Dacryocystitis Treatment & Management

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. Ampicillin-sulbactam, ceftriaxone, and moxifloxacin are possible antibiotic alternatives. Vancomycin should be considered for suspected MRSA infection. ^[15]

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.

A pointing nasolacrimal sac abscess should be lanced. A stent can be placed in the abscess cavity to allow irrigation of antibiotic solution.

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.

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. ^[16] For acute dacryocystitis, some clinicians perform external dacryocystorhinostomy several days after initiating systemic antibiotics. 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. ^[17] This may be appropriate in patients with chronic dacryocystitis. Lacrimal sac fistulization into the nose (dacryocystorhinostomy) has been performed successfully via a transcanalicular approach using a CO₂ 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. ^[18]

Endoscopic Endonasal dacryocystorhinostomy has also been extensively described for the treatment of dacryocystitis.  Success rates are generally comparable to or slightly lower than for external dacryocystorhinostomy surgery. ^{[19, 20]}   Studies have also looked at whether silicone intubation is necessary with dacryocystorhinostomy surgery and found that there was no significant difference in success rates with or without silicone intubation. ^[21]

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 skin is incised, 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.
• A self-retaining, spring-type retractor (eg, Agrikola) is placed in the wound.
• Steven tenotomy scissors, mosquito forceps, or periosteal elevators are used to bluntly dissect through the levator labii superioris alaeque nasi muscle down to the periosteum.
• Hemostasis is maintained throughout with bipolar or handheld cautery.
• 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.
• Some practitioners remove the self-retaining retractor and place a Goldstein retractor 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 can be 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. (Osteotomy can also be performed without a mechanical burr.)
• 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. In some cases, Steven tenotomy scissors are used to perform a 1-snip procedure on each puncta. Steps are as follows:

• 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. ^[22]
• 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. Stents may increase the success rate of DCR. ^[23] Bicanalicular silicone stents are inserted through the puncta and canaliculi and grasped in the nose under direct visualization with a straight hemostat or retrieved with a grooved director.
• 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. ^{[24, 25]}
• Two sutures (eg, 5-0 chromic or finer) 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 silicone stents can be tied with 2-3 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.

Consultations include the following:

• Otorhinolaryngology

• Infectious disease

• Neurosurgery

Dacryocystorhinostomy, when properly performed, is a very safe and effective procedure. However, as with all surgical procedures, severe complications can occur.

Hemorrhage is the most notable complication and has been reported to occur in approximately 3% of patients. Considerations are as follows:

• Bleeding is encountered commonly from the angular vessels, the nasal mucosa, and, occasionally, the anterior ethmoidal artery.

• Most cases of hemorrhage can be controlled with judicious use of cautery and cottonoids soaked in thrombin. Rarely, the nose must be packed.

• Any surgeon performing a dacryocystorhinostomy should be adept at placing an anterior nasal pack.

• A posterior nasal pack usually is not required. It has been noticed that insertion of an absorbable homeostatic agent, such as Instat or Gelfoam, soaked in thrombin is effective in decreasing the incidence of hemorrhage.

In patients who have undergone external DCR and develop a cutaneous scar, steroid injections can be administered.

Infection is also a serious concern with dacryocystorhinostomy. Almost routinely, patients with diabetes and children who undergo dacryocystorhinostomy are on postoperative oral antibiotics. Some surgeons advocate spraying antibiotic drops into the nose postoperatively. More commonly, a suture abscess is noted, which can be treated with removal of the offending suture, hot compresses, and oral and topical antibiotics.

Cerebrospinal fluid (CSF) leakage is the most dreaded complication of dacryocystorhinostomy. Because the cribriform plate lies just above the medial canthal tendon, tears in the bony plate with resultant CSF leakage can occur during creation of the osteotomy. Variations in anatomy are frequently responsible for the above complication. The author has observed a CSF leakage from dacryocystorhinostomy in a patient who had an arachnoid cyst extending from the anterior cranial fossa into the nasal vestibule just under the surface of the skin.

Failure of the dacryocystorhinostomy is most commonly due to an inadequate osteotomy or a fibrous closure at the surgical ostium. Most cases of the latter can be treated with dilation of the ostium with successively larger Bowman probes. Balloon dacryocystoplasty has been shown to be effective in patients who fail dacryocystorhinostomy surgery.

Rarely, a papilloma, which is occluding the ostium, can be seen intranasally. This can be removed during intranasal revision of the osteotomy.

Fortunately, few patients fail dacryocystorhinostomy; those patients who do most often necessitate placement of a Jones tube. In patients who have had DCR, but develop recurrent dacryocystitis without tearing, dacryocystectomy is a possible option.

Nasal hygiene with saline spray may help delay distal lacrimal outflow obstruction.

Infrequently, eyelid hygiene, including warm compresses and eyelid scrubs, may prevent some cases of dacryocystitis.

Most patients are treated surgically on an outpatient basis.

Admission to the hospital is required for the following:

• Patients who cannot have intravenous antibiotic administered by homecare
• Patients with orbital cellulitis
• Pediatric patients with periorbital or orbital cellulitis

Definitive surgical therapy should be performed; in most cases, this involves dacryocystorhinostomy.

Topical antibiotics include Polytrim, gentamicin, tobramycin, and TobraDex (antibiotic/steroid combination drop).

Occasionally, nasal decongestants (eg, Afrin) are used on a short-term basis.

Oral antibiotics are useful in patients with acute dacryocystitis who are not acutely ill.

Intranasal saline may be useful postoperatively to keep the surgical ostium clean and open.

Patients may require transfer for diagnostic evaluation of associated systemic illnesses, such as granulomatosis with polyangiitis (Wegener granulomatosis), sarcoidosis, leukemia, lymphoma, and melanoma.