Dacryocystitis Treatment & Management
- Author: Grant D Gilliland, MD; Chief Editor: Edsel Ing, MD, FRCSC more...
The treatment of dacryocystitis depends upon the clinical manifestations of the disease.
Acute dacryocystitis with orbital cellulitis
Acute dacryocystitis with orbital cellulitis necessitates hospitalization with intravenous (IV) antibiotics.
Appropriate neuroimaging studies should be obtained, and surgical exploration and drainage should be performed for focal collections of pus.
IV empiric antimicrobial therapy for penicillin-resistant Staphylococcus (nafcillin or cloxacillin) should be initiated immediately.
Blood cultures and cultures of the lacrimal secretions should be obtained prior to antibiotic therapy.
Treatment with warm compresses may aid in resolution of the disease.
Impending perforation should be treated with a stab incision of the skin.
Purulent infection of the lacrimal sac and skin
Purulent infection of the lacrimal sac and skin should be treated similarly. Hospitalization is not mandatory unless the patient's condition appears serious.
Treatment with oral antibiotics (eg, amoxicillin-clavulanate) is appropriate.
Cultures of the lacrimal fluid may be helpful. The presence of a lacrimal sac mucocele in adults mandates treatment even if asymptomatic.
The treatment of choice is a dacryocystorhinostomy whether the patient is symptomatic or not. Probing should not be performed because mucoceles often are not sterile and probing may incite a cellulitis.
Patients with chronic dacryocystitis caused by a partial or intermittent nasolacrimal duct obstruction may benefit from topical steroid drop treatment.
Congenital chronic dacryocystitis
Congenital chronic dacryocystitis may resolve with lacrimal sac massage, warm compresses, and topical and/or oral antibiotics.
See the list below:
Chronic dacryocystitis almost always dictates surgery for correction of symptomatology.
- If caused by allergic rhinitis or mild mucosal inflammation of the nasolacrimal duct mucosa, chronic dacryocystitis may improve with topical steroid drops.
- Occasionally, infracting of the inferior turbinate bone, submucous resection of the turbinate, and/or lacrimal outflow probing may be successful treatment of dacryocystitis.
In general, dacryocystitis is a surgical disease. Surgical success rates in the treatment of dacryocystitis are approximately 95%.
Acute cases are best treated surgically after the infection has subsided with adequate antibiotic therapy. 
- For acute dacryocystitis, an external dacryocystorhinostomy is preferred after several days of initiating antibiotic therapy.
- Rarely, dacryocystorhinostomy must be performed during the acute phase of the infection to facilitate clearing of the infection.
Some surgeons use an endonasal approach to dacryocystorhinostomy surgery with or without a laser.  This is most appropriate in patients with chronic dacryocystitis. Lacrimal sac fistulization into the nose (dacryocystorhinostomy) has been performed successfully via a transcanalicular approach using a CO 2 or KTP laser.
Balloon dacryoplasty has been popularized in the last several years. It appears to have a lower long-term success rate than the previous treatment modalities. It should be used in patients with circumscribed focal stenoses or occlusions of the nasolacrimal duct and is contraindicated in acute dacryocystitis, dacryocystolithiasis, and posttraumatic obstruction of the nasolacrimal duct. In one study, the long-term success rate of balloon dacryoplasty was 40.8% for complete obstructions and 68% for partial obstructions. 
A standard external dacryocystorhinostomy operation that is used in the treatment of dacryocystitis is discussed below. Instrumentation may vary, but the author prefers the following:
- After the patient is prepared and draped in the usual sterile fashion, the skin is incised 11 mm medial to the medial commissure, beginning at the level of the inferior margin of the medial palpebral tendon.
- The incision is made only through epidermis and dermis, avoiding the angular vessels, which are found 8-9 mm medial to the medial commissure. It is made parallel to the angle of the nose and is approximately 1.5-2.5 cm long.
- Sharp Steven tenotomy scissors are used to open the incision down to the orbicularis muscle.
- Hemostasis is maintained throughout with bipolar or handheld cautery.
- A self-retaining, spring-type retractor (Agrikola) is placed in the wound. With the use of 2 periosteal elevators, the orbicularis muscle is divided along the course of the muscle fibers down to the periosteum overlying the nasal bone.
- Then, the periosteum is incised sharply with a periosteal elevator along the course of the skin wound and elevated off the anterior lacrimal crest and lacrimal bone, both anteriorly and posteriorly.
- The self-retaining retractor is removed, and a Goldstein retractor is placed in the wound, retracting the periosteal flaps.
- The lacrimal sac is injected with 2% Xylocaine with epinephrine, and a small 0.25 X 0.25-inch cottonoid soaked in cocaine is placed in the lacrimal fossa medial to the lacrimal sac.
- With adequate irrigation and suction, a drill is used to burr the nasal bone just medial to the lacrimal sac. The drilling is continued in a circular pattern until the nasal mucoperiosteum becomes barely visible. (Blood is seen oozing from the site of the osteotomy.)
- The nasal mucoperiosteum is then injected with 2% Xylocaine with epinephrine until blanching is noted.
- A dental burnisher is used to separate the nasal mucoperiosteum from the overlying nasal bone.
- The anterior lacrimal crest and the wall of the lacrimal fossa are removed with a forward biting rongeur (eg, Kerrison rongeur). Frequently, a Lempert rongeur is used to remove the medial wall of the lacrimal fossa and any ethmoidal air cells in the vicinity of the lacrimal fossa.
- The osteotomy is enlarged superiorly to a level just under the inferior border of the medial canthal tendon and inferiorly to the portion of the medial wall of the nasolacrimal canal.
- If needed, cottonoid sponges soaked in thrombin are inserted into the wound for hemostasis.
A punctal dilator is used to dilate the upper and lower puncta. Steven tenotomy scissors are used to perform a 1-snip procedure on each puncta.
- A number 0 Bowman probe is inserted into the lower punctum and advanced medially, thereby tenting the lacrimal sac.
- A number 11 Bard-Parker blade is used to incise the medial wall of the lacrimal sac parallel to the skin wound.
- Sharp Steven tenotomy scissors are used to create an H-shaped incision in the medial wall of the lacrimal sac. Steven tenotomy scissors and Bishop-Harmon forceps are used to excise the posterior flap of the lacrimal sac.
- Biopsy of the lacrimal sac is performed if abnormal pathology is suspected based on the preoperative clinical presentation or if the appearance of the lacrimal sac is abnormal at the time of surgery.
- A periosteal elevator is inserted into the nose and used to tent the nasal mucoperiosteum laterally, while a number 11 Bard-Parker blade is used to incise the nasal mucoperiosteum horizontally.
- Steven tenotomy scissors are then used to create another H-shaped flap in the nasal mucoperiosteum. Again, the posterior flap is excised. Canalicular probes are inserted through the puncta and grasped in the nose under direct visualization with a straight hemostat.
- A piece of absorbable collagen (Instat) or Gelfoam soaked in thrombin is rolled and inserted posterior to the silicone in the region of the lacrimal sac.[11, 12]
- Two sutures of 4-0 chromic are used to approximate the anterior flap of the lacrimal sac and the anterior flap of the nasal mucoperiosteum; the needle is carried through the orbicularis to tent the flaps anteriorly.
- The periosteum of the nasal bone is then approximated with several interrupted 5-0 Vicryl sutures. The skin is closed with a running subcuticular 6-0 Vicryl and a running 6-0 plain, fast-absorbable suture.
- The canalicular probes are tied with 2 square knots and allowed to retract under the inferior turbinate.
- Antibiotic ointment is placed on the wound, and an adhesive bandage or dental roll is used to dress the wound.
See the list below:
Mills DM, Bodman MG, Meyer DR, Morton AD 3rd. The microbiologic spectrum of dacryocystitis: a national study of acute versus chronic infection. Ophthal Plast Reconstr Surg. 2007 Jul-Aug. 23(4):302-6. [Medline].
Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar B, et al. Dacryocystitis: Systematic Approach to Diagnosis and Therapy. Curr Infect Dis Rep. 2012 Jan 29. [Medline].
Burduk PK, Dalke K, Olejarz E. [Dacryocystitis as a complication of maxillofacial fracture repair with reconstruction]. Otolaryngol Pol. 2008. 62(5):536-9. [Medline].
Batra R, Mudhar HS, Sandramouli S. A unique case of IgG4 sclerosing dacryocystitis. Ophthal Plast Reconstr Surg. 2012 May-Jun. 28(3):e70-2. [Medline].
Mazow ML, McCall T, Prager TC. Lodged intracanalicular plugs as a cause of lacrimal obstruction. Ophthal Plast Reconstr Surg. 2007 Mar-Apr. 23(2):138-42. [Medline].
Ghose S, Chhabra MS, Thakar A, et al. Nasal endoscopy in congenital dacryocystitis. J Pediatr Ophthalmol Strabismus. 2006 Nov-Dec. 43(6):341-5. [Medline].
Baskin DE, Reddy AK, Chu YI, Coats DK. The timing of antibiotic administration in the management of infant dacryocystitis. J AAPOS. 2008 Oct. 12(5):456-9. [Medline].
Spielmann PM, Hathorn I, Ahsan F, Cain AJ, White PS. The impact of endonasal dacryocystorhinostomy (DCR), on patient health status as assessed by the Glasgow benefit inventory. Rhinology. 2009 Mar. 47(1):48-50. [Medline].
Konuk O, Ilgit E, Erdinc A, Onal B, Unal M. Long-term results of balloon dacryocystoplasty: success rates according to the site and severity of the obstruction. Eye. 2008 Dec. 22(12):1483-7. [Medline].
Merkonidis C, Brewis C, Yung M, Nussbaumer M. Is routine biopsy of the lacrimal sac wall indicated at dacryocystorhinostomy? A prospective study and literature review. Br J Ophthalmol. 2005 Dec. 89(12):1589-91. [Medline].
Wu W, Yan W, MacCallum JK, et al. Primary treatment of acute dacryocystitis by endoscopic dacryocystorhinostomy with silicone intubation guided by a soft probe. Ophthalmology. 2009 Jan. 116(1):116-22. [Medline].
Liang WH, Liang YQ, Deng XY, Yuan HZ. Spherical Headed Silicone Intubation in the Treatment of 26 Cases (31 eyes) of Chronic Dacryocystitis under Nasal Endoscopy. Yan Ke Xue Bao. 2011 Dec. 26(4):217-20. [Medline].
Miquel T, Abad S, Badelon I, et al. Successful treatment of idiopathic orbital inflammation with infliximab: an alternative to conventional steroid-sparing agents. Ophthal Plast Reconstr Surg. 2008 Sep-Oct. 24(5):415-7. [Medline].
Barmettler A, Ehrlich JR, Erlich J, Lelli G Jr. Current preferences and reported success rates in dacryocystorhinostomy amongst ASOPRS members. Orbit. 2013 Feb. 32(1):20-6. [Medline].
Vicinanzo MG, McGwin G, Boyle M, Long JA. The consequence of premature silicone stent loss after external dacryocystorhinostomy. Ophthalmology. 2008 Jul. 115(7):1241-4. [Medline].
Huang J, Malek J, Chin D, Snidvongs K, Wilcsek G, Tumuluri K, et al. Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy. Orbit. 2014 Apr. 33 (2):81-90. [Medline].
Owji N, Khalili MR. Normalization of conjunctival flora after dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2009 Mar-Apr. 25(2):136-8. [Medline].
Artenstein AW, Eiseman AS, Campbell GC. Chronic dacryocystitis caused by Mycobacterium fortuitum. Ophthalmology. 1993 May. 100(5):666-8. [Medline].
Asiyo MN, Stefani FH. Pyogenic granulomas of the lacrimal sac. Eye. 1992. 6 (Pt 1):97-101. [Medline].
Atkinson PL, Ansons AM, Patterson A. Infectious mononucleosis presenting as bilateral acute dacryocystitis. Br J Ophthalmol. 1990 Dec. 74(12):750. [Medline].
Avasthi P, Misra RN, Sood AK. Clinical and anatomical considerations of dacryocystitis. Int Surg. 1971 Mar. 55(3):200-3. [Medline].
Bareja U, Ghose S. Clinicobacteriological correlates of congenital dacryocystitis. Indian J Ophthalmol. 1990 Apr-Jun. 38(2):66-9. [Medline].
Berkefeld J, Kirchner J, Muller HM, Fries U, Kollath J. Balloon dacryocystoplasty: indications and contraindications. Radiology. 1997 Dec. 205(3):785-90. [Medline].
Berlin AJ, Rath R, Rich L. Lacrimal system dacryoliths. Ophthalmic Surg. 1980 Jul. 11(7):435-6. [Medline].
Brook I, Frazier EH. Aerobic and anaerobic microbiology of dacryocystitis. Am J Ophthalmol. 1998 Apr. 125(4):552-4. [Medline].
Cassady JV. Developmental anatomy of nasolacrimal duct. Arch Ophthalmol. 1952.
Cernea P, Talea L. [Congenital bilateral dacryocystitis and craniofacial dysraphia]. Oftalmologia. 1992 Apr-Jun. 36(2):135-9. [Medline].
Coden DJ, Hornblass A, Haas BD. Clinical bacteriology of dacryocystitis in adults. Ophthal Plast Reconstr Surg. 1993 Jun. 9(2):125-31. [Medline].
Dryden RM, Wulc AE. Lacrimal inflammations and infections. Oculoplastic, Orbital and Reconstructive Surgery. Vol. 2: 1417-23.
Ducasse A, Hannion X, Adam R, Segal A. [Neonatal dacryocystitis. A case report]. Bull Soc Ophtalmol Fr. 1990 Jun-Jul. 90(6-7):595-7. [Medline].
Dutton JJ. Standardized echography in the diagnosis of lacrimal drainage dysfunction. Arch Ophthalmol. 1989 Jul. 107(7):1010-2. [Medline].
Eshraghy B, Raygan F, Tabatabaie SZ, Tari AS, Kasaee A, Rajabi MT. Effect of mitomycin C on success rate in dacryocystorhinostomy with silicone tube intubation and improper flaps. Eur J Ophthalmol. 2012 May-Jun. 22(3):326-9. [Medline].
Filipowicz-Banachowa A. [Pathological changes found in the lacrimal sac during nasolacrimal duct surgery]. Klin Oczna. 1991 Feb-Mar. 93(2-3):89-90. [Medline].
Flanagan JC, Stokes DP. Lacrimal sac tumors. Ophthalmology. 1978 Dec. 85(12):1282-7. [Medline].
Garfin SW. Etiology of dacryocystitis and epiphora. Arch Ophthalmol. 1942. 27:167-88.
Ghose S, Mahajan VM. Fungal flora in congenital dacryocystitis. Indian J Ophthalmol. 1990 Oct-Dec. 38(4):189-90. [Medline].
Goldberg SH, Fedok FG, Botek AA. Acute dacryocystitis secondary to exudative rhinitis. Ophthal Plast Reconstr Surg. 1993. 9(1):51-2. [Medline].
Harley RD. Diseases of the lacrimal apparatus. Pediatr Clin North Am. 1983 Dec. 30(6):1159-66. [Medline].
Hartikainen J, Lehtonen OP, Saari KM. Bacteriology of lacrimal duct obstruction in adults. Br J Ophthalmol. 1997 Jan. 81(1):37-40. [Medline].
Hawes MJ. The dacryolithiasis syndrome. Ophthal Plast Reconstr Surg. 1988. 4(2):87-90. [Medline].
Heirbaut AM, Colla B, Missotten L. Silicone intubation for congenital obstruction of nasolacrimal ducts. Bull Soc Belge Ophtalmol. 1990. 238:87-93. [Medline].
Hurwitz JJ, Rodgers KJ. Management of acquired dacryocystitis. Can J Ophthalmol. 1983 Aug. 18(5):213-6. [Medline].
Karesh JW, Perman KI, Rodrigues MM. Dacryocystitis associated with malignant lymphoma of the lacrimal sac. Ophthalmology. 1993 May. 100(5):669-73. [Medline].
Lieb WE, Mohr A, Bruhl K. [The value of digital subtraction dacryocystography]. Fortschr Ophthalmol. 1989. 86(6):679-81. [Medline].
Liu X. [Culture of anaerobic bacteria and antibiotic sensitivity test in ocular infectious diseases]. Zhonghua Yan Ke Za Zhi. 1991 Mar. 27(2):80-3. [Medline].
Mainville N, Jordan DR. Etiology of tearing: a retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthal Plast Reconstr Surg. 2011 May-Jun. 27(3):155-7. [Medline].
Mandal R, Banerjee AR, Biswas MC, Mondal A, Kundu PK, Sasmal NK. Clinicobacteriological study of chronic dacryocystitis in adults. J Indian Med Assoc. 2008 May. 106(5):296-8. [Medline].
Marx JL, Hillman DS, Hinshaw KD, Olson JJ, Putterman AM, Lam S. Bilateral dacryocystitis after punctal occlusion with thermal cautery. Ophthalmic Surg. 1992 Aug. 23(8):560-1. [Medline].
Mauriello JA Jr, Palydowycz S, DeLuca J. Clinicopathologic study of lacrimal sac and nasal mucosa in 44 patients with complete acquired nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 1992. 8(1):13-21. [Medline].
McNab AA, Potts MJ, Welham RA. The EEC syndrome and its ocular manifestations. Br J Ophthalmol. 1989 Apr. 73(4):261-4. [Medline].
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. [Medline].
Rosen N, Sharir M, Moverman DC, Rosner M. Dacryocystorhinostomy with silicone tubes: evaluation of 253 cases. Ophthalmic Surg. 1989 Feb. 20(2):115-9. [Medline].
Schenck NL, Ogura JH, Pratt LL. Cancer of the lacrimal sac. Presentation of five cases and review of the literature. Ann Otol Rhinol Laryngol. 1973 Mar-Apr. 82(2):153-61. [Medline].
Singh M, Jain V, Singh SP, Gupta SC. Endoscopic dacryocystorhinostomy in cases of dacryocystitis due to atrophic rhinitis. J Laryngol Otol. 2004 Jun. 118(6):426-8. [Medline].
Sodhi PK. Early and late assessment of internal drainage of chronic dacryocystitis. Ophthalmologica. 2004 Jul-Aug. 218(4):288; author reply 289. [Medline].
Stefanescu-Dima A, Petria I, Craitoiu S. [Carcinoma of the lacrimal sac]. Rev Chir Oncol Radiol O R L Oftalmol Stomatol Ser Oftalmol. 1989 Jul-Sep. 33(3):231-4. [Medline].
Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology. 1995 Jul. 102(7):1065-70. [Medline].
Udovicki J. [Rhinolithiasis complicated by purulent dacryocystitis]. Med Pregl. 1989. 42(9-10):329-31. [Medline].
Valenzuela AA, McNab AA, Selva D, O'Donnell BA, Whitehead KJ, Sullivan TJ. Clinical features and management of tumors affecting the lacrimal drainage apparatus. Ophthal Plast Reconstr Surg. 2006 Mar-Apr. 22(2):96-101. [Medline].
van Bijsterveld OP, Klaassen-Broekema N. Lacrimal conjunctivitis. Bull Soc Belge Ophtalmol. 1990. 238:61-9; discussion 69-70. [Medline].
Vegh M, Nemeth J. [Ultrasound diagnosis of the lacrimal sack]. Fortschr Ophthalmol. 1990. 87(6):638-40. [Medline].
Viers R. Lacrimal disorders. Diagnosis and Treatment. St. Louis: CV Mosby; 1976. 72-88.
Wong SC, Healy V, Olver JM. An unusual case of tuberculous dacryocystitis. Eye. 2004 Sep. 18(9):940-2. [Medline].
Zapala J, Bartkowski AM, Bartkowski SB. Lacrimal drainage system obstruction: management and results obtained in 70 patients. J Craniomaxillofac Surg. 1992 May-Jun. 20(4):178-83. [Medline].