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ORIGINAL ARTICLE
Study on the Effectiveness of Antibiotic Prophylaxis in
External Dacryocystorhinostomy: A Review of 697 Cases
Sergio Pinar-Sueiro, M.D.*, Roberto-Víctor Fernández-Hermida, Ph.D.*,
Ane Gibelalde, M.D.†, and Lorea Martínez-Indart, B.Sc.‡
*Oculoplastics and Orbit, Ophthalmology Service of the Cruces Hospital, Barakaldo, Biscay; †Ophthalmology
Service, Donostia Hospital, San Sebastián, Guipúzcoa; and ‡Clinical Epidemiology of the Cruces Hospital,
Barakaldo, Biscay, Spain
Purpose: To evaluate the prophylactic use of antibiotics in
external dacryocystorhinostomy for the prevention of postoperative complications.
Methods: This study included 697 patients diagnosed with
distal nasolacrimal duct obstruction and who were operated on
by the same surgeon. Direct culture of the lacrimal sac content
was carried out. Data were collected regarding clinical signs
and symptoms, use of intraoperative antibiotics, results of
culture samples obtained during surgery, and antibiogram analysis. Also, the postoperative period was analyzed with regard to
the presence of postoperative complications.
Results: Out Of 697 patients, 536 were women. The mean
age at surgery was 67.0 ⫾ 13.3 years. Prior to surgery, 19.5%,
18.5%, 11%, and 17.8% of patients showed recurrent conjunctivitis, mucocele, mucopyocele, and episodes of acute dacryocystitis, respectively. Seventy-three patients did not receive
prophylactic treatment during surgery. A total of 8.3% of
lacrimal sacs were culture positive, the most commonly isolated organism being Staphylococcus aureus. The use of antibiotics during surgery was not associated with a lower rate of
postoperative complications. A statistically significant association was found between some clinical pictures, such as mucocele, mucopyocele, and dacryocystitis, and a higher rate of
positive cultures.
Conclusions: This study questions the generalized use of
prophylactic antibiotics for external dacryocystorhinostomy,
while providing evidence to indicate their use for patients who
have had prior episodes of mucocele, mucopyocele, or acute
dacryocystitis.
(Ophthal Plast Reconstr Surg 2010;0:000–000)
L
acrimal duct obstruction, both at the level of the lacrimal sac
and at that of the nasolacrimal duct, can affect patients of
both sexes and at any age. The most common cause of the
disease is the obstruction of the nasolacrimal duct acquired due
to idiopathic inflammatory stenosis, which mainly affects
middle-aged and elderly women.1 It can also be caused by
Accepted for publication January 23, 2010.
The authors declare no conflict of interest.
Presented in part at the 19th Congress of the Spanish Society of Ocular
Plastic Surgery and Orbit, Madrid, June 18 and 19, 2009.
Address correspondence and reprint requests to Sergio Pinar-Sueiro,
Av/Gernikako Arbola, N°38, 3°D, Barakaldo (C.P. 48902), Vizcaya,
España. E-mail: [email protected]
DOI: 10.1097/IOP.0b013e3181d644cf
Ophthal Plast Reconstr Surg, Vol. 0, No. 0, 2010
traumatic, infectious, inflammatory, and neoplastic processes and
by mechanical obstructions. In patients having epiphora and mucopurulent secretion, these distal obstructions turn the lacrimal sac
into a sealed compartment, leading to the potential development of
infections such as acute and chronic dacryocystitis.2
The usual clinical picture of those presenting an obstruction
of the nasolacrimal duct is epiphora. Most patients do not show
infectious signs at the level of the lacrimal duct for some years.3
Surgery is the only useful treatment for such distal
obstruction of the lacrimal duct. Some articles have reported
higher rates of infections in soft tissue and in the surgical
wound in those cases that have not received surgical antibiotic
prophylaxis.4
To date, there have been many studies focused on improving our understanding of the infectious pathology of the lacrimal
duct, and in most cases, Gram-positive organisms (Staphylococcus
epidermidis and S. aureus) have been isolated.5– 8
The aim of this study is to describe the microbiological
picture most commonly found in patients diagnosed with nasolacrimal duct obstruction and to evaluate the effectiveness of
the intravenous antibiotic prophylaxis commonly used during
external dacryocystorhinostomy surgery.
METHODS
This is a retrospective, observational, and descriptive study carried
out by reviewing the clinical records of 697 patients who underwent
external dacryocystorhinostomy due to nasolacrimal obstruction from
1997 to 2008. The confidentiality of the individuals was guaranteed,
according to what is established in the Spanish Organic Law 15/1999,
adopted December 13, 1999, for personal data protection.
Data Collection. Epidemiological information (sex, age at surgery)
and patients’ clinical data prior to surgery, evaluating whether they
presented with recurrent mucopurulent conjunctivitis, mucocele, or
mucopyocele or had any episode of acute dacryocystitis, were collected. In addition, the type of antibiotic used prophylactically (if used),
the results of the cultures obtained from the lacrimal sac, and the
sensitivity and antibiotic resistance profile from the antibiograms were
recorded. Finally, information regarding the postoperative course and
any complications experienced by the patients were noted.
Surgical Technique and Taking of Cultures. A total of 697 patients
had external dacryocystorhinostomy performed by the same surgeon.
General anesthesia was applied mainly to those younger than 20
years old. For the others, local and regional anesthesia and anesthesiologist-monitored sedation were used. Infiltration anesthesia was given
using 2% ibecaine to block infratrochlear and infraorbital nerves.
The corresponding nasal fossa was packed with a gauze moistened in anesthetic solution and epinephrine (1:100,000). The operation
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S. Pinar-Sueiro et al.
Ophthal Plast Reconstr Surg, Vol. 0, No. 0, 2010
was then performed according to the following surgical procere. A
straight cutaneous incision of approximately 1.5 cm was made parallel
to the inner edge of the affected side. After cauterization of the bleeding
site and separation of the angular vein, peristeum was elevated from the
bone wall above the anterior lacrimal crest. After this, the lacrimal sac was
separated from its fossa, the nasal pack was removed, and a rhinostomy
approximately 15 ⫻ 15 mm in diameter was performed using a Kerrison
punch and forceps.An H-shaped incision was made in the nasal mucosa to
create anterior and posterior flaps.
A Bowman probe was introduced through the lower lacrimal
punctum and canaliculus to locate the sac. The sac was opened with a
number 15 scalpel blade, opening toward the dome of the lacrimal sac
and nasolacrimal duct with Westcott scissors. Once the lacrimal sac
was opened, the existence of an anterior and posterior sac flap was
checked. A culture of the sac lumen was taken with a cotton swab. The
posterior flaps were sutured with vicryl 5/0, and a mini-Monoka
monocanalicular silicone stent (mini-Monoka, FCI Ophthalmics Inc.,
Marshfield Hills, MA, U.S.A.) was placed through the inferior lacrimal
punctum and passed into the nasal fossa. The anterior flap of the lacrimal
sac was sutured to the anterior flap of the nasal mucosa, and the medial
canthal ligament was reattached after desinsertion from the orbicularis
muscle, both using vicryl 5/0. Finally, a continuous mattress suture with
nylon 5/0 was used on the skin.
Subsequently, a cream containing dexamethasone and chloramphenicol was applied (Colircusi Deicol, ophthalmic ointment, Alcon
Cusi, S.A., El Masnou, Spain), followed by nonadherent (Tulgrasum,
Desma Laboratorio, Madrid, Spain) and compression dressings.
Patients were rechecked after 48 hours. The skin suture was
removed after 10 days, and the monocanaclicular stent was removed after
1 month, following confirmation of the patency of the lacrimal duct by
probing and irrigation through the lower lacrimal punctum.
Statistical Analysis. Qualitative variables were characterized using
frequency distributions and percentages. Measures of central tendency
such as mean and median, and measures of variability such as standard
deviation, maximum, and minimum were used for quantitative variables, depending on their distribution characteristics. In other words,
the mean and standard deviation were used if variables were not very
asymmetric, whereas if they were asymmetric, median, minimum, and
maximum were chosen.
The comparison of proportion between qualitative variables
was performed using the chi-square test or its corresponding corrections, such as the Fisher correction when expected frequencies were
less than 5.
Comparisons of continuous variables between 2 groups were
carried out using the nonparametric Mann-Whitney U test, as the
sample size was small.
Analysis was carried out using the SPSS version 16.0 statistical
package.
Perioperative prophylactic antibiotic
Prophylaxis
No
Yes
Total
A total of 697 patients were treated, of whom 76.9% (n ⫽ 536)
were women. The age of patients ranged between 2 and 98 years old,
with an average age of 67.0 ⫾ 13.3 years, which was significantly
higher (p ⬍ 0.001) for women (68.7 ⫾ 11.7 years) compared with men
(61.7 ⫾ 16.7 years). The average ages of patients with idiopathic,
traumatic, and congenital nasolacrimal duct obstructions were 66.3 ⫾
12.8 years, 43.0 ⫾ 23.2 years, and 23.9 ⫾ 20.1 years, respectively. One
patient diagnosed with ethmoid osteoma was 86 years old.
A total of 98.9% (n ⫽ 689) of patients treated had an idiopathically acquired etiology, 0.66% (n ⫽ 4) had a traumatic etiology, 0.4%
(n ⫽ 3) had congenital obstructions, and as mentioned, the obstruction
was caused by an ethmoid osteoma in one patient (0.1%). Among
Type
n
%
—
Cefazolin 400 mg
Cefazolin 1 g
Cefazolin 2 g
Amoxicillin clavulanic acid
Erythromycin
Vancomycin
Tobramycin
Gentamycin
Clindamycin
Total
—
73
3
272
300
26
10
6
1
5
1
624
697
10.5
0.4
39
43
3.7
1.4
0.9
0.1
0.7
0.1
89.5
100
women, 99.4% (n ⫽ 533) had an idiopathically acquired etiology, one
patient (0.1%) had a traumatic etiology, and another was diagnosed
with ethmoid osteoma (0.2%). Among men, 156 patients (96.9%) had
an idiopathically acquired etiology, although a higher proportion had a
clinical history of trauma causing the obstruction (1.9%, n ⫽ 3) and of
congenital obstructions (1.2%, n ⫽ 2).
A total of 19.5% (n ⫽ 136) of patients had recurrent mucopurulent
conjunctivitis, 18.5% (n ⫽ 129) had mucocele, and 11% (n ⫽ 77) had
mucopyocele, while 17.8% (n ⫽ 124) had episodes of acute dacryocystitis,
of which 2 cases (1.6%) were associated with orbital cellulitis. The
incidence of acute dacryocystitis prior to surgery was higher in women
(20.1%) than in men (9.9%) (p ⫽ 0.003). We did not find any
association between the age of the patients and the different clinical
TABLE 2. Bacteriology of the most commonly isolated
microorganisms in cultures obtained from intrasaccal
contents during surgery
Organisms isolated from lacrimal sac cultures
Group
Organisms
n
%
Gram-positive
Staphylococcus aureus
Streptococcus pneumoniae
Staphylococcus saprophyticus
Corynebacterium saprophyticus
Aerobic Gram-positive rods
Superficial saprophytic flora
S. viridans
Corynebacterium xerosis
S. anginosus
Lactococcus lactis
Total
Haemophilus influenzae
Serratia marcescens
Pseudomonas aeruginosa
Klebsiella pneumoniae
Alcaligenes xylosoxidans
Branhamella catarrhalis
H. parainfluenzae
Neisseria saprophyticus
Citrobacter freundii
Total
Candida saprophyticus
C. parapsilosis
Aspergillus and Mucor
Total
—
15
3
2
2
1
1
1
1
1
1
28
9
4
4
2
1
2
1
1
1
25
2
1
1
4
57
26.3
5.2
3.5
3.5
1.8
1.8
1.8
1.8
1.8
1.8
49.1
15.8
7.0
7.0
3.5
1.8
3.5
1.8
1.8
1.8
43.9
3.5
1.8
1.8
7.0
100%
Gram-negative
RESULTS
2
TABLE 1. Antibiotics used prophylactically during
external dacryocystorhinostomy surgery
Fungi
Total
© 2010 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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The Role of Antibiotics in External Dacryocystorhinostomy
Ophthal Plast Reconstr Surg, Vol. 0, No. 0, 2010
TABLE 3. Antibiotic sensitivity rates for
Gram-positive bacteria
TABLE 5. Antibiotic sensitivity rates for
Gram-negative bacteria
Percentage sensitivity for Gram-positive bacteria
Percentage sensitivity for Gram-negative bacteria
—
Sensitive
Resistant
n
—
Sensitive
Resistant
n
Fusidic acid
Amoxicillin/clavulanic acid
Ampicillin
Cefalotin
Cefazolin
Cefuroxime-axetil
Ciprofloxacin
Clindamycin
Chloramphenicol
Cloxacillin
Co-trimoxazole
Erythromycin
Gentamicin
Levofloxacin
Mupirocin
Penicillin
Rifampicin
Tetracycline
Tobramycin
Vancomycin
100% (n ⫽ 3)
64.3% (n ⫽ 18)
85.7% (n ⫽ 24)
100% (n ⫽ 9)
66.7% (n ⫽ 6)
100% (n ⫽ 11)
81.8% (n ⫽ 9)
84.2% (n ⫽ 16)
100% (n ⫽ 9)
90.91% (n ⫽ 10)
100% (n ⫽ 9)
87% (n ⫽ 20)
91.7% (n ⫽ 11)
100% (n ⫽ 9)
14.3% (n ⫽ 4)
64.3% (n ⫽ 9)
100% (n ⫽ 16)
81.8% (n ⫽ 9)
100% (n ⫽ 3)
100% (n ⫽ 6)
—
10.7% (n ⫽ 3)
14.3% (n ⫽ 4)
—
33.3% (n ⫽ 3)
—
18.2% (n ⫽ 2)
10.7% (n ⫽ 3)
—
9.10% (n ⫽ 1)
—
13% (n ⫽ 3)
8.3% (n ⫽ 1)
—
—
17.9% (n ⫽ 5)
—
7.1% (n ⫽ 2)
—
—
3
21
28
9
9
11
11
19
9
11
9
23
12
9
4
14
16
11
3
6
Amoxicillin/clavulanic acid
Ampicillin
Cefalotin
Cefazolin
Ceftriaxone
Cefuroxime-axetil
Ciprofloxacin
Clindamycin
Chloramphenicol
Cloxacillin
Co-trimoxazole
Gentamicin
Nitrofurantínoin
Norfloxacin
Piperacillin-tazobactam
Rifampicin
Tetracycline
Tobramycin
56.5% (n ⫽ 13)
45.5% (n ⫽ 5)
28.6% (n ⫽ 2)
—
100% (n ⫽ 22)
58.3% (n ⫽ 7)
100% (n ⫽ 16)
—
66.7% (n ⫽ 6)
100% (n ⫽ 2)
90% (n ⫽ 9)
100% (n ⫽ 8)
—
100% (n ⫽ 2)
100% (n ⫽ 2)
58.3% (n ⫽ 7)
77.8% (n ⫽ 7)
100% (n ⫽ 5)
43.5% (n ⫽ 10)
54.5% (n ⫽ 6)
71.4% (n ⫽ 5)
100% (n ⫽ 4)
—
41.7% (n ⫽ 5)
—
100% (n ⫽ 2)
33.3% (n ⫽ 3)
—
10% (n ⫽ 1)
—
100% (n ⫽ 1)
—
—
41.7% (n ⫽ 5)
22.2% (n ⫽ 2)
—
23
11
7
4
22
12
16
2
9
2
10
8
1
2
2
12
9
5
n, total number of samples tested for each antibiotic; Sensitive/Resistant,
percentage and number of samples showing sensitivity or resistance to the
antibiotic.
pictures, although a relationship was found between their signs and
symptoms. For example, patients with a history of recurrent mucopurulent conjunctivitis were associated with higher rates of mucocele,
compared with the rest of the sample (26.5% versus 16.6%, p ⫽ 0.008).
Also, patients with mucocele and mucopyocele were associated with
higher rates of acute dacryocystitis (27.1% versus 15.7%, p ⫽ 0.002
and 37.7% versus 15.3%, p ⬍ 0.001, respectively). Finally, as one
might expect, patients with mucocele were associated with a higher rate
of mucopyocele (p ⬍ 0.001).
A total of 10.5% of patients (n ⫽ 73) did not receive prophylactic antibiotic treatment during surgery. The other 624 patients were
TABLE 4. Antibiotic sensitivity rates for S. aureus in the
samples analyzed
Percentage sensitivity of S. aureus
—
Sensitive
Resistant
n
Amoxicillin/clavulanic acid
Ciprofloxacin
Cefazolin
Gentamicin
Co-trimoxazole
Rifampicin
Clindamycin
Vancomycin
Erythromycin
Penicillin
Tobramycin
Cloxacillin
Mupirocin
Cefuroxime-axetil
Chloramphenicol
Tetracycline
Fusidic acid
Cefalotin
80% (n ⫽ 8)
75% (n ⫽ 6)
75% (n ⫽ 6)
100% (n ⫽ 8)
100% (n ⫽ 8)
100% (n ⫽ 10)
100% (n ⫽ 10)
100% (n ⫽ 3)
91.7% (n ⫽ 11)
16.7% (n ⫽ 1)
100% (n ⫽ 3)
90.9% (n ⫽ 10)
100% (n ⫽ 4)
100% (n ⫽ 5)
100% (n ⫽ 4)
100% (n ⫽ 4)
100% (n ⫽ 3)
100% (n ⫽ 5)
20% (n ⫽ 2)
25% (n ⫽ 2)
25% (n ⫽ 2)
—
—
—
—
—
8.3% (n ⫽ 1)
83.3% (n ⫽ 5)
—
7.1% (n ⫽ 1)
—
—
—
—
—
—
10
8
8
8
8
10
10
3
12
6
3
11
4
5
4
4
3
5
given intravenous antibiotic prophylaxis during surgery. Cefazolin 2 g
(Table 1) was the most commonly prescribed antibiotic.
A positive culture was found in only 8.3% (n ⫽ 57) of lacrimal
sacs. Only organisms of one species were isolated in 99.71% of patients
(n ⫽ 695), while 2 species were isolated in the remaining 2 patients.
The most commonly isolated organisms were Gram-positive
bacteria (49.1%, n ⫽ 28), of which S. aureus was the most frequently
found (26.3%, n ⫽ 15), followed by Streptococcus pneumoniae (5.2%,
n ⫽ 3). Gram-negative bacteria were isolated in 43.9% (n ⫽ 25) of the
samples, of which Haemophilus influenzae was the most commonly
isolated (15.8%, n ⫽ 9), followed by Serratia marcescens (7.0%, n ⫽
4). Fungi species were isolated in 7.0% (n ⫽ 4) of the samples, with
Candida being the most commonly found genus (Table 2).
Sensitivity rates to various antibiotics for all Gram positive
organisms are shown in Table 3, and for S. aureus in Table 4. Similarly,
sensitivity rates for Gram negative organisms and for H. influenzae are
given in Tables 5 and 6.
The antibiotic showing the highest sensitivity rates in the
greatest number of samples with Gram-positive bacteria was rifampicin
(100%, n ⫽ 16). For Gram-negative bacteria, ceftriaxone (100%, n ⫽
22) was the antibiotic to which cultures showed the highest sensitivity.
For Gram-positive and Gram-negative bacteria combined, gentamycin
was the antibiotic with the best spectrum of activity, with measured
TABLE 6. Antibiotic sensitivity rates of H. influenzae in
the samples analyzed
Percentage sensitivity of H. influenzae
—
Sensitive
Resistant
n
Amoxicillin/clavulanic acid
Ampicillin
Ciprofloxacin
Ceftriaxone
Co-trimoxazole
Rifampicin
Erythromycin
Cefuroxime-axetil
Chloramphenicol
Tetracycline
100% (n ⫽ 8)
100% (n ⫽ 5)
100% (n ⫽ 3)
100% (n ⫽ 2)
100% (n ⫽ 5)
50% (n ⫽ 2)
100% (n ⫽ 3)
100% (n ⫽ 4)
100% (n ⫽ 3)
100% (n ⫽ 6)
—
—
—
—
—
50% (n ⫽ 2)
—
—
—
—
8
5
3
2
5
4
3
4
3
6
© 2010 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
3
T1
T2
T3– 4
T5– 6
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S. Pinar-Sueiro et al.
Ophthal Plast Reconstr Surg, Vol. 0, No. 0, 2010
complications between those patients receiving and not receiving
antibiotics.
TABLE 7. Description of the main postoperative
complications observed
Postoperative complications
Complications
No
Yes
n
%
—
633 90.8
Reobstruction
42 6
Epistaxis
3 0.4
Hypertrophic scar
4 0.6
Surgical wound dehiscence
2 0.3
Surgical wound fistula
1 0.1
Intranasal synechia
1 0.1
Persistence of mucopurulent conjunctivitis 2 0.3
Postsurgical neuralgia
2 0.3
Postoperative mucocele
1 0.1
Infection of surgical wound
6 0.8
Total
64 9.2
—
697 100%
Total
T7
Type
sensitivity rates to gentamycin of 91.7% (n ⫽ 11) for Gram-positive
strains and 100% (n ⫽ 8) for Gram-negative strains.
The rate of positive cultures was higher for those patients
presenting with mucocele, mucopyocele, and those with episodes of
dacryocystitis prior to surgery. We did not find any association between
age and gender of patients and the presence of a higher rate of positive
cultures.
A total of 9.2% (n ⫽ 64) of patients presented with postoperative complications, of which 8.7% were caused by infection of the
surgical wound (n ⫽ 6). The most common postoperative complication
was reobstruction of the nasolacrimal duct, accounting for 6% of all the
complications (Table 7).
Most importantly, we did not find any significant statistical
association between age, sex, clinical signs, and symptoms of the
patients and the use of intraoperative antibiotic prophylaxis with
respect to postoperative infections or to general postoperative complications. There were no differences in the rates of infection of other
DISCUSSION
The etiology of acquired obstructions of the nasolacrimal duct remains poorly understood. In fact, it is believed that
they may have a multifactorial cause, such as a narrow or
tightly angled lacrimal sulcus, hypertrophy of the nasal concha,
nasal septum deviation, facial trauma, prior episodes of acute
dacryocystitis, the use of topical drugs for the treatment of
glaucoma, and a wide range of pathological processes of the
lacrimal sac and fossa.9 –15
A total of 76.9% of the study patients were women,
which may be attributed to a smaller diameter of the lacrimal
sulcus demonstrated in women and patients with diagnosis of
nasolacrimal duct obstruction.16 –18
All the patients who were operated on had epiphora.
Other clinical signs and symptoms were less common; 17.8%
of patients had acute dacryocystitis, which was found to be
statistically associated with women (p ⫽ 0.003). This may be
related to the fact that women not only have smaller-diameter
lacrimal sulcus, but also tend to exhibit a more acute angle
between the lacrimal fossa and the direction of the nasolacrimal
duct, leading to a valve effect in the latter, which predisposes to
postsaccule dacryostenosis, blocking drainage and favoring
reflux and progressive inflammation of the lacrimal mucosa.19
These anatomical characteristics are responsible for the higher
occurrence of acquired nasolacrimal obstructions as well of
acute dacryocystitis found in women.
During the last 10 years, interesting studies have been
carried out on infections at the lacrimal duct level (Table 8).
Some of these studies have analyzed the most common microbiological species involved in chronic dacryocystitis,20 –23
acute dacryocystitis,24 heterogeneous groups of patients suffering from acute and chronic dacryocystitis,25,26 and patients
diagnosed with acquired obstruction of the nasolacrimal duct.8
There are also many ways of obtaining the sample, such as by
TABLE 8. Description of the main studies published on microbiology of acute and chronic infectious pathology of the
lacrimal sac/apparatus
Main microbiological studies on infectious pathology of the lacrimal pathway
Reference
Owji et al.
22
CD
Bharathi et al.26
Delia et al.
Type
23
AD and CD
CD
Mills et al.25
n
40
1891
421
AD and CD
89
CD
91
AD
39
Chaudhry et al.20
CD
188
Hartikainen et al.8
NLDO
118
Sun et al.21
Briscoe et al.
24
Sampling method
Intrasaccular sample
during DCR
Reflux after squeezing the
sac/needle aspiration
Intrasaccular sample
during DCR
Reflux after squeezing the
sac/needle aspiration/
intrasaccular sample
during DCR
Reflux after squeezing the
sac/sac irrigation
Reflux after squeezing/
punction
Reflux after squeezing the
sac/intrasaccular sample
during DCR
Reflux after squeezing/sac
irrigation
Positive
100%
Gram-positive
90% S. aureus
Gram-negative
2.5%
80.3%; CD:90%;
AD:57.4%
90.97%
70.9% S. aureus
29.1% P. aeruginosa
75% S. epidermidis
25% P. aeruginosa
89.88%
68.8% S. aureus
28.7% P. aeruginosa
85%
64.4% S. epidermidis
18.9% P. maltophilia
39% S. aureus
61% Pseudomonas
97.4%
53.7% S. epidermidis
26% H. influenzae
84%
62% S. epidermidis
20% H. influenzae
100%
AD, acute dacryocystitis; CD, chronic dacryocystitis; DCR, dacryocystorhinostomy; NLDO, nasolacrimal duct obstruction.
4
© 2010 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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Ophthal Plast Reconstr Surg, Vol. 0, No. 0, 2010
reflux of the secretion through the lacrimal punctus after
squeezing of the sac,8,20,21,25,26 reflux after irrigation through
the canaliculus,8,21 by needle aspiration of the sac,25,26 or by
obtaining the sample for culture directly from the lacrimal sac
lumen during dacryocystorhinostomy.20,22–24 Our study included a total of 697 patients with diagnosis of nasolacrimal
duct obstruction for whom surgery was indicated. Most patients
were operated on using the external DCR approach. However,
some patients presented with prior episodes of acute dacryocystitis (17.8%, n ⫽ 124), chronic dacryocystitis (19.5%,
n ⫽ 136), or signs such as mucocele (18.5%, n ⫽ 129) and
mucopyocele (11%, n ⫽ 77). All patients were operated on
by the same surgeon, after any nasolacrimal system infection
was adequately treated with antibiotics. Our technique of
obtaining culture samples directly from the lacrimal sac
lumen and the fact that the sampling was carried out in
aseptic conditions during the “cold” phase of the disease
may be determining factors in explaining our low overall
8.3% rate of positive culture. This is lower than other
studies, some of which had rates ranging from 80%26 to
100%.22 In addition, the rate of positive cultures isolated in
our group of patients with episodes of acute (29.3%) and
chronic (25.9%) dacryocystitis is lower than those indicated
by previous studies on microbiology in the context of acute
and chronic infections of the lacrimal sac.20 –23,25,26
We observed that there was a predominance of Grampositive (50.91%) over Gram-negative (41.82%) bacteria in the
positive samples. This result agrees with with what has been
described by the majority of prior studies.8,20 –23,25,26
Interestingly, the most commonly used antibiotics in
intraoperative prophylaxis during dacryocystorhinostomy surgery (cefazoline and amoxicillin/clavulanic acid) showed poor
overall sensitivity for the isolated Gram-positive and Gramnegative bacteria. This may explain their poor effectiveness
previously described for the prevention of postoperative infectious complications after endoscopic dacryocystorhinostomy
surgery.9
Our study throws into question the routine use of intraoperative prophylactic antibiotics during DCR surgery. Once
any clinical infection was treated and the patient presented for
surgery, the postitive culture rate for the lacrimal sac was low,
and we found no difference in postoperative infection or other
complication rates between those patients treated with intraoperative antibiotics and those not so treated.
However, we did find a statistically significant association between the presence of signs and symptoms prior to
surgery and the presence of positive cultures obtained directly
from the sac. Those signs associated with a higher rate of
positive culture were the presence of recurrent mucopurulent
conjuctivitis, mucocele, and acute dacryocystitis. This finding
may offer a justification for preoperative treatment and intraoperative antibiotic prophylaxis in patients presenting with
these signs and symptoms. However, we could not demonstrate that the generalized use of antibiotics in every undergoing dacryocystorhinostomy surgical intervention should
be recommended.
To conclude, despite the theoretical predisposition for
preoperative and postoperative infections to develop in patients, suffering from obstruction of the nasolacrimal duct,
the majority of patients do not have clinical signs and
symptoms of infection before surgery, and do not develop
postoperative infectious complications. However, those patients who present with a clinical picture of NLD infection,
such as dacryocystitis, are more likely to progress to mucocele and mucopyocele. It is therefore possible to define a
subset of patients at greater risk for developing postopera-
The Role of Antibiotics in External Dacryocystorhinostomy
tive infectious complications. These include those with actute dacryocystitis, mucocele, and mucopyocele, who will
have a higher rate of positive lacrimal sac culture. Finally,
while our study does not show that the routine use of
prophylactic antibiotics in DCR surgery lowers the rate of
postoperative infectious complication, nevertheless, the fact
that our higher-risk subset of patients show a greater rate of
postive lacrimal sac culture suggests that the surgeon might
consider the selective use of antibiotics in this small group
of patients.
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