Chronic Dacryocystitis - Standard Treatment Guidelines

Chronic dacryocystitis is an inflammatory condition of the lacrimal sac most commonly associated with partial or complete obstruction of the nasolacrimal duct. Most chronic dacryocystitis present with watering and discharge, but some may progress and cause severe ocular and extra ocular complication. Even in mild conditions, it may cause a significant ocular morbidity and loss of work place efficiency because watering can blur the vision momentarily, prevent a person from concentrating on some work and can be socially embarrassing. It affects all ages and all social strata but women are more likely to develop dacryocystitis because of their nasolacrimal ducts are anatomically narrower as compared to males. Approximately 3% of all the ophthalmic clinical visits and 1% of all emergency room visits are related to dacryocystitis. The underlying etiology, typical infectious organisms and preferred treatments are important issues to understand in the management of this common disorder.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Chronic Dacryocystitis. Following are the major recommendations :

Case definition:

Dacryocystitis is defined as inflammation of the lacrimal sac. The sac is a part of the lacrimal excretory system whose function is to transport the tears from the eyes to the nose.

Incidence of The Condition In Our Country

Chronic dacryocystitis is a common ophthalmic problem. Although there are no reliable figures that document the incidence or prevalence of chronic dacryocystitis, large studies from the west have documented it to be around 3% of all the clinical ophthalmic visits. Since the lacrimal system is prone to infections as it is contiguous with both conjunctiva and nasal mucosa, dacryocystitis is considered much more common in developing countries like India. The morbidity is much more than expected because of its chronic nature, social factors as discussed already, tendency for acute painful exacerbations and its complications.

Differential Diagnosis

Although chronic dacryocystitis is not very difficult to diagnose, there could still be certain atypical cases which may masquerade in a similar fashion and needs to be kept in mind. They include bacterial conjunctivitis, pre-septal cellulitis,

miebomitis, blepharitis and canaliculitis. Points that differentiate and favour bacterial conjunctivitis included sudden onset redness with discharge and diffuse conjunctival congestion. Pre-septal cellulitis is an acute inflammation involving the eyelid, not associated with discharge or long standing epiphora. Meibomitis and blepharitis are usually bilateral associated with irritation of the lid margins and burning sensation. Canaliculitis can be differentiated by focal swelling of the canalicular portion of the eyelid margin with pouting puncta and inspissated discharge.

Prevention And Counseling

There are no known preventive measures for chronic dacryocystitis. Infections and inflammations are the major known causes for it. Therefore a good hygiene can at least prevent secondary infections of the lacrimal sac from the conjunctiva and nasal mucosa.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

*Situation 1: At Secondary Hospital/ Non-Metro situation: Optimal Standards of Treatment in Situations where technology and resources are limited

Clinical Diagnosis :

History taking, comprehensive evaluation of the eye and understanding of the general epidemic prevalence of this condition in the society is crucial to establish a diagnosis. Patients usually come with typical history of chronic watering, matting of eye lashes on waking, discharge and redness of the eye.

Examination : The ocular examination includes recording visual acuity, an external eye examination and slit-lamp biomicroscopy.

Visual acuity measurement : Although visual acuity is normal in patients with dacryocystitis, discharge sliding across the eye may cause visual disturbances.

External examination :

The following points should be looked for:

1. Increased tear lake

2. Visible or palpable enlargement of the lacrimal sac

3. Discharge which at times may be copious.

4. Regurgitation on pressure over the lacrimal sac or ROPLAS test is a simple confirmatory test, which if positive is diagnostic of nasolacrimal duct obstruction and usually does not require further investigations.

5. Abnormalities of skin like crusting or eczematous lesions suggest chronic changes caused by watering. Skin may also show a lacrimal fistula or a scar of past acute dacryocystitis or lacrimal abscess.

Slit-lamp Biomicroscopy :

Should include evaluation of the following:

1. Increased tear film height.

2. Matted lashes.

3. Lacrimal puncta and canaliculi for pouting and discharge

4. Variable types of discharge like clear, mucoid or muco-purulent.

5. Micro regurgitation with ROPLAS test as described earlier can be useful in cases where there is no frank regurgitation.

6. Conjunctival congestion

Fluorescein Dye Disappearance test

This is a very useful physiological test which is based on the principle of evaluation of

residual fluorescien in the eye following instillation of one drop of fluorescein in

unanesthetized conjunctival sac. This is a useful functional test specifically in children

as it is easy to obtain results.

Standard procedure :

1. One drop of 1-2% fluorescein is instilled into the lower fornix of each eye.

2. After 5 minutes the thickness of the fluorescent tear meniscus is measured with the help of cobalt blue filter.

3. Children should be held upright during the test.

4. The tears normally drain down in 5 minutes. The test is positive if residual fluorescein is present.

5. The residual fluorescein is graded as Grade 0- No fluorescence , Grade 1- Thin strip of fluorescence, Grade 2- Between grade 1 and 3, and Grade 3- Wide, brightly fluorescence strip.

Diagnostic Probing and Syringing

This is a very simple clinical method which when employed appropriately give useful clues that helps the physician in knowing the presence, location and the form of
obstruction in the lacrimal excretory system. The test qualitatively establishes the patency or stenosis or complete obstruction of the canaliculi, lacrimal sac or nasolacrimal duct but does not give any information on functional insufficiencies.

Standard procedure :

1. Place a drop of topical anesthetic in the conjunctival cul-de-sac.

2. The punctum and the ampulla are dilated with a punctual dilator.

3. A blunt lacrimal canula is placed in the inferior canaliculus and the lower eyelid is pulled down and laterally to straighten the lower canaliculus and evert the punctum away from the ocular surface.

4. The tip is placed first vertically and then horizontally with the eyelid on stretch. The tip is advanced 6-7 mm into the canaliculi and sterile water is used as an irrigant. The irrigation should begin in the canaliculi so that the incoming passages are dilated and the mucosa is less traumatized.

5. Irrigation should be preferred when the tip is in the lacrimal sac. Simultaneous probing can also be done with the same tip of the canula. A hard stop rules out canalicular obstruction whereas a soft stop is indicative of such obstructions.

6. Irrigation should now be interpreted. In a normal passage the saline is felt in the nose or the throat by the patient. Regurgitation through the opposite punctum with a hard stop suggests a nasolacrimal duct obstruction. Regurgitation through the opposite punctum with a soft stop suggests a common canalicular block. In cases of upper or lower canalicular block, regurgitation is seen through the same puncta. Partial regurgitation is associated with partial blocks respectively.

Investigations:

Chronic dacryocystitis is usually diagnosed by history, physical examination and simple investigations where needed.

Microbiological work up: A regular microbiological examination is not necessary unless there are recurrent attacks of acute dacryocystitis, lacrimal abscess or any associated canaliculitis. If additional microbiological work up is needed or other imaging modalities like computed tomography or dacryocystography is the felt need than a referral to higher center must be thought of.

Treatment:

The treatment of choice in chronic dacryocystitis is dacryocystorhinostomy (DCR). Additional procedures along with dacryocystorhinostomy like intubation, use of adjunctive pharmacotherapy like mitomycin-C and canalicular trephining depends upon multiple factors like presence of canalicular obstructions, intra-sac synechiae or

repeat surgeries. Dacryocystorhinostomy is a bypass procedure that creates an anastomosis between the lacrimal sac and the nasal mucosa via a bony ostium. It may be performed through an external skin incision or endo-nasally with or without endoscopic visualization or via the transcanalicular approach. The most commonly done approach is the External DCR which is still considered as a gold standard in management of chronic dacryocystitis.

Standard procedure

1. Adequate nasal decongestion and nasal packing preoperatively is helpful.

2. Anesthesia can be local or general. Local anesthesia includes topical in conjunctival cul-de-sac, infratrochlear block and local infiltration.

3. Skin incision either straight or curvilinear can be used.

4. Periosteum over the anterior lacrimal crest is raised and the lacrimal sac is reflected laterally.

5. A large bony osteum is created respecting the anatomic boundaries.

6. Flaps of nasal mucosa and lacrimal sac raised. Posterior flaps are excised.

7. Adjunctive pharmacotherapy or intubation is done if needed.

8. Anterior flaps are sutured with 6-0 vicryl and skin is sutured with 6-0 silk or prolene.

9. Nasal packing is done to soak the blood and hemostasis.

Standard Operating procedure

In Patient

• Admit patients after the surgical procedure to monitor the vitals and signs of bleeding especially if they are from far off places.


• Admit patients with complications like orbital cellulitis or severe acute dacryocystitis for intravenous antibiotics.

Out Patient: Not applicable.

Day Care : Patients after the surgical procedure are kept under observation for 4-5 hours for any bleeding and then can be discharged if they are stable.

Referral criteria:

• Lacrimal obstruction at multiple sites.

• Failed Dacryocystorhinostomy.

• Complications of chronic dacryocystitis like recurrent acute exacerbations or orbital cellulitis.

• Chronic dacryocystitis associated with systemic diseases like sarcoidosis or wegeners granulomatosis.

• Chronic dacryocystitis associated with suspected dacryolithiasis.

• Chronic dacryocystitis where there is a suspicion of a lacrimal sac tumor.

*Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available

Clinical Diagnosis:

Apart from the regular history taking, care should be exercised to fully understand the treatment history of the patient, including all the medications along with the dosage schedules which were prescribed at the secondary centre. In fact, withdrawal of strong topical antibiotics may be warranted. A fresh comprehensive clinical examination, as detailed in the previous section should be performed without being biased by the referral report.

Diagnostic Nasal Endoscopy :

Nasal examination especially nasal endoscopy is obligatory for every lacrimal patient. An endocsopy provides a clear diagnostic looks for nasal anatomical variations, nasal polyps, deviated nasal septum or tumors of the lacrimal sac. It is a very important for clinical evaluation in postoperative patients and after failed lacrimal surgery. The procedures are performed through rigid or flexible 2.7mm or 4mm endoscopes.

Standard procedure :

1. Nasal mucosa is decongested and anesthetized with topical medications.

2. The patient either sits or lies in a relaxed position.

3. Nasal vestibule, inferior meatus, floor of the nose and nasopharynx are examined.

4. Middle turbinates and meatus is examined and then the scope is directed postero-superiorly to evaluate the spheno-ethmoidal recess and superior meatus.

Investigations:

As the patients are referred from a secondary centre for a non responsiveness to treatment or when diagnosis is additional microbiological and imaging studies may be required.

• Culture: Culture and sensitivity of the discharge is indicated specially in cases of orbital cellulitis or recurrent lacrimal abscess. When performed, collect discharge with a calcium alginate swab moistened with saline. Apart from smears for grams and giemsa staining, culture onto blood and chocolate agar is

taken.

• Imaging: CT Scans are useful in elucidating facial skeletal anomalies, fractures or foreign bodies as the cause of lacrimal disorder. It is also useful rule out occult malignancy or mass as a cause of dacryocystitis. Dacryocystography(DCG) with subtraction or CT-DCG is very sensitive to study the anatomy of the lacrimal sac and surrounding structures. Dacryoscintigraphy (DSG) is done with the help of Technetium 99 and gamma camera and is useful in providing certain insights into the functional causes of epiphora.

Treatment:

The treatment strategies should be revisited to check for adequacy, appropriateness and affordability. If the culture and other tests show a different organism, then the treatment regimen should be modified.

Surgical procedure includes:

1. External Dacryocystorhinostomy or repeat external DCR as described in the earlier section.

2. Endoscopic endonasal revision of past DCR.

3. Endoscopic guided secondary intubations

4. Canalicular trephining and use of monoka stents

5. Laser assisted DCR or Laser assisted revision of a failed DCR.

6. Conjunctival DCR with Jones tubes.

7. Balloon assisted DCR revision.

8. Balloon dacryoplasty and canaliculoplasty.

Standard Operating procedure

In Patient :

1. All procedures planned under general anesthesia.


2. Revision DCR’s as there is more tendency to bleed in postoperative period.


3. Patients with complications like orbital cellulitis on referral or postoperative severe bleeding.

Out Patient: Not applicable.

Out Patient : Patients after the surgical procedure are kept under observation for 4-5 hours for any bleeding and then can be discharged if they are stable.

Referral criteria:

not applicable.

WHO DOES WHAT? And TIMELINES

Doctor

1. Patient history is taken and a clinical examination performed.


2. Infective material is obtained from discharge and smear are prepared and also materials are inoculated directly onto culture media


3. Documenting the medical record


4. Plan treatment guidelines and perform surgery if necessary .


5. He/she should also ensure that needy patients receive necessary care directly or through referral to appropriate persons and facilities that will provide such care, and he or she supports activities that promote health and prevent disease.

Nurse/Technician:

1. Prepare Slide, Media for smear and culture.


2. To monitor the patients who are admitted.


3. To maintain separate inpatient and outpatient record.


4. To maintain lab reports.

Resources Required

Guidelines by The Ministry of Health and Family Welfare :

Dr. Venkatesh Prajna Chief- Dept of Medical Education, Aravind Eye Hospitals, Madurai