  Case of the Week - Patient Summary 5937
Peer Reviewed and Certified - |
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| Demographics: 43 y.o. woman |
| History & Chief complaint: |
43 y/o female with 1 month history of purluent d/c from left tear puncta
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| Physical exam and Laboratory: |
Purulent dicharge and tearing from left tear puncta
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| Summary of Findings: |
Enlargement of bony canal of left nasolacrimal duct with central fluid attenuation and non-calcified sepations. Peripheral enhancement of left canthus/nasolacrimal duct region. No calcification of canal. Canthal findings only, no other preseptal or postseptal involvement
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| Differential Diagnosis: |
Dacrocystitis (dacrocystocele) with or without orbital involvement.
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| Diagnosis: |
 Dacrocystitis
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| Confirmed by: Clinical response to antibiotics with resolution of epiphora |
| Treatment and Followup: |
Oral antibiotics (IV antibiotics if orbit is involved) with repeat imaging as clinically indicated. Probe placement in duct if antibiotic therapy alone proves inadequate.
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Dacrocystitis, or inflammation/infection of the lacrimal drainage system, can produce tearing and ocular injection. Gentle pressure over the lacrimal sac evokes pain and reflux of mucus or puss from the tear puncta. Dacrocystitis typically occurs after obstruction of the lacrimal system. It is treated with topical and systemic antibiotics, followed by probing surgery to reestablish patency. Complete (90%) or incomplete (10%) obstruction of the nasolacrimal system can occur. The most common site of obstruction is the junction of the lacrimal sac and nasolacrimal duct. The second most common site of obstruction is the common canaliculs. Less frequently, obstruction occurs within the lacrimal sac. Various factors cause obstruction, including congenital stenosis inflammatory processes, trauma, foreign bodies and tumors.
Inflammatory obstruction can result in a filling defect in the canaliculi or obstructed nasolacrimal sac on dacrocystography. Filling defects can result from a mycotic concretion from Actinomyces Israeli or simply an air bubble in the lacrimal sac. Fistulae and diverticula of the canaliculi or lacrimal sac are usually the result of longstanding obstruction, remaining until adequate drainage is restored. Chronic dacrocystitis may result in formation of an abscess-like dacrocystocele. A dacrocystocele may show more peripheral enhancement, demonstrating a “walled-off” appearance.
Imaging is useful for demonstration of extent of disease, for evaluation orbital involvement. In this case, there was no involvment of post-septal structures, a vision threatening complication.
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