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Basics ⬇

[Section Outline]

Author:

ShariSchabowski

Daniella C.Lucas

Description!!navigator!!

Epidemiology!!navigator!!

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, usually shortly after birth

Etiology—Dacryoadenitis

  • Most commonly caused by systemic inflammatory conditions:
    • Autoimmune diseases
    • Sjögren syndrome
    • Sarcoidosis
    • Crohn disease
    • Tumor
  • Infectious causes may be primary or may occur secondary to contiguous spread from bacterial conjunctivitis or periorbital cellulites
  • Acute, suppurative:
  • Chronic dacryoadenitis:
    • Nasal flora > ocular flora
Pediatric Considerations
  • Viruses most common cause in children:
    • Epstein-Barr virus
    • Mumps
    • Adenovirus
    • Cytomegalovirus
    • Herpes simplex virus
    • Varicella-zoster virus
  • 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, followed by S. epidermidis, pneumococcus, and Pseudomonas aeruginosa

Complications may include formation of draining fistulae, recurrent conjunctivitis, and even abscesses or orbital cellulitis

Pediatric Considerations
  • In congenital form, presentation occurs in infancy as a result of dacryocystoceles, or in the newborn due to retained amniotic fluid
  • 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 pneumoniae

Diagnosis ⬆ ⬇

[Section Outline]

Both will present as a unilateral, red, painful eye

Signs and Symptoms!!navigator!!

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:
    • S-shaped lid
  • 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. gonorrhoeae conjunctivitis:
  • Morbidity very high:
    • Visual loss likely
    • Systemic illness probable
  • 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!!navigator!!

Complete eye exam, including visual acuity, extraocular movements, slit-lamp, and funduscopic exam:

Pediatric Considerations
Careful inspection for evidence of extension to orbital cellulitis or meningitis is essential

Diagnostic Tests & Interpretation!!navigator!!

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
  • US can be used to differentiate normal lacrimal sacs from chronic dacryocystitis by comparing the echogenicity

Differential Diagnosis!!navigator!!

Treatment ⬆ ⬇

[Section Outline]

ED Treatment/Procedures!!navigator!!

Dacryoadenitis

  • Cool compresses to decrease inflammation and nonsteroidal pain medication
  • Takes 4-6 wk for symptoms to resolve
  • Viral etiology:
    • Typically self-limited inflammation
  • Bacterial etiology:
  • Tetanus toxoid if necessary
  • Incision and drainage rarely necessary except in very severe cases:
    • Perform with consultation to facial surgery service or ophthalmology
Pediatric Considerations
  • Cool compresses
  • Analgesics
  • If cause unclear, treat with antibiotics as with adults

Dacryocystitis

  • Drainage of infected sac is essential:
    • Warm compresses and gentle massage to relieve obstruction
    • May facilitate outflow from obstructed tract with nasal introduction of vasoconstricting agent
    • Incision and drainage only in severe cases:
      • Typically done by ophthalmology
      • Avoid in ED when possible
      • May result in fistula formation
    • Duct instrumentation to facilitate drainage is not indicated in acute setting:
      • Reserve instrumentation for nonacute setting, if necessary at all
      • Manipulation while duct is inflamed may cause injury to duct and permanent obstruction from scarring and stenosis
    • Topical ophthalmic antibiotic drops to prevent secondary conjunctivitis
  • Systemic antibiotics to resolve infection and prevent spread to adjacent structures:
    • Oral for mild infection
    • Intravenous when febrile or severe infection
  • Analgesics
Pediatric Considerations
  • Newborns respond well to massage and topical antibiotics in ∼95% of cases
  • If no resolution in first year of life, may require probing of duct by ophthalmologist
  • Children <4 yr old who develop dacryocystitis:
    • At increased risk for H. influenzae infection, if not immunized:
      • Given typical age of presentation, complete immunization is unlikely at primary presentation
      • Recommended schedule 2, 4, 6, and 12-15 mo
    • H. influenzae type B carries high risk for bacteremia, septicemia, and meningitis
    • Treat afebrile, well-appearing children with responsible parent with oral cefaclor or amoxicillin/clavulanate
    • Administer cefuroxime IV in acutely ill patients

Medication!!navigator!!

Follow-Up ⬆ ⬇

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

Pearls and Pitfalls ⬆ ⬇

  • In cases of red eye with lid swelling, specifically examine the lacrimal structures for evidence of involvement
  • Skin incision and drainage of dacryocystitis should be avoided whenever possible to avoid fistula formation:
    • Intranasal vasoconstricting agents should be used primarily to facilitate drainage

Additional Reading ⬆ ⬇

See Also (Topic, Algorithm, Electronic Media Element)

Codes ⬆

ICD9

ICD10

SNOMED