Dacryocystitis: Symptoms, Types, Causes and Treatment

Dacryocystitis is an inflammation or infection of the lacrimal (tear) sac, most often resulting from obstruction of the nasolacrimal duct. It can cause pain, swelling, and persistent tearing, and if left untreated, may lead to significant complications. Understanding the symptoms, types, causes, and latest treatment strategies for dacryocystitis is essential for both patients and healthcare providers. This article offers a comprehensive, evidence-based overview, drawing from the latest clinical studies and research findings.

Symptoms of Dacryocystitis

Recognizing the symptoms of dacryocystitis is crucial for early diagnosis and prompt treatment. The condition can present with a wide range of signs, from mild discomfort to severe swelling and systemic illness.

Symptom	Description	Frequency/Association	Source(s)
Watering	Excessive tearing (epiphora)	Most common (up to 89%)	1, 3
Discharge	Mucopurulent or purulent eye discharge	Common (47%); may be copious	1, 3
Swelling	Swelling near the inner corner of the lower eyelid	34%; often erythematous and tender	1, 2, 3
Pain	Localized pain over lacrimal sac	23%; more pronounced in acute cases	1, 3
Redness	Erythema overlying the lacrimal sac	Typical in acute cases	3
Tenderness	Painful on palpation	23%; may indicate abscess formation	1, 3
Fever	Systemic sign, especially in acute cases	Occasionally present	3
Complications	Abscess, cellulitis, meningitis (rare)	Severe/untreated cases	3

Table 1: Key Symptoms

Understanding the Symptoms

Dacryocystitis can manifest acutely or chronically, and the symptoms often reflect the severity and duration of the inflammation.

Acute Symptoms

• Watering and Discharge: The most frequent symptom is persistent watering of the eye (epiphora), often accompanied by mucopurulent or purulent discharge. This discharge may be especially noticeable in the morning or after gentle pressure is applied over the lacrimal sac area 1, 3.
• Swelling and Redness: Acute dacryocystitis typically causes rapid-onset swelling, redness, and tenderness at the inner corner of the lower eyelid, just below the medial canthus. The overlying skin may appear shiny and taut, and an abscess can form in severe cases 1, 2, 3.
• Pain and Tenderness: Localized pain and tenderness are hallmarks of acute infection, and pressure over the area may express pus through the punctum 1, 3.
• Fever and Systemic Signs: Some patients, especially infants and the immunocompromised, may develop fever or more generalized symptoms 3.

Chronic Symptoms

• Chronic Watering: Chronic dacryocystitis is often more insidious, with patients reporting long-standing, intermittent tearing and mild discharge. Swelling and pain are usually less prominent 1.
• Recurrent Infections: Repeated episodes of acute inflammation may occur, punctuated by periods of mild symptoms 1.

Complications

If untreated, dacryocystitis may progress to:

• Abscess formation: Collection of pus in the lacrimal sac, which can rupture onto the skin 3.
• Orbital cellulitis: Infection spreading to tissues around the eye, potentially leading to vision loss or systemic illness 3.
• Meningitis: Rare but serious, due to extension of infection 3.

Types of Dacryocystitis

Dacryocystitis is broadly classified based on the onset, duration, and underlying pathology.

Type	Onset/Duration	Common Features	Source(s)
Acute	Sudden, short-term	Red, swollen, painful, febrile	1, 3, 5
Chronic	Gradual, long-standing	Persistent watering, mild swelling	1, 5, 6
Congenital	Neonates/infants	Often due to duct obstruction	3
Recurrent	Intermittent episodes	Alternating acute and chronic signs	8

Table 2: Types of Dacryocystitis

Acute Dacryocystitis

• Presentation: Sudden onset of pain, swelling, redness, and discharge. Fever may be present. The area over the lacrimal sac is tender and may develop into an abscess 1, 3, 5.
• Population: Can affect all ages but often seen in adults and sometimes in neonates due to congenital nasolacrimal duct obstruction 3.

Chronic Dacryocystitis

• Presentation: Symptoms develop slowly and are less severe. Patients usually experience intermittent tearing and mild to moderate discharge. There may be a non-tender swelling over the sac, without acute redness or pain 1, 5, 6.
• Population: More common in adults, especially middle-aged women 1, 5.

Congenital Dacryocystitis

• Presentation: Seen in newborns and infants, often due to incomplete canalization of the nasolacrimal duct. Presents with tearing and discharge, sometimes progressing to acute inflammation 3.
• Risks: Higher risk of serious complications such as orbital cellulitis and meningitis in this group 3.

Recurrent Dacryocystitis

• Presentation: Alternating episodes of acute inflammation and periods of mild, chronic symptoms. Often seen in patients with partial duct obstruction 8.

Causes of Dacryocystitis

The development of dacryocystitis is multifactorial, involving anatomical, infectious, and sometimes systemic factors.

Cause	Description	Notable Pathogens/Factors	Source(s)
Duct Obstruction	Blockage of nasolacrimal duct	Congenital or acquired	3, 11
Bacterial Infection	Secondary infection of stagnant tears	Staph. aureus, CoNS, Pseudomonas, etc.	1, 4, 5, 6, 7, 8, 12
Anatomical Changes	Age-related or post-surgical changes	Narrowing, fibrosis	8, 11
Sinus Disease	Spread of sinonasal inflammation	Paranasal sinus involvement	2
Rare Causes	Fungal, viral, or parasitic infection	Candida, others	7, 12

Table 3: Principal Causes of Dacryocystitis

Duct Obstruction: The Central Factor

• Pathophysiology: The most common underlying cause is obstruction of the nasolacrimal duct. This leads to stasis of tears, creating a favorable environment for microbial growth 3, 11.
• Types of Obstruction:
  • Congenital: Incomplete opening of the duct in infants 3.
  • Acquired: Due to age, trauma, surgery, inflammation, or tumors 8, 11.

Infectious Etiology

• Bacterial Pathogens: Once the duct is obstructed, bacteria proliferate in the stagnant fluid.
  • Acute Dacryocystitis: Predominantly caused by Staphylococcus aureus and Pseudomonas aeruginosa 1, 4, 5, 6.
  • Chronic Dacryocystitis: More often due to coagulase-negative staphylococci (Staph. epidermidis), S. aureus, and Streptococcus pneumoniae 4, 5, 6, 12.
  • Anaerobes and Others: Propionibacterium acnes, Peptostreptococcus, and, less commonly, fungi such as Candida albicans 7, 12.
• Antibiotic Resistance: Increasing resistance patterns, especially in chronic cases, highlight the need for culture-guided therapy 5, 6.

Anatomical and Systemic Risk Factors

• Age and Gender: More common in middle-aged and older adults, with a female preponderance, likely due to narrower ducts 1, 5.
• Sinus and Nasal Disease: Inflammatory diseases of the paranasal sinuses can contribute to or exacerbate dacryocystitis, especially in acute episodes 2.
• Other Factors: Trauma, prior surgeries, and systemic illnesses (e.g., immunosuppression) may increase risk 8, 11.

Rare and Unusual Causes

• Fungal, Viral, Parasitic: While most cases are bacterial, rare instances of fungal (e.g., Candida) or viral infections are documented, particularly in immunocompromised patients 7, 12.

Treatment of Dacryocystitis

Optimal management of dacryocystitis aims to control infection, relieve symptoms, and address the underlying obstruction to prevent recurrence.

Treatment	Approach/Modality	Indications & Notes	Source(s)
Antibiotics	Oral/IV, topical	Empirical, then tailored to culture	1, 3, 4, 5, 6, 11, 12
Supportive Care	Warm compresses, massage	Especially in mild or early cases	3
Surgical Drainage	Incision/drainage of abscess	For abscess or severe cases	3, 9, 10, 13
Dacryocystorhinostomy (DCR)	External or endoscopic surgical bypass	Restores drainage, definitive therapy	9, 10, 11, 13
Silicone Intubation	Tube placed to maintain duct patency	Often adjunct to DCR	9, 13
Laser-assisted DCR	Minimally invasive endonasal surgery	Effective for abscess/obstruction	10

Table 4: Main Treatment Approaches

Antibiotic Therapy

• Empirical Treatment: Initial therapy targets both Gram-positive and Gram-negative organisms. Common effective choices include vancomycin, cephalosporins, fluoroquinolones (e.g., ciprofloxacin), and gentamicin 1, 4, 5, 11, 12.
• Tailored Therapy: Adjusted based on culture and sensitivity results, especially important in recurrent or chronic cases with higher resistance rates 5, 6.
• Route: Oral antibiotics are standard in adults; IV therapy is reserved for severe cases or young children 3, 11.

Supportive Measures

• Warm Compresses: Help localize infection and promote drainage 3.
• Nasolacrimal Massage: Particularly useful in infants with congenital blockages 3.

Surgical Management

• Abscess Drainage: If an abscess forms, prompt incision and drainage are necessary 3.
• Definitive Surgery (Dacryocystorhinostomy - DCR):
  • External DCR: Traditional gold standard; creates a new drainage pathway between the lacrimal sac and nasal cavity 11.
  • Endoscopic (Endonasal) DCR: Less invasive, with faster recovery and comparable success rates, especially in acute settings 9, 10, 13.
  • Laser-assisted DCR: Minimally invasive, effective for acute dacryocystitis with abscess 10.
  • Silicone Intubation: Tubes are sometimes placed to keep the passage open during healing 9, 13.

Timing of Surgery

• Acute Phase: Previously, surgery was delayed until after infection control. Newer evidence supports primary endoscopic DCR during the acute episode, resulting in rapid symptom relief and high anatomical and functional success rates 9, 10, 13.
• Chronic Cases: Surgery is often elective, timed to optimize patient safety and outcomes 11.

Special Considerations in Children

• Conservative First: Most congenital cases respond to massage and antibiotics.
• Surgical Intervention: Probing and, if necessary, DCR for persistent obstruction 3.

Conclusion

Dacryocystitis is a potentially serious infection of the lacrimal sac, most often resulting from nasolacrimal duct obstruction. Its symptoms, causes, and treatment options are diverse and must be tailored to individual patient needs and circumstances. Rapid recognition and appropriate management are vital to prevent complications and ensure optimal recovery.

Key Takeaways:

• Symptoms: Watering, discharge, swelling, redness, pain, and sometimes fever are common; chronic cases may be more subtle.
• Types: Includes acute, chronic, congenital, and recurrent forms, each with distinct presentations.
• Causes: Most cases follow duct obstruction with secondary infection by bacteria such as Staph. aureus, coagulase-negative staphylococci, and Pseudomonas species; rarer causes include fungi.
• Treatment: Involves antibiotics, supportive care, and often surgical intervention (DCR), with endoscopic and laser-assisted techniques offering faster recovery and high success rates.

Early diagnosis and a systematic approach—combining clinical assessment, microbiological guidance, and individualized therapy—are essential for effective management of dacryocystitis.