Dacryocystitis and Dacryoadenitis, Emergency Medicine

Basics

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:

Acquired:
- Uncommon

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:
- Autoimmune diseases
- Sj ¶gren syndrome
- Sarcoidosis
- Crohns disease
- Tumor
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:
  - Staphylococcus aureus
  - Streptococci
  - Chlamydia trachomatis
  - Neisseria gonorrhea
Chronic dacryoadenitis:
- Nasal flora > ocular flora

Viruses most common cause in children:
- Mumps
- Measles
- Epstein-Barr virus
- Cytomegalovirus
- Coxsackievirus
- 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

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

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.

Diagnosis

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:
- 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

Promptly determine clinical probability of spread from N. gonorrhea 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

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

Flip lids
Examine nasal passages

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:
- Autoimmune diseases
- Lacrimal gland tumor
- Hordeolum
- Periorbital cellulitis
- Severe blepharitis
- Orbital cellulitis
- Insect bite
- Traumatic injury
- Orbital or lacrimal gland tumor
Dacryocystitis:
- Insect bite
- Traumatic injury
- Acute ethmoid sinusitis
- Periorbital cellulitis
- Acute conjunctivitis

Treatment

Ed Treatment/Procedures

Early diagnosis and initiation of treatment will reduce risk of extension of infection to adjacent structures and systemic infection.
Topical antibiotics may be considered to treat or avoid conjunctivitis.

Dacryoadenitis

Cool compresses to decrease inflammation and nonsteroidal pain medication
Viral etiology:
- Typically self-limited inflammation
Bacterial etiology:
- Antibiotics
- Oral for mild infection:
  - Cephalexin
  - Amoxicillin/clavulanate
- IV for severe infection:
  - Cefazolin
  - Ticarcillin/clavulanate
Tetanus toxoid if necessary
Incision and drainage rarely necessary except in very severe cases:
- Perform with consultation to facial surgery service or ophthalmology

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

Newborns respond well to massage and topical antibiotics in ~95% of cases.
If no resolution in 1st yr of life, may require probing of duct by ophthalmologist
Children <4 yr old who develop dacryocystitis:
- At increased risk for Haemophilus 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

Amoxicillin/clavulanate (Augmentin): 500 mg (peds: 20-40 mg of amoxicillin/kg/24h) PO q8h
Cefaclor: 500 mg (peds: 20-40 mg/kg/24h) immediate release PO TID
Cefazolin: 500-1,000 mg (peds: 50-100 mg/kg/24h) IV q6-8h
Cefuroxime: 750-1,500 (peds: 50-100 mg/kg/24h) mg IV q8h
Cephalexin: 500 mg (peds: 25-100 mg/kg/24h) PO QID
Erythromycin ophthalmic ointment: 2 drops QID to affected eye
Tetracaine and phenylephrine topical solution single-dose nasal spray
Ticarcillin/clavulanate: 3.1 g (peds: 200-300 mg of ticarcillin/kg/24h) IV q4-6h
Trimethoprim-polymyxin ointment: 2 drops QID to the affected eye

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

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.

Codes

ICD9

375.00 Dacryoadenitis, unspecified
375.30 Dacryocystitis, unspecified
375.32 Acute dacryocystitis
375.01 Acute dacryoadenitis
375.02 Chronic dacryoadenitis
375.03 Chronic enlargement of lacrimal gland
375.0 Dacryoadenitis
375.42 Chronic dacryocystitis
771.6 Neonatal conjunctivitis and dacryocystitis

ICD10

H04.009 Unspecified dacryoadenitis, unspecified lacrimal gland
H04.309 Unspecified dacryocystitis of unspecified lacrimal passage
H04.329 Acute dacryocystitis of unspecified lacrimal passage
H04.019 Acute dacryoadenitis, unspecified lacrimal gland
H04.001 Unspecified dacryoadenitis, right lacrimal gland
H04.002 Unspecified dacryoadenitis, left lacrimal gland
H04.003 Unspecified dacryoadenitis, bilateral lacrimal glands
H04.00 Unspecified dacryoadenitis
H04.011 Acute dacryoadenitis, right lacrimal gland
H04.012 Acute dacryoadenitis, left lacrimal gland
H04.013 Acute dacryoadenitis, bilateral lacrimal glands
H04.01 Acute dacryoadenitis
H04.021 Chronic dacryoadenitis, right lacrimal gland
H04.022 Chronic dacryoadenitis, left lacrimal gland
H04.023 Chronic dacryoadenitis, bilateral lacrimal gland
H04.02 Chronic dacryoadenitis
H04.301 Unspecified dacryocystitis of right lacrimal passage
H04.302 Unspecified dacryocystitis of left lacrimal passage
H04.30 Unspecified dacryocystitis
H04.321 Acute dacryocystitis of right lacrimal passage
H04.322 Acute dacryocystitis of left lacrimal passage
H04.323 Acute dacryocystitis of bilateral lacrimal passages
H04.32 Acute dacryocystitis
H04.411 Chronic dacryocystitis of right lacrimal passage
H04.412 Chronic dacryocystitis of left lacrimal passage
H04.413 Chronic dacryocystitis of bilateral lacrimal passages
H04.419 Chronic dacryocystitis of unspecified lacrimal passage
H04.41 Chronic dacryocystitis
P39.1 Neonatal conjunctivitis and dacryocystitis

SNOMED

85777005 Dacryocystitis (disorder)
86927009 Dacryoadenitis
25470000 Acute dacryocystitis
2589008 Acute dacryoadenitis (disorder)
23735003 Neonatal dacryocystitis (disorder)
286942005 Dacryocystitis, acute/chronic
4760008 Chronic dacryoadenitis (disorder)
84627005 Chronic dacryocystitis

Home

Erectile Dysfunction

Doctor123.org