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Dacryocystitis Treatment & Management

  • Author: Grant D Gilliland, MD; Chief Editor: Edsel Ing, MD, FRCSC  more...
Updated: Feb 01, 2016

Medical Care

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.

Chronic dacryocystitis

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.


Surgical Care

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. [7]
    • 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. [8] 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. [9]
  • 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.[10]
    • 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:

  • Otorhinolaryngology
  • Infectious disease
  • Neurosurgery
Contributor Information and Disclosures

Grant D Gilliland, MD Private Practice, Texas Ophthalmic Plastic, Reconstructive and Orbital Surgery Associates

Grant D Gilliland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, Texas Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Chief Editor

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

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Acute dacryocystitis.
A 2-week-old infant with life-threatening amniotocele causing airway compromise.
Postoperative image of same patient as in Media file 2, 1 year after drainage of amniotocele.
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