Clinical Presentation
A 61-year-old woman presents with a complaint of painful swelling of the left lower eyelid that has been slowly progressing for 2 weeks (Figure 1). Before the swelling, she had chronic tearing out of the left eye for more than 1 year.
Figure 1. Photo of a patient with left lower lid edema and erythema, centered around the medial canthus and spreading to the upper and lower lids and cheek.
Past medical history: Patient denies facial/nasal trauma or sinus disease in the past.
Medications: None
On ocular examination:
Visual acuity: 20/25 right eye, 20/40 left eye
Pupils: equally reactive, no afferent pupillary defect
Color vision: symmetric, no red desaturation
Visual field: Full to finger counting
Motility: Full, left eye, with slight discomfort on medial gaze of the left eye
External examination of the eyelids showed edema and erythema of the medial left lower eyelid.
Slit lamp examination showed trace conjunctival injection in the left eye. The remainder of the examination was unremarkable.
Diagnostic Question
What is the differential diagnosis at this juncture?
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The erythema and edema of the lower eyelid is most likely infectious in nature and less likely inflammatory. Preseptal vs postseptal cellulitis needs to be determined. Because motility is essentially full, orbital cellulitis is unlikely. With the previous history of tearing on the same side as the infection, a diagnosis of acute dacryocystitis is likely.
Diagnostic Question
What might help determine the underlying pathology?
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Massage of the lacrimal sac might reveal mucopurulent discharge. The enlarged lacrimal sac might also transilluminate. Irrigation of the nasolacrimal duct is contraindicated in this case because it may exacerbate the infection.
An imaging study can also be helpful. Both CT and MRI can identify the infection of the lacrimal sac and also evaluate for associated orbital involvement. B-scan ultrasound can also image the lacrimal sac to disclose fluid filling suggestive of dacryocystitis.
A CT scan of the orbits (Figure 2) did reveal an enlarged lacrimal sac consistent with dacryocystitis. No associated orbital or sinus infection was found.
Figure 2. CT scan. Axial cut of a soft tissue window discloses enlargement of the left lacrimal sac, with associated preseptal inflammation. No orbital or sinus involvement is shown.
Diagnostic Question
On the basis of the studies, what is your working diagnosis now?
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Acute dacryocystitis.
Diagnostic Question
What are the treatment options for this patient?
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Therapy is based both on the clinical severity of the lacrimal sac infection and the comfort of the patient. In a patient with minimal discomfort whose infection is not progressing rapidly, a course of broad spectrum oral antibiotics is warranted. This may completely resolve symptoms or just be temporizing until definitive surgery can be performed. Nasal decongestants may also be of benefit.
In situations in which the infection is progressing or the patient is in significant discomfort, incision and drainage of the lacrimal sac is warranted. Some feel that an infected lacrimal sac cannot be drained without significant discomfort under local anesthesia. However, if a good anterior ethmoidal block is given, the procedure can be performed successfully. After the lacrimal sac is drained, cultures should be taken, and the sac should be irrigated and packed with sterile gauze. The packing can be removed over the course of a few days.
Incision and curettage is not a definitive treatment; dacryocystorhinostomy (DCR), either via endonasal or external approach, is the final treatment of choice.