Only dacrocystitis

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### DACRYOCYSTITIS Inflammation of the lacrimal sac, occurring in two forms: congenital and adult dacryocystitis. | Feature | Congenital Dacryocystitis | Adult Dacryocystitis | | :------------------ | 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Acute Dacryocystitis | | | :------------------ | 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---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|**1. Etiology** - **Membranous occlusion** at its lower end (valve of Hasner) - Other causes: epithelial debris, upper end membranous occlusion, non-canalization, bony occlusion - Common bacteria: Staphylococci, Pneumococci, Streptococci **2. Clinical Features** - **Epiphora** (after 7 days of birth) - Copious mucopurulent discharge - **Positive Regurgitation Test** - Swelling on sac area (may appear) **3. Differential Diagnosis** - Ophthalmia neonatorum - Congenital glaucoma **4. Complications** - Recurrent conjunctivitis - Acute/chronic dacryocystitis - Lacrimal abscess - Fistula formation **5. Treatment** - **Conservative (up to 6-9 months):** - Massage over lacrimal sac + topical antibiotics - Lacrimal syringing (if no cure by 3 months) - **Surgical (if conservative fails):** - Probing of NLD (Bowman’s probe, 6-12 months) - Balloon catheter dilation (if probing fails or for scarring) - Intubation with silicone tube (if repeated failures) - Dacryocystorhinostomy (DCR) (after 4 years, if all else fails) | **Chronic Dacryocystitis** **1. Etiology (Multifactorial)** - **Predisposing factors:** - Age (40-60 years) - Sex (80% females, narrower bony canal) - Race (rarer in Negroes) - Heredity (facial configuration) - Socio-economic status (lower group) - Poor personal hygiene - **Factors for tear stasis:** - Anatomical (narrow bony canal, partial canalization, folds) - Foreign bodies - Excessive lacrimation - Mild inflammation (epithelial debris, mucus plugs) - Obstruction of lower NLD by nasal diseases (polyps, deviated septum, tumors) - **Source of infection:** Conjunctiva, nasal cavity, paranasal sinuses - **Causative organisms:** Staphylococci, Pneumococci, Streptococci, Pseudomonas. Rarely chronic granulomatous (TB, syphilis, leprosy, rhinosporiodosis). **2. Clinical Features (Four Stages)** - **Stage of chronic catarrhal dacryocystitis:** - Watering eye, mild redness - Syringing: clear fluid or mucoid flakes - Dacryocystography: NLD block, normal sac - **Stage of lacrimal mucocele:** - Constant epiphora, swelling below inner canthus - Regurgitation test: milky/gelatinous mucoid fluid - Dacryocystography: distended sac, NLD block - Encysted mucocele: blocked canaliculi, large fluctuant swelling, negative regurgitation - **Stage of chronic suppurative dacryocystitis (pyocoele):** - Epiphora, recurrent conjunctivitis, swelling with erythema - Regurgitation: frank purulent discharge - Encysted pyocoele: blocked canaliculi - **Stage of chronic fibrotic sac:** - Small fibrotic sac due to repeated low-grade infections - Persistent epiphora and discharge - Dacryocystography: very small sac, irregular folds **3. Complications** - Chronic conjunctivitis, acute dacryocystitis - Ectropion, maceration, eczema of lower lid - Corneal ulceration risk - Endophthalmitis risk (pre-intraocular surgery syringing) **4. Treatment** - **Conservative:** Probing and syringing (only recent cases) - **Balloon catheter dilation** (partial NLD obstruction, ~50% success) - **Dacryocystorhinostomy (DCR):** Operation of choice, re-establishes drainage. Control infection before surgery. - **Dacryocystectomy (DCT):** Only when DCR is contraindicated (e.g., very young/old, shrunken sac, granulomatous infections, tumors, gross nasal disease, unskilled surgeon). - **Conjunctivodacryocystorhinostomy (CDCR):** For blocked canaliculi. --- **Acute Dacryocystitis** **1. Etiology** - Acute exacerbation of chronic dacryocystitis - Acute peridacryocystitis (from neighboring infected structures: paranasal sinuses, bones, dental abscess) - Causative organisms: *Streptococcus haemolyticus, Pneumococcus, Staphylococcus* **2. Clinical Features (3 Stages)** - **Stage of cellulitis:** - Painful, red, hot, firm, tender swelling in sac region - Epiphora, constitutional symptoms (fever, malaise) - Redness/edema spread to lids and cheek - Resolution possible with treatment; self-resolution rare - **Stage of lacrimal abscess:** - Continued inflammation, canaliculi occlusion - Sac filled with pus, distends, anterior wall ruptures - Large fluctuant swelling (lacrimal abscess), points below and outer side - **Stage of fistula formation:** - Untreated abscess discharges spontaneously - External fistula below medial palpebral ligament - Rarely, internal fistula into nasal cavity **3. Complications** - Acute conjunctivitis, corneal abrasion/ulceration - Lid abscess, osteomyelitis of lacrimal bone - Orbital cellulitis, facial cellulitis, acute ethmoiditis - Rarely cavernous sinus thrombosis, generalized septicemia **4. Treatment** - **Cellulitis stage:** - Systemic + topical antibiotics - Systemic anti-inflammatory analgesics - Hot fomentation - **Lacrimal abscess stage:** - Above treatment + incision and drainage of pus when pointing - Follow with DCT or DCR to prevent recurrence - **External lacrimal fistula:** - Control acute infection with antibiotics - Fistulectomy + DCT or DCR operation