18/11/2025
Acute Dacryocystitis:
Acute dacryocystitis is an acute bacterial infection of the lacrimal sac, usually secondary to nasolacrimal duct obstruction (NLDO).
It results in painful swelling at the medial canthus of the eye.
Etiology (Causes)
Most common bacteria
Staphylococcus aureus
Streptococcus pneumoniae
Less common: H. influenzae, Pseudomonas, anaerobes
Predisposing factors
Nasolacrimal duct obstruction (primary acquired NLDO)
Trauma
Nasal/sinus diseases
Deviated nasal septum
Post-viral inflammation
Clinical Features / Presentation
Symptoms
Sudden onset swelling near the medial canthus
Severe pain
Redness and tenderness
Epiphora (excessive tearing)
Discharge — mucopurulent
Low-grade fever sometimes present
History of recurrent tearing before acute attack
Signs
Erythematous (red), warm, tender swelling over the lacrimal sac area
(just below the medial canthus)
Edematous skin — tense and shiny
Pressure on sac → purulent reflux through the punctum
(if canaliculi are patent)
Preauricular lymph nodes usually not enlarged (unlike viral conjunctivitis)
No periorbital involvement unless complicated
Important Clinical Point
Swelling does NOT extend above the medial canthal tendon
(helps differentiate from preseptal/orbital cellulitis)
Differential Diagnosis
Preseptal cellulitis
Orbital cellulitis
Lacrimal sac mucocele
Nasolacrimal duct obstruction without infection
Canaliculitis (infection of canaliculus)
Complications (If untreated)
Lacrimal sac abscess
Fistula formation
Preseptal cellulitis
Orbital cellulitis (rare but dangerous)
Cavernous sinus thrombosis (VERY rare)
Chronic dacryocystitis
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Investigations
Mainly clinical, but may use:
Culture & sensitivity of discharge
CBC (if systemically ill)
Imaging (CT orbit) only in severe or atypical cases
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Management
1. Acute phase treatment
A. Medical treatment
Warm compresses 3–4 times/day
Systemic antibiotics (most important):
Co-amoxiclav
Cephalexin
Clindamycin (if penicillin allergy)
Topical antibiotics (supportive):
Tobramycin
Moxifloxacin
B. Pain control
NSAIDs or paracetamol
C. Avoid
Probing during acute infection (risk of spreading infection)
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2. If abscess forms
Incision and drainage (I&D) over the sac area
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3. Definitive treatment
Once the acute infection settles:
DCR — Dacryocystorhinostomy
The definitive cure
Creates a new pathway between lacrimal sac and nasal cavity
If DCR not possible
Dacryocystectomy (DCT) (removal of sac)—rare, for elderly or non-functional sac.
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