Dacryocystitis

My summary

Diagnosis

medial swelling with pus from the punctum

Management

  • Assess for, and exclude: preseptal cellulitis, orbital cellulitis

    • Features of preseptal cellulitis include:

    • Features of orbital cellulitis include: optic nerve involvement (RAPD, loss of red sat, loss of brilliance, ONH swelling), EOM pain and restriction

  • Assess the contralateral side. Use a cotton tip to express subtle dacryocystitis

  • Swab m/c/s

  • Decide on OPD f/u with PO Abx vs. admission with IV Abx

    • Reasons to admit: involved preseptal cellulitis

Kanski

warm compresses

oral antibiotics such as flucloxacillin or amoxicillin clavulanic acid

do not irrigate

do not probe

consider incision and drainage if the pus points and an abscess is about to pop. This has a risk of a forming a persistent fistula

dacryocystorhinostomy can be beneficial after the acute infection has subsided to treat nasolacrimal duct obstruction

Wills

Use a cotton tip bud to press on the lacrimal sac to express pus bilaterally. This may reveal subtle involvement of contralateral side

exclude orbital cellulitis

swab m/c/s

antibiotics

  • PO Augmentin

    • Bactrim if has history of MRSA

  • Febrile / unwell = IV

Topical antibiotic drops in conjunction with antibiotic therapy

warm compresses followed by massaging for 10 minutes four times a day

once infection has resolved, evaluate patency of the NLD via probing and irrigation, if not patent, consider dacryocystorhinostomy with silicone tube

RVEE

Most commonly due to NLDO -> tear stasis -> secondary infection

mostly frequency presents as an acquired condition in adults

up to 20% of children have NLDO, but dacryocystitis is rare

common organisms include:

  • staphylococcus

  • streptococcus pyogenes

  • streptococcus pneumoniae

consider CT orbits and paranasal sinuses in cases not responding to antibiotic therapy

chloramphenicol if conjunctiva inflammed

antibiotics, adult

  • PO fluclox 500 - 1000 mg QID for 5 days, or

  • PO amox/clav forte 875 mg BD for 5 days

  • If more severe

    • IV ceftriaxone 1-2 g OD or divided BD

antibiotics, children

  • PO flucloxacillin 12.5 mg/kg (up to 500 mg) PO QID for 5 days

  • PO amox/clav 22.5 mg/kg BD for 5 days

Kanski infection is usually due to obstruction organisms implicated include: - staphylococcus - streptococcus

Treatment - Warm compresses - antibiotics such as flucloxacillin or amoxicillin with clavulanic acid - you should NOT irrigate or probe (?why, someone must have tried this and it didn’t work) - you should NOT I&D because then you get a permanent fistula forming, see the image below - After the infection subsides, dacrycystorhinostomy can be required to prevent recurrence

- fistula following I&D apparently, from Kanski

Kanski is excellent as a FIRST point of contact for clinical ophthalmology I suspect that reading Wills Eye AFTER Kanski is probably a good idea

**What does wills eye manual add to the above?

It gives you some other differentials to consider it gives you some stuff to do in the clinic Yeah wills is excellent for the right reasons

Other notes This patient that I saw was on flucloxacillin (sure, makes sense) and ceftriaxone??? why? For gram neg cover? then why not just amoxicillin clavulanic acid? That’s an excellent question. What is the difference in coverage between amox clav and ceftriaxone