Tear-Sac Infections & Lacrimal Trauma

Infections of the Lacrimal System

Dacryoadenitis (Lacrimal Gland Infection)

• Inflammation or infection of the lacrimal gland in the superolateral orbit
• Acute: bacterial (Staphylococcus, Streptococcus) or viral (EBV, mumps, CMV, VZV); painful S-shaped lid deformity; treat with systemic antibiotics or antivirals
• Chronic: associated with systemic disease — sarcoidosis, Sjögren’s syndrome, lymphoma, IgG4-related disease; biopsy of the lacrimal gland is often required to establish diagnosis

Canaliculitis

Canaliculitis is infection of the canaliculus (the channel connecting the punctum to the lacrimal sac). It is commonly misdiagnosed and undertreated — always consider it when a patient has a “chronic conjunctivitis” of one eye that fails to respond to drops.

• Most common cause: Actinomyces israelii (80% of cases); the organism forms sulphur granules (concretions) within the canaliculus
• Other causes: Propionibacterium, Fusobacterium, Candida, Aspergillus, herpes simplex
• Classic signs: unilateral red eye, mucopurulent discharge, swollen pouting punctum (the “lacrimal pouch sign”); yellow concretions expressed from the punctum on compression
• Diagnosis: clinical — probe passes easily but with a “gritty” sensation; microscopy and culture of expressed material confirms organism
• Treatment: canaliculotomy (incision of the canaliculus through its posterior wall) with curettage of concretions, followed by irrigation with penicillin or povidone-iodine. Topical antibiotics alone almost always fail. Incomplete concretion removal leads to recurrence

Dacryocystitis — Acute

Acute dacryocystitis is a bacterial infection of the lacrimal sac, almost always arising from nasolacrimal duct obstruction with stasis of tears and secondary infection.

• Presentation: sudden-onset pain, redness, and tender swelling at the medial canthus below the medial canthal tendon (this location distinguishes dacryocystitis from ethmoid sinusitis or subcutaneous abscess, which present above or along the tendon)
• Common organisms: Staphylococcus aureus (most common), Streptococcus pneumoniae, Haemophilus influenzae, gram-negative rods in immunocompromised patients
• Treatment:
  • Oral antibiotics (Augmentin, Keflex) for mild-to-moderate cases
  • IV antibiotics (nafcillin, vancomycin for MRSA coverage) for severe disease, periorbital spread, or failure of oral therapy
  • Warm compresses
  • Do not probe an acutely infected system — probing risks spreading infection and creating a fistula
  • Incision and drainage if abscess forms and is fluctuant
  • DCR surgery after the acute infection resolves (typically 4–6 weeks later) to prevent recurrence
• Complications if untreated:
  • Preseptal (periorbital) cellulitis
  • Orbital cellulitis and abscess (sight- and life-threatening)
  • Lacrimal fistula (spontaneous drainage through the skin)
  • Mucocele (chronic distended, obstructed sac without acute infection)
  • Cavernous sinus thrombosis (rare but potentially fatal)

Dacryocystitis — Chronic

• A chronically obstructed lacrimal sac that is distended with mucoid or mucopurulent fluid with minimal acute inflammation
• Presents as recurrent episodes of mild discharge and epiphora, with a soft, compressible swelling at the medial canthus
• Pressure on the sac expresses mucoid material through the punctum (regurgitation test positive)
• May harbor dacryoliths (stones) from Actinomyces or Candida species
• Treatment: DCR surgery; topical antibiotics provide only temporary symptomatic relief

Lacrimal Trauma — Canalicular Lacerations

Canalicular lacerations occur when trauma to the medial eyelid severs the canaliculus. Because the canaliculus lies just beneath the skin medial to the punctum, even seemingly superficial medial eyelid lacerations frequently involve it. If not repaired promptly and correctly, permanent epiphora results.

Recognition

• Any laceration medial to the punctum should be assumed to involve the canaliculus until proven otherwise
• Common mechanisms: dog bites (very high frequency of canalicular involvement), fist injury, motor vehicle accident, fishhook
• The lower canaliculus is injured more commonly than the upper
• Both canaliculi may be involved if trauma crosses both lids

Repair Principles

Canalicular repair must be performed within 24–48 hours for best results. The key steps:

1. Identify both ends of the lacerated canaliculus under magnification (surgical microscope or loupes)
2. Place a stent (silicone tube) to maintain the lumen during healing and prevent stricture
3. Reapproximate the canalicular ends over the stent with fine absorbable sutures (7-0 Vicryl or 8-0 Vicryl)
4. Repair the eyelid in layers

Stent Options

• Monocanalicular stent (Mini-Monoka): stent placed only in the injured canaliculus; plugs at the punctum; avoids potential damage to the normal canaliculus. Preferred for isolated lower canalicular laceration
• Bicanalicular stent: looped through both upper and lower canaliculi; retrieved nasally. Required when the common canaliculus or lacrimal sac is involved. Disadvantage: potential trauma to the uninvolved canaliculus
• Stents removed at 3–6 months

Success Rate

• Prompt, meticulous primary repair achieves functional patency in approximately 85–90% of cases
• Delayed repair or failure of initial repair may require DCR or ultimately Jones tube if the canaliculus cannot be reconstructed