A 68-year-old man with a history of chronic epiphora and recurrent bouts of medial canthal swelling presents with acute onset fever (38.5°C), severe pain over the medial canthus, and inability to open the left eye due to periorbital edema. On examination, there is a fluctuant mass below the medial canthus with overlying skin erythema and cellulitis extending to the upper eyelid. Vision is normal and extraocular movements are intact. Which of the following is the most appropriate immediate management?

Explanation

## Management of Acute Dacryocystitis with Abscess Formation **Key Point:** Acute dacryocystitis complicated by abscess formation requires **immediate incision and drainage** followed by systemic antibiotics and definitive surgical correction. ### Clinical Significance of Abscess Formation The presence of a fluctuant mass indicates pus collection that will not resolve with antibiotics alone. Delay in drainage risks: - Spontaneous rupture with fistula formation - Spread to periorbital tissues (preseptal cellulitis) - Potential orbital cellulitis if medial rectus involvement occurs - Systemic sepsis ### Stepwise Management Algorithm ```mermaid flowchart TD A[Acute Dacryocystitis with Abscess]:::outcome --> B[Incision & Drainage under LA]:::action B --> C[Send pus for culture & sensitivity]:::action C --> D[Start Systemic Antibiotics IV/Oral]:::action D --> E{Clinical improvement in 48-72 hrs?}:::decision E -->|Yes| F[Continue antibiotics for 7-10 days]:::action E -->|No| G[Reassess for orbital involvement]:::urgent F --> H[Warm compresses + topical antibiotics]:::action H --> I[Dacryocystorhinostomy after acute phase resolves]:::action G --> I ``` ### Why Incision and Drainage is Mandatory | Reason | Explanation | |--------|-------------| | **Pus under pressure** | Fluctuant mass indicates collection requiring evacuation | | **Culture & sensitivity** | Guides targeted antibiotic therapy | | **Prevents complications** | Reduces risk of fistula, cellulitis, orbital spread | | **Systemic toxicity** | Fever and periorbital edema indicate significant infection | | **Rapid symptom relief** | Drainage provides immediate decompression | **High-Yield:** The combination of **fever, fluctuance, and periorbital cellulitis** is an absolute indication for surgical drainage. Do NOT rely on antibiotics alone in this scenario. ### Technique 1. Local anesthesia (1% lidocaine with epinephrine) over the medial canthus 2. Small incision (0.5–1 cm) over the fluctuant area 3. Blunt dissection to open the abscess cavity 4. Drain pus for culture 5. Gentle irrigation with normal saline 6. Leave wound open to drain or place a small wick **Clinical Pearl:** Even after successful drainage, **definitive dacryocystorhinostomy is required** to prevent recurrence, as the underlying nasolacrimal duct obstruction remains. **Mnemonic: ABSCESS** — Antibiotics (systemic), Bacterial culture, Systemic signs (fever), Cellulitis (periorbital), Evacuation (I&D), Surgical drainage, Subsequent dacryocystorhinostomy [cite:Khurana 6e Ch 9]