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Summary Table

FEATURE	Details
Risk Factors	Neonates (congenital nasolacrimal duct obstruction), females > males (narrower bony nasolacrimal canal), age > 40, chronic sinusitis, nasal/facial trauma, dacryolith formation
Etiology	Obstruction of the nasolacrimal duct leading to stasis and secondary bacterial infection of the lacrimal sac. Most common organisms: Staphylococcus aureus, Streptococcus species (acute); Staphylococcus epidermidis, Actinomyces (chronic)
Patient Presentation	Unilateral pain, swelling, and redness over the medial canthus/lacrimal sac area; tearing (epiphora); mucopurulent discharge from the punctum on palpation
Classic Physical Exam	Tender, erythematous swelling inferior and medial to the medial canthus; expressible purulent material from the punctum upon pressure over the lacrimal sac; may progress to preseptal cellulitis or fistula formation
Key Diagnostic Results	Clinical diagnosis in most cases; dacryocystography or lacrimal scintigraphy confirms obstruction site; CT orbit/sinuses if orbital cellulitis or abscess is suspected
Management	Acute: warm compresses, systemic antibiotics (amoxicillin-clavulanate or cephalosporin), I&D if abscess forms. Definitive: dacryocystorhinostomy (DCR) after acute infection resolves. Congenital: lacrimal sac massage (Crigler maneuver), probing if persistent beyond 6 to 12 months
Keywords	"Swelling near inner corner of the eye," "tearing with discharge," "pain at medial canthus," "expressible purulent material from punctum," "nasolacrimal duct obstruction"

1. Pathophysiology

The lacrimal drainage system begins at the puncta on the upper and lower eyelids, continues through the canaliculi, converges at the lacrimal sac (located in the lacrimal fossa of the medial orbital wall), and drains into the nasolacrimal duct, which empties into the inferior nasal meatus beneath the inferior turbinate.

Dacryocystitis develops when the nasolacrimal duct becomes obstructed, causing stagnation of tears within the lacrimal sac. This stagnant fluid becomes a culture medium for bacterial colonization, leading to infection and inflammation of the sac itself. The obstruction can be congenital (failure of canalization of the valve of Hasner at the distal end of the nasolacrimal duct) or acquired (chronic inflammation, dacryolith, trauma, or involutional stenosis).

In acute dacryocystitis, rapid bacterial proliferation causes distension of the lacrimal sac with purulent material. The infection may extend beyond the sac wall into surrounding soft tissues, producing preseptal cellulitis or, rarely, a lacrimal sac abscess that can fistulize to the skin surface. The reason the swelling localizes inferior to the medial canthal tendon is that the lacrimal sac sits in the lacrimal fossa just below and behind the tendon. This anatomical landmark is tested frequently: swelling above the tendon suggests a different etiology (e.g., dermoid cyst, encephalocele).

In chronic dacryocystitis, low-grade infection causes persistent tearing and intermittent mucopurulent discharge without significant pain or erythema. The sac may become distended (mucocele) and palpable as a non-tender mass at the medial canthus.

In congenital dacryocystitis, an imperforate membrane at the valve of Hasner causes tear stasis from birth, presenting as persistent tearing and crusting in the first weeks of life. If the stagnant fluid becomes infected, the condition progresses to acute dacryocystitis of infancy, which can be distinguished from simple nasolacrimal duct obstruction by the presence of erythema and tenderness over the sac.

2. Classification and Clinical Manifestation

Classification	Onset	Clinical Features	Key Distinguishing Feature
Acute Dacryocystitis	Sudden	Painful, erythematous, tender swelling at medial canthus; purulent discharge expressible from punctum; fever possible; may progress to abscess or preseptal cellulitis	Pain, erythema, and tenderness with systemic signs
Chronic Dacryocystitis	Insidious	Persistent epiphora (tearing), recurrent conjunctivitis, painless or mildly tender swelling at medial canthus, mucoid or mucopurulent reflux on sac compression	Chronic tearing with minimal inflammatory signs; recurrent episodes of conjunctivitis
Congenital Dacryocystitis	Birth to first weeks of life	Tearing and mucopurulent discharge since birth, erythema and swelling over sac if secondarily infected	Age of onset (neonate/infant); imperforate valve of Hasner

Complication

Complication	Description
Lacrimal sac abscess	Fluctuant, pointing swelling; requires incision and drainage
Lacrimal fistula	Spontaneous drainage track from sac to skin surface
Preseptal cellulitis	Extension of infection to periorbital soft tissue anterior to the orbital septum
Orbital cellulitis	Rare but serious; proptosis, ophthalmoplegia, pain with eye movement; requires urgent CT and IV antibiotics

3. Diagnostic Workup

Test	Role	Findings
Clinical examination	Best initial diagnostic approach	Tender erythematous swelling at medial canthus; purulent reflux from punctum on sac compression
Dye disappearance test	Screening for lacrimal drainage obstruction	Fluorescein persists in the conjunctival sac after 5 minutes (normally clears), indicating impaired drainage
Lacrimal irrigation	Confirms nasolacrimal duct obstruction	Inability to irrigate fluid into the nose, with reflux through the opposite punctum
Dacryocystography (DCG)	Gold standard for localizing the site of obstruction	Contrast injected through punctum; identifies level and nature of obstruction on imaging
Lacrimal scintigraphy	Functional assessment of drainage	Technetium-99m tracer placed in conjunctival sac; delayed transit indicates functional obstruction
CT orbit/sinuses	If complications suspected	Evaluates for abscess formation, orbital cellulitis extension, or bony pathology
Culture of expressed discharge	Guides antibiotic therapy in refractory cases	Identifies causative organism and antibiotic sensitivity

Acute dacryocystitis is primarily a clinical diagnosis. The classic presentation of a tender, erythematous swelling localized below the medial canthal tendon, combined with purulent reflux from the punctum on compression of the sac, is highly characteristic and often sufficient for diagnosis without further investigation.

The dye disappearance test is a simple, non-invasive screening tool. A drop of fluorescein is instilled into both eyes, and after 5 minutes, the clinician checks whether dye has cleared. Asymmetric retention strongly suggests obstruction on the affected side. This test is particularly useful in pediatric patients who are uncooperative for irrigation.

Lacrimal irrigation is the confirmatory bedside test for nasolacrimal duct patency. Saline is injected through the lower punctum. In a patent system, the patient reports tasting or swallowing fluid. In complete obstruction, fluid refluxes through the upper punctum, and nothing reaches the nose.

Dacryocystography is the most accurate test for defining the exact anatomical location of obstruction and is typically ordered when surgical planning (DCR) is being considered. It can differentiate between canalicular, sac-level, and duct-level obstruction.

CT imaging is reserved for complicated cases where orbital cellulitis, abscess formation, or an underlying mass is suspected. It is not part of the routine workup for uncomplicated dacryocystitis.

4. Management and Treatment

Setting	Treatment	Details
Acute dacryocystitis (mild)	Warm compresses + oral antibiotics	Amoxicillin-clavulanate 875/125 mg PO twice daily for 7 to 10 days; alternatives: cephalexin 500 mg PO four times daily, or clindamycin if penicillin-allergic
Acute dacryocystitis (severe / preseptal cellulitis)	IV antibiotics	Ampicillin-sulbactam 3 g IV every 6 hours or ceftriaxone 1 g IV daily; transition to oral once clinical improvement
Lacrimal sac abscess	Incision and drainage + antibiotics	I&D with culture of aspirated material; systemic antibiotics as above
Definitive surgical management	Dacryocystorhinostomy (DCR)	Performed after resolution of acute infection; creates a direct anastomosis between lacrimal sac and nasal mucosa, bypassing the obstructed nasolacrimal duct
Congenital (initial)	Crigler maneuver (lacrimal sac massage)	Digital pressure applied over the lacrimal sac in a firm downward stroke 2 to 3 times daily; topical antibiotic drops (e.g., erythromycin ophthalmic) if discharge present
Congenital (persistent beyond 6 to 12 months)	Nasolacrimal duct probing	Thin probe passed through the canaliculus and duct to rupture the imperforate membrane at the valve of Hasner; success rate > 90% when done before age 12 months
Congenital (failed probing)	Balloon dacryoplasty or silicone intubation	Balloon catheter dilation or stent placement to maintain patency

Acute management begins with warm compresses to the affected area and systemic antibiotics. The antibiotic choice should cover gram-positive organisms, particularly S. aureus and Streptococcus species. Amoxicillin-clavulanate is the first-line oral agent. If the patient has a penicillin allergy, clindamycin or a fluoroquinolone may be substituted, though fluoroquinolones should be avoided in children.

A fluctuant abscess requires incision and drainage before antibiotics alone can resolve the infection. Culture of the drained material guides targeted antibiotic therapy.

The key concept tested is the timing of definitive surgery. DCR should not be performed during the acute phase because of the risk of spreading infection and distorted tissue planes. Once the acute infection has fully resolved (typically 4 to 6 weeks later), elective DCR is performed. External DCR involves a skin incision and creating a bony ostium between the lacrimal fossa and the nasal cavity. Endoscopic (endonasal) DCR achieves the same goal without a skin incision and is increasingly preferred.

For congenital dacryocystitis, the initial management is conservative. The Crigler maneuver applies hydrostatic pressure to the nasolacrimal duct, which can rupture the membranous obstruction at the valve of Hasner. Parents should be instructed to perform this 2 to 3 times daily. The majority of cases (approximately 90%) resolve spontaneously by age 12 months. If epiphora and recurrent infection persist beyond this age, nasolacrimal duct probing under brief general anesthesia is indicated.

5. Differential Diagnosis and Distractors

Differential	Why It Looks Similar	Key Discriminator
Preseptal (periorbital) cellulitis	Periorbital erythema and swelling; can coexist with dacryocystitis	Preseptal cellulitis involves diffuse eyelid swelling without a focal point at the medial canthus; no purulent reflux from the punctum on sac compression
Orbital cellulitis	Periorbital swelling with fever	Orbital cellulitis produces proptosis, restricted and painful extraocular movements, and decreased visual acuity; these findings are absent in isolated dacryocystitis
Acute anterior ethmoid sinusitis	Medial canthal swelling and tenderness	Sinusitis presents with nasal congestion, purulent rhinorrhea, and facial pain/pressure over the ethmoid region; no expressible material from the punctum
Dermoid cyst (medial canthus)	Non-tender medial canthal swelling	Dermoid cyst is congenital, firm, non-tender, and non-transilluminant; no tearing, no purulent discharge; located at or above the medial canthal tendon
Lacrimal gland inflammation (dacryoadenitis)	Periorbital swelling with tearing	Dacryoadenitis causes swelling at the superolateral orbit (lacrimal gland location), producing an S-shaped ptosis of the upper eyelid; this is anatomically opposite to dacryocystitis at the inferomedial canthus
Chalazion (medial aspect)	Eyelid lump near the medial canthus	Chalazion is a lipogranulomatous inflammation of a meibomian gland within the tarsal plate itself; it is not associated with tearing or discharge from the punctum

6. Traps and High-Yield Pearls

The most common way students lose points on dacryocystitis questions is by confusing the anatomical location of the lacrimal sac with the lacrimal gland. Dacryocystitis produces swelling at the inferomedial canthus (where the lacrimal sac sits), while dacryoadenitis produces swelling at the superolateral orbit (where the lacrimal gland sits). If a vignette describes swelling "below and medial to the medial canthal tendon," think dacryocystitis. If it describes swelling of the "outer upper eyelid," think dacryoadenitis.

A second common trap involves the management of congenital nasolacrimal duct obstruction. Students frequently jump to probing as the initial step. The correct first-line approach is conservative: lacrimal sac massage (Crigler maneuver) and observation, because the vast majority of cases resolve by 12 months. Probing is reserved for cases that persist beyond this window.

Third, test-writers love to present an acute dacryocystitis case and ask about the "next best step" after the acute infection has resolved. The answer is elective dacryocystorhinostomy, not continued antibiotics. Without addressing the underlying anatomical obstruction, recurrence is essentially inevitable.

Finally, be aware that any patient with dacryocystitis who develops proptosis, ophthalmoplegia, or visual changes has likely progressed to orbital cellulitis, which changes the management entirely to urgent CT imaging and IV antibiotics. This escalation is a tested decision point.

The core competency being tested is the ability to localize periorbital pathology based on anatomical landmarks, sequence the workup from clinical diagnosis to confirmatory imaging when needed, and correctly time conservative versus surgical intervention.

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