History   
A 67-year-old black female presented to the emergency department with a chief complaint of a red, painful right eye. She also reported increased tearing O.D. Her systemic history was unremarkable, and she reported no known allergies or current medications.

Diagnostic Data
Her best-corrected entering visual acuity measured 20/25 O.D. and 20/20 O.S. Anterior segment examination revealed the presence of epiphora and mucopurulent discharge, which was oozing from the inferior punctum. The patient suggested that the application of pressure over the site of inflammation was painful and increased the volume of discharge. We noted no anterior chamber reaction in her right eye.

Her pupils were equally round and reactive, with no evidence of afferent defect. Intraocular pressure measured 16mm Hg O.U. Additionally, the dilated fundus examination of both eyes was normal––with quiet nerves, grounds and peripheries.

The pertinent external examination findings are illustrated in the photograph.

Your Diagnosis
How would you approach this case? Does this patient require any additional tests? What is your diagnosis? How would you manage this patient? What’s the likely prognosis?

Discussion
Schirmer testing may be performed to determine if epiphora was caused by hypersecretion or abnormal lid function. Nasolacrimal patency or blockage may be assessed by the type 1 Jones dye test. If dye is recovered (a positive Jones test), no blockage is present. A negative test indicates obstruction, but not location. Dilation and irrigation never should be attempted on an actively inflamed nasolacrimal apparatus. Culturing the discharge from the punctum could assist in determining pathogen specificity and antibiotic sensitivity. A computed tomography scan of the orbits can be ordered to evaluate for abscess or suspected mass.

Our patient presented with a red, painful right eye as well as increased tearing. What is your diagnosis?

The diagnosis in this case is dacryocystitis with secondary preseptal cellulitis. Dacryocystitis represents an inflammation of the lacrimal sac, and is the most common lacrimal apparatus infection.^1,2 Blockage of the lacrimal sac causes tear stagnation, which fosters an environment that is conducive to bacterial overgrowth.

Common signs and symptoms include localized pain and erythema as well as swelling of the lacrimal sac region. Epiphora, conjunctivitis, and mucoid discharge from the punctum following applied pressure over the region are also frequently observed.³ In many cases, the lacrimal sac ruptures and drains through the skin. The individual may also be febrile. It is important to note that dacryocystitis can be acute or chronic.^1-3

Dacryocystitis is relatively common in the general population, with the majority of cases presenting during the first or fifth decade of life.^4,5 Infantile or congenital dacryocystitis occurs in 3% to 6% of infants, due to either epithelial debris blocking the duct or incomplete development of the lacrimal canal.⁵ Dacryocystitis secondary to nasolacrimal duct obstruction is more common in older individuals as a result of mucosal degeneration, ductile stenosis and tear stagnation.⁵

The majority of dacryocystitis cases (70% to 83%) occur in postmenopausal women.⁵ In such instances, the osteoporotic process causes stenosis within the nasolacrimal apparatus. Additionally, hormonal changes may lead to obstruction caused by desquamation.⁶

Acute dacryocystitis commonly progresses to preseptal cellulitis as a result of the sac lying anteriorly to the orbital septum.² While documented in the literature, abscesses with resultant orbital cellulitis are a rare consequence of dacryocystitis and may be attributable to multiple anatomical attachment barriers that help combat infection.^6-8 These defenses include the attachment of the orbital septum to the posterior lacrimal crest, lacrimal fascia, the medial canthal ligament’s posterior limb, and deep heads of the preseptal and pretarsal orbicularis.⁶

Patients who present with proptosis, painful and/or limited motilities and pupillary defects need emergent hospitalization.⁸ Other severe cases may involve immunocompromised individuals who are at risk for mucormycosis.⁹ This fungal infection usually occurs in patients with diabetic ketoacidosis, which creates an encouraging environment for fungal growth.⁹

The most common bacterial isolates in dacryocystitis are P. aeruginosa, S. aureus, Enterobacter aerogenes, Citrobacter, S. pneumoniae, E. coli and Enterococcus.^10-11 Therefore, treatment requires both topical and systemic regimens that cover penicillinase-producing staphylococcal organisms.¹² Current management in children with mild, afebrile cases includes 20mg/kg to 40mg/kg of Augmentin (amoxicillin/clavulanate, GlaxoSmithKline) or Ceclor (cefaclor, Eli Lilly) per day, divided into three equal doses. Oral antibiotic alternatives in adults include amoxicillin, cephalexin or azithromycin, if sensitivities exist.¹² In both populations, topical anti-infectives should also coincide with oral treatment. Warm compresses and analgesic therapy assist in pain and inflammation management.¹²

Symptomatic epiphora as a result of acute or chronic dacryocystitis can be managed surgically with dacryocystorhinostomy (DCR). This procedure creates an anastomosis between the medial lacrimal sac and the lateral nasal cavity.¹³ Removable silicone tubing is inserted into and through the entire length of the nasolacrimal apparatus. This intubation ensures the patency of the canal and prevents closure secondary to scarring.

Antimetabolites (mitomycin-C, 5-fluorouracil) at the surgical site also have been advocated to control scarring.¹³ External DCR is the most common approach and has a 90% success rate.^13,14 The newer endoscopic nasal DCR eliminates the cutaneous scar, but success rates are slightly lower than those achieved with external DCR.^13-15

Our patient was treated with 500mg cephalexin p.o. q6h and topical 0.5% moxifloxacin q.i.d. O.D. Unresolved epiphora and further testing indicated lacrimal duct obstruction. We referred our patient for external DCR which was successful.

1. Ramesh S, Ramakrishnan R, Bharathi MJ, et al. Prevalence of bacterial pathogens causing ocular infections in South India. Indian J Pathol Microbiol. 2010 Apr-Jun;53(2):281-6.
2. Freedman JR, Markert MS, Cohen AJ. Primary and secondary lacrimal canaliculitis: a review of literature. Surv Ophthalmol. 2011 Jul-Aug;56(4):336-47.
3. Maheshwari R, Maheshwari S, Shah T. Acute Dacryocystitis Causing Orbital Cellulitis and Abscess. Orbit. 2009;28(2-3):196-9.
4. Henney SE, Brookes MJ, Clifford K, Banerjee A. Dacryocystitis presenting as post-septal cellulitis: a case report. J Med Case Reports. 2007 Sep 5;1:77.
5. Babar TF, Masud MZ, Saeed N. An analysis of patients with chronic dacryocystitis. J Postgrad Med Inst. 2004 Mar;18(3):424-31.
6. Bharathi MJ, Ramakrishnan R, Maneksha V, et al. Comparative bacteriology of acute and chronic dacryocystitis. Eye (Lond). 2008 Jul;22(7):953-60.
7. Garcia GH, Harris GJ. Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988–1998. Ophthalmology. 2000 Aug;107(8):1454-6; discussion 1457-8.
8. Witteborn M, Mennel S. Restricted eyeball with proptosis. Ophthalmologe. 2011 Mar;108(3):275-7.
9. Mallis A, Mastronikolis SN, Naxakis SS, et al. Rhinocerebral mucormycosis: an update. Eur Rev Med Pharmacol Sci. 2010 Nov;14(11):987-92.
10. Kubal A, Garibaldi D. Dacryoadenitis caused by methicillin-resistant Staphylococcus aureus. Ophthal Plast Reconstr Surg. 2008 Jan-Feb;24(1):50-1.
11. Briscoe D, Rubowitz A, Assia E. Changing bacterial isolates and antibiotic sensitivities of purulent dacryocystitis. Orbit. 2005 Jun;24(2):95-8.
12. Bertino JS. Impact of antibiotic resistance in the management of ocular infections: the role of current and future antibiotics. Clin Ophthalmol. 2009 Sep;3(9):507-21.
13. Morgan S, Austin M, Whittet H. The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy. Br J Ophthalmol. 2004 Jan;88(1):139-41.
14. Costa MN, Marcondes AM, Sakano E, Kara-José N. Endoscopic study of the intranasal ostium in external dacryocystorhinostomy postoperative. Influence of saline solution and 5-fluorouacil. Clinics (Sao Paulo). 2007 Feb;62(1):41-6.
15. Meister EF, Otto M, Rohrwacher F, et al. Current recommendations of dacryocystorhinostomy. Laryngorhinootologie. 2010 Jun;89(6):338-44.