Dacryocystitis

DACRYOCYSTITIS, dacryocystitis (from Greek dacryon—tear and cystis—bladder), inflammation of the lacrimal sac. From the lacrimal puncta down the flow of tears to the lower opening of the nasolacrimal duct runs a complex and finely segmented system of passages, connecting the conjunctival sac (a kind of basin for tears) with the nasal cavity. Various sections of this pathway can become diseased independently, but in clinical practice, these independent diseases are either initial symptoms or partial manifestations of a more widespread inflammatory process involving the entire lacrimal pathway, with a particularly characteristic symptom complex on the part of the lacrimal sac. Therefore, by dacryocystitis, one must understand a whole series of inflammatory conditions, sometimes acute, sometimes chronic, sometimes more limited, sometimes widespread, united by symptoms of dysfunction of the inflamed lacrimal sac. The lacrimal sac occupies a prominent place in diseases of the lacrimal pathway. Its anatomical structure and position in the form of a diverticulum between two sharp constrictions in the channel of the tear flow, and its activity in the process of tear conduction with the participation of the orbicularis oculi muscle, create favorable conditions for the development of various inflammatory processes within it.

Clinical picture. The earliest, main symptom of an inflammatory condition of the lacrimal pathways is epiphora (illacrimatio, epiphora). It often precedes inflammation, indicating an obstruction in tear conduction, for example in the nasolacrimal duct, which may subsequently lead to changes of an inflammatory nature. Epiphora is initially temporary, appearing and intensifying in the cold, in the wind, or in smoky air, but gradually becomes constant, persistent, and burdensome to the patient. When the tear has a normal character and there are no other external symptoms explaining the epiphora (e.g., facial nerve paralysis, ectropion of the lower eyelid), then one speaks of a narrowing of the nasolacrimal duct (stenosis ductus naso-lacrimalis), and the nature of this narrowing and its location are determined by methodical examination.

The instillation of colored liquids (e.g., fluorescein) into the eye and observation of their appearance in the nose allows, in some cases, for judgment regarding the presence of a narrowing and its degree. Irrigation of the lacrimal pathways using an Anel syringe, the blunt, slightly curved needle of which is inserted through the lower lacrimal punctum into the lacrimal canaliculus (see Figure 1), satisfies this purpose better.

Depending on the presence of a narrowing and its degree, the injected liquid either flows out freely

or does not enter the nose at all, but returns back through the upper lacrimal punctum. Figure 1. Irrigation of the nasolacrimal duct. (From Axenfeld.)

The question of where the obstruction to the flow of tears is located and what it consists of can be answered only by probing, which is simultaneously a therapeutic measure (see below). Probing shows that there are favorite sites for strictures: the place where the lacrimal canaliculi enter the sac and especially the place where the lacrimal sac transitions into the nasolacrimal duct. With a probe, it is partly possible to determine the nature of the obstructions (swollen mucosa, scars), their compliance, the presence of diverticula, and the condition of the bony walls (erosions in them). Recently, roentgenoscopy of the lacrimal passages has been used with success, by first filling them with radiopaque substances (bismuth, barium salts, Thorium anhydricum, iodumbrin, especially lipiodol). On the images, strictures and dilations of the lumen of the lacrimal passages, deviations in their course, etc., appear clearly. Thus, the clinical picture of a stricture of the nasolacrimal duct is usually based on an inflammatory process with changes in the mucous membrane. When, in addition to lacrimation, a new symptom appears—discharge from the lacrimal sac upon pressure on it—then one speaks of dacryocystitis. In catarrhal dacryocystitis, the expressed fluid appears turbid and contains mucus. In purulent dacryocystitis (dacryocystoblennorrhea), the discharge has the character of pus. However, the appearance of the discharge and its quantity can undergo great changes in one and the same patient. Along with the appearance of discharge from the sac, external signs of its disease are noted in the form of swelling in the region of the inner canthus of the eyelids. Painless in chronic dacryocystitis, this swelling can be of various sizes. Often it is barely noticeable, and only the striking appearance of mucus or pus from the lacrimal puncta upon pressure on it indicates its serious significance. In other cases, when the process lasts for years and the walls of the sac have undergone strong stretching from the constant accumulation of pus, the sac protrudes sharply under the skin in the form of a rounded cyst-like tumor, which immediately subsides when the contents of the sac are emptied into the nose or eye by pressure. Sometimes the communication of the lacrimal sac with adjacent parts of the lacrimal passage ceases, and the picture of hydrops sacci lacrimalis is obtained: the sac turns into a painless cyst the size of a pea or a hazelnut, giving a sensation of fluctuation and not changing volume under pressure. Even the mere cessation of normal tear conduction can cause, due to the constant wetting of the skin of the face with tears and due to changes in the flora of the conjunctival sac, a number of changes in the position of the eyelid and in the state of its skin and mucous covering. When the conjunctiva is subjected to constant contamination by pus protruding from the sac with various pathogenic microbes (mainly pneumococci), then persistent blepharitis and conjunctivitis with their consequences are common companions of dacryocystitis. It is known that unilateral chronic blepharoconjunctivitis forces one to pay special attention to the state of the lacrimal sac. Dacryocystitis can also threaten vision (and even the existence of the eyeball) as a source of dangerous infections. All operations on the eyeball are absolutely contraindicated as long as dacryocystitis exists. Minor damage to the epithelial covering of the cornea, e.g., from a foreign body, innocent under normal conditions, acquires fatal significance in the presence of dacryocystitis. The etiological significance of dacryocystitis in the development of pneumococcal corneal ulcer (ulcus corneae serpens). Left to itself, dacryocystitis can last for a long time, proceeding sometimes more covertly, under the guise of stenosis of the nasolacrimal duct, sometimes more overtly, with discharge from the lacrimal sac, with changes in it and surrounding organs. In some cases, however, violent outbreaks of an acute process are observed, rapidly spreading to the skin of the face. This is phlegmonous dacryocystitis (phlegmona sacci lacrimalis), proceeding with a general reaction of the whole organism, with high-degree phlegmonous edema, resembling facial erysipelas. Acute phenomena can resolve without suppuration, and then the disease returns to its previous chronic state. But more often the phlegmon opens (spontaneously or surgically) to the outside, the process quickly subsides; a fistulous communication forms between the sac and the outer coverings, giving free exit to pus to the outside (fistula sacci lacrimalis). After the closure of the fistula, new, repeated outbreaks of phlegmonous inflammation are possible if more normal conditions for the drainage of lacrimal fluid are not restored or if an operation of extirpation of the lacrimal sac or dacryocystorhinostomy (see) is not performed. Sometimes the disease subsides for a long time or permanently, leaving a barely noticeable fistula ("hair" fistula), which can be recognized by a drop of turbid or clear fluid appearing from it upon pressure on the sac. Etiology, pathogenesis, pathological anatomy. Dacryocystitis is far from a rare disease, but its distribution is extremely uneven. Its frequency reaches 3.5-6.5% of the total number of eye patients in some areas of the USSR. Observed very rarely among wealthy individuals living in good hygienic conditions, this disease is especially common among the poor segments of the population, where syphilis, tuberculosis, scrofula, and chronic inflammatory processes in the nose and conjunctiva (trachoma) are common. In view of the location of the lacrimal passages between two cavities opening to the outside (nose and conjunctiva), a painful process, in particular infections, can spread to them, both from the nose and from the eye. The latter source seems most likely; the tear moves from the eye to the nose, and all kinds of pathogens of conjunctivitis can easily be carried by its current into the lacrimal drainage channels. Nevertheless, in acute infectious conjunctivitis caused by Bac. Koch-Weeks [see color plate (vol. VII, art. 303-304), fig. 2], Bac. influenzae, pneumo-, gono-, staphylo- and streptococci, when microbes are carried in masses into the lacrimal passages, complications in the form of dacryocystitis are never observed either during or after the conjunctivitis. The case of Aust with gonorrheal dacryocystitis is the only one in the literature. In chronic infectious conjunctivitis, conditions for infection of the lacrimal sac are more favorable. However, in diplobacillary blepharoconjunctivitis, when the inner angle of the palpebral fissure is affected and the mucosa of the sac comes into close contact with a large number of Bac. Morax-Axenfeld, the lacrimal sac never suffers. In trachoma, dacryocystitis is encountered not infrequently (according to Kuhnt, in 32%). The interpretation of the relationship between trachoma and dacryocystitis causes many disputes. Some authors, like Kuhnt, finding the same changes in the mucosa of the sac as in the conjunctiva, speak of trachoma sacci lacrimalis, of infection of the conjunctiva with trachoma from the side of the primarily affected lacrimal sac. Others are skeptical about trachoma of the lacrimal sac, especially since the mucosa of the sac normally contains follicles; and in dacryocystitis, these follicular formations in the strongly swollen and folded mucosa of the sac are very strongly developed. Thus, with normal patency of the nasolacrimal passages, infectious processes in the conjunctiva do not have a harmful effect on the lacrimal sac. For its disease, a disorder of this patency is necessary, the presence of strictures that stop the natural process of self-cleaning. The starting point for these strictures is usually the nasal cavity, various pathological processes in it. Thus, already in newborns, more often in infants, in the first weeks of their life, dacryocystitis is observed from the closure of the lumen of the nasolacrimal duct by an embryonic membrane or a muco-gelatinous plug. The rupture, the reverse development of this membrane eliminates the dacryocystitis. More serious significance for the lacrimal sac have various chronic processes in the nasal cavity, especially on the basis of syphilis, tuberculosis, and scrofula, chronic inflammatory processes in the nose and in the conjunctiva (trachoma). In view of the location of the lacrimal passages between two cavities opening to the outside (nose and conjunctiva), a painful process, in particular infections, can spread to them, both from the nose and from the eye. The latter source seems most likely; the tear moves from the eye to the nose, and all kinds of pathogens of conjunctivitis can easily be carried by its current into the lacrimal drainage channels. Nevertheless, in acute infectious conjunctivitis caused by Bac. Koch-Weeks [see color plate (vol. VII, art. 303-304), fig. 2], Bac. influenzae, pneumo-, gono-, staphylo- and streptococci, when microbes are carried in masses into the lacrimal passages, complications in the form of dacryocystitis are never observed either during or after the conjunctivitis. The case of Aust with gonorrheal dacryocystitis is the only one in the literature. In chronic infectious conjunctivitis, conditions for infection of the lacrimal sac are more favorable. However, in diplobacillary blepharoconjunctivitis, when the inner angle of the palpebral fissure is affected and the mucosa of the sac comes into close contact with a large number of Bac. Morax-Axenfeld, the lacrimal sac never suffers. In trachoma, dacryocystitis is encountered not infrequently (according to Kuhnt, in 32%). The interpretation of the relationship between trachoma and dacryocystitis causes many disputes. Some authors, like Kuhnt, finding the same changes in the mucosa of the sac as in the conjunctiva, speak of trachoma sacci lacrimalis, of infection of the conjunctiva with trachoma from the side of the primarily affected lacrimal sac. Others are skeptical about trachoma of the lacrimal sac, especially since the mucosa of the sac normally contains follicles; and in dacryocystitis, these follicular formations in the strongly swollen and folded mucosa of the sac are very strongly developed. Thus, with normal patency of the nasolacrimal passages, infectious processes in the conjunctiva do not have a harmful effect on the lacrimal sac. For its disease, a disorder of this patency is necessary, the presence of strictures that stop the natural process of self-cleaning. The starting point for these strictures is usually the nasal cavity, various pathological processes in it. Thus, already in newborns, more often in infants, in the first weeks of their life, dacryocystitis is observed from the closure of the lumen of the nasolacrimal duct by an embryonic membrane or a muco-gelatinous plug. The rupture, the reverse development of this membrane eliminates the dacryocystitis. More serious significance for the lacrimal sac have various chronic processes in the nasal cavity, especially on the basis of syphilis, tuberculosis, and scrofula. Direct spread of the process upward along the nasolacrimal duct, blockage of the lower opening or its lumen by growths, ulcers, bone processes in the nasal process of the maxilla, in the inferior turbinate, in the lacrimal bone, in the anterior cells of the ethmoid labyrinth, cicatricial shrinkage during all these processes and after them, after atrophic rhinitis (ozaena) and other painful changes in the nose easily involve the tear-conducting path, especially the lacrimal sac, in the suffering directly or indirectly. This also explains the appearance of patients with dacryocystitis (broad, flat nose, saddle-shaped bridge of the nose, scrofulous lymphatic habitus), and the frequent bilaterality of the process, its prolonged course, and the failure of conservative therapy in many cases. It is also understandable the variety of pathological-anatomical changes and the uncertainty of bacteriological findings. In ordinary purulent dacryocystitis, the mucosa of the sac turns out to be strongly thickened, infiltrated, covered with thickened epithelium, in places desquamated, in places penetrating deeply in the form of pseudo-glandular depressions and cavities. The mucosa forms deep folds and protrusions, protruding here and there into the lumen of the sac with polypous growths. Among microbes, pneumococcus, various types of staphylococci and streptococci, Bact. coli commune, etc., are most often found.

Sometimes the lumen of the sac is filled with colonies of pneumococcus. In other cases, the wall of the sac is affected by tubercles, granulations protrude into the cavity of the sac, penetrate into the eroded bone, and the matter leads to the formation of a fistula sacci lacrimalis interim. In hydrops sacci lacrimalis, the walls of the sac are thinned, stretched, the folds of the mucous membrane are smoothed out, and the cavity contains a microbe-free, often transparent fluid. Traumatic injuries of the nose, especially wounds during the war, can also be the cause of dacryocystitis. In rare cases, the disease is concentrated in the lacrimal canaliculi, not spreading further to the lacrimal sac, thereby proving once again the predominant importance of the nasal cavity in the pathology of dacryocystitis. Thus, local inflammations with an accumulation of pus are observed in the lacrimal canaliculi; sometimes, with the obliteration of both ends, cystic dilations of them occur. But dacryoliths are especially interesting, dense concretions, most often in the lower canaliculus, formed by masses of the fungus Streptothrix. Previously, this disease was described under the name of actinomycosis of the lacrimal canaliculus, although a true ray fungus was never found in this case. The diagnosis of dacryocystitis is easy if there is discharge from the sac upon pressure on it. If this is not the case, which may be a temporary phenomenon, and if there is no swelling or enlargement of the lacrimal sac, then the main symptom of the disease of the lacrimal passages—epiphora—is carefully studied in order to exclude its causes lying outside these passages. Examination of the entire eyeball, irrigation and probing of the nasolacrimal duct, and rhinological examination clarify the anatomical and etiological diagnosis. In particular, hydrops sacci lacrimalis can be confused with mucocele ethmoidalis; phlegmonous dacryocystitis—with facial erysipelas, with a furuncle. Treatment. First of all, the underlying nasal disease must be eliminated as much as possible. Often this is enough to cure dacryocystitis, but for the most part, it is impossible to do without special treatment of the lacrimal passages. The goal of treatment is the restoration of normal lacrimal conduction between the conjunctival sac and the nasal cavity by eliminating the inflammatory process in the mucous membrane of these passages and stenoses along their course. In mild, non-neglected cases, systematic irrigation and probing give good results. Probing is performed with great caution using Bowman probes or thicker Cooper probes with a gradual transition from thin numbers to thicker ones. The forced dilation of the nasolacrimal duct proposed by Ziegler, and in the USSR by Golovin, using very thick dilators (of the Hegar uterine dilator type), inserted one after another during one operative session, is not yet a common method. Most ophthalmologists still strive to insert probes without any violence, avoiding traumatization of the bones and mucous membrane. The probe is usually inserted through the lower lacrimal canaliculus, and its movement follows the course of the lacrimal passages (see Figure 2).

-% of the canaliculus, direction

If the opening of the canaliculus is narrowed, recourse is had to dilating it with the help of a conical probe. Probing is facilitated even more if the canaliculus is slit with a Weber probe-pointed knife. Only the outer ¹/₄ is slit

wherein Figure 2. Probing of the lacrimal passages: moment.

but towards the lacrimal lake. However, many oculists avoid slitting and probe without it. A probe passed horizontally through the lacrimal canaliculus abuts against the inner wall of the lacrimal sac, then sharply changes its direction to vertical and is carefully advanced downwards along the course of the nasolacrimal duct. The probe is left in place for ¹/₄-¹/₂ hour; this procedure is repeated daily or every other day with a gradual transition to thicker probes. Probing is combined with irrigation of the duct with antiseptic or astringent solutions. In purulent dacryocystitis, probing requires great caution due to the possibility of damaging the wall of the sac or duct and introducing infection into the surrounding tissues (phlegmonous dacryocystitis, inflammation of the orbital cellular tissue). Irrigations and probings alternate, and treatment can drag on for an indefinitely long time. The chances of success are even weaker with dilation of the lacrimal sac, with atony of its walls, when normal lacrimal conduction is impossible even after the elimination of stenoses. Meanwhile, abundant discharge of pus from the sac constantly maintains blepharoconjunctivitis and threatens the eyeball. Recently, attempts have been made to overcome infection in dacryocystitis with the help of Besredka's antivirus, in some cases with success. When prolonged conservative treatment does not lead to the goal, obstacles to lacrimal conduction are insurmountable, the lacrimal sac secretes a lot of pus, especially when there is a lacrimal fistula, bone damage, atony, and hydrops sacci lacrimalis—then the idea of extirpation of the lacrimal sac arises. Under these conditions, removal of the sac is especially indicated in persons who, due to their professional and social position, are particularly exposed to eye injuries and do not have enough leisure time and means to protect the cornea from possible infection by prolonged conservative treatment (workers, farmers). In this regard, extirpation of the sac is a true prophylacticum for ulcus serpens corneae. Finally, this operation is absolutely indicated if it is necessary to perform cataract extraction, iridectomy, or another operation on the eyeball in a patient suffering from dacryocystitis. After extirpation of the lacrimal sac, epiphora often weakens significantly, and sometimes after a few months or years, it ceases altogether. If it continues to exist and greatly burdens the patient, then removal of the glandulae lacrimalis palpebralis is recommended. In recent years, extirpation of the sac is increasingly being replaced by dacryocystorhinostomy (see).