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Dacryocystitis and Dacryoadenitis, Emergency Medicine

Basics

Description

- 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

- Swelling and tenderness greatest in temporal aspect of upper lid under orbital rim: - 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

- Tests of expressed material (used to help direct specific antibiotic treatment): - Gram stain - Culture and sensitivity - Chocolate agar plating if GC suspected

- 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

  • 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:

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 diseasesSj ¶gren syndromeSarcoidosisCrohns diseaseTumor
  • 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 aureusStreptococciChlamydia trachomatisNeisseria gonorrhea
  • Chronic dacryoadenitis:Nasal flora > ocular flora
  • Viruses most common cause in children:MumpsMeaslesEpstein-Barr virusCytomegalovirusCoxsackievirusVaricella-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 flowStasis in this conduit results in overgrowth of bacteria and infection.Infection may be recurrent and may become chronic:Most common bacteria: Sinus > ocular floraS. 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:
  • Mass may be palpable
  • May be associated with:Extensive cellulitisConjunctival injection and dischargeIncrease or decrease in tear productionIpsilateral conjunctival injection and chemosisIpsilateral preauricular adenopathySystemic 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 likelySystemic 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 stainCulture and sensitivityChocolate 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 diseasesLacrimal gland tumorHordeolumPeriorbital cellulitisSevere blepharitisOrbital cellulitisInsect biteTraumatic injuryOrbital or lacrimal gland tumor
  • Dacryocystitis:Insect biteTraumatic injuryAcute ethmoid sinusitisPeriorbital cellulitisAcute 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:AntibioticsOral for mild infection:CephalexinAmoxicillin/clavulanateIV for severe infection:CefazolinTicarcillin/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 obstructionMay facilitate outflow from obstructed tract with nasal introduction of vasoconstricting agentIncision and drainage only in severe cases:Typically done by ophthalmologyAvoid in ED when possibleMay result in fistula formationDuct instrumentation to facilitate drainage is not indicated in acute setting:Reserve instrumentation for nonacute setting, if necessary at allManipulation 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 infectionIntravenous 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 moH. 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 appearanceConcomitant medical problems including diabetes or immunosuppressionExtensive cellulitisSuspicion of adjacent spread with deep tissue involvement or meningitis or Neisseria meningitidis
  • Children:Acutely ill appearanceConcomitant medical problemsExtensive cellulitisHigh 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Conjunctivitis
  • Hordeolum and Chalazion
  • Periorbital and Orbital Cellulitis
  • Red Eye

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