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CLINICAL MANAGEMENT GUIDELINES
Dacryocystitis (acute)
Aetiology
Bacterial infection of lacrimal sac
Usually secondary to blockage of nasolacrimal duct
Commonest in infants and post-menopausal women
Relatively rare in older children
Infection may be due to Gram positive or Gram-negative organisms:
Staphylococcus aureus and Streptococcus pneumoniae are the most
common isolates amongst Gram-positive bacteria and Haemophilus
influenzae, Serratia marcescens and Pseudomonas aeruginosa amongst
Gram-negative bacteria
Predisposing factors
Maxillary sinusitis
Trauma to adjacent tissues
Nasal or sinus surgery
Congenital obstruction of nasolacrimal duct (see Clinical Management
Guideline on Nasolacrimal Duct Obstruction)
Symptoms
Sudden onset
Pain
Tender swelling over lacrimal sac (anatomically located just below the
medial palpebral ligament)
Epiphora
Fever (raised temperature)
Signs
Red, tender swelling centred over lacrimal sac and extending
around the orbit
Purulent discharge expressible from one or both puncta when
pressure is applied over the lacrimal sac (NB likely to be painful for
patient)
Sac may discharge on to skin surface
(NB important to distinguish between acute dacryocystitis, in which sac
is full of pus, and mucocoele in which sac is filled with mucoid material
in the absence of infection)
Frequently, patients may present with conjunctivitis and preseptal
cellulitis. Rarely, the infection extends behind the septum, causing
orbital cellulitis
Differential diagnosis Facial cellulitis, preseptal cellulitis, orbital cellulitis (check ocular motility
and look for proptosis) (Refer to Clinical Management Guideline on
Cellulitis [preseptal and orbital])
Acute frontal sinusitis (inflammation involves the upper eyelid)
Infection following superficial trauma/abrasion of skin
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Do not attempt to probe the lacrimal system during acute
Non pharmacological
infection (risk of spreading infection)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pharmacological
Topical antibiotic to prevent bacterial conjunctivitis: e.g. chloramphenicol
drops and/or ointment for not less than 5 days
For mild and non-febrile cases, consider prescribing systemic antibiotic,
e.g. co-amoxiclav or, where there is a penicillin allergy, erythromycin
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Management Category
A2 (modified, as condition not sight-threatening): for severe cases and
in all children, give first aid measures and refer as emergency (same
day) to ophthalmologist or A&E Department. Cases are severe if
patient is febrile and/or systemically unwell or if an abscess has developed
Dacryocystitis (acute)
Version 10, Page 1 of 2
Date of search 22.05.15; Date of revision 13.06.16; Date of publication 01.09.16; Date for review 21.05.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Dacryocystitis (acute)
(i.e. pointing on surface)
A3 (modified, as condition not sight-threatening): for milder cases not
responsive to systemic antibiotic within 7 days, refer urgently (within one
week) to ophthalmologist
B1: in mild cases responsive to systemic antibiotic treatment, monitor for
obstruction of the nasolacrimal drainage system (see Clinical
Management Guideline on Dacryocystitis [chronic])
B3: management to resolution if no long-term sequelae
Possible management by Ophthalmologist
Incision and drainage where appropriate
Systemic (including parenteral) antibiotics
Follow-up may include investigation and surgical intervention for
nasolacrimal duct obstruction
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Pinar-Sueiro S, Sota M, Lerchundi TX, Gibelalde A, Berasategui B, Vilar
B, Hernandez JL. Dacryocystitis: Systematic Approach to Diagnosis and
Therapy. Curr Infect Dis Rep. 2012;14(2):137-46
LAY SUMMARY
Dacrocystitis means inflammation of the tear sac, the small chamber in which the tear fluid collects
as it drains from the eye surface, which is beneath the skin alongside the inner corner of the eye.
It is commonest in infants and middle-aged women and is usually caused by an infection by
commonly occurring bacteria (germs). It starts suddenly with pain and tenderness over the tear
sac and the patient may quickly develop a fever (raised temperature). The infection may also
cause conjunctivitis (infection of the transparent membrane over the white of the eye) and cellulitis
(infection of the soft tissues surrounding the eye). Sometimes the sac bursts, releasing pus on to
the skin surface.
It is important to try to distinguish between this condition and a serious infection of the eye socket
(orbital cellulitis) itself, especially in children, who should be referred to hospital the same day for
emergency treatment. Treatment includes antibiotics, which may have to be given via a needle
into a vein, and surgery to encourage pus from the infection to drain away.
Dacryocystitis (acute)
Version 10, Page 2 of 2
Date of search 22.05.15; Date of revision 13.06.16; Date of publication 01.09.16; Date for review 21.05.17
© College of Optometrists