A 52-year-old woman presents with a 3-week history of purulent discharge from the left eye, persistent epiphora, and swelling below the medial canthus. On examination, there is a tender, erythematous swelling over the lacrimal sac region. Pressure over the lacrimal sac elicits purulent material from the lacrimal punctum. The patient denies recent trauma or systemic illness. What is the most likely diagnosis?

## Clinical Diagnosis: Acute Dacryocystitis ### Key Clinical Features **Key Point:** Acute dacryocystitis presents with the classic triad of epiphora, purulent discharge, and swelling below the medial canthus. The patient's presentation is pathognomonic for acute dacryocystitis: - **Epiphora** (excessive tearing) — due to nasolacrimal duct obstruction - **Purulent discharge** from the lacrimal punctum — indicates bacterial infection of the lacrimal sac - **Tender, erythematous swelling** below the medial canthus — localized inflammation of the lacrimal sac - **Positive lacrimal sac pressure test** — purulent material expressed from the punctum confirms sac involvement ### Pathophysiology 1. Nasolacrimal duct obstruction (congenital or acquired) 2. Stasis of lacrimal secretions within the sac 3. Secondary bacterial colonization (commonly *Staphylococcus aureus*, *Streptococcus pneumoniae*, or anaerobes) 4. Acute inflammation and abscess formation ### Diagnostic Criteria | Feature | Acute Dacryocystitis | Canaliculitis | Lacrimal Gland Dacryoadenitis | |---------|----------------------|---------------|------------------------------| | **Location of swelling** | Below medial canthus (lacrimal sac) | Along canaliculus (medial lid margin) | Upper lateral orbit | | **Discharge character** | Purulent from punctum | Mucoid/granular, may contain concretions | Serous or mucoid | | **Tender mass** | Over lacrimal sac | Along canalicular course | Upper lateral orbit | | **Systemic signs** | Common (fever, malaise) | Minimal | Mild to moderate | **Clinical Pearl:** The lacrimal sac pressure test (Regnier's test) is highly specific — expression of pus from the punctum when pressure is applied over the lacrimal sac confirms sac pathology and rules out canaliculitis (where discharge is granular and does not express from punctum). ### Management Approach ```mermaid flowchart TD A[Acute Dacryocystitis Suspected]:::outcome --> B{Systemic toxicity?}:::decision B -->|Yes| C[Hospitalize, IV antibiotics]:::action B -->|No| D[Outpatient management]:::action C --> E[Broad-spectrum IV antibiotics]:::action D --> F[Topical + oral antibiotics]:::action E --> G[Warm compresses, analgesics]:::action F --> G G --> H{Resolution in 48-72 hrs?}:::decision H -->|Yes| I[Continue antibiotics, arrange probing/DCR]:::action H -->|No| J[Incision & drainage of abscess]:::urgent J --> K[Definitive: Dacryocystorhinostomy DCR]:::action ``` **High-Yield:** Acute dacryocystitis requires systemic antibiotics (not topical alone) because the infection is within the lacrimal sac, not on the ocular surface. Topical antibiotics serve as adjunctive therapy only. ### Treatment 1. **Acute phase:** - Systemic antibiotics (oral amoxicillin-clavulanate or fluoroquinolone; IV cefazolin if hospitalized) - Topical antibiotics (fluoroquinolone drops) - Warm compresses and analgesics - NSAIDs for anti-inflammatory effect 2. **If abscess forms or no improvement in 48–72 hours:** - Incision and drainage (I&D) of the abscess 3. **Definitive management:** - Dacryocystorhinostomy (DCR) — surgical creation of a fistula between lacrimal sac and nasal cavity to bypass the obstructed nasolacrimal duct - Performed after acute infection resolves (typically 2–4 weeks later) **Mnemonic: DACRY** — **D**ischarge (purulent), **A**cute swelling, **C**anthus (medial), **R**egnier's test positive, **Y**et (systemic antibiotics needed). [cite:Khurana Comprehensive Ophthalmology 7e Ch 5]