Chronic Dacryocystitis

Definition : Chronic inflammation of the lacrimal sac secondary to obstruction of the nasolacrimal duct. This is the most common lacrimal sac disorder.

Etiology

Predisposing factors:

• Nasolacrimal duct obstruction.
Acute dacryocystitis.

Causative agent:

• Pneumococci: 80% of cases.

• Staph, Strept, Trachoma & Fungi.

• TB & Syphilis: Rare.

Symptoms

1. Watery eye.
2. Discharge.

Signs

1. Red & hyperaemic inner canthus.

2. Swelling of the lacrimal sac: Below the medial palpebral ligament.

3. + ve regurgitation test: Regurgitation of mucous or pus. It becomes -ve on formation of a mucocele.

Complications

1. Chronic conjunctivitis.

2. Vicious circle of epiphora, eczema & ectropion.

3. Hypopyon ulcer.

4. Endophthalmitis: Following an intraocular operation.

5. Mucocele & pyocele: If the canaliculi are obstructed.

6. Acute dacryocystitis, abscess & lacrimal fistula.

Investigations :

Clinical evaluation & investigations of epiphora

1. History: Exclude lacrimation.

Bilateral watering of the eye is usually due to lacrimation, while unilateral watering is usually due to epiphora.

2. Examination:

• Eyelids: Exclude trichiasis, ectropion & blepharitis.

• Lacrimal sac: Swelling & dacryocystitis.

• Nose: Polyps & deviated nasal septum.

3. Investigations:

1. Regurgitation test: Positive in cases with NLD obstruction.

2. Jones test.

3. Dacryocystography.

4. Plain X-ray: Diagnosis of tumors & fractures.

5. Tuberculin test for TB.

6. Diagnostic probing & scintillography.

1. Regurgitation test: Press on the lacrimal sac against the lacrimal bone:

• + ve regurge: Reflux of pus or tears from the puncti NLD.

• -ye regurge: No reflux patent lacrimal passages.

2. Jones test:

I. Type I: Instill a

drop of fluorescin in the conjunctural sac & insert a coil on pellet soaked in xylocaine (Usneezing reflex) under the inferior nasal turbinate.

• Results:

1. The cotton is stained with fluorescin patent lacrimal passages.

2. Not stained: Proceed to Jones test type II.

II. Type II: After type I, irrigate the lacrimal passage with saline.

• Results:

1. If fluorescin is recovered: There is partial or functional obstruction of the passes.

2. If fluorescin is not recovered: There is complete obstruction.

3. Dacryocystography:

Useful for detection of the following: Tumors & calculi appearing as filling defects. Time needed to fill & empty the sac.

4. Plain X-ray: To detect tumors & fractures.

Treatment

Aim:

1. Restore communication between the lacrimal sac & the nose.

2. Treatment of infection.

Lines:

1. Treatment of the cause of obstruction.

2. Dacryocystorhinostomy :

Principle : Connecting the lacrimal sac to the nasal mucosa bypassing the obstructive NLD.

Indications:

• Chronic dacryocystitis.

• Mucocele of the lacrimal sac.

• Lacrimal fistula (+ fistulectomy).

Contraindications:

• Extensive adhesions & neglected cases.

• Nasal pathology eg atrophic rhinitis.

• TB & lacrimal sac tumors.

• Hypopyon ulcer.

3. Dacryocystectomy :

Principle : Removal of the lacrimal sac.

Indications : Neglected cases, when DCR is contraindicated.

Congenital NLD obstruction (Infantile dacryocystitis) Etiology : Imperforate hasener's valve (Most common).

Symptoms : Epiphora, 2-3 weeks after birth, is reported by the mother.

Signs

1. Regurgitation test clear fluid, mucous or frank pus.

2. Recurrent conjunctivitis.

Treatment

1. Hydrostatic massage: Instruct the mother to press on the lacrimal sac in a downwards direction. This may help removing any epithelial remnants & opening hasener's valve.

2. Antibiotics.

3. Probing: Of great success rate.

4. Repeated syringing & irrigation.

5. Intubation of the lacrimal drainage system (Silicone tube).

6. Dacryocystorhinostomy (DCR).