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{{cite book |last=Jeffrey |first=Hurwitz |title=Ophthalmology, Fourth Edition |publisher=Elsevier |date=2014 |pages=1346-1351 |chapter=Chapter12.15:The Lacrimal Drainage System |isbn=978-1-4557-5001-6}} Dacryocystitis Dacryocystitis may be classified as acute, subacute, or chronic. It may be localized in the sac, extend to include a pericystitis, or progress to orbital cellulitis. When dacryocystitis is localized to the sac, a palpable painful swelling occurs at the inner canthus ( Fig. 12-15-7 ), and obstruction is present at the junction of the nasolacrimal sac and duct. A pre-existing dacryocystocele may or may not be present. When the infection develops, the lateral expansion of the nasolacrimal sac tends to push on the common canaliculus and produce a kink within it, with the result that the sac is no longer reducible. Approximately 40% of initial attacks do not recur, but in the other 60% of patients, repeated attacks occur. Chronic dacryocystitis may be the end stage of acute or subacute dacryocystitis, but it may present initially as a subclinically infectious cause of nasolacrimal duct obstruction. A common organism involved is Staphylococcus aureus . In some cases, especially in young women, stones may develop that lead to intermittent attacks of dacryocystitis; this has been termed acute dacryocystic retention syndrome. In dacryocystitis with pericystitis there is percolation of infected debris through the mucosal lining of the wall of the sac, and infection around the sac is present. The infection may spread to the anterior orbit and produce a tremendous amount of eyelid swelling ( Fig. 12-15-8 ). If the infection proceeds posterior to the orbital septum a true orbital cellulitis may occur, resulting in globe proptosis or displacement, afferent pupillary defect, motility disturbance, optic neuropathy, and even blindness. More info on page

{{cite book |last=Durand |first1=Marlene |title=Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases Updated Edition, Eighth Edition |publisher=Elsevier |date=2015 |pages=1432-1438 |chapter=Chapter 118:Periocular infections |isbn=978-1-4557-4801-3}} Dacryocystitis Dacryocystitis, or inflammation of the lacrimal sac, is the most common infection of the lacrimal system. It arises because of obstruction of the lacrimal duct, pooling of tears in the lacrimal sac, and subsequent infection. Obstruction may be congenital or may result from trauma, tumors, infection, or inflammation of the duct. Acute dacryocystitis symptoms include pain, swelling, and erythema near the nasal corner of the eye. There is usually epiphora (excessive tearing) and a purulent discharge. Infants often have lacrimal duct obstruction with epiphora, but acute dacryocystitis complicates the obstruction in only 3%. 49 The most common causes of acute dacryocystitis are S. aureus and streptococci. Gram-negative bacilli accounted for 25% of isolates in one study, with Escherichia coli as the most frequent gram-negative organism isolated. 50 Treatment requires antibiotic therapy (e.g., ampicillin-sulbactam) and usually incision and drainage of a lacrimal sac abscess. In one study, incision and drainage was an outpatient procedure requiring only local anesthesia in approximately 80% of cases. 51 A repeat drainage procedure was required within 1 month in 8%. Chronic or recurrent dacryocystitis usually requires a surgical procedure, dacryocystorhinostomy (DCR). One study found that cultures taken at the time of DCR surgery were positive in nearly half of the 114 patients studied, although only one fifth of the patients had a history of dacryocystitis. 52 Staphylococcus epidermidis and S. aureus were the only organisms isolated in 45% and 24% of culture-positive cases. Whether these reflect nasal flora contamination is unknown. Gram-negative bacilli composed a larger percentage of isolates in patients with a history of dacryocystitis, a finding also noted by others. 53 Gram-negative bacilli were present in 26% of cultures in a recent study, with H. influenzae predominating. 54 Anaerobes were found in 19%. Fungi have been reported as a cause of two cases of dacryocystitis, including one with mucormycosis involving the lacrimal sac. 55 Rhinosporidium seeberi, an aquatic protistan parasite seen especially in tropical climates such as southern India, may cause chronic dacryocystitis. A recent report from India described 50 patients seen with ocular rhinosporidiosis over a 2.5-year period; half had conjunctival involvement, and 26% had lacrimal sac involvement. 56 Bloody discharge from the puncta was a feature of lacrimal sac infection, and at surgery, a pink, vascularized growth was found in the lacrimal sac. Patients with an episode of acute dacryocystitis who do not ultimately undergo a DCR procedure may have further episodes of acute dacryocystitis. One study found that 4 of 16 patients with a lacrimal abscess who did not eventually have a definitive procedure (DCR or dacryocystectomy) developed a recurrent lacrimal sac abscess. 51

PMID: 17603466- Dacryocystitis is an inflammation of the lacrimal sac, which usually occurs because of obstruction of the nasolacrimal duct.1 The obstruction may be an idiopathic inflammatory stenosis (primary acquired nasolacrimal duct obstruction)2 or may be secondary to trauma, infection, inflammation, neoplasm, or mechanical obstruction (secondary acquired lacrimal drainage obstruction).3 Obstruction of the nasolacrimal duct leading to stagnation of tears in a pathologically closed lacrimal drainage system can result in dacryocystitis. The most common infection of the lacrimal apparatus is dacryocystitis. The lacrimal excretory system is prone to infection and inflammation for various reasons. This mucus membrane-lined tract is contagious with two surfaces (conjunctival and nasal mucosal) that are normally colonized with bacteria. The functional purpose of the lacrimal excretory system is to drain tears from the eye into the nasal cavity. Obstruction of the nasolacrimal duct from whatever source results in stasis with the accumulation of tears, desquamated cells, and mucoid secretions superior to the obstruction. This creates a fertile environment for secondary bacterial infection.1 Obstructed nasolacrimal duct may occur in any age group. Congenital blockage occurs in 3–6% of term infants.16 In most of these cases, the nasal end of the duct is blocked by epithelial debris or an imperforate mucosal membrane resulting from incomplete canalization of the embryonic duct.16 Primary and secondary acquired nasolacrimal duct obstruction usually occurs mainly in middle-aged or older people with a 3 : 1 female preponderance due to obliteration of the lumen.2 Similarly in this study, patients with age greater than 30 years were significantly more in number in chronic dacryocystitis (90%) than those aged less than 31 years (10%). The over all female-to-male ratio in this study was 3.9 : 1and female subjects (80.9%) were significantly more in number in chronic dacryocystitis than male subjects (19.1%).The microbiology of dacryocystitis may differ in acute and chronic infections. Acute dacryocystitis is often caused by Gram-negative rods.1, 4 In chronic dacryocystitis, mixed bacterial isolates are more commonly found with the predominance of Streptococcus pneumoniae and Staphylococcus spp.1, 5 Fungal infections caused by Candida albicans and Aspergillus spp occur infrequently.1 During the past 20 years, there have been only a few studies on the bacteriology of chronic dacryocystitis. According to them, coagulase-negative staphylococci (CoNS) and Staphylococcus aureus are the most frequently isolated organisms in lacrimal sac infections.There are distinct patterns of geographical variation in terms of aetiology according to the local climate in infective keratitis9 and also in microbial conjunctivitis.10 Hence, an understating of the region-wise aetiological agents is important in the management of these diseases. The purpose of this study was to identify the bacterial aetiology and to determine the in vitro antibacterial susceptibility and resistance of bacterial pathogens to commonly used antibacterial agents, and an attempt was also made to compare the spectrum of bacterial pathogens and their susceptibility in both acute and chronic dacryocystitis. This retrospective analysis included patients with acute and chronic dacryocystitis who underwent microbiological evaluation presenting between January 2000 and December 2005. Patients were examined on the slit-lamp biomicroscope by a group of ophthalmologists, and cases of dacryocystitis were identified and categorized as acute or chronic, based on their signs and symptoms.1, 11 Acute dacryocystitis was diagnosed in patients with exquisite pain, redness, and swelling in the tear sac area, tearing or discharge in conjunctiva, and tender swelling over the lacrimal sac region. Chronic dacryocystitis was diagnosed in patients with persistent epiphora and regurgitation of mucoid or mucopurulent material on pressure over the sac area or regurgitation of mucoid or mucopurulent discharge on irrigation of the lacrimal drainage system.

PMID: 16286415 Dacryolithiasis occurs in patients with chronic underlying dacryocystitis. Denuded epithelial cells clump together with exudated proteins and debris, forming a cast in the lacrimal sac. With time, the material eventually mineralizes, most typically with calcium (2). Dacryoliths are typically found in the setting of chronic infections with superimposed fungal colonization. They are found in up to 30% of patients with chronic dacryocystitis (3), are difficult to identify on conventional radiographs, and appear as round or oval filling defects on dacryocystography. On a CT scan, dacryoliths are characterized by focal areas of high attenuation within a soft-tissue attenuation mass in the region of the lacrimal sac (4). They may have a peripheral rim of calcification, giving a “rice kernel” appearance. Dacryocystitis is characterized by epiphora, erythema, and edema in the region of the medial epicanthus and lacrimal puncta as the result of an infection of the nasolacrimal sac. Often there is mucopurulent discharge from the puncta and associated conjunctivitis. Obstruction or stricture of the nasolacrimal drainage is generally an underlying factor. A brief review of the normal anatomy of the nasolacrimal system is included for clarity. The lacrimal drainage system consists of upper and lower canaliculi, a lacrimal sac, and a lacrimal duct. The upper and lower canaliculi originate as a small opening in the medial lid margins, which are termed “puncta.” The canaliculi course medially and drain excess tears from the surface of the eyes. They combine to form a common channel called the sinus of Maier, which drains into the posterior wall of the lacrimal sac. The nasolacrimal duct drains the sac via the nasolacrimal canal into the nasal cavity below the inferior turbinate (4). The incidence of dacryocystitis occurs in a bimodal distribution, with greater frequency in neonates and in people more than 40 years of age (5). Most cases in neonates represent congenital abnormalities. The sexes are affected equally. Most cases are related to incomplete recanalization of the distal nasolacrimal duct in the region where it enters the nasal cavity. A thin membrane is often present covering the opening. The membrane will sometimes rupture on its own, or it may require instrumentation (6). In the group of patients of more than 40 years of age, the infections relate to acquired abnormalities. Commonly, women are affected more than men, and whites are affected more than blacks. Similar to that in neonates, obstruction at the opening of the nasolacrimal duct into the inferior meatus is often the underlying factor. Contributing conditions may include rhinitis, sinusitis, enlarged turbinates or adenoids, foreign bodies, septal deviation, tumors, mucoceles, nasal septal abscess, iatrogenic causes, and trauma. The obstruction and subsequent stagnation of the tear flow predisposes to infection (2, 3, 5). The microbiology of dacryocystitis mimics normal conjunctival flora in most instances. The most common aerobic organisms include Staphylococcus epidermidis, S aureus, Streptococcus, Pseudomonas, and Pneumococcal species. The most common anaerobic organisms isolated from the lacrimal sacs in adults with dacryocystitis include Peptostreptococcus, Propionibacterium, Prevotella, and Fusobacterium species. Gram-negative bacteria are associated with copious discharge. The most common gram-negative bacteria isolated are Pseudomonas aeruginosa and Escherichia coli (5). In chronic dacryocystitis, there can be superinfection with fungal species including Actinomyces, Aspergillus, and Candida species (5). Treatment of acute dacryocystitis typically involves treatment with antibiotics in the acute phase, which may or may not be followed by an external dacryocystorhinostomy or other interventional procedure (3). Patients typically do not require hospitalization unless there are complicating factors such as orbital cellulitis. Other complications include abscess and fistula formation. Chronic dacryocystitis typically requires surgery or an interventional procedure. Occasionally, chronic dacryocystitis relating to allergies may improve with topical steroids (6). Surgical success rates in the treatment of dacryocystitis are approximately 90% (5). Balloon dacryoplasty, with or without stent placement, may be useful in patients with circumscribed focal stenosis or occlusions of the nasolacrimal duct (3). Not all that swells in the region of the medial epicanthi represents infection. Multiple entities can cause masslike swelling. An enlarged sac that is noninfected is termed a “dacryocystocele.” Epithelial tumors are the most common tumors of the lacrimal sac. The malignant causes include squamous cell carcinoma, adenoid cystic carcinoma, oncocytic carcinoma, and epidermoid carcinoma. The benign lesions include papilloma, dermoid cysts, mucoepidermoid cysts, and adenoma. Lymphoproliferative disorders, primarily lymphoma, are the second most common types of tumors. Rarely mesenchymal tumors occur and include hemangioma, hemangiopericytoma, melanoma, fibroma, fibrous histiocytoma, neurilemmoma, and plexiform neuroma. Granulomatous diseases such as sarcoid and Wegener’s granulomatosis can affect the lacrimal sac. Secondary involvement from cutaneous squamous and basal cell carcinomas can occur. Metastatic disease of the lacrimal sac is rare

Wadgaonkar, S.P., Patil, P.A., Nikumbh, D.B., Rathod, S.S. and Sawat, C.M., 2016. Epidemiology of chronic dacryocystitis with special reference to socioeconomic status: A rural hospital study. Indian Journal of Clinical and Experimental Ophthalmology, 2(1), pp.52-56. Introduction Dacryocystitis is an inflammation and infection of lacrimal sac located between the medial canthus of the eye and nose. It is an important cause of ocular morbidity in India1. Both eyes may be affected. The disease occurs as an isolated incident (acute) or ongoing (chronic) form2. Chronic Dacryocystitis is commonly encountered by an ophthalmologist accounting for 87.1% of epiphora, which causes social embarrassment due to chronic watering from eyes2,3. It commonly affects females over 40 years of age with peak incidence in 60 to 70 years4. It is more common in Whites than in Negros and more common in India as being tropical country. It has higher incidence among people of lower socioeconomic status4. It is usually caused by partial or complete obstruction in lacrimal sac or within nasolacrimal duct. The causes of acquired obstruction are infection, inflammation, neoplasms and trauma5. Patient with chronic Dacryocystitis may remain asymptomatic or have watering, discharge from the eye and swelling at lacrimal region.5 Untreated Dacryocystitis never undergoes spontaneous resolution. It tends to progress as wall of the sac become atonic and contents can be evacuated only by the external pressure6. Acute Dacryocystitis may lead to lacrimal abscess. If untreated it may causes unilateral chronic conjunctivitis, corneal ulcer, lacrimal abscess, fistula and panophthalmitis may occur if any intra ocular surgery is performed in presence of unrecognized Dacryocystitis4. Other complications are orbital cellulitis; cavernous sinus thrombosis and orbital thromboplebitis4. Most of the people consider watering from eyes as minor discomfort and avoid themselves from presenting to ophthalmologist as they are unaware of the deleterious complications.