Dacrocystitis: Diagnosis and Management

Dacrocystitis: Diagnosis and Management

Presented By: Dr Sahil Thakur

Moderated By: Dr Amit Raj

Intr

od

uct

ion

• Dacryocystitis is commonly encountered by an ophthalmologistaccounting for 87% of epiphora, which causes social embarrassmentdue to chronic watering from eyes.

• It commonly affects females over 40 years of age with peak incidencein 60 to 70 years.

• It has higher incidence among people of lower socioeconomic status.

• The prevalence of chronic dacryocystitis in cataract population hasbeen reported as 6.6%. It has also been reported as an importantcause of endophthalmitis thus it is imperative to evaluate the patientfor this condition before surgery.

Thomas R, Thomas S, Braganza A, Muliyil J. Evaluation of the role of syringing prior to cataract surgery. Indian J Ophthalmol 1997;45:211-4

Mal R, Banerjee AR, Biswas MC, Mondal A, Kundu PK,

Sasmal NK. Clinico bacteriological study of chronic

dacryocystitis in adults.J Indian Med Assoc. 2008.

Sch

emat

ics

of

Sem

inar • Anatomy

• Dacrocystitis: Definition/ Types

• Risk Factors

• Etiology

• Clinical Tests

• Imaging

• Management Outline for Acute/Chronic Dacrocystitis

• Surgical Options

• Recent Advances

• Conclusion

An

ato

my

Dac

rocy

stit

is: D

efin

itio

n• Dacryocystitis is an infection of the lacrimal sac, secondary to obstruction

of the nasolacrimal duct at the junction of lacrimal sac.

• The term derives from the Greek dákryon (tear), cysta (sac), and -itis(inflammation).

• Signs and symptoms may differ according to the etiology of the clinicalpicture.

• Under normal conditions, the mucosa of the lacrimal sac is highly resistantto infection. However, infections of the tear duct may develop, triggered byfunctional problems.

• Although there are several causes, the main mechanism for the occurrenceof dacryocystitis is distal obstruction of the nasolacrimal duct, which leadsto the retention of tears and detritus at the bottom of the conjunctival sacat the level of the lacrimal sac.

• A “critical mass” of bacteria may be reached, overwhelming the anti-infection response of the lacrimal sac mucosa, leading to an acute orchronic infection.

Dac

rocy

stit

is: C

lass

ific

atio

n

Dacrocystitis

Acquired Congenital

Acute Chronic Acute on Chronic

Acu

te D

acro

cyst

itis

• Acute dacryocystitis consists of inflammation of the lacrimal sac, ingeneral caused by infection. This pathology is predominantly found inadult women, while it is also relatively common in young infants.

• The most notable common signs and symptoms are reddening, oedemaand the presence of a painful area of induration overlying thenasolacrimal sac, specifically just below the anatomical boundary of themedial canthal ligament.

• Epiphora and discharge may also be observed. In particular, whenpressure is applied to the inflamed tear duct, purulent material may beexpressed through the lacrimal punctum.

• Frequently, patients may present conjunctivitis and preseptal cellulitis.Rarely, the infection extends beyond the septum, and causes orbitalcellulitis.

Ch

ron

ic D

acro

cyst

itis

• This is more common than acute dacryocystitis and there are severalstages of presentation:

Catarrhal: there is intermittent conjunctival hyperaemia andepiphora, with mucoid discharge that is normally sterile.

Lacrimal sac mucocele: stagnant tears collect and there is dilation ofthe lacrimal sac, with mucoid content.

Chronic suppurative: epiphora and chronic conjunctivitis areobserved, with erythema of the lacrimal sac. There is reflux ofpurulent material with pressure, and microorganisms are oftenisolated.

Dac

rocy

stit

is in

Ch

ildre

n• Dacryocystitis is rare in children and, when it

occurs, it is almost always associated withcongenital nasolacrimal duct obstruction. Ithas been reported that up to 6% of healthynewborns have this type of obstruction but, ofthese, only 2.9% develop acute dacryocystitis.

• The rate is around 60% in those withcongenital dacryocoele.

• The diagnosis is clinical and must bedifferentiated from preseptal cellulitis andmucocele, by the presence of hardening,inflammation and/or hyperaemia at the levelof the medial canthal ligament, associatedwith the presence of mucopurulent materialthat drains through the lacrimal punctum andepiphora.

Ris

k Fa

cto

rs•Most common risk factor is Nasolacrimal duct

obstruction.

•Higher rates of both acute and chronic dacryocystitishave been reported among women even 70% in somecase series.

•Upto 28.6% have associated nasal pathology like DNS,rhinitis, inferior turbinate hypertrophy.

•Dacroliths seen in 6 to 18 % patients undergoing DCR.These have been shown to have a relationship withmakeup/cosmetics and Candida hyphae.

Pinar-Sueiro, S., Sota, M., Lerchundi, TX. et al. Curr Infect Dis Rep (2012) 14: 137. doi:10.1007/s11908-012-0238-8

Etio

logy

• Staphylococcus aureus and Streptococcus pneumoniae being the mostcommon among Gram-positive and Haemophilus influenzae, Serratiamarcescens and Pseudomonas aeruginosa among Gram-negativebacteria.

• Anaerobic microorganisms have been isolated in as many as 15.7% ofthe positive cultures, in some studies, the most common genus beingBacteroides (5.7%).

• As for fungi, they have been reported to be present in 4% to 7% ofcases, the most commonly isolated genus being Candida, althoughAspergillus and Mucor may also be found.

Clin

ical

Tes

tsTo evaluate patient for dacrocystitis we need to perform the following tests:

1. Examination of adnexa and puncta

2. ROPLAS

3. Snap back test/ Pinch test and Examination of Lids

4. Fluorescein Dye Disappearance Test

5. Tear Film Break up Time

6. Jones Dye Test

7. Syringing and Probing

8. Schirmer’s Test

ASSESS LACRIMAL DYSFUNCTION

ASSESS LACRIMAL DRAINAGE FUNCTION AND PATENCY

ASSESS LEVEL OF OBSTRUCTION

ASSESS TEAR PRODUCTION

RO

PLA

S• Technique: The anterior lacrimal crest is identified by tracing

the inferior orbital margin medially and superiorly. The indexfinger is then directed behind the crest and used to applypressure on the sac area in an upward and medial directionso as to express the contents of the lacrimal sac into theconjunctiva. Any reflux of fluid or purulent material from thepuncta is noted.

• ROPLAS has a sensitivity of 88.9% and specificity of 99.0% ascompared to syringing when used for cataract patients.

Thomas R, Thomas S, Braganza A, Muliyil J. Evaluation of the role of syringing prior to cataract surgery. Indian J Ophthalmol1997;45:211-4

Flu

ore

scei

n D

ye D

isap

pea

ran

ce

Test

Sch

irm

er’s

Tes

t

Syri

ngi

ng

Test

Syringing Pressure Syringing

IMA

GIN

G

The following imaging modalities are available to us that further supplement the clinical tests:

•Dacryocystography (DCG)

•Nuclear lacrimal scintigraphy

•Computed Tomography (CT)

•Magnetic Resonance Imaging (MRI)

DC

G• Dacryocystography is an anatomical investigation and is

indicated if there is a block on syringing in the lacrimalsystem, and thus it can help in creating an image of howthe internal anatomy of the lacrimal system looks.

• Indications of DCG:

1. Complete obstructions: the size of the sacdetermination of the exact location of an obstruction(common canaliculus, sac)

2. Incomplete obstructions and intermitent tearing:location of the stenosis; diverticuli; stones; and noanatomical pathology (functional disorders)

3. Failed lacrimal surgery: size of the sac

4. Suspicion of sac tumors, traumatic injury to the face

DC

GRadiological Criteria of Lacrimal Pathology:

1. Regurgitation of (radio-opaque) fluid into the conjunctival sac (retention of fluid, absence of fluid in the nose, fluctuation of lumen of lacrimal system)

2. Irregularity in contrast

3. Cystic dilation and aneurysm

4. Deformation and drawing of the lacrimal sac

Nu

clea

r La

crim

al S

cin

tigr

aph

y•Nuclear lacrimal scintigraphy is a simple, non-

invasive physiological test that evaluates patency of the lacrimal system.

• Scintigraphy uses a radiotracer (technetium-99m pertechnetate), which is very easily detectable with a gamma camera.

CT

Scan

•CT is required in the following situations:

1. Following trauma

2. To evaluate a patient with a suspected lacrimal sac malignancy

3. To evaluate the infant with a medial canthal mass

MR

I an

d M

RD

CG

• Magnetic resonance imaging combined with contrastagent offers many advantages over other imagingstudies. Here lacrimal system is not cannulated and isnot under increased hydrostatic pressure, which gives atrue functional status of nasolacrimal drainage system.

• Gadolinium is used as topical solution (1:10–1:100 innormal saline)—one drop per minute for 5 minutes.

• MRI is reserved in cases where tumors are suspected.

AD

VA

NTA

GE

Man

agem

ent:

Acu

te

Dac

rocy

stit

is• In adults, the most widely recommended treatment for the

management of people with acute dacryocystitis consists of theapplication of heat with massage, systemic antibiotics (oral orintravenous administration, as appropriate) and percutaneous abscessdrainage.

• On the other hand, for cases that course with a clear abscess,drainage by puncture and aspiration of the lacrimal sac seems to bethe technique of choice for treatment, as well as for the diagnosticinformation it provides.

• Sometimes it is not possible to drain sufficient mucopurulent materialfrom the sac, leading to recurrent and prolonged inflammation, theformation of lacrimal cutaneous fistulae adjacent to the medialcanthal ligament, and of fibrous and granulation tissue in the lacrimalsac.

Man

agem

ent:

Acu

te

Dac

rocy

stit

is• Classically, surgical intervention has not been considered an option for

the treatment of purulent acute dacryocystitis due to the risk ofclinical worsening and spread of the infection.

• However, there is a growing interest in the role of transcanalicularendoscopic laser-assisted dacryocystorhinostomy and nasalendoscopic surgery for the management of this type of infection.

• This allows simultaneous diagnosis and treatment of the nasal abnormality underlying the infection (nasal septum deviation, middle turbinate hypertrophy, or chronic ethmoid sinusitis.

• Recent studies show that endoscopic technique can be treatment of choice from the start, since it is more effective than conservative treatment and achieves earlier resolution of the condition than with external dacryocystorhinostomy (3.4±1 and 8.3±1.3 days, respectively)

Cahill KV, Burns JA. Management of acute

dacryocystitis in adults. Ophthal Plast

Reconstr Surg. 1993;9:38–41.

Wu W, et al.: Primary treatment of acute dacryocystitis

by endoscopic DCR with silicone intubation guided by a

soft probe. Ophthalmology 2009.

Acu

te D

acro

cyst

itis

: Ch

ildre

n• In the particular case of pediatric patients with acute

dacryocystitis, there is an association with a higher rate of intranasal mucocele, preseptal cellulitis and retrobulbarabscesses.

• Intubation of the nasolacrimal duct, hospital admission and the use of intravenous antibiotics have been recommended.

• Given this risk, of systemic spread in up to 17.5% of patients who undergo intubation prior administration of systemic antibiotics 24h before surgery is recommended.

Jones LT,Wobig JL, eds.: Surgery of the eyelids and lacrimal system.

Birmingham, AL: Aesculapius Publishing Co, 1976: 185–93.

Walland MJ, Rose GE. Soft tissue infections after open lacrimal

surgery. Ophthalmology. 1994;101:608–11.

Man

agem

ent:

Ch

ron

ic

Dac

rocy

stit

is• Management of chronic dacryocystitis varies according to the

age of patients.

• In adults, it has been proposed that patients with lacrimalsac swelling and suspicion of obstruction of the lacrimaldrainage system associated with tear stones should betreated conservatively; using lacrimal sac massage andlacrimal irrigation until symptoms improve, reserving surgeryfor cases refractory to these techniques.

• If surgery is planned, studies recommend the use ofprophylactic antibiotics for dacryocystorhinostomy especiallyin patients who have had prior episodes of mucocele,mucopyocele, or acute dacryocystitis.

Ch

ron

ic D

acro

cyst

itis

: Ped

iatr

ic

Pati

ent

• If clinical signs are suggestive of congenital nasolacrimal ductobstruction, being the patient less than 12 months of age,conservative treatment is recommended as more than 90% ofthese patients experience spontaneous resolution.

• Early surgery (nasolacrimal intubation) should be indicated if thepatient associates a dacryocele or episodes of acute dacryocystitis.Between 12 and 18 months of age nasolacrimal probing isrecommended.

• Patients between 18 and 36 months could benefit of nasolacrimaldilation or intubation.

• Patients older than 3 years of age, dacryocystorhinostomy isindicated. Antibiotic prophylaxis during or after surgery is notessential, unless the patient has mucopurulent collection inconjunctival sac after expression of the lacrimal sac.

There are four markings at10 mm intervals.• When the first mark at 10 mm

approaches the punctum, tip ofthe probe enters the lacrimal sac.

• As 20 mm approaches thepunctum, tip of the probe is at thelevel of the upper end of thenasolacrimal opening.

• As 30 mm approaches thepunctum, tip of the probe is atvalve of Hasner.

• Beyond 30 mm probe is in thenasal cavity, in the inferior meatus.

• At 40 mm tip of the probe is onthe floor of the nose, which givesan indication to stop furtherprobing.

• Probing was first practiced by Anel in 1713 and popularized by Bowman in 1857.

• Probing is indicated between 6 months and 13 months of age.

Pro

bin

g

Wh

at if

Pro

bin

g Fa

ils?

Takahashi, Y., Kakizaki, H., Chan, W. O. and Selva, D. (2010), Management of congenital nasolacrimal duct obstruction. Acta Ophthalmologica, 88: 506–513.

Silic

on

Tu

be

Intu

bat

ion

Takahashi, Y., Kakizaki, H., Chan, W. O. and Selva, D. (2010), Management of congenital nasolacrimal duct obstruction. Acta Ophthalmologica, 88: 506–513.

Surg

ical

Op

tio

ns •DCR

ExternalEndonasal

•Conjunctivodacryocystorhinostomy (CDCR)

•Minimal Invasive Lacrimal SurgeryBalloon Dacroplasty9mm Balloon assisted DCR

•Dacryocystorhinostomy (DCR) introduced by Totiin 1904 is a lacrimal drainage operation in which a fistula is created between the lacrimal sac and the nasal cavity in order to bypass an obstruction in the nasolacrimal duct.

• The procedure can be performed via an external skin incision (external DCR) or through the nose (endoscopic DCR), either under local anesthesia, with or without intravenous sedation, or under general anesthesia.

DC

R

Exte

rnal

DC

R• Indications

1. Chronic epiphora due to a nasolacrimal duct obstruction

2. Recurrent or chronic dacryocystitis

3. Failed probings and silicone intubations in a child

4. Proposed intraocular surgery in the presence of nasolacrimal duct obstruction

•Contraindications

1. Acute dacryocystitis

2. Malignant lacrimal sac tumor

Exte

rnal

DC

RSurgical Procedure

The operation consists of four parts:

1. Skin incision, retraction of the wound, and exposure of the lacrimal fossa

2. The osteotomy

3. The mucosal flaps and stent placement

4. The wound closure

Exte

rnal

DC

R: I

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Exte

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DC

R: L

and

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Exte

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DC

R: O

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Exte

rnal

DC

R: O

steo

tom

y

Extent of osteotomy should be as follows:Posteriorly: Till lamina papyracea.Superiorly: At or slightly above level of MPL.Anteriorly and Inferiorly: As much as possible

Exte

rnal

DC

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d

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lap

s

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rnal

DC

R: F

lap

Clo

sure

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DC

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ns

Modifications in DCR:1) Single flap: There seems to be no difference in outcome of

the surgery if the posterior flaps are excised and only theanterior flaps are sutured.

2) Mitomycin C: Use of Mitomycin C, an anti-proliferative agentin a concentration of 0.2 to 0.4 mg/ml of has been reportedincrease the success rate of DCR to around 95%.The techniqueinvolves placing a sponge soaked in Mitomycin C over theanastomosed posterior flaps and osteotomy site for 30 minutes.

Serin D,et al. External Dacryocystorhinostomy: Double-Flap Anastomosis or Excision of the Posterior Flaps. Ophthal Plastic and Reconst Surg; 23(1) 28–31.

Liao SL, Kao SCS, Tseng JHS, Chen MS, Hou PK. Results of intraoperative mitomycin C application in dacryocystorhinostomy. Br J Ophthalmol 2000;84:903–906.

Exte

rnal

DC

R: M

od

ific

atio

ns

3) Silicone tube intubation: Bicanalicular silicone tubeintubation is useful in cases with associated canalicularstenosis, post traumatic nasolacrimal duct obstruction andtreating previously failed DCR. The use of silicone intubationalong with DCR has reportedly increased the success rate to95%. Kashkouli MB, Parvaresh MM, Modarreszadeh M, Hashemi M, Beigi B.

Factors affecting the success of external dacryocystorhinostomy. Orbit2015; 22(4): 247-55.

Exte

rnal

DC

R: M

od

ific

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ns

4) Fistulectomy: In cases of fistula formation additionalfistulectomy is required with DCR. Sometimes infected lacrimalsac along with necrotic tissue is to be extensively removed andsuch cases require lacrimal intubation along with DCR to makesure that the newer tract remains patent. Systemic antibioticsare essential to prevent relapse.

Exte

rnal

DC

R: C

om

plic

atio

ns

Early complications include wound dehiscence, wound infection, tube displacement, excessive rhinostomy crusting and intranasal synechiae.

Exte

rnal

DC

R: C

om

plic

atio

ns

Intermediate complications include granulomas at therhinostomy site, tube displacements, intranasal synechiae,punctal cheese-wiring, prominent facial scar andnonfunctional DCR.

Exte

rnal

DC

R: C

om

plic

atio

ns

Late complications include rhinostomyfibrosis, webbed facial scar, medialcanthal distortion, and failed DCR.

1. Fistula formation2. Lacrimal abscess3. Orbital cellulitis4. Meningitis5. Cavernous sinus thrombosis

RA

RE

SEQ

UEL

AE

End

on

asal

DC

RThe operation consists of four parts:

1. The fashioning of a nasal mucosal flap

2. The osteotomy

3. The opening of the lacrimal sac and the creation of anterior and posterior flaps

4. The manipulation and replacement of the nasal mucosal flap and placement of the silicone stent

End

on

asal

DC

R: M

uco

sal F

lap

End

on

asal

DC

R: O

steo

tom

y

End

on

asal

DC

R: L

acri

mal

Fla

p

End

on

asal

DC

R: I

ntu

bat

ion

End

on

asal

DC

R

End

on

asal

DC

R: P

ost

Op

Car

e • Irrigation of the nose at least twice a day to remove driedclots and debris for a minimum period of 2 weekspostoperatively.

• Steroid nasal spray and a decongestant nasal spray nasal areprescribed for 5 days.

• Gentle syringing of the lacrimal drainage system isundertaken 1 week following the surgery.

• Endoscopic examination to remove excessive intranasaldebris.

• Stent removed in clinic endoscopically 6 to 8 weekspostoperatively.

• Topical or systemic antibiotics are only used in patients whohave had previous dacryocystitis or who are diabetic orimmuno- compromised.

Lase

r as

sist

ed E

nd

on

asal

DC

R• In an attempt to achieve precise bone removal with

meticulous hemostasis, the laser DCR was developed andfirst described by Massaro et al in 1990.

• The Ho:YAG laser fibers have multiple use specification andthis can potentially reduce the cost per procedure. Themajor disadvantage is the splattering of tissue with soiling ofthe lens, requiring frequent cleaning and more collateraldamage when compared with the KTP laser.

• The KTP/532 with its star-pulse mode is most suitable as itvaporizes the bone effortlessly and without splattering. Themajor disadvantage of the KTP is that the optical fiber ismarketed for single use and therefore the cost per procedurefor these lasers is significantly higher.

Lase

r as

sist

ed E

nd

on

asal

DC

R• Literature reports success rates for the various

lasers of around 60–80%.

• Conventional DCR has better surgical outcomethan Endonasal DCR with laser because of awider bony opening and it obviates the thermaldamage caused by the laser which producesmore fibrosis and occlusion at the rhinostomysite.

Weber, et al. Atlas of Lacrimal Surgery, Springer, 2009.

End

on

asal

DC

R: A

dva

nta

ges

1. Short operating time (30 to 45 min)

2. Minimal postoperative morbidity

3. Minimal disruption of adjacent structures

4. No cutaneous scarring

5. High patient acceptance

6. Easy revision surgery

7. Ideal for the patient with a bleeding diathesisor who is using anti-coagulants

8. Nasal pathology can be treated simultaneously

•Conjunctivodacryocystorhinostomy (CDCR) isthe creation of a passage for drainage oftears from the conjunctival culde-sac, at themedial canthus, to the middle meatus of thenose.

•To maintain the patency, a pyrex glass orother tube is inserted in the fistula.

•The procedure was first described by LesterJones in 1965, and the standard glass tubesare named Jones tubes.

Co

nju

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ivo

dac

ryo

cyst

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ino

sto

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(CD

CR

)

Co

nju

nct

ivo

dac

ryo

cyst

orh

ino

sto

my

(CD

CR

)

• Literature reports over 90% of patients free of symptoms of watering after insertion of the Jones tube.

• Tube extrusion, malposition or migration is the most common complication after surgery. The rate may be as high as 50% or more of the patients.

• The high rate of complications, maintenance, and secondary procedures required may cause dissatisfaction even in patients with a successful functioning CDCR.

Co

nju

nct

ivo

dac

ryo

cyst

orh

ino

sto

my

(CD

CR

)

Zilelioglu G, Gündüz K.Conjunctivodacryocystorhinostomy with Jones tube. A 10-year study. Doc Ophthalmol. 1996-1997; 92(2):97-105.

Smar

t Pr

ob

e

Bal

loo

n D

acro

pla

sty

• Balloon dacryoplasty is a term used for a set of minimally invasivelacrimal procedures that utilizes specially designed balloons,targeted at different points in the lacrimal system for a wide rangeof indications.

• Balloons were first used by Becker and Berry in 1989.• A 2 mm balloon is used for patients less than 30 months of age and

3 mm for children more than 30 months of age. Also available are4mm and 5mm balloons.

• The indications of balloon dacryoplasty for CNLDOs are: Failed probing Failed intubation Older children (> 12 months of age) Down’s syndrome or any syndromic association with CNLDO.

Bal

loo

n D

acro

pla

sty

9m

m B

allo

on

ass

iste

d D

CR

• Primary endoscopic DCR using the 9 mm nasal balloon catheter is a goodalternative to an external or endoscopic DCR. It was introduced and popularizedby Silbert DI.

• The advantages of this procedure include: Reduced operative trauma Less bleeding Faster and less time consuming No need for powered endoscopic instruments Less postoperative morbidity Early rehabilitation High success rates.

• Balloon dacryoplasty for CNLDO is a very effective treatmentmodality.

• The success rates range from 76% to 83% in various largecase series.

• The results of primary endoscopic 9 mm balloon DCR’s inadults in long term are also appearing to be quiteencouraging. Silbert DI in a large case series of 97 patientsshowed a success rate of 92%.

Bal

loo

n D

acro

pla

sty:

Res

ult

s

Silbert DI, Matta NS. Outcomes of 9 mm balloon-assisted

endoscopic dacryocystorhinostomy: retrospective review

of 97 cases. Orbit. 2010.

Yuksel D, Ceylan K, Erden O, et al. Balloon dilatation for

treatment of congenital nasolacrimal duct obstruction. Eur

J Ophthalmol. 2005.

End

on

asal

DC

R: W

hat

's N

ew? Combined Transcanalicular Endonasal Diode Laser Dacryocystorhinostomy

85.4% of 125 cases had complete resolution of their symptoms. The functional success ratedecreased to 67.7% at 6 months, to 63.3% at first year, and to 60.3% at second year, while thepatency of the lacrimal drainage system was restored in 93.1%, 74.6%, 69.5%, and 68.2% of thecases, respectively.

CONVENTIONAL TEACHING CURRENT SCENARIO

The

DC

R C

on

un

dru

m: E

xter

nal

or

End

on

asal • There is an overall result favoring external DCR with a success rate

of 84% (897/1068) for END-DCR and 87% (863/993) for EXT-DCR,but when (Endonasal with Drill) EM-DCR and (Endonasal with Laser)EL-DCR are separately compared to EXT-DCR, the success rates ofEM-DCR are comparable to EXT-DCR (87%; 624/714), while theresults of EL-DCR (77%; 273/354) clearly favor EXT-DCR.

• The metanalysis recommends Endonasal DCR with mechanical drillas the procedure of choice among the three.

Orbit, 2015

Co

ncl

usi

on

Sum

mar

y• Dacrocystitis is an important disease that an

ophthalmologist may come across often in dailypractice.

• It is direct relationship with cataract surgeryoutcome and hence needs to be timely diagnosedand managed.

• CNLDO is an important cause of dacrocystitis inchildren and can be easily managed with propercare.

Sum

mar

y• Silicon tube intubation can be used in cases of failed

probing.• In adults DCR is an effective way to manage

dacrocystitis. The scale is tipping towardsendoscopic approach but external DCR is still thegold standard.

• Newer modalities like balloon dacroplasty can betried in children where probing fails and adultpatients who prefer cosmesis.

Dacrocystitis: Diagnosis and Management

Health & Medicine

Transcript of Dacrocystitis: Diagnosis and Management