant

morbidity and mortality. If morbidity and mortality. If

not treated promptly and not treated promptly and

aggressively, newborn aggressively, newborn

infants can experience infants can experience

orbital cellulitis (because the orbital cellulitis (because the

orbital septum is formed orbital septum is formed

poorly in infants), brain poorly in infants), brain

abscess, meningitis, sepsis, abscess, meningitis, sepsis,

and death. and death.

Acute dacryocystitis Acute dacryocystitis

•• sudden onset of pain, erythema, and edema overlying sudden onset of pain, erythema, and edema overlying the lacrimal sac region. the lacrimal sac region.

•• It is not uncommon for the sac to rupture and fistulize It is not uncommon for the sac to rupture and fistulize through the skin; this fistula commonly closes after a through the skin; this fistula commonly closes after a few days of drainage few days of drainage

•• Conjunctival injection and preseptal cellulitis often Conjunctival injection and preseptal cellulitis often occur in conjunction with acute dacryocystitis occur in conjunction with acute dacryocystitis

•• More serious sequelae of acute dacryocystitis include More serious sequelae of acute dacryocystitis include extension into the orbit with formation of an abscess extension into the orbit with formation of an abscess and development of orbital cellulitis and development of orbital cellulitis

chronic dacryocystitis chronic dacryocystitis

•• Tearing is the most common presentation Tearing is the most common presentation

•• Mattering:Mattering:

A)This is caused by the obstruction of drainage of the A)This is caused by the obstruction of drainage of the mucous layer of the tear film with collection of debris mucous layer of the tear film with collection of debris and denuded epithelial cells from the surface of the and denuded epithelial cells from the surface of the eye. eye.

B)Frequently, it may be associated with B)Frequently, it may be associated with conjunctivitis. This is attributed to the toxic nature of conjunctivitis. This is attributed to the toxic nature of the debris to the surface of the eye or because of the debris to the surface of the eye or because of exotoxins produced by staphylococcal organismsexotoxins produced by staphylococcal organisms

acute dacryocystitisacute dacryocystitis

•• The conventional treatment of acute dacryocystitis with The conventional treatment of acute dacryocystitis with abscess formation includes the use of warm compresses, abscess formation includes the use of warm compresses, systemic antibiotics, percutaneous drainage of the abscess, and systemic antibiotics, percutaneous drainage of the abscess, and external dacryocystorhinostomy (DCR) following resolution external dacryocystorhinostomy (DCR) following resolution of the acute infection of the acute infection

•• Primary acute endonasal DCR offers potential advantages over Primary acute endonasal DCR offers potential advantages over standard treatment with rapid improvement in pain, earlier standard treatment with rapid improvement in pain, earlier resolution of infection, and the economic benefits of reduced resolution of infection, and the economic benefits of reduced patient length of stay without the need for later readmission fopatient length of stay without the need for later readmission for r external or indeed endonasal D external or indeed endonasal D

PhysicalPhysical

Signs Signs

•• Fever results from a fulminant bacterial or fungal infection in Fever results from a fulminant bacterial or fungal infection in the lacrimal sac, which spreads to the surrounding tissues. the lacrimal sac, which spreads to the surrounding tissues.

•• Leukocytosis also is common in acute dacryocystitis. Leukocytosis also is common in acute dacryocystitis.

•• Cellulitis Cellulitis

•• Altered visual acuity Altered visual acuity

•• Conjunctivitis frequently is associated with acute and chronic Conjunctivitis frequently is associated with acute and chronic dacryocystitis dacryocystitis

•• Medial canthal fullness and tenderness are common in both Medial canthal fullness and tenderness are common in both acute dacryocystitis and chronic dacryocystitis acute dacryocystitis and chronic dacryocystitis

Cellulitis Cellulitis

•• Cellulitis is seen predominately in acute Cellulitis is seen predominately in acute

dacryocystitis dacryocystitis

•• Orbital cellulitis :This is a rare, but serious, Orbital cellulitis :This is a rare, but serious,

complication of dacryocystitis. It is associated complication of dacryocystitis. It is associated

most commonly with acute dacryocystitis and most commonly with acute dacryocystitis and

congenital acute dacryocystiticongenital acute dacryocystiti

•• Decreased visual acuity: the increased tear film on the Decreased visual acuity: the increased tear film on the surface of the eye. surface of the eye.

•• Periorbital edema :the inflammation associated with Periorbital edema :the inflammation associated with the buildup of toxic debris on the surface of the eye the buildup of toxic debris on the surface of the eye and exotoxins secreted by staphylococcal organisms and exotoxins secreted by staphylococcal organisms living on the surface of the eye.living on the surface of the eye.

Lab StudiesLab Studies

•• In most patients, physicians make a clinical diagnosis of In most patients, physicians make a clinical diagnosis of dacryocystitis dacryocystitis

•• Supportive laboratory analysis Supportive laboratory analysis

•• Blood cultures and cultures of the ocular surface, nose, and Blood cultures and cultures of the ocular surface, nose, and lacrimal sac discharge may prove useful in determining the lacrimal sac discharge may prove useful in determining the appropriate antibiotic therapy appropriate antibiotic therapy

•• Antineutrophil cytoplasmic antibody testing may be useful in Antineutrophil cytoplasmic antibody testing may be useful in ruling out Wegener granulomatosis ruling out Wegener granulomatosis

•• Antinuclear antibody (ANA) testing may be useful in the very Antinuclear antibody (ANA) testing may be useful in the very rare cases of dacryocystitis caused by lupus rare cases of dacryocystitis caused by lupus

Imaging StudiesImaging Studies

•• Plain films :facial skeletal anomalies or foreign Plain films :facial skeletal anomalies or foreign

bodies, posttraumatic etiologies bodies, posttraumatic etiologies

•• CT scans : an occult malignancy or mass, post CT scans : an occult malignancy or mass, post

traumatic causes traumatic causes

•• MRIs are not as useful as CT scans but can be helpful MRIs are not as useful as CT scans but can be helpful

in differentiating cystic lesions from solid mass in differentiating cystic lesions from solid mass

lesions. MRIs can be useful in identifying patients lesions. MRIs can be useful in identifying patients

with lacrimal sac diverticuli, with lacrimal sac diverticuli,

Dacryocystography (DCG) & Dacryocystography (DCG) &

Dacryoscintigraphy Dacryoscintigraphy

•• are useful adjunctive diagnostic modalities are useful adjunctive diagnostic modalities when anatomical abnormalities of the when anatomical abnormalities of the nasolacrimal drainage system are suspected.nasolacrimal drainage system are suspected.

•• Subtraction DCG with CT scan is also very Subtraction DCG with CT scan is also very sensitive to study the anatomy of the lacrimal sensitive to study the anatomy of the lacrimal sac and surrounding structures.sac and surrounding structures.

•• Functional testsFunctional tests

The bacteriology of dacryocystitisThe bacteriology of dacryocystitis

•• The bacteriology of dacryocystitis mimics normal conjunctival The bacteriology of dacryocystitis mimics normal conjunctival flora in most instances. flora in most instances.

•• The most common aerobic organisms isolated from the The most common aerobic organisms isolated from the lacrimal sacs in adults :lacrimal sacs in adults :S epidermidis, S aureus,S epidermidis, S aureus, and and Streptococcus, Pseudomonas,Streptococcus, Pseudomonas, and and PneumococcusPneumococcus species. species. S S epidermidisepidermidis is the most common isolate followed by is the most common isolate followed by S aureusS aureus. .

•• The most common anaerobic organisms : The most common anaerobic organisms : Peptostreptococcus, Peptostreptococcus, Propionibacterium, PrevotellaPropionibacterium, Prevotella, and , and FusobacteriumFusobacterium species. species.

•• GramGram--negative bacteria : in patients with copious discharge. negative bacteria : in patients with copious discharge. The most common :The most common :E coliE coli. .

•• Rarely, fungi have been isolated from infected lacrimal sacs Rarely, fungi have been isolated from infected lacrimal sacs (commonly associated with dacryolith formation (commonly associated with dacryolith formation

The Microbiologic Spectrum of The Microbiologic Spectrum of

Dacryocystitis (Acute Versus Chronic Dacryocystitis (Acute Versus Chronic

Infection) Infection) •• The Microbiologic Spectrum of Dacryocystitis: A The Microbiologic Spectrum of Dacryocystitis: A National Study of Acute Versus Chronic Infection National Study of Acute Versus Chronic Infection

•• GramGram--positive organisms were much more common positive organisms were much more common than Gramthan Gram--negative organisms overall, and the negative organisms overall, and the proportions did not differ significantly between the proportions did not differ significantly between the groups. groups. StaphylococcusStaphylococcus was the most common isolate was the most common isolate in both groups, but there was a greater frequency of in both groups, but there was a greater frequency of methicillinmethicillin--resistant resistant Staphylococcus aureusStaphylococcus aureus (MRSA) (MRSA) isolates in the acute group. The results of this study isolates in the acute group. The results of this study have important implications for the treatment of have important implications for the treatment of dacryocystitis. dacryocystitis.

•• A total of 180 strains were isolated from the 85 bacterial A total of 180 strains were isolated from the 85 bacterial samples, including 150 strains of aerobic bacteria and 30 samples, including 150 strains of aerobic bacteria and 30 strains of anaerobic bacteria. Fungi were found in eight strains of anaerobic bacteria. Fungi were found in eight samples and actinomyces in three samples. The bacterial samples and actinomyces in three samples. The bacterial species that were most frequently found were Staphylococcus species that were most frequently found were Staphylococcus species, representing 34.5% of all strains, followed by species, representing 34.5% of all strains, followed by Corynebacterium diphtheroides (15.5%) Corynebacterium diphtheroides (15.5%)

•• Gram positive cocci was the predominant pathogen of chronic Gram positive cocci was the predominant pathogen of chronic dacryocystitis. Levodacryocystitis. Levo--ofloxacin and amikacin had the best ofloxacin and amikacin had the best effect in vitro. effect in vitro.

changing trends within the changing trends within the

microbiologic spectrummicrobiologic spectrum

•• Recent articles, however, have suggested the possibility of Recent articles, however, have suggested the possibility of changing trends within the microbiologic spectrum of changing trends within the microbiologic spectrum of dacryocystitis. Specifically, an increased frequency of Gramdacryocystitis. Specifically, an increased frequency of Gram--negative and MRSA infections has been suggested negative and MRSA infections has been suggested

•• Cephalosporins and amoxicillin/clavulanic acid combined Cephalosporins and amoxicillin/clavulanic acid combined (Augmentin) accounted for more than 75% of the initial (Augmentin) accounted for more than 75% of the initial systemic antibiotics chosen. The majority of cases (86.4%) systemic antibiotics chosen. The majority of cases (86.4%) treated with systemic antibiotics (empiric and secondary treated with systemic antibiotics (empiric and secondary cultureculture--guided) showed clinical improvement. guided) showed clinical improvement.

•• The clinical suspicion for MRSA infection may certainly be The clinical suspicion for MRSA infection may certainly be increased in cases resistant to empiric antibiotic therapy increased in cases resistant to empiric antibiotic therapy

Dacryolith formation Dacryolith formation

•• in 14in 14--16% of patients 16% of patients

•• Patients with a history of acute dacryocystitis Patients with a history of acute dacryocystitis

have a higher incidence of dacryolith have a higher incidence of dacryolith

formation than those with chronic formation than those with chronic

dacryocystitis. dacryocystitis.

ManagementManagement ((Acute dacryocystitis)Acute dacryocystitis)

•• The treatment of dacryocystitis depends upon the The treatment of dacryocystitis depends upon the

clinical manifestations of the disease : with or without clinical manifestations of the disease : with or without

preseptal cellulitis and orbital cellulitispreseptal cellulitis and orbital cellulitis

•• The conventional treatment of acute dacryocystitis The conventional treatment of acute dacryocystitis

with abscess formation includes the use of warm with abscess formation includes the use of warm

compresses, systemic antibiotics, percutaneous compresses, systemic antibiotics, percutaneous

drainage of the abscess, and external drainage of the abscess, and external

dacryocystorhinostomy (DCR) following resolution dacryocystorhinostomy (DCR) following resolution

of the acute infectionof the acute infection

Medical Care Medical Care

(Acute dacryocystitis)(Acute dacryocystitis)

•• Treatment with warm compresses may aid in resolution of the diseTreatment with warm compresses may aid in resolution of the diseasease

•• Cephlosporine and amoxicilin, In penicilin allergic patients: clCephlosporine and amoxicilin, In penicilin allergic patients: clindamycin, indamycin, ciprofloxacin and azithromycin ciprofloxacin and azithromycin

•• hospitalization with intravenous (IV) antibiotics. hospitalization with intravenous (IV) antibiotics.

•• IV empiric antimicrobial therapy for penicillinIV empiric antimicrobial therapy for penicillin--resistant resistant StaphylococcusStaphylococcus(nafcillin or cloxacillin) should be initiated immediately (nafcillin or cloxacillin) should be initiated immediately

•• Blood cultures and cultures of the lacrimal secretions should beBlood cultures and cultures of the lacrimal secretions should be obtained obtained prior to antibiotic therapy. prior to antibiotic therapy.

•• Impending perforation should be treated with a stab incision of Impending perforation should be treated with a stab incision of the skin the skin

Endoscopic DCR in acute Endoscopic DCR in acute

dacryocystitisdacryocystitis

•• Primary acute endonasal DCR offers potential Primary acute endonasal DCR offers potential

advantages over standard treatment with rapid advantages over standard treatment with rapid

improvement in pain, earlier resolution of improvement in pain, earlier resolution of

infection, and the economic benefits of infection, and the economic benefits of

reduced patient length of stay without the need reduced patient length of stay without the need

for later readmission for external or indeed for later readmission for external or indeed

endonasalendonasal

Chronic Dacryocystitis Chronic Dacryocystitis

•• oral antibiotics oral antibiotics

•• The treatment of choice is a dacryocystorhinostomy The treatment of choice is a dacryocystorhinostomy whether the patient is symptomatic or not. Probing whether the patient is symptomatic or not. Probing should not be performed because mucoceles often are should not be performed because mucoceles often are not sterile and probing may incite a cellulitis. not sterile and probing may incite a cellulitis.

•• Patients with chronic dacryocystitis caused by a Patients with chronic dacryocystitis caused by a partial or intermittent nasolacrimal duct obstruction partial or intermittent nasolacrimal duct obstruction may benefit from topical steroid drop treatment. may benefit from topical steroid drop treatment.

Congenital Chronic DacryocystitisCongenital Chronic Dacryocystitis

•• Congenital chronic dacryocystitis may resolve Congenital chronic dacryocystitis may resolve

with lacrimal sac massage, warm compresses, with lacrimal sac massage, warm compresses,

and topical and/or oral antibiotics. and topical and/or oral antibiotics.

Surgical CareSurgical Care

•• In general, dacryocystitis is a surgical disease. In general, dacryocystitis is a surgical disease. Surgical success rates in the treatment of Surgical success rates in the treatment of dacryocystitis are approximately 95%. dacryocystitis are approximately 95%.

•• If caused by allergic rhinitis or mild mucosal If caused by allergic rhinitis or mild mucosal inflammation of the nasolacrimal duct mucosa, inflammation of the nasolacrimal duct mucosa, chronic dacryocystitis may improve with topical chronic dacryocystitis may improve with topical steroid drops. steroid drops.

•• Occasionally, infracting of the inferior turbinate bone, Occasionally, infracting of the inferior turbinate bone, submucous resection of the turbinate, and/or lacrimal submucous resection of the turbinate, and/or lacrimal outflow probing may be successful treatment of outflow probing may be successful treatment of dacryocystitis. dacryocystitis.

Fistulae and DiverticulaFistulae and Diverticula

•• Congenital lacrimal system anomalies other than nasolacrimal ducCongenital lacrimal system anomalies other than nasolacrimal duct t obstruction are uncommon. obstruction are uncommon.

•• Fistulae and diverticula can originate from the canaliculus, lacFistulae and diverticula can originate from the canaliculus, lacrimal sac, or rimal sac, or the duct the duct

•• both patients presented in adulthood and both had a history of rboth patients presented in adulthood and both had a history of recurrent ecurrent presumed acute dacryocystitis without epiphorapresumed acute dacryocystitis without epiphora

•• Congenital lacrimal drainage system anomalies should be considerCongenital lacrimal drainage system anomalies should be considered in the ed in the diagnosis of recurrent dacryocystitis in cases where the lacrimadiagnosis of recurrent dacryocystitis in cases where the lacrimal system l system appears patent. The infection can involve a fistula or diverticuappears patent. The infection can involve a fistula or diverticulum. lum.

•• Recommended treatment is excision of the outpouching with closurRecommended treatment is excision of the outpouching with closure of its e of its connection to the lacrimal system and dacryocystorhinostomy may connection to the lacrimal system and dacryocystorhinostomy may be be considered if nasolacrimal duct obstruction is presen considered if nasolacrimal duct obstruction is presen

Medical/Legal PitfallsMedical/Legal Pitfalls

•• Failure to recognize associated conditions, Failure to recognize associated conditions,

such as Wegener granulomatosis, lymphoma, such as Wegener granulomatosis, lymphoma,

basal cell carcinoma, melanoma, and foreign basal cell carcinoma, melanoma, and foreign

bodies bodies

Failure to recognize signs and symptoms of Failure to recognize signs and symptoms of

dacryocystitis dacryocystitis

Endophthalmitis after intraocular surgery due Endophthalmitis after intraocular surgery due

to unrecognized dacryocystitisto unrecognized dacryocystitis

Canaliculitis Canaliculitis

•• Challenge for patients and Challenge for patients and clinitiansclinitians

•• Caused by variety of Caused by variety of bacteria,viruses and mycotic bacteria,viruses and mycotic organism(organism(Actinomyces Actinomyces israeliisraeli, , Propionibacterium Propionibacterium propionicus,propionicus, and yeastsand yeasts ))

•• Pain and swelling in the Pain and swelling in the medial canthal regionmedial canthal region

•• persistend weeping, persistend weeping, accompanied by follicular accompanied by follicular conjunctivitisconjunctivitis

•• The punctum is dilated or The punctum is dilated or poutting and canaliculai and poutting and canaliculai and punctum are erythematuspunctum are erythematus

•• Thick granular discharge is Thick granular discharge is often expressed from the often expressed from the punctum punctum

•• Dacryoliths often Dacryoliths often accompany inflammation in accompany inflammation in the regionthe region

•• Canaliculitis tends to exhibit Canaliculitis tends to exhibit a female predominancea female predominance

Actinomyces spActinomyces sp

•• is an anaerobic Gramis an anaerobic Gram--positive bacillus present positive bacillus present

in normal flora of mucous membranes. It is the in normal flora of mucous membranes. It is the

most common organism associated with most common organism associated with

canaliculitis.canaliculitis.

•• Actinomyces sp.Actinomyces sp. has also been reported in has also been reported in

association with concretions of the association with concretions of the

nasolacrimal system.nasolacrimal system.

DacryolithsDacryoliths

TreatmentTreatment

•• Difficult to eradicateDifficult to eradicate

•• Culture should be obtained Culture should be obtained

•• Conservative management: warm compress,digital Conservative management: warm compress,digital massage and topical antibioticsmassage and topical antibiotics

•• Symptoms can persist despite treatment with Symptoms can persist despite treatment with antibiotics until therapeutic treatment with antibiotics until therapeutic treatment with canliculotomy and curettage.canliculotomy and curettage.

•• Recurrence after adequate treatment is rareRecurrence after adequate treatment is rare

•• Evaluation of obstruction before canliculotomy to Evaluation of obstruction before canliculotomy to prevent recurrence prevent recurrence

•• A case of chronic A case of chronic ActinomycesActinomyces canaliculitis canaliculitis

with associated pyogenic granuloma formation with associated pyogenic granuloma formation

and bloody tears and bloody tears