OcuLearning › Adnexa

Dacryocystitis

URGENT — Adnexa

Symptoms

Painful, red swelling at the medial canthus.

Excessive tearing (epiphora).

Mucopurulent discharge expressible from the puncta.

Fever or malaise in severe cases.

Clinical Findings

Acute signs

  • Tender, erythematous, fluctuant swelling over the lacrimal sac.
  • Swelling is located below the medial canthal tendon.
  • Reflux of purulent material from the puncta upon sac compression.
  • Potential progression to preseptal or orbital cellulitis.

Chronic signs

  • Recurrent mucoid or mucopurulent discharge without acute inflammation.
  • Epiphora with expressible mucoid material.
  • Possible cutaneous fistula in neglected cases.

Pediatric considerations

  • Congenital dacryocele (amniocele) appearing in the first weeks of life.
  • Potential airway compromise in infants due to associated intranasal cysts.

Etiology

Adult predisposition

  • Acquired nasolacrimal duct obstruction (NLDO) is the primary cause.
  • Pathogens: Staphylococcus aureus (including MRSA), Streptococcus pneumoniae, and Haemophilus influenzae.
  • Gram-negative organisms (Pseudomonas) more common in hospitalized/immunocompromised patients.

Congenital & other

  • Persistent imperforate valve of Hasner.
  • Lacrimal sac dacryoliths or tumors (suspect if mass is chronic or unilateral).

Red Flags

Signs of orbital cellulitis (proptosis, restricted motility, decreased vision).

Mass above the medial canthal tendon or bloody discharge → rule out lacrimal sac tumor.

Congenital dacryocele + respiratory distress → urgent airway evaluation for intranasal cyst.

Black nasal eschar in immunocompromised/diabetic patients → consider mucormycosis.

Investigations

Acute workup

  • Gram stain and culture of expressed purulent material.
  • CT orbits and sinuses with contrast if orbital extension or atypical features are suspected.

Chronic/atypical workup

  • Lacrimal sac biopsy for chronic masses or suspected malignancy.
  • Dacryocystography (DCG) or dye disappearance test after acute inflammation resolves.

Treatment

Pharmacotherapy

  • Mild: Oral Cephalexin (500 mg QID) or Amoxicillin-clavulanate (875 mg BID) x 7–10 days.
  • Severe/Febrile: IV Cefazolin or Vancomycin/Ceftriaxone (if orbital/MRSA concern).
  • Note: Topical antibiotics provide minimal benefit alone.

Mechanical & surgical

  • Warm compresses and sac massage.
  • Transcutaneous I&D below the medial canthal tendon for fluctuant abscesses.
  • Definitive DCR (external or endoscopic) is curative for underlying NLDO.
  • Congenital Dacryocele: Probing under anesthesia ± intranasal cyst marsupialization.

Clinical Pearl

Acute dacryocystitis occurs below the medial canthal tendon. A mass above the tendon is a tumor until proven otherwise. In newborns, medial canthal swelling (dacryocele) is an airway emergency until the nose is cleared of cysts.

Differential Diagnosis

  • Preseptal cellulitis (no punctal reflux)
  • Acute ethmoid sinusitis
  • Lacrimal sac tumor (mass often extends above medial canthal tendon)
  • Canaliculitis (Actinomyces; pouting punctum and sulfur granules)
  • Congenital dacryocele

Related Adnexa Conditions