An Infant With Redness and Swelling Near the Eye

Ann L. Chou; Kimberly G. Yen, MD

Disclosures

March 19, 2013

Case Diagnosis

This patient's presentation is consistent with dacryocystitis, an infection of the lacrimal sac.

Because the child has no proptosis, signs of motility deficit, or pain on eye movement, orbital cellulitis is not a consideration.

A chalazion would not be located in this area, but closer to the eyelid margin.

Hemangiomas and lymphangiomas would not be associated with tenderness, erythema, and ocular discharge.

Clinical Course

The patient was admitted to the hospital for treatment with intravenous antibiotics. He underwent probing with tubes on the right side in the operating room and was subsequently discharged home on a full course of oral antibiotics. His dacryocystitis resolved, and he returned to the clinic a few months later to have his tubes removed.

Discussion

Dacryocystitis, an infection or inflammation of the lacrimal sac, is most commonly found in infants and children. Patients present with a painful erythematous area over the lacrimal sac region, with mucopurulent discharge. Acute dacryocystitis usually involves sudden onset of tenderness, warmth, and redness and is less common than the chronic form. Chronic dacryocystitis presents in several stages, beginning with stagnant tear collection and bacterial growth in the lacrimal sac and leading to persistent epiphora and reflux of purulent material with pressure.[1]

Nasolacrimal duct obstruction is the typical underlying cause of dacryocystitis; this occurs in the neonate owing to incomplete canalization at the distal end of the nasolacrimal duct. Lack of tear drainage permits retention of tears and debris in the lacrimal sac, resulting in increased susceptibility to infection and accumulation of colonizing bacteria.[1] Gram-positive organisms, such as Staphylococcus aureus and alpha-hemolytic streptococci, are most often isolated in cases of dacryocystitis.[2] Other risk factors for dacryocystitis include female sex, nasal abnormalities, and the presence of dacryoliths.[1]

Although the majority of congenital nasolacrimal duct obstructions resolve spontaneously in infants within the first 6 months of life, some obstructions are persistent. These persistent obstructions can lead to dacryocystitis, which requires immediate treatment to prevent abscesses, draining fistulae, or orbital cellulitis.[3] Treatment involves oral or intravenous antibiotics, followed by a probing and intubation procedure to open the nasolacrimal duct. The drained purulent material may be cultured and used to guide antibiotic therapy.[1,2,3]

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