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Acute Dacryocystitis Resistant to Oral Antibiotic Treatment
Abstract
Cases of acute dacryocystitis can fail to respond to oral antibiotics, requiring intravenous
antibiotics and dacryostorhinotomy (DCR). This report reviews the frequency, likely
causes, and management strategies for treating resistant dacryocystitis.
I. Case History:
 66 year old Caucasian male presented with eye pain OD
o Onset = 3 days ago
o Symptoms worsening with pain scaled as 5/10
o Accompanied by swelling of the nasolacrimal sac
o No changes in vision, fever, itching, tearing, or discharge.
 Ocular History:
o Unremarkable OU
o Visited outpatient clinic 1 day prior to his appointment
 Treatment initiated but no improvement of symptoms
after 2 days:
 875 mg Augmentin BID x 10 days
 Warm compresses TID OD
 Medical History: (+)HTN, DM, TIA, Hypothyroidism
 Medications: Artificial Tears-PRN OU, Metformin, Insulin, Lisinopril,
Levothryoxine, Warfarin
 Allergies: Lyrica, Gabapentin
II. Pertinent Findings
 Clinical Examination:
o VA(cc): OD: 20/20-2, OS: 20/20
o Extraocular Muscles: FROM OU; (+) dull pain/soreness in all
gazes OD
o Pupils, confrontation visual fields, and Ishihara color vision
testing were unremarkable OD and OS
o External Examination: (-)proptosis OU
o Slit Lamp Examination:
 Lids/Lashes:
 1.5mmx2mm tender nodule of nasolacrimal sac
OD
 Erythema, pain/tender on palpation
 Unable to express contents with palpation.
 All other structures were unremarkable OU
o IOP: 16/16 mmHg
o Undilated 78D Slit Funduscopy: Unremarkable OU
o Physical: Alert and Oriented x 3; Temperature: 99.9F
 Laboratory Studies: Culturing of lacrimal sac fluid
o Staphylococcus Lugdunensis
 Gram-positive Coagulase-negative

 Has spherical cells that appear in clusters
Radiology Studies: Unremarkable Orbital CT scan without deviation
into post-septal region.
III. Differential diagnosis
 Primary Diagnosis: Dacryocystitis
 Other Differentials:
o Pre-septal cellulitis
 Focal swelling of one of the meibomian glands
 No pain on eye movement
o Orbital cellulitis
 Fever, proptosis, APD, and/or changes in color vision
 Positive orbital CT
o Canaliculitis
 Pouted/inflamed puncta
 Follicular conjunctivitis
o Dacryostocele
 Congenital blockage of Rosenmuller valve and Hasner
valve
 Grey-blue cystic swelling just below the medial canthus
IV. Diagnosis and Discussion
 Dacryocystitis is inflammation of the lacrimal sac secondary to
nasolacrimal obstruction and growth of bacteria due to stationary fluid
within the lacrimal sac.
 Symptoms:
o Epiphora, redness, and tenderness of the tissue over the lacrimal
sac
 Pathogens:
o Common Pathogens are Gram-positive bacteria5,6
 Staphylococcus Aureus
 Staphylococcus Epidermidis
 Staphylococcus Virdians
o Uncommon Pathogens are Gram-negative bacteria5,6
 Pseudomonas aeruginosa
V. Treatment and Management
 Treatment of the patient in this case report
o Day 1 = Day of Consult
 Continue warm compresses & ocular massage
 Increase Augmentin to TID x 10days
 Add Naproxen 500mg BID
o Day 3
 No improvement noted
 Referral to Ophthalmology for incision, drainage, and
culturing of lacrimal sac fluid.
 Patient admitted and IV Clindamycin initiated
o Day 4


o Day 5

o Day 6


2.0cm reduction in infraorbital erythema
Continue IV clindamycin
Significant improvement surrounding incision site
Continuing improvement in clinical appearance and
symptoms
o Day 7
 Improvement with 4 day IV clindamycin.
 Patient discharged from hospital
 Start 14 day course of 150 mg oral clindamycin at home
 Discontinue 875mg augmentin
o Day 15
 Well healed incision
 No need to restart oral antibiotics
 Patient to complete EnDCR with oculoplastic clinic in 6
weeks.
Common Dacryocystitis Treatments:
o Warm compresses
o Systemic antibiotics
 Augmentin
 Cephalosporins
 Clindamycin
o Surgery = dacryostorhinotomy (DCR).
 Purpose:
 Drain lacrimal sac fluid to ward off acute infection
 Alleviate symptoms (epiphora)
 Complications: prolong healing, cutaneous scarring, and
fistula formation7.
 Surgical Types:
 External DCR (ExDCR)
 Incision made over the skin & lacrimal bone
is removed to extrapolate the contents of the
sac
 93.8% success rate in comparison to orals
alone6
 Endoscopic DCR (EnDCR)
 Parts of the nasal mucosa are removed to
create an opening near the lacrimal bone,
which creates a bridge between the sac and
nasal mucosa
 Drills or lasers can be used to make the
incisions
 Can reach the lacrimal sac through noninfected tissue




Can prevent spread of infection that could
be potentiated with external DCR or
incision/drainage
 96.2% success rate4
 90% patency versus 60% seen in ExDCR4
 Swelling & edema & epiphora symptoms
resolve faster with EnDCR7
 92.3% reduction in epiphora in 2-3
days
 Less chance of needing repeat
drainage
 Possible sequelae if aggressive surgical treatment
not enacted
 orbital cellulitis
 orbital abscess
Bacterial Susceptibility
o Cephalosporins and Augmentin combat 86.4% of acute
dacryocystitis6
o Ceftriaxone, erythromycin, gentamycin are more effective than
ampicillin, amoxicillin, penicillin, and tetracycline2
o Gram-positive bacteria such as S. Aureus showed good sensitivity
to penicillin, cephalosporins, and vancomycin1
o Some common gram negative bacteria were sensitive to penicillin,
quinolones, and aminoglycosides1
Bacterial Resistance:
o 28.6% of acute dacryocystitis cases are resistant to initial antibiotic
treatment6
o 33% of S. Aureus showed resistance to erythromycin, tetracycline,
and penicillin2
o In the Mill’s study, 5/23 of the S. Aureus isolates were MRSA,
which were mostly found in acute cases6
Bibliography
1.
Ali, Mohammad Javed, The microbiological profile of lacrimal
abscess: two decades of experience from a tertiary eye care center.
Journal of Ophthalmic Inflammation and Infection. 2013; 3:57: 15.
2.
Assefa, Yared, Bacteriological profile and drug susceptibility
patterns in dacryocystitis patients attending Gondar University
Teaching Hospital, Northwest Ethiopia. BioMed Central
Ophthalmology. 2015;15:34:1-8.
3.
Ben Simon, Guy J. External versus Endoscopic
Dacryocystorhinostomy for Acquired Nasolacrimal Duct
Obstruction in a Tertiary Referral Center. Ophthalmology. 2005.
112:8: 1463-1468.
4.
Christy, Naja, Long-term Outcomes of Powered Endoscopic
5.
6.
7.
Dacryocystorhinostomy in Acute Dacryocystitis. The
Larynoscope. 2015;1-3.
Eshraghi, Bahram, Microbiologic spectrum of acute and chronic
dacryocystitis. Int J Ophthalmology. 2014;7 (5): 864-867.
Mills, David M. The Microbiologic Spectrum of Dacryocystitis: A
National Study of Acute Versus Chronic Infection. Ophthalmic
Plastics and Reconstructive Surgery. 2007; 23:4: 302-306.
Naik, Sudhir M. Endonasal DCR with Silicon Tube Stents: A
Better Management for Acute Lacrimal Abscesses. Indian Journal
Otolaryngology Head Neck Surgery. 2013; 65:2: S343-S349.
VI. Conclusion
o The most common etiology of dacryocystitis is gram positive
bacteria.
o The patient in this case report was infected with Gram-positive
Staphylococcus Lugdunensis
o 1st Line treatment with Augmentin did not resolve the patient’s
condition
o 2nd line treatment was then initiated with Clindamycin and
Endoscopic DCR, due to worsening of his condition, unresolved
symptoms, and suspicion for presence of a resistant bacteria, which
have a high incidence in acute cases
o Combined antibiotics with surgical approach in persistent &
chronic cases resolve symptoms fast
 Endonasal DCR is the preferred surgery