You may only think of tears as those salty drops that fall from your eyes when you cry. Actually, your tears clean your eyes every time you blink. Tears also keep your eyes moist, which is important for your vision.

Tear glands produce tears, and tear ducts carry the tears from the glands to the surface of your eye. Problems with the tear system can include too many tears, too few tears, or problems with the tear ducts. Treatment of the problem depends on the cause.

In a healthy eye, lubricating tears called basal tears continuously bathe the cornea, the clear, dome-shaped outer surface of the eye. With every blink of the eye, basal tears flow across the cornea, nourishing its cells and providing a layer of liquid protection from the environment.

When the glands nearby each eye fail to produce enough basal tears, or when the composition of the tears changes, the health of the eye and vision are compromised. Vision may be affected because tears on the surface of the eye play an important role in focusing light.

Tears are a complex mixture of fatty oils, water, mucus, and more than 1500 different proteins that keep the surface of the eye smooth and protected from the environment, irritants, and infectious pathogens.

Tears form in three layers:

• An outer, oily (lipid) layer, produced by the Meibomian glands, keeps tears from evaporating too quickly and helps tears remain on the eye.
• A middle (aqueous) layer contains the watery portion of tears as well as water-soluble proteins. This layer is produced by the main lacrimal gland and accessory lacrimal glands. It nourishes the cornea and the conjunctiva, the mucous membrane that covers the entire front of the eye and the inside of the eyelids.
• An inner (mucin) layer, produced by goblet cells, binds water from the aqueous layer to ensure that the eye remains wet.

Although the eye and skin have distinct anatomy, they are both in direct contact with the external environment. An important component of the eye is the nasolacrimal drainage system, which serves as a conduit for the fluid of the eye, called tears. Tears flow from the external eye to the nasal cavity by the lacrimal apparatus, which is composed of the structures involved in tear production. The lacrimal gland, above the eye, secretes tears to keep the eye moist. There are two small openings, one on the inside edge of the upper eyelid and one on the inside edge of the lower eyelid, near the nose. Each of these openings is called a lacrimal punctum. Together, these lacrimal puncta collect tears from the eye that are then conveyed through lacrimal ducts to a reservoir for tears called the lacrimal sac, also known as the dacrocyst or tear sac.

From the sac, tear fluid flows via a nasolacrimal duct to the inner nose. Each nasolacrimal duct is located underneath the skin and passes through the bones of the face into the nose. Chemicals in tears, such as defensins, lactoferrin, and lysozyme, help to prevent colonization by pathogens. In addition, mucins facilitate removal of microbes from the surface of the eye.

The surfaces of the eyeball and inner eyelid are mucous membranes called conjunctiva. The normal conjunctival microbiota has not been well characterized, but does exist. One small study (part of the Ocular Microbiome project) found twelve genera that were consistently present in the conjunctiva. These microbes are thought to help defend the membranes against pathogens. However, it is still unclear which microbes may be transient and which may form a stable microbiota.

Use of contact lenses can cause changes in the normal microbiota of the conjunctiva by introducing another surface into the natural anatomy of the eye. Research is currently underway to better understand how contact lenses may impact the normal microbiota and contribute to eye disease.

The watery material inside of the eyeball is called the vitreous humor. Unlike the conjunctiva, it is protected from contact with the environment and is almost always sterile, with no normal microbiota.

Interference with the secretion of tears by the lacrimal glands. Obstruction of the LACRIMAL SAC or NASOLACRIMAL DUCT causing acute or chronic inflammation of the lacrimal sac (DACRYOCYSTITIS). It is caused also in infants by failure of the nasolacrimal duct to open into the inferior meatus and occurs about the third week of life. In adults occlusion may occur spontaneously or after injury or nasal disease. (Newell, Ophthalmology: Principles and Concepts, 7th ed, p250)

The eyeball is kept moist and healthy by a thin film of tears that is continuously produced by the lacrimal gland situated underneath the top eyelid. Every time you blink, tears are swept towards the inside corner of the eye and drained through two tiny tubes called lacrimal canaliculi. From there, tears pass into the nasolacrimal sac, then into the nasolacrimal duct to the nose and, ultimately, to the throat for swallowing.A blockage along any point of this tear duct system is known as a blocked tear duct or dacryostenosis. The symptoms include a pus-like discharge. Some babies are born with a blockage (congenital dacryostenosis). A range of conditions and events can cause acquired dacryostenosis. In adults, most cases are due to thickening of the lining of the duct leading eventually to blockage.

Symptoms of a blocked tear duct

The symptoms of a blocked tear duct can include:

• watering eye
• tears running down the face
• discharge of pus
• crusted mucus along the eyelashes
• increased susceptibility to eye infections.

Causes of a blocked tear duct

Some of the causes of a blocked tear duct include:

• congenital conditions – some babies are born with a blockage within the tear duct system, usually the nasolacrimal duct. The thin membrane that seals the nasolacrimal duct in utero fails to open at birth or soon after
• chronic nose infections – chronic sinusitis may irritate the tissues and form scars, which may block the tear duct system
• nose trauma – such as a broken nose. The injured tear duct system may be blocked by scar tissue
• inflammation of the lining of the tear duct – in most adult cases, the lining of the tear duct becomes thicker with age, eventually leading to blockage
• conjunctivitis – infection and inflammation of the conjunctiva (the thin membrane covering the eye). In rare cases, the tear duct system may become infected and blocked, especially after some viral infections.

Dacryocystitis

Trapped tears in the nasolacrimal sac can create the perfect breeding ground for bacteria. An infected nasolacrimal sac is called dacryocystitis. The symptoms include:

• fever
• redness, swelling and tenderness beside the bridge of the nose, next to the affected eye
• in severe cases, the infected sac may form an abscess.

Diagnosis of a blocked tear duct

A blocked tear duct is diagnosed using a number of tests, including:

• physical examination – including medical history
• ophthalmic examination – to check for other possible causes
• particular tests to check for tear drainage – for example, a special fluid is flushed into the affected tear duct opening. A diagnosis of blocked tear duct is made if the patient can’t taste the fluid in their throat
• x-ray or CT scan – taken of the tear duct area (dacryocystogram).

Treatment for a blocked tear duct

Treatment for a blocked tear duct depends on the cause, but may include:

• observation with no intervention. A baby’s tear ducts may spontaneously unblock before the age of 12 months
• if the baby’s tear duct doesn’t unblock by itself, it may be necessary to professionally ‘pop’ the membrane. This is a small operation that requires a general anaesthestic
• deep massage of the nasolacrimal duct for babies may be ordered, but it is difficult to do well
• antibiotics, to treat any bacterial infections
• surgery, to make a drainage hole from the tear duct system into the nose (dacryocystorhinostomy or DCR).
• surgical drainage of abscess, if necessary
• the frequent application of hot compresses
• pain-relieving medications.

Introduction

Dacryocystitis is characterized as an inflammatory state of the nasolacrimal sac. It is typically caused by an obstruction within the nasolacrimal duct and subsequent stagnation of tears in the lacrimal sac. When the lacrimal sac inflames and swells at the inferomedial canthus, dacryocystitis can be appreciated clinically. Understanding the anatomy and flow of tears leads to a better understanding of dacryocystitis and potential multilevel involvement.

The flow of tears will usually begin with tear production by the lacrimal gland. The tears will lubricate the eye until they are collected into the superior and inferior puncta and drained into the superior and inferior canaliculi. From there, tears will drain into the common canaliculus. At this point, they will then pass through the valve of Rosenmuller into the lacrimal sac. The lacrimal sac will then collect the tears and flow down the nasolacrimal duct, pass through the distal valve of Hasner, and finally pass into the nasal cavity.

Etiology

Dacryocystitis can be classified into acute or chronic and acquired or congenital.

An acute infectious state typically causes acute dacryocystitis. In the United States, the most common organism is Staphylococcusand Streptococcus species,followed by Haemophilus influenza and Pseudomonas aeruginosa.

Chronic dacryocystitis is a result of chronic obstruction due to systemic disease, repeated infection, dacryoliths, and chronic inflammatory debris of the nasolacrimal system. Some common systemic diseases include Wegener’s granulomatosis, sarcoidosis, and systemic lupus erythematosus.

Acquired states are typically due to repeated trauma, surgeries, medications, and neoplasms. Among traumatic causes of nasolacrimal obstruction, nasoethmoid fractures seem to be most common. Endonasal and endoscopic sinus procedures have the highest association. Common topical medications associated with acquired states are timolol, pilocarpine, dorzolamide, idoxuridine, and trifluridine. The most common systemic medications are fluorouracil and docetaxel. Primary lacrimal sac tumors and benign papillomas tend to be the most common neoplasms.

Congenital forms are due to a membranous obstruction at the valve of Hasner in the distal nasolacrimal duct. Before delivery, the nasolacrimal system is filled with amniotic fluid. When the amniotic fluid fails to be expressed from the nasolacrimal system, it becomes purulent within a few days of delivery and becomes pathologic.

Epidemiology

There is a bimodal distribution with most cases either occurring just after birth in congenital cases or in adults older than 40 years of age. Congenital dacryocystitis occurs in roughly 1 in 3884 live births. In adults, whites tend to be more affected. Females make up nearly 75% of all cases.

Serious morbidity and mortality are low with dacryocystitis. However, in congenital dacryocystitis, there can be significant morbidity and mortality if not treated promptly and appropriately.

Pathophysiology

Dacryocystitis, regardless of etiology, is almost always caused by an obstruction in the nasolacrimal system with the resultant stagnation of tears. There can be obstructions at any level of the nasolacrimal system. Stagnation of tears will provide a favorable environment for infectious organisms to propagate and proteinaceous debris to form. The lacrimal sac will then inflame causing the characteristic swelling in the inferomedial portion of the orbit.

Histopathology

Findings will most commonly be consistent with fibrosis and non-granulomatous inflammation in cases of chronic dacryocystitis. Sarcoidosis, lymphoma, and papilloma are among other common findings.

History and Physical

In acute cases, symptoms may occur over several hours to several days. A careful external eye exam must be performed. The medial canthus overlying the lacrimal space will appear erythematous, tender, and edematous. It is not uncommon for the bridge of the nose to be involved. It is however uncommon that the superomedial aspect of the orbit is involved. Frequently, the mucopurulent material can be expressed from the superior and inferior puncta. There may also be an increase in tears; in chronic dacryocystitis, tearing may be the only symptom. Mattering can be present due to a tear film. Tear films will typically cause conjunctival injection and a mild decrease in visual acuity. Visual acuity testing is vital. Any acute changes not explained by tear filming should raise concern for extensive involvement. Emergent ophthalmological consultation is warranted in this scenario. Furthermore, erythema involving the whole orbit is not characteristic of dacryocystitis and should lead the examiner to an alternative diagnosis. Any pain with extraocular movement should also raise suspicion for alternative diagnoses.

Evaluation

Diagnosis of dacryocystitis is primarily clinical based on history and physical exam findings. Cultures and gram staining can be obtained by expressing purulent material via the Crigler massage. In toxic appearing patients, particularly those with fever or acute visual changes, laboratory studies and blood cultures should be considered. Also, consider emergent ophthalmological consultation in these cases. Strong consideration should be given to CT scan if orbital cellulitis or extensive infection is suspected. If there are anatomical concerns, a plain-film dacryocystogram (DCG) can be performed by qualified personnel. Subtraction DCG technique will potentially help improve the viewing quality of the image.

In chronic cases, appropriate serologic testing can be performed if systemic diseases are suspected as the underlying cause. Antineutrophilic cytoplasmic antibody testing can be performed if Wegener’s granulomatosis is suspected. Likewise, antinuclear antibody (ANA) testing can be pursued if systemic lupus erythematosus is suspected.

Treatment / Management

Treatment of acute dacryocystitis includes conservative measures such as warm compresses and attempts of Crigler massage. For uncomplicated cases, consideration of oral antibiotics should be given. Coverage should be aimed at gram-positive organisms, particularly antistaphylococcal agents. In complicated cases or patients who appear toxic, intravenously antibiotics should be administered. Empiric antibiotics should include gram positive and gram negative coverage. Lacrimal probing is discouraged in the acute phase. For recurrent infections, referral to ophthalmology for surgical evaluation is advised.

Chronic dacryocystitis is almost always managed surgically with high success rates. Probing is accepted as first-line management in chronic cases and can be done in the outpatient setting. Inevitably, patients will likely need to progress to further surgical options to treat the condition. Balloon dacryoplasty, nasolacrimal intubation, and nasolacrimal stenting have all been attempted with variable first-time success rates. If these therapies fail, evaluation for percutaneous dacryocystorhinostomy (DCR) or endonasal dacryocystorhinostomy (EN-DCR) is then pursued.

Treatment of congenital dacryocystitis includes conservative measures first. Crigler massage should be taught to parents or caregivers to perform at home. Topical antibiotics can be considered for acute flares. About 90% of congenital dacryocystitis will resolve by six months to one year of age with conservative measures. If conservative measures happen to fail, a referral is then made to ophthalmology for nasolacrimal probing. Nasolacrimal probing is successful in more than 70% of cases. If symptoms recur, balloon dacryoplasty, nasolacrimal intubation, or nasolacrimal stenting can be pursued. Ultimately, if these measures fail, then dacryocystorhinostomy by percutaneous or endonasal approach will serve as the definitive treatment.

Differential Diagnosis

The differential diagnosis includes:

• Preseptal/periorbital cellulitis

• Orbital cellulitis

• Sebaceous cyst

• Frontal, ethmoid, or maxillary sinusitis

• Neoplasm

• Ectropion of lower eyelid

• Dacryoadenitis

Prognosis

In general, the prognosis for dacryocystitis is good. Simple probing techniques are highly successful. DCR has been reported to be more than 93% to 97% successful. In congenital cases, 90% will resolve by one year of age with conservative measures alone.

Pearls and Other Issues

Disposition from acute care settings are dependent on the extent of infection, comorbidities, and access to prompt ophthalmological follow up. Uncomplicated cases can be discharged with appropriate treatment, and adequate follow up. Complicated cases, particularly those with fever or acute visual changes, should be admitted with ophthalmology consultation. Complications of dacryocystitis can be devastating. These can include orbital cellulitis, the formation of lacrimal fistulas, meningitis, brain abscess formation, cavernous sinus thrombosis, severe sinusitis, permanent loss of vision, and even death.

Enhancing Healthcare Team Outcomes

Patients with dacryocystitis often initially present to the emergency room, primary care clinic, urgent care or see a nurse practitioner. In general, dacryocystitis is managed by the ophthalmologist and primary care providers should avoid probing or manipulating the nasolacrimal duct. The treatment of acute dacryocystitis includes conservative measures such as warm compresses and attempts of Crigler massage. For uncomplicated cases, consideration of oral antibiotics should be given.

In complicated cases or patients who appear toxic, intravenously antibiotics should be administered. Empiric antibiotics should include gram positive and gram negative coverage. Lacrimal probing is discouraged in the acute phase. For recurrent infections, referral to ophthalmology for surgical evaluation is advised.

The outlook for most patients with simple obstruction is good but for those with complex obstruction, the outcomes are guarded and can interfere with vision and lifestyle.