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Clinicopathologic Reports, Case Reports, and Small Case Series
August 2002

Orbital Cellulitis and Abscess Secondary to Dacryocystitis

Arch Ophthalmol. 2002;120(8):1096-1099. doi:

The symptoms of nasolacrimal duct obstruction include epiphora, conjunctivitis, and mucoid discharge. Dacryocystitis may develop when bacterial overgrowth occurs in the stagnant fluid of the lacrimal sac. Whereas acute dacryocystitis is usually characterized by tender preseptal cellulitis, chronic dacryocystitis typically manifests as painless purulent reflux from the lacrimal sac. Antibiotic therapy is indicated for acute infections, and dacryocystorhinostomy is the definitive treatment.

Although anterior extension into the preseptal soft tissues occurs more often in acute dacryocystitis, orbital extension can occur, although rarely, and result in orbital cellulitis and abscess formation.19 Posterior extension into the orbit can result in devastating visual compromise. We describe a series of 4 patients with orbital cellulitis and abscesses secondary to dacryocystitis (Table 1).

Table 1. Orbital Cellulitis and Abscesses Secondary to Dacryocystitis in 4 Patients 

*DCR indicates dacryocystorhinostomy.
Report of Cases
Case 1

A 38-year-old woman had a history of epiphora for many years but declined surgical treatment. She had 1 previous episode of dacryocystitis that resolved with systemic antibiotics. She sought care because of a 1-week history of painful swelling and decreased vision in her left eye.

On examination, her visual acuity was 20/20 OD and no light perception OS. A left afferent pupillary defect was present. Her left globe was markedly proptotic, tense to retropulsion, and restricted in all fields of gaze. Dilated funduscopic examination revealed hyperemia of the left disc. A computed tomographic scan revealed a medial orbital abscess. No sinus disease was noted.

The patient was started on intravenous cefazolin and gentamicin sulfate. She underwent an emergent orbitotomy with abscess drainage through a medial Lynch incision. Copious amounts of necrotic purulent material were drained. A direct communication was noted between the posterior aspect of the lacrimal sac and the intraconal space. The intraconal abscess was also evacuated. A dacryocystorhinostomy was performed. Cultures grew Staphylococcus aureus. Postoperatively, the patient had resolution of the orbital inflammation and proptosis, but her visual acuity remained no light perception OS.

Case 2

A 64-year-old woman was hospitalized with jaundice, anorexia, and hepatic failure secondary to chronic alcoholism. Two days after admission, swelling of the right upper and lower eyelids was noted. She was afebrile but had a white blood cell count of 22.5 × 103/µL with leukocytosis. Empiric intravenous vancomycin hydrochloride was started by the admitting service. Ophthalmic consultation was obtained.

Her visual acuity was light perception OD. An afferent pupillary defect was present. Marked right proptosis, diminished extraocular motility, chemosis, and conjunctival hyperemia were also noted. Dilated fundus examination showed right choroidal folds and retinal edema. A computed tomographic scan showed a large, irregular mass in the medial and posterior orbit displacing the globe and optic nerve. There was enlargement of the medial rectus muscle and contrast enhancement of the posterior sclera. The bony orbit was intact, and the sinuses were clear.

A differential diagnosis of orbital cellulitis with abscess, idiopathic orbital inflammation, hematogenous dissemination, and malignancy was considered. Intravenous antibiotics were continued with minimal improvement. During the next several days, the patient's medical condition deteriorated due to gastrointestinal bleeding and ascites. Once the patient was medically stable, a medial orbitotomy through a Lynch incision was performed. Upon dissection between the medial and superior recti muscles into the intraconal space, an abscess was encountered surrounding the optic nerve. The abscess was noted to be extending from the area of the lacrimal sac. Purulent material was drained, and a communication with the abscess was identified. Several dacryoliths were removed. An osteotomy into the nasal cavity and a dacryocystorhinostomy with silicone stents were performed. Cultures grew nonenterococcal group D streptococci, Streptococcus viridans, and Streptococcus intermedius. Postoperatively, the patient had resolution of proptosis and improved ocular motility, except for an adduction deficit. Her visual acuity remained light perception OD.

Case 3

A 62-year-old woman sought care from her ophthalmologist with a 5-day history of tearing and swelling of the left upper and lower eyelids. Her ocular history included nasolacrimal obstructive symptoms for many years and prior episodes of dacryocystitis. Oral cephalexin monohydrate (250 mg, 4 times daily) was prescribed. During the next 2 days, she developed proptosis and chemosis of the left eye and was referred for consultation.

Her visual acuity with correction was 20/20 OD and 20/60 OS. A trace left afferent pupillary defect was noted. Marked chemosis and erythema were noted, and 13 mm of relative proptosis was measured. A motility examination showed severely restricted ductions of the left globe. Her intraocular pressure was 19 mm Hg OD and 46 mm Hg OS. Dilated fundus examination showed slight hyperemia of the left nerve. The patient was afebrile but had a white blood cell count of 11.6 × 103/µL with leukocytosis. An orbital computed tomographic scan showed a large medial orbital mass contiguous with the lacrimal sac, suggestive of an abscess. The paranasal sinuses were clear. The patient was hospitalized, and intravenous cefazolin and gentamicin were initiated. Urgent medial orbitotomy through a Lynch incision was performed. The lacrimal sac and the superior aspect of the nasolacrimal duct were found to be grossly dilated and tense. The sac was opened, and copious purulent material was removed and cultured. Three large dark-gray dacryoliths were extracted from the sac. Examination of the sac revealed a fistulous communication extending from the sac into the medial intraconal space. A dacryocystorhinostomy was performed with silicone stents.

During the next several days, the patient showed gradual improvement. Cultures grew S viridans, S intermedius, and Veillonella parvula. Infectious disease consultation recommended 3 weeks of intravenous cefazolin and 1 week of oral cephalexin. Follow-up at 8 weeks after the operation revealed complete resolution of the proptosis, edema, and chemosis. Adduction was nearly full. Visual acuity measured 20/25 OS. A residual left afferent pupillary defect was present with slight pallor of the left optic nerve.

Case 4

A 51-year-old, otherwise healthy man sought care because of a 2-day history of right-sided medial canthal swelling, pain, redness, and tearing. He was previously seen by his internist, who prescribed oral erythromycin stearate. For several weeks before seeking care, he noted intermittent epiphora and swelling that could be relieved with digital massage. His medical history was unremarkable except for a penicillin allergy.

On examination, his visual acuity was 20/20 OU. Medial canthal and lower-eyelid edema and erythema were present. His motility was full, and there was no proptosis. Initial computed tomographic scanning showed an enlarged lacrimal sac and surrounding soft tissue inflammation (Figure 1, A). Intravenous vancomycin and gentamicin were initiated. During the next 2 days, improvement was noted; however, on the third day, when the patient complained of increased pain, his examination showed 3 mm of proptosis, increased resistance to retropulsion, diminished extraocular movements, and marked induration of the medial canthal region. His vision remained 20/20 OU, and no afferent pupillary defect was present. A repeated computed tomographic scan showed marked orbital soft tissue inflammation and a medial orbital abscess (Figure 1, B). Intravenous trovafloxacin mesylate was initiated for improved anaerobic coverage. When no clinical improvement was noted 24 hours later, the patient underwent an endoscopic dacryocystorhinostomy with evacuation of copious purulent material from the lacrimal sac. Silicone stents were also placed. The results of cultures were negative. A lacrimal sac biopsy specimen showed acute and chronic inflammation. Follow-up at 1 week showed intact vision, resolution of edema, full ocular motility, and no proptosis. His stents were removed at 6 months, and his dacryocystorhinostomy was patent.

A, Coronal computed tomographic scan of a 51-year-old, otherwise
healthy man shows dacryocystitis before orbital cellulitis and abscess formation.
Note the proximity of the lacrimal sac to the intraconal space. B, Coronal
computed tomographic scan shows progression to orbital abscess (arrow), indenting
the globe.

A, Coronal computed tomographic scan of a 51-year-old, otherwise healthy man shows dacryocystitis before orbital cellulitis and abscess formation. Note the proximity of the lacrimal sac to the intraconal space. B, Coronal computed tomographic scan shows progression to orbital abscess (arrow), indenting the globe.

Comment

Patients with nasolacrimal duct obstruction seek treatment primarily to relieve symptoms of epiphora, irritation, and mucoid discharge. If obstruction progresses to acute dacryocystitis, pain and swelling of the lacrimal sac region occur, necessitating systemic antibiotics and definitive surgical treatment. In chronic dacryocystitis, patients often obtain temporary relief of symptoms with external decompression of the lacrimal sac. If dacryocystitis is untreated, orbital extension has been reported.19 These cases are summarized in Table 2.

Table 2. Orbital Extension in Patients With Dacryocystitis* 

*NLP indicates no light perception; ellipses, not available.

This study describes our series of 4 patients who developed orbital cellulitis and orbital abscesses arising from dacryocystitis. Of 4 patients, 3 had intraconal spread of the orbital abscess and culture-proven bacterial infections; 3 patients also had prior episodes of dacryocystitis. Each of these findings deserves further discussion.

Most patients with dacryocystitis develop preseptal cellulitis and not orbital extension. This has been attributed to the orbital septum by its insertion on the posterior lacrimal crest, limiting spread to the orbit.5 Several other barriers exist posteriorly, including the lacrimal fascia, the posterior limb of the medial canthal ligament, and deep heads of the pretarsal and preseptal orbicularis muscles (Horner muscle). Because the orbital septum and the medial canthal ligament insert on both the anterior and posterior lacrimal crests, we postulate that the main barrier to posterior extension is the deep heads of the preseptal and pretarsal orbicularis muscles. Hence, the anatomic barriers to prevent egress from the lacrimal sac are greater posteriorly than anteriorly.

Once the posterior barriers of the lacrimal sac have been breached, access to the intraconal space is essentially unimpeded, except for the Tenon fascia and the intermuscular septum. Because of the anterior and inferior location of the nasolacrimal sac in relation to the globe, a channel of communication can form between the medial and inferior rectus muscles directly to the intraconal space. Intraconal abscess formation can lead to rapid vision loss, necessitating urgent surgical intervention.

Although intravenous antibiotics were initiated immediately in all patients, surgical drainage is the definitive treatment. Surgical intervention in all 4 cases consisted of dacryocystorhinostomy with placement of silicone stents and orbital abscess drainage. Of 4 cases, 3 had an external approach, and 1 case had an endoscopic intranasal approach. All patients had a patent dacryocystorhinostomy at the last follow-up visit (range, 2-19 months).

The clinical bacteriological characteristics of dacryocystitis in adults have been studied previously.10 In our series, 2 of 4 patients had polymicrobial infections, 1 patient had a single organism, and 1 had no isolates. When examining the isolates from our series and the previously reported cases from Table 2, we find that, in general, younger patients (<3 years) tended to have single isolates, and older patients tended to have polymicrobial infections. These findings parallel those seen in orbital abscesses secondary to sinus disease.11

In our series, 3 of 4 patients had a prior history of dacryocystitis. In fact, of the reported cases in Table 2, 6 (40%) of 15 had prior dacryocystitis. In addition, 5 (33%) of 15 had dacryoliths, including 2 patients who did not have a prior history of dacryocystitis but had dacryoliths found intraoperatively. We believe that prior dacryocystitis is a risk factor for orbital extension. Distension of the lacrimal sac during episodes of dacryocystitis can stretch the lacrimal sac walls and its posterior barriers (posterior limb of the medial canthal ligament, Horner muscle, and septum). These barriers weaken from distension and cause breaches and rarefaction, increasing the likelihood of posterior spread.

Other causes of orbital cellulitis secondary to dacryocystitis have been postulated.1,2 In 1 case report, the authors speculated that postoperative soft tissue swelling from blepharoplasty might have contributed to the obstruction of an already compromised lacrimal outflow system.2 Other authors have theorized that orbital involvement could have resulted from spread of infection from the lacrimal sac to the ethmoid sinus through the lamina papyracea, with subsequent extension from the sinus to the orbit.1 None of our cases had any evidence of sinus disease, and it is more likely that any sinus opacification seen is secondary to adjacent inflammation from the dacryocystitis or unrelated sinus disease. Other possible causes include hematogenous spread from other systemic sources and, in some cases, a primary orbital cellulitis that can extend into the lacrimal sac without the dacryocystitis necessarily being causal.

In summary, our series of orbital cellulitis and abscess secondary to dacryocystitis has been presented. Orbital cellulitis and abscess can rapidly progress to an intraconal abscess and can cause severe visual sequelae if untreated. Prompt recognition and appropriate surgical management of this condition are necessary to prevent vision loss. Prior dacryocystitis is a risk factor for developing orbital extension, and patients with prior episodes of dacryocystitis who elect not to have a lacrimal bypass operation should bewarned of these potential consequences.

This study was supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, NY.

The views expressed in this article are those of the authors and do not reflect the official policy of the US Army, the Department of Defense, or the US government.

Corresponding author and reprints: Don O. Kikkawa, MD, University of California, San Diego, Department of Ophthalmology, 9415 Campus Point Dr, La Jolla, CA 92093-0946 (e-mail: dkikkawa@ucsd.edu).

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