Acute Dacryocystitis ophthalmology

Definition: Acute suppurative inflammation of the lacrimal sac, characterized by a painful swelling in the region of the sac.

Etiology & Pathogenesis

May develop in two distinct ways:

• 1. Acute Exacerbation
  Arising from existing Chronic Dacryocystitis.
• 2. Acute Peridacryocystitis
  Direct involvement from infected neighboring structures:
  • Paranasal sinuses
  • Surrounding bones
  • Dental abscess or caries teeth (upper jaw)

Causative Organisms:

• Streptococcus haemolyticus
• Pneumococcus
• Staphylococcus

Clinical Stages

1. Stage of Cellulitis

• Symptoms: Painful swelling (red, hot, firm, tender), epiphora, fever, malaise.
• Extent: Redness/oedema spreads to lids and cheek.
• Outcome: May resolve with treatment, but self-resolution is rare.

2. Stage of Lacrimal Abscess

• Canaliculi get occluded due to oedema.
• Sac fills with pus → distends → anterior wall ruptures → Pericystic swelling.
• Pointing: Usually points below and to the outer side (due to gravity & medial palpebral ligament).

3. Stage of Fistula Formation

• If unattended, abscess discharges spontaneously.
• External Fistula: Below the medial palpebral ligament.
• Internal Fistula: Opens into nasal cavity (Rare).

Complications

Treatment

Medical Management

1. Antibiotics: Systemic and topical (Mainstay of treatment).
2. Supportive: Anti-inflammatories, analgesics, hot fomentation (for pain/oedema).

Surgical Management

Drainage of Lacrimal Abscess:

• Indication: If abscess is formed.
• Technique: Small incision in inferior part → gently squeeze pus → Betadine gauze dressing.

Dacryocystorhinostomy (DCR)

Goal: Create a communication between the lacrimal sac and the nasal cavity.

A. Conventional External Approach

1. Anaesthesia: General (preferred) or Local.
2. Incision: Curved (anterior lacrimal crest) or Straight (8mm medial to medial canthus).
3. Exposure: Medial Palpebral Ligament (MPL) dissected; Periosteum reflected laterally.
4. Osteotomy: 15 mm x 10 mm bony window made (removing ant. lacrimal crest & fossa bones).
5. Flaps: "H" shaped flaps created in both Lacrimal Sac and Nasal Mucosa.
6. Suturing: Posterior flaps sutured (6-0 vicryl/catgut) → Anterior flaps sutured.
7. Closure: MPL, Orbicularis, Skin.

B. Endonasal DCR

Gaining popularity (Eye + ENT collaboration).

1. Prep: Nasal decongestant + Local anaesthetic. Injection of Lignocaine+Adrenaline.
2. Identification: Light pipe inserted via canaliculus → Transillumination seen inside nose.
3. Opening Creation: Removal of nasal mucosa & bone (12mm x 10mm) via instruments or Holmium YAG Laser.
4. Stenting: Silicone tubes passed via canaliculi into rhinostomy.
5. Post-op: Stents removed after 8-12 weeks.

C. Endocanalicular Laser DCR

• Laser probe passed through the canaliculus.
• Quick, local anaesthesia, good for elderly.
• Limitation: Lower success rate (70%).