Dacryocystitis is an inflammatory process in the lacrimal sac that develops against the background of obliteration or stenosis of the nasolacrimal canal. Dacryocystitis is manifested by constant lacrimation, mucopurulent discharge from the eyes, hyperemia and swelling of the lacrimal muscle, conjunctiva and semilunar fold, swelling of the lacrimal sac, local soreness, narrowing of the eye slit. Diagnosis of dacryocystitis includes consultation with an ophthalmologist with examination and palpation of the lacrimal sac area, conducting a lacrimal-nasal test of West, radiography of the lacrimal ducts, instillation fluorescein test. Treatment of dacryocystitis may consist in probing and rinsing the lacrimal-nasal canal with antiseptic solutions, the use of antibacterial drops and ointments, physiotherapy; if ineffective, dacryocystoplasty or dacryocystorinostomy is indicated.
Dacryocystitis accounts for 5-7% of the total pathology of the lacrimal organs diagnosed in ophthalmology. In women, the lacrimal sac becomes inflamed 6-8 times more often than in men, which is due to the narrower anatomical structure of the channels. Dacryocystitis mainly affects people aged 30-60 years; dacryocystitis of newborns is isolated in a separate clinical form. The danger of dacryocystitis, especially in children, is a high probability of developing purulent-septic complications from the subcutaneous tissue of the eyelids, cheeks, nose, soft tissues of the eye socket, brain (purulent encephalitis, meningitis, brain abscess).
Normally, the secret produced by the lacrimal glands (lacrimal fluid) washes the eyeball and flows to the inner corner of the eye, where there are so-called tear points leading to the tear tubules. Through them, the tear first enters the lacrimal sac, and then flows through the nasolacrimal canal into the nasal cavity. With dacryocystitis, due to the obstruction of the nasolacrimal canal, the process of lacrimal drainage is disrupted, which leads to the accumulation of tears in the lacrimal sac – a cylindrical cavity located in the upper part of the nasolacrimal canal. Stagnation of tears and infection of the lacrimal sac leads to the development of inflammation in it – dacryocystitis.
According to clinical forms, there are chronic, acute dacryocystitis (abscess or phlegmon of the lacrimal sac) and dacryocystitis of newborns. Depending on the etiology, dacryocystitis can be viral, bacterial, chlamydial, parasitic, post-traumatic.
The pathogenesis of dacryocystitis of any form is based on obstruction of the nasolacrimal canal. In the case of dacryocystitis of newborns, this may be due to a congenital anomaly of the lacrimal pathways (true atresia of the nasolacrimal canal), a gelatinous plug that did not resolve at the time of birth, or the presence of a dense epithelial membrane in the distal part of the nasolacrimal canal.
In adults, stenosis or obliteration of the nasolacrimal canal leading to dacryocystitis can occur as a result of edema of the surrounding tissues in acute respiratory viral infections, chronic rhinitis, sinusitis, nasal cavity polyps, adenoids, fractures of the bones of the nose and orbit, damage to tear points and tubules as a result of injury to the eyelids, and other causes.
Stagnation of the lacrimal fluid leads to the loss of its antibacterial activity, which is accompanied by the proliferation of pathogenic microorganisms in the lacrimal sac (more often staphylococci, pneumococci, streptococci, viruses, less often tuberculosis bacillus, chlamydia and other specific flora). The walls of the lacrimal sac gradually stretch, an acute or sluggish inflammatory process develops in them – dacryocystitis. The secret of the lacrimal sac loses its abacteriality and transparency and turns into mucopurulent.
Predisposing factors to the development of dacryocystitis are diabetes mellitus, decreased immunity, occupational hazards, sudden temperature changes.
Clinical manifestations of dacryocystitis are quite specific. In the chronic form of dacryocystitis, persistent lacrimation and swelling in the projection of the lacrimal sac are observed. Pressing on the area of swelling leads to the release of mucopurulent or purulent secretions from the lacrimal points. There is hyperemia of the lacrimal muscle, conjunctiva of the eyelids and the semilunar fold. A prolonged course of chronic dacryocystitis leads to ectasia (stretching) of the lacrimal sac – in this case, the skin over the ectated cavity of the sac becomes thinner and acquires a bluish hue. With chronic dacryocystitis, there is a high probability of infection of other membranes of the eye with the development of blepharitis, conjunctivitis, keratitis or purulent corneal ulcer, followed by the formation of a cataract.
Acute dacryocystitis occurs with more vivid clinical symptoms: sharp redness of the skin and painful swelling in the area of the inflamed lacrimal sac, swelling of the eyelids, narrowing or complete closure of the eye slit. Hyperemia and swelling can spread to the back of the nose, eyelids, cheek. In appearance, skin changes resemble erysipelas of the face, but with dacryocystitis there is no sharp delineation of the focus of inflammation. In acute dacryocystitis, there are twitching pains in the orbit, chills, fever, headache and other signs of intoxication.
After a few days, the dense infiltrate over the lacrimal sac softens, fluctuation appears, the skin above it turns yellow, which indicates the formation of an abscess that can spontaneously open. In the future, an external (in the area of the facial skin) or internal (in the nasal cavity) fistula may form at this place, from which a tear or pus is periodically released. When the pus spreads to the surrounding tissue, the phlegmon of the eye socket develops. Acute dacryocystitis quite often takes a recurrent course.
In newborns, dacryocystitis is accompanied by swelling above the lacrimal sac; pressure on this area causes the release of mucus or pus from the lacrimal points. Dacryocystitis of newborns can be complicated by the development of phlegmon.
Dacryocystitis is recognized on the basis of a typical picture of the disease, characteristic complaints, external examination data and palpatory examination of the lacrimal sac area. When examining a patient with dacryocystitis, lacrimation and swelling in the gas area are detected; when palpating the inflamed area, soreness and discharge of purulent secretions from tear points are determined.
The study of the patency of the lacrimal pathways in dacryocystitis is carried out with the help of a Vesta (tubular) color sample. To do this, a tampon is inserted into the appropriate nasal passage, and a solution of collargol is instilled into the eye. If the lacrimal pathways are passable, traces of a coloring substance should appear on the tampon within 2 minutes. In the case of a longer time of staining the tampon (5-10 min.), the patency of the lacrimal pathways can be doubted; if the collargol has not been released within 10 min. the Vesta test is regarded as negative, which indicates the obstruction of the lacrimal pathways.
To clarify the level and extent of the lesion, diagnostic probing of the tear ducts is performed. Conducting a passive lacrimal-nasal test for dacryocystitis confirms the obstruction of the lacrimal pathways: in this case, when trying to flush the lacrimal-nasal canal, the fluid does not pass into the nose, but flows out through the tear points.
Fluorescein instillation test, biomicroscopy of the eye are used in the complex of ophthalmological diagnosis of dacryocystitis. Contrast radiography of the lacrimal pathways (dacryocystography) with iodolipol is necessary for a clear understanding of the architectonics of the lacrimal pathways, localization of the stricture zone or obliteration. To identify microbial pathogens of dacryocystitis, the discharge from tear points is examined by bacteriological seeding.
For the purpose of clarifying diagnosis, a patient with dacryocystitis should be examined by an otolaryngologist with rhinoscopy; according to indications, consultations are scheduled with a dentist or maxillofacial surgeon, traumatologist, neurologist, neurosurgeon. Differential diagnosis of dacryocystitis is carried out with canaliculitis, conjunctivitis, erysipelas.
Acute dacryocystitis is treated inpatient. Before the infiltrate softens, systemic vitamin therapy is carried out, UHF therapy and dry heat are prescribed for the area of the lacrimal sac. When fluctuation occurs, the abscess is opened. In the future, drainage and washing of the wound with antiseptics (furacilin, dioxidin, hydrogen peroxide) are carried out. Antibacterial drops (levomycetin, gentamicin, sulfacetamide, miramistin, etc.) are instilled into the conjunctival sac, antimicrobial ointments (erythromycin, tetracycline, ofloxacin, etc.) are laid. At the same time, systemic antibacterial therapy with broad-spectrum drugs (cephalosporins, aminoglycosides, penicillins) is carried out with dacryocystitis. After the acute process is stopped in the “cold” period, dacryocystorinostomy is performed.
Treatment of dacryocystitis in newborns is carried out in stages and includes performing a descending massage of the lacrimal sac (for 2-3 weeks), washing the lacrimal-nasal canal (for 1-2 weeks), conducting retrograde probing of the lacrimal canal (2-3 weeks), probing the nasolacrimal pathways through the lacrimal points (2-3 weeks). If the treatment is ineffective, when the child reaches the age of 2-3 years, endonasal dacryocystorinostomy is performed.
The main method of treatment of chronic dacryocystitis is surgery – dacryocystorinostomy, which involves the formation of an anastomosis between the nasal cavity and the lacrimal sac for effective drainage of lacrimal fluid. Minimally invasive methods of treatment of dacryocystitis – endoscopic and laser dacryocystorinostomy – have become widespread in surgical ophthalmology. In some cases, the patency of the nasolacrimal canal with dacryocystitis can be restored with the help of bougie or balloon dacryocystoplasty – the introduction of a probe with a balloon into the duct cavity, when inflated, the inner lumen of the canal expands.
In order to avoid the formation of a purulent corneal ulcer, patients with dacryocystitis are prohibited from using contact lenses, applying blindfolds, performing any ophthalmological manipulations related to touching the cornea (tonometry, ultrasound of the eye, gonioscopy, etc.).
Prognosis and prevention
Usually, the prognosis for uncomplicated dacryocystitis is favorable. The outcome of a corneal ulcer can be a thorn, which leads not only to a cosmetic defect, but also to a persistent decrease in vision; when the ulcer is perforated, endophthalmitis and subatrophy of the eye develop. The course of dacryocystitis can be complicated by phlegmon of the orbit, thrombophlebitis of the orbital veins, thrombosis of the cavernous sinus, inflammation of the meninges and brain tissue, sepsis. In this case, the probability of disability and death of the patient is high.
Prevention of dacryocystitis requires adequate and timely treatment of diseases of the ENT organs, avoiding injuries to the eyes and facial skeleton.