What Is Dacryocystitis (Tear Duct Infection)?

Dacryocystitis refers to an infection of the tear sacs, which are part of the tear drainage system in the eye. Tears drain from each eye through small canals (drainage canals), a tear sac, and a tear duct. Drainage canals are found at the inner corner of each upper and lower eyelid, and they carry away tears that have rinsed the front surface of the eye. These canals empty into the tear sac, also known as the lacrimal sacs, through which tears move into the tear duct (nasolacrimal duct) and then into the nose.

The usual cause of dacryocystitis is a blockage in the tear duct and backup of tears in the tear sac. The tear sac can become inflamed and swell, resulting in dacryocystitis. This condition often triggers watery eyes, redness, and eye discharge. 

How Tears Are Produced

Tears are produced by the lacrimal glands located at the upper eyelid, above the eyes. When people blink, the tears spread on the eye region, keeping it moist and helping focus light for clear vision. Tears then drain into the puncta, tiny holes in the upper and lower eyelids. They then pass through the drainage canals and into the lacrimal sac. After that, tears flow down the nasolacrimal duct and into the nasal cavity. It is estimated that a person produces 15 to 30 gallons of tears every year.

When this drainage system is partially or completely obstructed, tears cannot be drained, resulting in an infection.

Types of Dacryocystitis

Tear duct infection can be classified as acute, chronic, congenital, or acquired. Acute and chronic refer to the duration of symptoms, while congenital and acquired refer to the onset and cause of the condition.

Each type of dacryocystitis has different characteristics:

• Acute: Acute dacryocystitis occurs when there is excessive bacterial growth in the eye region and it blocks the lacrimal sac. It usually lasts less than three months. In the United States, the most common bacteria related to acute dacryocystitis are Staphylococcus and Streptococcus, followed by Haemophilus influenza and Pseudomonas aeruginosa, which are also related to conjunctivitis. This form of dacryocystitis usually resolves with systemic antibiotics.
• Chronic: Chronic dacryocystitis lasts for a long time and the chronic obstruction in this case is due to a systemic disease, repeat infection, dacryoliths, and chronic inflammatory debris of the nasolacrimal system. It typically presents with less inflammatory signs. People with Wegener's granulomatosis, sarcoidosis, and lupus have higher chances of developing this type of dacryocystitis. Surgical therapy to treat the underlying cause is needed.
• Congenital: It often occurs when there is an obstruction of the valve of Hasner, located at the distal portion of the nasolacrimal duct. If the amniotic fluid is not cleared from the nasolacrimal system a few days after delivery, it can become purulent and lead to congenital dacryocystitis.
• Acquired: This type of dacryocystitis is often a result of repeat trauma, surgeries, medications, and neoplasms.

Symptoms

Dacryocystitis symptoms are often mild, but in severe cases, it can cause a fever. An abscess (a collection of pus) can form and rupture through the skin.

The symptoms of acute and chronic dacryocystitis are different, however.

Acute

Acute dacryocystitis will often have sudden symptoms, and they may occur over several hours to several days.

Symptoms often appear over the medial canthus (the point where the upper and lower eyelids meet) and the area overlying the lacrimal sacs, and they include:

• Pain
• Redness, which can extend to the bridge of the nose
• Swelling
• Purulent discharge
• Tearing

Chronic

The most common symptoms of chronic dacryocystitis are excessive tearing and discharge. People with this kind of dacryocystitis may also notice changes in visual acuity due to tear film production.

Complications

The blocked tear ducts are easy to treat and symptoms improve with treatment in most cases. Although it is uncommon, some cases of acute dacryocystitis can lead to complications, including:

• Lacrimal fistulas
• Lacrimal sac abscesses
• Meningitis
• Cavernous sinus thrombosis
• Vision loss

The consequences of these complications can be devastating, so a prompt referral to an ophthalmologist for evaluation is important.

Causes and Risk Factors

Causes

Dacryocystitis is caused by a blocked tear duct. Tears become trapped in the sac and form a pool. Bacteria can then begin to grow in the tear pool and create an infection. Both the trapped tears and infection will cause swelling and irritation.

Risk Factors

Some factors increase the chances of a person developing dacryocystitis:

• Females are at greater risk due to their narrower duct diameter compared with males
• Older age leads to narrowing of the punctual openings, slowing tear drainage
• Dacryoliths, which is a collection of shed epithelial cells, lipids, and amorphous debris within the nasolacrimal system 
• Nasal septum deviation, rhinitis, and turbinate hypertrophy
• Damage to the nasolacrimal system due to trauma of the nasoethmoid region or endoscopic/endonasal procedures
• Neoplasm within the nasolacrimal system
• Systemic disease such as Wegener’s granulomatosis, sarcoidosis, and lupus, or lacrimal sac tumors
• Medications such as timolol, pilocarpine, idoxuridine, and trifluridine 

Diagnosis

The diagnosis of dacryocystitis is primarily based on history and physical exams. An eye specialist may request additional tests to rule out other conditions and confirm the diagnosis.

Different tests and exams will be used to diagnose the different types of dacryocystitis.

Lab Tests

People with chronic cases of dacryocystitis will need serologic testing since systemic conditions are suspected. For example, antineutrophil cytoplasmic antibody (ANCA) testing may be useful to test for Wegener's granulomatosis, while antinuclear antibody testing (ANA) and double-stranded DNA (dsDNA) can be used if lupus is suspected.

In acute cases, a Crigler massage can be performed to obtain a sample for culture and gram stain. 

Eye Exam

During an eye exam, your healthcare provider will measure the production of tears, as well as the position and function of the eyelids and eyelid muscles. They will also perform an irrigation test to determine whether the tear ducts are indeed blocked.

Imaging

Imaging is not typically needed for diagnosis unless suspicion arises on history and physical (for example, patient has bloody tears). It may also be recommended for those who are acutely toxic or experience visual changes, along with bloodwork. CT scans may be taken in cases of orbital cellulitis or extensive infection. Dacryocystography or plain film dacrosystogram (DCG) can be performed when anatomic abnormalities are suspected. Nasal endoscopy is used to exclude problems such as septal deviation or inferior meatal narrowing.

Differential Diagnosis

Some diseases that have similar symptoms to dacryocystitis are:

• Acute ethmoid sinusitis
• Infected sebaceous cysts
• Cellulitis
• Eyelid ectropion 
• Punctal ectropion
• Allergic rhinitis
• Lacrimal sac or sinonasal tumor

Treatment 

Treatment is focused on correcting the underlying cause of dacryocystitis. It is typically more conservative in children since congenital dacryocystitis typically resolves by one year of age. Treatment options will also differ by type of dacryocystitis.

Home Remedies

Some home remedies can help to relieve the symptoms and treat acute dacryocystitis:

• Warm compress: Put a washcloth under warm water and wipe the pus out of your eye. Carefully place the washcloth over the eye for five minutes. It relieves the pain and makes the Crigler massage more effective.
• Crigler massage: After removing the warm compress, place your index finger on the eye corner and gently press it. It is normal to see some pus or fluid coming out from the eye. Wipe it off and wash your hands. 

Medication

Antibiotics are prescribed for some cases of acute dacryocystitis. Oral antibiotics can treat the condition quickly. A severe infection requires initial IV antibiotics and observation in the hospital.

If a person with acute dacryocystitis has worsening symptoms, even with oral antibiotics or shows evidence of orbital cellulitis, they may be given IV antibiotics.

Surgical Procedures

Surgery is typically used to treat chronic cases of dacryocystitis. There are different types of surgeries, and the patient should discuss with the healthcare provider the best options:

• Nasolacrimal probing: It involves passing a probe into the lacrimal sac and down through the nasolacrimal duct to open the obstruction at the lower end of the duct. It is successful at treating the problem in 70% of cases.
• Balloon dacryoplasty: A thin catheter with a tiny balloon will be inserted through the nose. When it reaches the tear duct, the healthcare provider will blow the balloon multiple times until the blockage is gone.
• Nasolacrimal intubation or stenting: A thin tube or stent is inserted through the puncta to the nose. The tube will stop the blockage and drain the tears.
• Dacryocystorhinostomy: This procedure creates a new passage between the tear duct sac and the nose, bypassing the blockage and allowing tears to drain normally again. Dacryocystorhinostomy is performed if other forms of surgical therapy fail.