treatment plan

Lacrimal System Infections

BY WILLIAM L. MILLER, OD, PhD, FAAO

When patients complain of unilateral tearing, mattering, and nasal tenderness, consider the possibility of dacryocystitis and/or canaliculitis. The latter uncommon disease represents a less serious condition classically caused by Actinomyces species of bacteria. However a recent report by Zaldivar et al (2009) demonstrated other causative species including Streptococcus and Staphylococcus as well as Propionibacteria. Other known causes may include herpes, fungus, and yeast. Both conditions occur as either acute or chronic cases and are caused by tear stasis within the lacrimal drainage apparatus, thus promoting microbiologic growth.

Canaliculitis

Not only will canaliculitis patients have unilateral epiphora and medial canthus tenderness, they may also have a unilateral conjunctivitis (more severe in the inferior nasal quadrant) and discharge in and around the punctal region. The conjunctivitis tends to be refractory to conventional treatments. The punctum will take on a pouted appearance (externally pointed and prominent) and will be inflamed. Regurgitation of mucopurulent discharge from the punctum on digital massage will be visible. The eyelid will appear thickened and edematous in the area surrounding the punctum.

Canaliculus stenosis or blockage from dacryoliths, punctal occlusive devices, or lodged foreign bodies may cause canaliculitis. Long-term management includes removing the blockage by expression through the punctum. After the blockage has been cleared, a topical antibiotic (polymyxin B/trimethoprim solution or tobramycin and bacitracin/neomycin/polymyxin B ung) may also be added to combat the infectious vector. Cultures and smears of the discharge can aid your antimicrobial choice, which may infrequently include an antifungal (nystatin) or antiviral (trifluridine). The canaliculus can also be irrigated with a penicillin G solution and then followed with your topical antibiotic.

In cases in which this is unsuccessful, refer patients to an oculoplastic specialist who may perform a canaliculectomy with resultant irrigation using an antibiotic or betadine solution. Other such cases may benefit from a dacryocystorhinostomy (DCR).

Dacryocystitis

Dacryocystitis is a more serious condition, and when left untreated can progress to orbital/preseptal or facial cellulitis. This condition, although demonstrating some of the same clinical features of canaliculitis, involves an inflammation and infection of the lacrimal sac. It can occur rarely in infants, in whom it must be addressed quickly due to the immature nature of the lid structure. Most cases of dacryocystitis occur in patients older than age 40, with many occurring in the seventh and eighth decade of life due to changes in elasticity and patency of the nasolacrimal drainage system. Imaging such as CT scans, MRIs or dacryocystography may also be helpful adjuncts in cases of trauma, suspected anatomical malformations, or malignancy.

Some dacryocystitis patients may be febrile and have an elevated leukocyte count during the course of the disease, neither of which occurs in canaliculitis. Overtly ill patients may require hospitalization and IV antibiotics. Manage patients who don't have a fever with Augmentin (Glaxo- SmithKline) or cephalexin 500 mg PO, t.i.d. for seven to 10 days. Add to this a topical antibiotic solution or ointment, warm compresses, and oral analgesics such as aspirin or ibuprofen.

Many patients may also suffer from rhinitis or sinusitis, as these may be associated with the condition. Once the infection has been controlled, a surgical option is almost always a necessity. An external or endonasal DCR has nearly a 95-percent success rate. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #175.

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Dr. Miller is an associate professor and chair of the Clinical Sciences Department at the University of Houston College of Optometry. He is a member of the American Optometric Association and serves on its Journal Review Board. You can reach him at wmiller@uh.edu.