Dacryocystitis Workup

Updated: Oct 08, 2019
  • Author: Grant D Gilliland, MD; Chief Editor: Edsel Ing, MD, MPH, FRCSC  more...
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Workup

Laboratory Studies

In most cases, dacryocystitis is a clinical diagnosis.

Supportive laboratory analysis includes a complete blood count to assess the degree of leukocytosis; however, this rarely may assist in the determination of leukemia as an etiology of the lacrimal sac infection.

Blood cultures and cultures of the ocular surface, nose, and lacrimal sac discharge may prove useful in determining the appropriate antibiotic therapy.

Antineutrophil cytoplasmic antibody testing may be useful in ruling out granulomatosis with polyangiitis (Wegener granulomatosis) as a cause of dacryocystitis and nasolacrimal duct obstruction.

Antinuclear antibody (ANA) testing may be useful in the very rare cases of dacryocystitis caused by lupus involvement of the lacrimal drainage system with resultant obstruction and infection.

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Imaging Studies

Plain films may be useful in elucidating facial skeletal anomalies or foreign bodies as the cause of the lacrimal disorder. In addition, occasionally, posttraumatic etiologies and mass lesions are noted on plain films as the cause of dacryocystitis.

Echography rarely is used. In most cases, it demonstrates enlargement and engorgement of the lacrimal sac. Rarely, lacrimal sac foreign bodies or masses are noted on echography.

CT scans are useful in patients suspected of harboring an occult malignancy or mass as a cause of dacryocystitis. In addition, posttraumatic causes of dacryocystitis usually are noted with CT scans.

MRIs are not as useful as CT scans but can be helpful in differentiating cystic lesions from solid mass lesions. MRIs can be useful in identifying patients with lacrimal sac diverticuli, which can cause recurrent dacryocystitis without epiphora and failure of surgical correction.

Dacryocystography (DCG) and dacryoscintigraphy are useful adjunctive diagnostic modalities when anatomical abnormalities of the nasolacrimal drainage system are suspected. Subtraction DCG with CT scan is also very sensitive to study the anatomy of the lacrimal sac and surrounding structures.

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Other Tests

Schirmer basic secretor testing

Ensure that epiphora is not related to hypersecretion or abnormal lid function or position.

Baseline tear secretion can be measured with the Schirmer basic secretor test.

Dye disappearance testing

A somewhat subjective test, it is used to assess the disappearance of fluorescein dye when placed in the eye. The ocular surface is evaluated at the slit lamp to determine disappearance of the fluorescein dye. This test is useful in children.

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Procedures

Many practitioners do not perform Jones tests, but they are discussed in this article for the sake of completeness.

Jones I dye test

With the Jones I dye test, functional and anatomical obstruction of the nasolacrimal system can be assessed.

A positive result indicates no anatomical or functional blockage to tear flow.

A negative result indicates a lacrimal drainage system problem (ie, anatomical or functional blockage).

Jones II dye test

A Jones II dye test is used to determine the presence or absence of anatomical obstruction of the nasolacrimal outflow system.

A positive Jones II dye test (colored fluid from the nose) indicates a patent system anatomically.

In light of a negative Jones I dye test, a positive Jones II dye test indicates either partial obstruction of the nasolacrimal system or a false-negative Jones I test.

A negative Jones II eye test (clear fluid from the nose) indicates functional blockage of the nasolacrimal system. This is common with horizontal laxity of the lower eyelid or flaccidity of the canalicular system.

If no fluid can be irrigated with the Jones II test, complete nasolacrimal obstruction is present.

Nasal endoscopy

Nasal endoscopy is frequently useful in assessing the etiology of dacryocystitis. [11] Tumors, papillomas, hypertrophy of the inferior turbinate, nasal septal deviation, and inferior meatal narrowing may be noted as causes of dacryocystitis.

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Histologic Findings

Pathologic changes found in the lacrimal drainage system are related primarily to the etiology of the disease.

Because the most common underlying pathogenic factor is distal obstruction of the lacrimal drainage system with subsequent stagnation and infection, the most common pathologic finding in the lacrimal drainage system is inflammatory change. Chronic inflammation and fibrosis of the lacrimal sac are present in varying degrees in most patients.

Focal ulceration and loss of goblet cells are not uncommon.

Focal abscesses and granuloma formation also have been noted in the lacrimal sac.

The pathologic changes in the nasolacrimal duct and nasal mucosa follow closely to those in the lacrimal sac.

Chronic inflammation and fibrosis are the most common histologic changes noted in both the nasal mucosa and the nasolacrimal duct.

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