The document discusses dacrocystitis, an infection of the lacrimal sac often caused by obstruction of the nasolacrimal duct, with clinical presentations including pain, swelling, and potential complications like abscess formation. Treatment options range from warm compresses and antibiotics to surgical interventions like dacryocystorhinostomy and dacryocystectomy, depending on the severity and nature of the condition. The document details various surgical techniques, success rates, and potential complications associated with these procedures.

1. DACROCYSTITIS
19/MAY/2021
Dr Shayri Pillai
2ND Year Ophthalmology Resident
Liberia Eye Centre
JFK Memorial Medical Center
L V Prasad Eye Institute

2. INTRODUCTION
 Infection of the lacrimal sac
 Usually secondary to obstruction of the
nasolacrimal duct
 Acute or chronic
 Most commonly staphylococcal or streptococcal

3. Clinical findings include
Edema and erythema with distention of the lacrimal sac
Degree of discomfort ranges from none to severe pain
Complications include
Dacryocystocele formation
Chronic conjunctivitis, and spread to adjacent structures
(orbital or facial cellulitis)

4. Acute dacryocystitis
Presentation -subacute onset of pain in the medial
canthal area-Associated with epiphora
A very tender, tense red swelling develops at the
medial canthus
Progresses to abscess formation -associated
preseptal cellulitis

5. Treatment
Initial treatment -application of warm
compresses
Oral antibiotics such as flucloxacillin or co-amoxiclav
Irrigation and probing should not be performed
Incision and drainage -if pus points and an abscess is
about to drain spontaneously-this carries the risk of a
persistent sac–skin fistula
Dacryocystorhinostomy

7. Chronic dacryocystitis
Presentation-
chronic epiphora,
Associated with Chronic or recurrent unilateral
conjunctivitis
Mucocoele
Treatment- dacryocystorhinostomy

9. Conventional (external approach) dacryocystorhinostomy
(DCR)
indicated for obstruction distal to the medial
opening of the common canaliculus and consists of
anastomosis of the lacrimal sac to the mucosa of the
middle nasal meatus

11. The procedure is usually performed under
hypotensive general anaesthesia
A vertical skin incision is made 10 mm medial to the inner
canthus, the medial canthal tendon and lacrimal sac
exposed and reflected
After removal of the intervening bone the sac is incised
Attached to an opening created in the nasal mucosa
The success rate is over 90%

12. Causes of failure include
inadequate size and position of the ostium, unrecognized common
canalicular obstruction, scarring and the ‘sump syndrome’,
in which the surgical opening in the lacrimal bone is too small and too high
Complications
include cutaneous scarring, injury to medial canthal
structures, haemorrhage, infection and cerebrospinal fluid
rhinorrhoea if the subarachnoid space is inadvertently
entered

13. Endoscopic DCR encompasses several techniques
A light pipe can be passed through the canalicular
system into the lacrimal sac to guide an endoscopic
approach
Within the nose, or a microendoscopic transcanalicular
procedure -can be performed using a drill or laser to
establish communication with the nasal cavity

14. Advantages over conventional DCR include
Less marked systemic disturbance with minimal
blood loss and a lower risk of cerebrospinal
fluid leakage, the avoidance of a skin incision and
Generally a shorter operating time
Disadvantages include
a slightly lower success rate and visualization difficulties,
meaning that additional procedures are sometimes
needed

15. Other procedures, often reserved for partial nasolacrimal
duct obstruction, include
- Probing
- Intubation
- Stent
- Insertion and balloon dacryocystoplasty

16. Dacryocystectomy
Dacryocystectomy is useful in the management of two
types of patients:
the elderly patient with chronic dacryocystitis without
epiphora and the patient with a lacrimal sac tumor
Dacryocystectomy with isolation and excision of the
nasolacrimal sac may be performed -under either local or
general anesthesia
If tumor is suspected, general anesthesia is preferred

19. Skin marking uses an Iliff type incision starting at
the superior border of the medial canthal tendon
and curving downward along the anterior lacrimal
crest
--Better aesthetic results are obtained by aligning
this incision with the patient's natural relaxed skin
tension lines

20. Incision can be made with a 15 blade
--CO2 laser, monopolar needle tip, radiofrequency
wire, or other devices are preferred sometimes
Dissect down to the anterior lacrimal crest
--Incise the periosteum using a monopolar cautery
with needle tip
Use a Freer periosteal elevator to elevate the
lacrimal sac from the lacrimal fossa
Insert a Bowman probe and visualize in the sac

21. Free the lacrimal sac superiorly
Take care not to enter the nasal cavity, particularly if
there is concern for a lesion
The posterior portion of the dissection encounters the
ethmoid bone, which is very thin
Isolate the anterior crus of the medial canthal tendon
and cut using Westcott scissors to improve
visualization
Removal of the lacrimal sac

22. If a tumor is present and contained within the lacrimal
sac, it is recommended to leave the sac intact to the
best extent possible
If a tumor has eroded through the lacrimal sac,
biopsy with frozen section analysis may be indicated
The lacrimal sac is then amputated from the
nasolacrimal duct as inferiorly as possible

23. •In setting of dacryocystitis-copious irrigation of the
fossa with saline or antibiotic solution is indicated
Confirm the sac has been removed by placing a
Bowman probe in the lower punctum and
visualizing it exiting the common canaliculus
The superior opening of the nasolacrimal duct, now
exposed, should be sealed to prevent reflux of nasal
contents into the lacrimal sac fossa

24. Repair the medial canthal tendon using a 5-0
polyglactin or polypropylene suture in a horizontal
mattress fashion
Medial orbital fat can be mobilized and secured to the
periosteum using 6-0 polyglactin suture to fill the
lacrimal sac fossa and reduce or eliminate dead space
Orbicularis is closed using buried 6-0 polyglactin
suture
Skin is closed using 6-0 plain gut or polypropylene
suture in a running or interrupted fashion

25. Thank you!
Excellence Equity Efficiency
L V Prasad Eye Institute