eMedicine Specialties > Ophthalmology > Lacrimal System

Dacryocystitis

Author: Grant D Gilliland, MD, Private Practice, Texas Ophthalmic Plastic, Reconstructive and Orbital Surgery Associates
Contributor Information and Disclosures

Updated: Aug 18, 2009

Introduction

Background

The lacrimal excretory system is prone to infection and inflammation for various reasons. This mucous membrane-lined tract is contiguous with 2 surfaces (conjunctival and nasal mucosal) that are normally colonized with bacteria. The functional purpose of the lacrimal excretory system is to drain tears from the eye into the nasal cavity. Stagnation of tears in a pathologically closed lacrimal drainage system can result in dacryocystitis.

Acquired dacryocystitis can be acute or chronic.¹ Acute dacryocystitis is heralded by the sudden onset of pain and redness in the medial canthal region. An insidious onset of epiphora is characteristic of chronic inflammation or infection of the lacrimal sac.

Pathophysiology

The naso-optic fissure is the source of origin of the lacrimal drainage system. The ectoderm in this region thickens and becomes embedded in the mesenchyme between the lateral nasal and maxillary processes. This cord of ectoderm subsequently canalizes and opens into the conjunctival fornix prior to opening into the nasal vestibule. Frequently, this opening into the nasal cavity is incomplete at birth. Canalization of the lacrimal excretory system begins in the superior portion first and is segmental, only later coalescing to form a continuous lumen. The canaliculi, which develop as outpouchings from the solid cord of ectodermal tissue prior to canalization, also canalize prior to the vertical portions of the nasolacrimal duct.

Many variations in the anatomy of the lacrimal drainage system have been noted. Normally, tears drain into the lacrimal system through two puncta, one present in the upper lid and the other in the lower lid. More commonly, the lower punctum lies slightly temporal to the upper punctum.

The connections from the puncta to the lacrimal sac are called canaliculi. These canaliculi have a short vertical segment, averaging 2 mm in length, and a longer horizontal segment, averaging 10-12 mm in length.

An ampulla connects the vertical and horizontal segments. The individual canalicular horizontal segments join to form a common canaliculus in 90% of patients. This common canaliculus dilates, forming the sinus of Maier just lateral to the lacrimal sac.

A fold of mucosa known as the valve of Rosenmüller marks the junction of the lacrimal sac and the common canaliculus. The lacrimal sac lies in the bony lacrimal fossa derived from the lacrimal and maxillary bones. The average width of the sac is approximately 6-7 mm and the length varies from 12-15 mm. The mucosa of the sac is lined by pseudostratified columnar epithelium with substantial amounts of lymphoid and elastic tissue interposed within the connective tissue layer. The sac is normally irregular and flat in shape with a collapsed lumen.

The lacrimal sac is covered on its outer surface by the lacrimal fascia of the periorbita. This fascia splits to envelop the lacrimal sac between the attachments of the lacrimal fascia to the anterior and posterior lacrimal crests. The lacrimal sac mucosa only loosely adheres to the lacrimal fascia. However, posterior to the sac are the deep heads of the pretarsal and preseptal orbicularis muscles. Anteriorly, the medial canthal tendon covers the upper two fifths of the lacrimal sac.

The nasolacrimal duct averages 18 mm in length and 4.5-5 mm in diameter. Multiple valves are present in the nasolacrimal duct, representing analog from the segmental canalization of the ectodermal cord that develops into the nasolacrimal duct. Of these, the most prominent valves are the valve of Taillefer, the valve of Krause, and the valve of Hasner (located at the junction of the duct with the nasal mucosa). Like the lacrimal sac, the nasolacrimal duct is lined by pseudostratified columnar epithelium.

The lacrimal, maxillary, and ethmoid bones form the bony nasolacrimal canal. The bulk of the duct is contributed by the maxilla, anteriorly, laterally, and posteriorly. The lacrimal bone forms the medial wall superiorly, and the inferior concha of the ethmoid bone forms the medial wall of the canal inferiorly. The mucosal opening of the nasolacrimal duct under the inferior turbinate lies 5-8 mm from the anterior tip of the inferior turbinate. The lacrimal bone and the nasal process of the maxilla make up the lacrimal fossa equally. The anterior and posterior lacrimal crests form the anterior and posterior borders of the lacrimal fossa, respectively.

The dimensions of the lacrimal fossa are 4-8 mm in width, 15 mm in height, and 2 mm in depth. Ethmoid air cells in approximately 40-60% of patients separate the lacrimal fossa from the nasal cavity, although considerable variability exists in the number and location of these air cells. The lacrimal sac fossa lies at the level of the anterior tip of the middle turbinate.

Frequency

United States

Individuals with brachycephalic heads have a higher incidence of dacryocystitis than dolichocephalic or mesocephalic skulls. This is because brachycephalic skulls demonstrate a narrower diameter of inlet into the nasolacrimal duct, the nasolacrimal duct is longer, and the lacrimal fossa is narrower. Furthermore, patients with a flat nose and narrow face are at a higher risk for developing dacryocystitis, presumably because of the narrow osseous nasolacrimal canal.

In 1883, Nieden noted a 9% incidence of hereditary lacrimal excretory system inflammation. This is significantly higher than what has been found by the author in studies.

Mortality/Morbidity

Dacryocystitis occurs in the following 3 forms: acute, chronic, and congenital.

• In acute dacryocystitis, patients can experience severe morbidity and rarely mortality. Morbidity is related primarily to the lacrimal sac abscess and spread of the infection.
• Chronic dacryocystitis is rarely associated with severe morbidity unless caused by a systemic disease. The primary morbidity is associated with chronic tearing, mattering, and conjunctival inflammation and infection.
• Congenital dacryocystitis is a very serious disease associated with significant morbidity and mortality. If not treated promptly and aggressively, newborn infants can experience orbital cellulitis (because the orbital septum is formed poorly in infants), brain abscess, meningitis, sepsis, and death. Congenital dacryocystitis can be associated with an amniotocele, which, in severe cases, can lead to airway obstruction. More indolent forms of congenital dacryocystitis can be difficult to diagnose and can be associated with chronic tearing, mattering, amblyopia, and failure to thrive.

Race

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

Sex

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

Age

Lacrimal sac infections and inflammations commonly occur in 2 discrete age categories, infants and adults older than 40 years. Acute dacryocystitis in newborns is rare, occurring in fewer than 1% of all newborns. Acquired dacryocystitis is primarily a disease of females and is most common in patients older than 40 years, with a peak in patients aged 60-70 years.

Clinical

History

• Acute dacryocystitis is manifested by the sudden onset of pain, erythema, and edema overlying the lacrimal sac region.
  • The tenderness is characteristically localized in the medial canthal region but may extend to the nose, cheek, teeth, and face.
  • Thermography has demonstrated an intensive hemifacial reaction in patients with acute dacryocystitis. Frequently, a purulent discharge is noted from the puncta.
  • It is not uncommon for the sac to rupture and fistulize through the skin; this fistula commonly closes after a few days of drainage.
  • Conjunctival injection and preseptal cellulitis often occur in conjunction with acute dacryocystitis.
  • Epiphora is invariably present, and it is not uncommon for a palpable mass to be noted inferior to the medial canthal tendon.
  • A few patients present with fever, prostration, and an elevated leukocyte count.
  • More serious sequelae of acute dacryocystitis include extension into the orbit with formation of an abscess and development of orbital cellulitis. When this occurs, it may lead to blindness, cavernous sinus thrombosis, and death.
• Tearing is the most common presentation of chronic dacryocystitis and is related to the obstruction of the outflow of tears, debris, and epithelial cells from the surface of the eye.
• Mattering
  • This is caused by the obstruction of drainage of the mucous layer of the tear film with collection of debris and denuded epithelial cells from the surface of the eye.
  • Frequently, it may be associated with conjunctivitis. This is attributed to the toxic nature of the debris to the surface of the eye or because of exotoxins produced by staphylococcal organisms, which normally reside on the external surface of the eye and are not cleared by the normal tear outflow.
• Cellulitis is seen predominately in acute dacryocystitis and is due to bacterial overgrowth with rupture through the wall of the lacrimal sac into surrounding soft tissue.
• Orbital cellulitis
  • This is a rare, but serious, complication of dacryocystitis. It is associated most commonly with acute dacryocystitis and congenital acute dacryocystitis.
  • Commonly, orbital cellulitis presents as an inflamed painful eye with abnormal motility, abnormal pupil examination, and decreased visual acuity.
  • Massive periorbital edema and erythema is not uncommon.
• Decreased visual acuity
  • A commonly observed complaint, it is primarily due to the increased tear film on the surface of the eye. This increased tear film abnormally refracts light and is associated with fluctuating visual acuity.
  • In addition, the standard 3 layers of the tear film, mucus, aqueous, and oil, are abnormal and are present in abnormal proportions.
• Periorbital edema
  • This usually is related to the inflammation associated with the buildup of toxic debris on the surface of the eye and exotoxins secreted by staphylococcal organisms living on the surface of the eye.
  • Periorbital edema is most pronounced in the morning and subsides late in the day because of repeated contractures of the orbicularis muscle milking the edema from the soft tissues around the eye.

Physical

• Fever results from a fulminant bacterial or fungal infection in the lacrimal sac, which spreads to the surrounding tissues. This is not uncommonly associated with significant sinus disease.
• Leukocytosis also is common in acute dacryocystitis.
• Cellulitis surrounding the affected lacrimal sac is common in patients with acute dacryocystitis. This can spread to involve the orbit and cause orbital cellulitis.
• Altered visual acuity most frequently is caused by an abnormal tear film with abnormal refraction of light at the air-tear film interface. It also can be due to corneal surface irregularities resulting from chronic surface inflammation.
• Altered pupillary reaction is only seen in severe cases of dacryocystitis associated with an orbital cellulitis. This is due to increased intraorbital pressure and necrosis of the pupillomotor fibers in the orbit.
• Diplopia is also rare and is seen in patients with orbital cellulitis resulting from acute dacryocystitis. These patients have orbital inflammation involving the extraocular muscles, which causes the muscles to dysfunction, resulting in diplopia.
• Loss of peripheral vision is also rare and caused by orbital cellulitis secondary to acute dacryocystitis. This results in an optic neuropathy with loss of peripheral vision. Many times, this can be subtle and can be detected on perimetry testing.
• Conjunctivitis frequently is associated with acute and chronic dacryocystitis. It is primarily due to the buildup of toxic debris on the surface of the eye, including the exotoxin produced by staphylococcal organisms, which normally inhabit the surface of the eye.
• Medial canthal fullness and tenderness are common in both acute dacryocystitis and chronic dacryocystitis, which is due to distention of the lacrimal sac and resultant infection of the lacrimal sac. Rarely, an occult tumor or cyst can be the cause of the medial canthal fullness.
• Tearing is most commonly due to obstructed outflow of the tear system but may be exacerbated by conjunctivitis. Rarely, patients with acute or chronic dacryocystitis have no complaints of tearing but have other sequelae of tear sac infection, including redness, cellulitis, pain, fullness, and purulent discharge.

Causes

• In congenital dacryocystitis, incomplete canalization of the nasolacrimal duct (specifically at the valve of Hasner) is clearly important in the pathogenesis. However, since the incidence of congenital dacryocystitis is much lower than the incidence of incomplete canalization, factors other than developmental ones appear to play a role in the pathogenesis. Neonatal infection is another important factor in the development of congenital dacryocystitis.
• Both aerobic bacteria and anaerobic bacteria have been cultured from pediatric and adult patients with dacryocystitis. The most common organisms isolated from the lacrimal sacs of children with dacryocystitis include Staphylococcus aureus, Haemophilus influenzae, beta-hemolytic streptococci, mycobacterial species, and pneumococci. Methicillin-resistant Staphylococcus aureus (MRSA) is more common in patients with acute dacryocystitis than with chronic dacryocystitis.
• Structural abnormalities of the midface also should be considered.
• Nasal pathology that can predispose to dacryocystitis includes the following: hypertrophied inferior turbinate, deviated nasal septum, nasal polyp, and allergic rhinitis.
• Obstruction of the nasolacrimal duct by a tight inferior meatus has been noted in many infants.
• The etiology of dacryocystitis includes nasal disease and ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome, as outlined below.
• Nasal disease
  • Sinusitis (maxillary, ethmoidal)
  • Hypertrophic rhinitis
  • Vasomotor rhinitis
  • Syphilitic rhinitis
  • Rhinitis ozaenosa
  • Adenoids
  • Eczema of nares
  • Purulent rhinitis
  • Nasal trauma
  • Ethmoidal tumor
  • Nasal tumor
  • Atrophic rhinitis sicca
  • Rhinitis fibrinosa
  • Enlarged inferior turbinate
  • Foreign body in the nose
  • Septal deviation
  • Frontal sinus neoplasm
  • Nasal mucosal infection
  • Diphtheria
  • Measles
  • Scarlatina
  • Nasal septal abscess
  • Ethmoidal mucocele
  • Rhinolithiasis
  • Bacterial - Tuberculosis, syphilis, trachoma, Staphylococcus epidermidis (most common), Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Pneumococcus, Propionibacterium acnes, Mycobacterium fortuitum
  • Viral - Infectious mononucleosis
  • Fungal -Candida albicans, Aspergillus niger 
• EEC syndrome
  • Osteoporosis
  • Lupus
  • Scleroma
  • Plasmoma
  • Leukemic infiltration
  • Trauma - Naso-orbital fractures, LeFort II fractures²
  • Postinflammatory stenosis of nasolacrimal duct
  • Graft-versus-host disease
  • Iatrogenic - Caldwell-Luc operation, Lautenschlager-Halle ozena operation, radical maxillectomy, ethmoidectomy, Sturmann-Canfield operation, postpunctal occlusion
  • Lacrimal sac tumor - Lymphoma, fibroepithelioma, transitional cell carcinoma, lymphoblastoma, neurilemoma, angiosarcoma, hemangiopericytoma, pseudotumor, melanoma, metastatic carcinomas, benign polyps
  • Lacrimal sac cyst
  • Postirradiation fibrosis
  • Wegener granulomatosis
  • Facial skeletal anomalies
  • Dacryolithiasis
  • Cilia impaction in lacrimal sac
  • Impacted punctal plugs - Studies have documented an increased risk of canaliculitis and dacryocystitis associated with intracanalicular punctal plugs.³
• In acquired dacryocystitis, obstruction of the lower part of the nasolacrimal system frequently is present. Because of the intimate relationship of the nasolacrimal duct with the nose and paranasal sinuses, these structures are commonly associated as an etiologic factor in the pathogenesis of dacryocystitis.
• One of the more common associations, if not a factor in the etiology of dacryocystitis, is ethmoidal inflammation. Because only a very thin lamina of bone is present between the ethmoid air cells and the lacrimal sac, it is not uncommon for inflammation of the ethmoid sinuses to cause dacryocystitis.
• An ocular origin for inflammation of the lacrimal system is less common than a nasal origin.
• Several cases of obstruction of the nasolacrimal duct by impacted cilia have been described.
• Profuse secretion and stagnation of tears in the lacrimal sac, which may occur in uncorrected astigmatism and hypermetropia, may contribute to the development of dacryocystitis.
• Most cases of dacryocystitis in adults are caused by stenosis of the lacrimal duct with resultant stagnation of lacrimal fluid and subsequent infection.
• Approximately 50% of patients undergoing surgery for dacryocystitis have positive culture results; of these, pure cultures are obtained in 71% of them, with mixed cultures in the remaining 29% of patients.
• The bacteriology of dacryocystitis mimics normal conjunctival flora in most instances.
  • The most common aerobic organisms isolated from the lacrimal sacs in adults with dacryocystitis include S epidermidis, S aureus, and Streptococcus, Pseudomonas, and Pneumococcus species. S epidermidis is the most common isolate followed by S aureus.
  • The most common anaerobic organisms isolated from the lacrimal sacs in adults with dacryocystitis include Peptostreptococcus, Propionibacterium, Prevotella, and Fusobacterium species.
  • Gram-negative bacteria have been reported to occur more frequently in patients with copious discharge. The most common gram-negative bacteria isolated were E coli.
  • Gram-negative organisms account for 27% of the cultured organisms, with P aeruginosa and E coli being the most common.
  • Some studies have found Pneumococcus to be the most common isolate in dacryocystitis.
  • Rarely, fungi have been isolated from infected lacrimal sacs (commonly associated with dacryolith formation).
• Dacryolith formation has been noted in 14-16% of patients with dacryocystitis. Patients with a history of acute dacryocystitis have a higher incidence of dacryolith formation than those with chronic dacryocystitis.
• When a tumor is present in the lacrimal sac, most are epithelial (ie, carcinomas, papillomas). The most common nonepithelial malignancy is a lymphoma. Epithelial tumors tend to be more common in men than in women, and nonepithelial tumors tend to be more common in women than in men.

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