Dacryocystitis – Infection of the lacrimal ducts
Dacryocystitis is an infection of the tear ducts, specifically the lacrimal sac located at the beginning of the tear canals. The sac is situated in the inner corner of the eye. This infection is caused by a blockage of the tear duct, resulting in tear stasis and maceration within the sac. When the lacrimal sac becomes infected, it becomes inflamed and swells. The condition is characterized by painful swelling of the inner corner of the eye, with pus refluxing when pressed. It primarily affects newborns and the elderly. Treatment involves emergency antibiotics to treat the infection, followed by clearing the blockage of the tear ducts once the infection is under control.
Definition
Dacryocystitis is an infection of the lacrimal sac, a portion of the lacrimal duct.
This is a swelling designed to store tears at the inner corner of the eye, before they flow into the nasal cavities.
It develops in acute form (1 sudden attack) or chronic form (inflammatory flare-ups).
Understanding the anatomy and pathways of tears
Tears are produced by the lacrimal glands. They are located in the upper and outer corner of the eye, under the frontal bone.
Once secreted, the tears will flow onto the surface of the eye, allowing for its lubrication.
With each blink, tears are gradually pushed out through the eyelids towards the inner corner of the eye, where the lacrimal meatus is located.
This circuit allows for drainage and renewal. The lacrimal meatus is a small opening leading to the lacrimal ducts, the drainage channel that empties into the nasal cavities.
Who is affected?
Dacryocystitis occurs primarily:
After birth (congenital dacryocystitis) in cases of immaturity of the lacrimal ducts.
In adults over 40 years of age (acute dacryocystitis) in cases of acquired obstruction of the lacrimal ducts.
Causes
Dacryocystitis is the combination of two factors: an obstruction of the tear ducts, and a bacterial infection that can develop.
In children, obstruction of the tear ducts is usually due to an immaturity of the valve of Hasner, the small flap that prevents nasal secretions from flowing back into the tear ducts.
In adults, the obstruction is most often acquired. It is usually due to a calcific clot formed by tears or to trauma to the lacrimal duct.
The bacteria responsible for acute dacryocystitis are generally: streptococcus, staphylococcus, and Haemophilus. These are the same bacteria that cause otitis and sinusitis.
Risk factors
The risk factors for dacryocystitis are varied but are almost always related to obstruction of the nasolacrimal duct.
Sex – Women are more at risk due to the narrower diameter of their canal.
Age – Aging causes a narrowing of the orifices, which slows down the drainage of tears.
Blood clots – Also called dacryoliths. Often occurring without a known cause, these are calcareous clots created by tears and the nasal mucosa.
Nasal obstruction – In cases of deviated nasal septum, rhinitis and hypertrophy of the turbinates, obstructing the lower part of the lacrimal pathways.
Trauma – By sectioning a lacrimal duct.
Tumor – Due to compression in the nasolacrimal system.
Symptoms and signs
Dacryocystitis can present in acute or chronic form. The two forms differ in the severity of the symptoms. Here are the main ones:
Swelling and redness (erythema) at the inner corner of the eye (canthus), which may spread to the eyelid.
Purulent discharge.
Swelling of the lacrimal sac.
Pain upon palpation.
Tearing.
Signs of complication
Unfortunately, the infection can spread to the rest of the ocular structures, particularly the orbit.
In cases of significant pain on eye movement, intense fever, or altered consciousness, the presence of orbital cellulitis should be suspected.
Diagnosis
The diagnosis of dacryocystitis is clinical. The ophthalmologist notes swelling at the inner corner of the eye, with or without pus reflux upon palpation. The rest of the evaluation aims to assess the impact of this infection. Thus, the doctor looks for:
An extension of the infection to the eyelids and face.
An eye movement disorder.
The impact of the infection on the cornea.
Signs of orbital compression: pupils of different sizes (anisocoria) or protruding eye (exophthalmos).
In severe cases, the assessment may be supplemented by:
Facial imaging (scan).
A blood test to look for significant inflammation.
A sample of pus.
Treatment
A distinction must be made between emergency treatment, i.e. controlling the infection, and prevention of recurrence, i.e. relieving the obstruction of the tear ducts.
Treatment of the infection
The infection must be treated first. Treatment consists of:
Oral antibiotics, with or without antibiotic eye drops. The most frequently used combination is amoxicillin + clavulanic acid (Augmentin®) combined with rifamycin eye drops.
Massages and saline washes to flush out the pus.
Pain relievers to treat the pain: paracetamol (Doliprane). Anti-inflammatory drugs such as ibuprofen and corticosteroids are strictly contraindicated because they worsen the infection.
Treatment of the obstruction
The definitive treatment consists of treating the underlying cause of the dacryocystitis. It should only be carried out once the infection is under control.
In adults, treatment is surgical and involves dacryocystorhinostomy (DCR): the lacrimal sac is opened to the lacrimal fossa. Less frequently, a simple unblocking of the lacrimal ducts is performed.
In children, congenital tear duct obstruction has a 90% chance of resolving spontaneously before the age of one, so no treatment is initially undertaken. If excessive tearing persists, a probe is inserted into the tear ducts to dilate the valve of Hasner.
Prognosis and complications
When treated early, dacryocystitis has an excellent prognosis, with no sequelae.
Possible complications include:
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Lacrimal sac abscess
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Meningitis
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Cavernous sinus thrombosis
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And, in exceptional cases, loss of vision or death.