CHRONIC DACRYOCYSTITIS

Chronic dacryocystitis is more common than the acute
dacryocystitis.
Etiology
The etiology of chronic dacryocystitis is
multifactorial. The well-established fact is a vicious
cycle of stasis and mild infection of long duration.The
etiological factors can be grouped as under:
A. Predisposing factors
1. Age. It is more common between 40 and 60 years
of age.
2. Sex. The disease is predominantly seen in females
(80%) probably due to comparatively narrow
lumen of the bony canal.
3. Race. It is rarer among Negroes than in Whites;
as in the former NLD is shorter, wider and less
sinuous.
4. Heredity. It plays an indirect role. It affects the
facial configuration and so also the length and
width of the bony canal.
5. Socio-economic status. It is more common in low
socio-economic group.
6. Poor personal hygiene. It is also an important
predisposing factor.
B. Factors responsible for stasis of tears in
lacrimal sac
1. Anatomical factors, which retard drainage of tears
include: comparatively narrow bony canal, partial
canalization of membranous NLD and excessive
membranous folds in NLD.
2. Foreign bodies in the sac may block opening of
NLD.
3. Excessive lacrimation, primary or reflex, causes
stagnation of tears in the sac.
4. Mild grade inflammation of lacrimal sac due to
associated recurrent conjunctivitis may block the
NLD by epithelial debris and mucus plugs.
5. Obstruction of lower end of the NLD by nasal
diseases such as polyps, hypertrophied inferior
concha, marked degree of deviated nasal septum,
tumours and atrophic rhinitis causing stenosis
may also cause stagnation of tears in the lacrimal
sac.
C. Source of infection. Lacrimal sac may get infected
from the conjunctiva, nasal cavity (retrograde
spread), or paranasal sinuses.
D. Causative organisms. These include: staphylococci,
pneumococci, streptococci and Pseudomonas
pyocyanea. Rarely chronic granulomatous
infections like tuberculosis, syphilis, leprosy and
occasionally rhinosporiodosis may also cause
dacryocystitis.
Clinical picture
Clinical picture of chronic dacryocystitis may be
divided into four stages:
1. Stage of chronic catarrhal dacryocystitis. It is
characterised by mild inflammation of the lacrimal sac
associated with blockage of NLD. In this stage the
only symptom is watering eye and sometimes mild
redness in the inner canthus. On syringing the lacrimal
sac, either clear fluid or few fibrinous mucoid flakes
regurgitate. Dacryocystography reveals block in NLD,
a normal-sized lacrimal sac with healthy mucosa.
2. Stage of lacrimal mucocoele. It follows chronic
stagnation causing distension of lacrimal sac. It is
characterised by constant epiphora associated with
a swelling just below the inner canthus (Fig. 15.8).
Milky or gelatinous mucoid fluid regurgitates from
the lower punctum on pressing the swelling.
Dacryocystography at this stage reveals a distended
sac with blockage somewhere in the NLD.
Sometimes due to continued chronic infection,
opening of both the canaliculi into the sac are blocked
and a large fluctuant swelling is seen at the inner
canthus with a negative regurgitation test. This is
called encysted mucocele.
3. Stage of chronic suppurative dacryocystitis. Due
to pyogenic infections, the mucoid discharge
becomes purulent, converting the mucocele into
‘pyocoele’. The condition is characterised by
epiphora, associated recurrent conjunctivitis and
swelling at the inner canthus with mild erythema of
the overlying skin. On regurgitation a frank purulent
discharge flows from the lower punctum. If openings
of canaliculi are blocked at this stage the so called
encysted pyocoele results.
4. Stage of chronic fibrotic sac. Low grade repeated
infections for a prolonged period ultimately result in
a small fibrotic sac due to thickening of mucosa, which
is often associated with persistent epiphora and
discharge. Dacryocystography at this stage reveals
a very small sac with irregular folds in the mucosa.
Complications
Chronic intractable conjunctivitis, acute on chronic
dacryocystitis.
Ectropion of lower lid, maceration and eczema of
lower lid skin due to prolonged watering.
Simple corneal abrasions may become infected
leading to hypopyon ulcer.
If an intraocular surgery is performed in the
presence of dacryocystitis, there is high risk of
developing endophthalmitis. Because of this,
syringing of lacrimal sac is always done before
attempting any intraocular surgery.
Treatment
1. Conservative treatment by repeated lacrimal
syringing. It may be useful in recent cases only. Longstanding
cases are almost always associated with
blockage of NLD which usually does not open up
with repeated lacrimal syringing or even probing.
2. Dacryocystorhinostomy (DCR). It should be the
operation of choice as it re-establishes the lacrimal
drainage. However, before performing surgery, the
infection especially in pyocoele should be controlled
by topical antibiotics and repeated lacrimal syringings.
3. Dacryocystectomy (DCT). It should be performed
only when DCR is contraindicated. Indications of
DCT include: (i) Too young (less than 4 years) or too
old (more than 60 years) patient. (ii) Markedly
shrunken and fibrosed sac. (iii) Tuberculosis, syphilis,
leprosy or mycotic infections of sac. (iv) Tumours of
sac. (v) Gross nasal diseases like atrophic rhinitis (vi)
An unskilled surgeon, because it is said that, a good
‘DCT’ is always better than a badly done ‘DCR’.
4. Conjunctivodacryocystorhinostomy (CDCR). It is
performed in the presence of blocked canaliculi.