DESCRIPTION 
- Dacryoadenitis and dacryocystitis are inflammatory conditions affecting the lacrimal system of the eye:
- Dacryoadenitis is inflammation or infection of the lacrimal gland from which tears are secreted.
- Dacryocystitis is an infection within the lacrimal drainage system.
- Dacryoadenitis may be a primarily inflammatory condition or an infectious process resulting from contiguous spread from a local source or systemic infection.
- Dacryocystitis is a suppurative infection involving an obstructed lacrimal duct and sac.
EPIDEMIOLOGY
Dacryoadenitis is an uncommon disorder more commonly seen on the left:
Dacryocystitis is a more common disorder most often occurring in adult females > 30 yr old but may be seen in infants
Etiology—Dacryoadenitis
- Most commonly caused by systemic inflammatory conditions:
- Infectious causes may be primary or may occur secondary to contiguous spread from bacterial conjunctivitis or periorbital cellulites
- Acute, suppurative:
- Bacteria most common cause in adults:
- Chronic dacryoadenitis:
- Nasal flora > ocular flora
Pediatric Considerations
- Viruses most common cause in children:
- Slowly enlarging mass may be dermoid
Etiology—Dacryocystitis - Under normal conditions, tears drain via pumping action at the lacrimal duct, moving tears to lacrimal sac and then into middle turbinate/sinuses.
- Symptoms begin when duct to lacrimal sac becomes partially or completely obstructed:
- In acquired form, chronic inflammation related to ethmoid sinusitis is a commonly implicated cause but many nasal and systemic inflammatory conditions have been correlated with this process:
- May also occur secondary to trauma, a dacryolith, after nasal or sinus surgery or by any local process that might obstruct flow
- Stasis in this conduit results in overgrowth of bacteria and infection.
- Infection may be recurrent and may become chronic:
- Most common bacteria: Sinus > ocular flora
- S. aureus is the most common organism
Complications may include formation of draining fistulae, recurrent conjunctivitis, and even abscesses or
orbital cellulitisPediatric Considerations
- In congenital form, presentation occurs in infancy as a result of dacryocystoceles
- High morbidity and mortality associated with this form:
- Caused by systemic spread of infectious process or bacterial overgrowth in a partially obstructed gland
- The most common organism is Streptococcus pneumonia.
[Outline]
Both will present as a unilateral, red, painful eye.
SIGNS AND SYMPTOMS
Dacryoadenitis
May present as an acute or indolent swelling and erythema of upper eyelid
- Swelling and tenderness greatest in temporal aspect of upper lid under orbital rim:
- Mass may be palpable
- May be associated with:
- Extensive cellulitis
- Conjunctival injection and discharge
- Increase or decrease in tear production
- Ipsilateral conjunctival injection and chemosis
- Ipsilateral preauricular adenopathy
- Systemic toxicity may be present
- Normal visual acuity, slit-lamp, and funduscopic exams
- May cause pressure on the globe or globe displacement:
- Visual distortion may occur.
- Chronic form: Slowly progressive, painless swelling
ALERT
Promptly determine clinical probability of spread from N. gonorrhea conjunctivitis:
- Morbidity very high:
- Treatment differs significantly from other causes.
Dacryocystitis
Presents as an acutely inflamed, circumscribed mass extending inferiorly and medially from inner canthus:
- Epiphora or excessive tearing—hallmark symptom:
- Tear outflow is obstructed.
- Discharge from punctum:
- Pressure on the inflamed mass may result in purulent material from the punctum.
- This may be diagnostic.
- Cellulitis extending to lower lid may be present
- Low-grade fever may be present, but patient rarely appears toxic.
ESSENTIAL WORKUP
Complete eye exam, including visual acuity, extraocular movements, slit-lamp, and funduscopic exam:
- Flip lids
- Examine nasal passages
Pediatric Considerations
Careful inspection for evidence of extension to orbital cellulitis or meningitis is essential.
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Tests of expressed material (used to help direct specific antibiotic treatment):
- Gram stain
- Culture and sensitivity
- Chocolate agar plating if GC suspected
- CBC and blood cultures
Imaging
CT of orbit/sinus to evaluate deep-tissue extension or possible underlying disorder in dacryoadenitis particularly with recurrent cases or in children at risk for orbital cellulitis extending from dacryocystitis.
DIFFERENTIAL DIAGNOSIS
- Dacryoadenitis:
- Dacryocystitis:
- Insect bite
- Traumatic injury
- Acute ethmoid sinusitis
- Periorbital cellulitis
- Acute conjunctivitis
[Outline]
DISPOSITION
Admission Criteria
- Adults:
- Febrile or toxic appearance
- Concomitant medical problems including diabetes or immunosuppression
- Extensive cellulitis
- Suspicion of adjacent spread with deep tissue involvement or meningitis or Neisseria meningitidis
- Children:
- Acutely ill appearance
- Concomitant medical problems
- Extensive cellulitis
- High risk for H. influenzae (nonvaccinated)
- If reliable follow-up within 24 hr cannot be arranged
Issues for Referral
Dacryoadenitis and dacryocystitis should be referred promptly to ophthalmology:
- Patients with dacryocystitis require further evaluation to confirm complete drainage of sac and to assess need for further intervention to avoid recurrence.
- Availability of follow-up should be confirmed and ophthalmologic consultation should be completed prior to discharge.
- Goold LA, Madge SN, Au A. Acute suppurative bacterial dacryoadenitis: A case series. Br J Ophthalmol. 2013;97(6):735–738.
- Kiger J, Hanley M, Losek JD. Dacryocystitis: Diagnosis and initial management in pediatric emergency medicine. Pediatr Emerg Care. 2009;25(10):667–669.
- Pinar-Sueiro S, Sota M, Lerchundi TX, et al. Dacryocystitis: Systematic approach to diagnosis and therapy. Curr Infect Dis Rep. 2012;14:137–146.
- Wald ER. Periorbital and orbital infections. Infect Dis Clin North Am. 2007;21:393–408.
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