Minimally Invasive Management of Infantile Dacryocystitis with Lacrimal Abscess: A Case Report

Introduction

Infantile acute dacryocystitis is a relatively rare yet critical condition affecting newborns and infants. Acute dacryocystitis is distinguished by the sudden onset of pain, redness, and acute inflammation of the lacrimal sac. Management of acute dacryocystitis in newborns is challenging, especially in the absence of systemic antibiotics administration and when the lacrimal abscess is extensive. We report the case of a 37-day-old male infant with acute dacryocystitis and lacrimal abscess that was successfully treated with an initial modified decompression and nasolacrimal duct probing approach without systemic antibiotics.

Infantile acute dacryocystitis often results from congenital nasolacrimal duct obstruction (NLDO) due to a failure of canalization of the distal end of the nasolacrimal duct [1]. This can lead to persistence of a membranous web at the level of the Hassner valve [2]. Failure of canalization causes tears and debris to stagnate in the lacrimal sac, creating an ideal environment for bacterial growth and infection [3]. The reported incidence of acute dacryocystitis in infants and congenital lacrimal duct obstruction is 2.9% [4], and clinical diagnosis of infantile acute dacryocystitis is based on typical signs and symptoms. Acute dacryocystitis can progress rapidly, giving rise to serious complications such as lacrimal abscess formation, spontaneous external lacrimal fistula, orbital cellulitis, and even life-threatening sepsis [5,6]. Early intervention is essential to prevent adverse outcomes and ensure optimal recovery in these vulnerable patients.

The management of infantile acute dacryocystitis has been a subject of debate, with different approaches advocated by various pediatric and ophthalmic groups [7,8]. Some have advocated conservative measures involving broad-spectrum antibiotics and analgesics, while others have emphasized aggressive management, including early probing or dacryocystorhinostomy (DCR) [9]. While pre-treatment antibiotics along with probing is the most common and effective method in most cases, the ideal treatment strategy for acute dacryocystitis with giant lacrimal abscess in infants remains challenging in specific clinical scenarios. Giant lacrimal abscess can progress rapidly; therefore, the tension of the super-thin skin needs to be depressed as soon as possible, because delayed treatment can lead to fistula formation or scarring. This report describes a 37-dayold male infant with acute dacryocystitis and lacrimal abscess managed with decompression and nasolacrimal duct probing.

Case Report

A 30-day-old male infant was brought to a local clinic with conjunctivitis, excessive tearing and redness, and a warm mass localized inferiorly to the medial canthus of the right eye. He was diagnosed with acute dacryocystitis and a lacrimal abscess. He had a history of Cesarean section due to dystocia. His other medical history was unremarkable. Culture of the conjunctival sac secretion revealed the growth of methicillin-sensitive Staphylococcus. He received local treatment with tobramycin eye drops and ointment. Despite the initial treatment, his symptoms worsened, and the skin of the lacrimal abscess became thin. One week after the initial treatment, the parent brought the infant to our emergency unit. Upon arrival, he had no purulent drainage or conjunctivitis after 1 week of treated with topical tobramycin, but the fluctuant warm mass in the lacrimal sac area became larger and noticeable. He had no fever and had mild discomfort due to epiphora. The white cell count, C-reactive protein, and procalcitonin levels were within the normal range. The parents declined a head CT and ultrasound examination upon request, as well as the systemic antibiotics administration due to the potential adverse effects in a newborn. Also, the infant’s vital signs were within the normal range, so the parents requested other treatment options. To address the thin skin in the lacrimal sac area, our treatment plan aimed to reduce the tension of the abscess through aspiration from the lacrimal passage without a skin incision.

A decompression and probing procedure was performed, as shown in Figure 1. To begin the intervention, we instilled 0.5% proparacaine hydrochloride eye drops in the affected eye to minimize discomfort throughout the procedure. We then carefully checked the appearance and location of the giant lacrimal abscess with a swaddle wrap restraint with the assistance of an experienced nurse (Figure 1A). Subsequently, we gently inserted an 8-gauge probing syringe with a blunt end and a side hole (Figure 2) into the obstructed canaliculus (upper or lower) to recanalize the lacrimal drainage pathway. Also, the eyelid was pulled toward the temporal side and the lower canalicular cavity was straightened (Figure 1B). This method, together with the blunt-end side-hole probe, avoided the formation of false passages and fistulous tract or the occurrence of other iatrogenic injuries. This step effectively restored the normal physiological function of the lacrimal drainage system. The syringe was carefully connected to facilitate withdrawal of accumulated pus, thereby achieving efficient decompression of the lacrimal sac (Figure 1B). We carefully withdrew the pus present in the lacrimal sac into the syringe, relieving tension and pressure within the sac and the overlying skin. The next stage involved a comprehensive probing procedure to meticulously remove the blockage of the nasolacrimal duct (Figure 1C). This approach ensured the lacrimal drainage pathway was completely restored, reducing the risk of recurrent abscess formation and establishing a functional and patent nasolacrimal duct. The appearance after decompression and probing is shown in Figure 1D.

This procedure led to immediate disappearance of the dacryocystitis and giant lacrimal abscess (Figure 3). The probing was performed through the lower canaliculus. However, the following day, the giant lacrimal abscess reappeared with dark skin. A repeated decompression and probing procedure resulted in resolution of the dacryocystitis and giant lacrimal abscess (Figure 4). On the third day, the dacryocystitis and giant lacrimal abscess had disappeared, with a good esthetic result.

The infant was completely cured (Figure 5) and the lacrimal sac abscess had subsided. The skin recovered and gradually returned to normal color. The symptoms of epiphora disappeared. Follow-up examinations at 2 weeks and 2 months after admission revealed no recurrence of swelling (Figure 5).

Discussion

Dacryocystitis is an infection or inflammation of the lacrimal sac, commonly due to nasolacrimal duct obstruction. It most often affects infants and older adults, presenting as pain, swelling, and redness over the medial canthus, sometimes with purulent discharge. Acute cases are usually treated with antibiotics, while chronic cases may require surgical intervention, such as probing or dacryocystorhinostomy (DCR), to restore normal tear drainage [10].

Infantile acute dacryocystitis is mostly caused by distal congenital NLDO. These obstructions lead to prolonged retention of tears and debris within the lacrimal sac, promoting bacterial growth and infection. Fistula development between the skin and the lacrimal sac is rare. In a case series, 5.6% of patients developed a fistula [2]. The rapid spread of the infection beyond the lacrimal sac can result in an underdeveloped immune response, valveless veins, constricted lacrimal drainage that encourages secretion stagnation, and increased susceptibility to colonization by respiratory pathogens [5]. Staphylococcus and Streptococcus species were the most common pathogens in acute dacryocystitis [10]. In our case, Staphylococcus spp was found to grow in the culture of conjunctival sac secretion, similar to previously reported cases. Systemic antibiotics on Staphylococcus spp were not applied right after the onset of dacryocystitis, which might be the main cause for the rapid progression of the lacrimal abscess.

Various methods have been applied to dacryocystitis to resolve nasolacrimal duct obstruction, including Crigler lacrimal sac compression [5], probing, silicone stenting, balloon catheter dilation, DCR, and open dacryocystectomy [11]. Traditional probing is effective in any cases of infantile dacryocystitis, especially when combined with intravenous antibiotics at an early stage [12]. However, in cases with giant lacrimal abscess, reducing the tension of the lacrimal sac, in addition to reopening the lacrimal drainage system, is crucial. Performing endoscopic or external DCR in infants poses several difficulties due to the limited space within the nasal cavity. In cases with smaller vertical heights, there is an increased risk of cerebrospinal fluid leak. The ongoing anatomical development in infants also contributes to less well-defined anatomical boundaries, increasing the risk of orbital perforation and insufficient exposure of the lacrimal sac, which contributes to a higher failure rate when performed by less experienced practitioners [9]. Additionally, endoscopic DCR requires specific equipment to be performed, which may not be available in all hospitals or clinics. DCR procedures carry a greater risk of complications, including intraoperative hemorrhage, trauma, loss of nasal mucosa, and scarring, further underscoring the need for careful patient selection and experienced surgical expertise in these cases.

Our modified approach demonstrated that decompression of the lacrimal sac through probing and internal drainage of purulent material is an effective and minimally invasive option for giant lacrimal abscesses in infantile acute dacryocystitis. This procedure offers several advantages, as it is safe, quick, easy, and more cost-effective than other surgical procedures. We performed it with a traditional 8-gauge probing syringe with a blunt end and a side hole, which is available in most ophthalmic clinics. This procedure does not require the special surgical instrumentation needed for endonasal DCR [13] nor does it necessitate external skin incisions for drainage. By restoring the normal anatomical structure and physiological function without creating a bypassing lacrimal drainage passage, it provides a more natural and effective solution. Moreover, probing can be performed under local anesthesia with proper restraint, potentially reducing the systemic effects and the cost of treatment under general anesthesia. Throughout the procedure, we maintained a keen focus on preserving the delicate structures in the nasal cavity to prevent any inadvertent damage or complications. In severe cases, the abscess may reappear if the pus drainage was insufficient or there was a recurrence of blockage. In such cases, the procedure can be repeated. In our case, a repeat procedure was needed as the giant abscess reappeared after the initial treatment. Due to the easy and quick procedure and local anesthesia without skin incision or extra scar formation, the parents agreed to a repeat decompression and probing and were satisfied with the outcome, and there was no progression or swelling recurrence. In less severe cases, the one-time procedure is adequate for complete resolution of the lacrimal abscess.

Major factors for successful decompression are selecting appropriate instruments and carefully maneuvering in the obstructed canaliculus and lacrimal sac. In our patient, the eyelid was pulled toward the temporal side and the lower canalicular cavity was straightened for easy access of the probe to the bottom of the lacrimal sac without creating a false passage. The syringe was used to withdraw pus for decompression of the lacrimal sac. In contrast to previous reports, the probing was successful even without visualization under special endoscopic guidance [13,14]. There is ongoing debate about the necessity of pre-operative antibiotics before probing. Ganguly et al [15] advised that routine probing does not warrant antibiotic prophylaxis. As the underlying cause of acute dacryocystitis is usually NLDO, probing serves as a treatment option. Bhawesh et al [12] compared initial surgical approach versus secondary procedure after systemic antibiotics in the acute phase. However, in cases of an infantile acute dacryocystitis, bacteremia occasionally occurs, thus justifying the need for pre-probing antibiotics [16]. Pollard also supported the use for antibiotics, demonstrating a 100% success rate in a series of 25 infants with acute dacryocystitis, none of whom developed post-procedure complications such as sepsis or cellulitis [4]. Administering antibiotic prophylaxis may also reduce the chances of requiring a second procedures in infants experiencing an acute infection [12,13]. In our case, we did not prescribe intravenous antibiotics due to quick recovery and refusal of the parents. Standardized intravenous antibiotics should be administered in cases of suspected orbital cellulitis with fever or when clinical and laboratory findings indicate bacteremia.

Meticulous attention to detail and focus on preserving the delicate anatomical structures during the procedure contributes to its overall safety and success rate. This innovative approach represents a promising alternative to more complex interventions, offering numerous advantages for the treatment of infantile acute dacryocystitis with giant lacrimal abscess. The successful outcomes observed in this case highlight the potential value of this approach in the armamentarium of surgical options for this unique patient population. Limitations of this study include the retrospective nature and the lack of assessment for bacteremia due to quick recovery. Also, our method provides an alternative way to quickly resolve infantile acute dacryocystitis and lacrimal abscess. A more cautious treatment standard involves monitoring vital signs of the infant and performing a head CT to make the differential diagnosis and check for involvement of orbital cellulitis, which is essential to avoid life-threatening complications. Further research and validation through more extensive studies are warranted to consolidate the evidence supporting the effectiveness and safety of this surgical approach. Wherever possible, the use of systemic antibiotics is needed when infection is spreading. The importance of standard and prompt treatment should be explained fully to the parents to get informed consent and cooperation.

Conclusions

Infantile acute dacryocystitis with giant lacrimal abscess is a potentially serious condition. We present the case of a 37-day-old male infant with acute dacryocystitis and a giant lacrimal abscess that was quickly cured with a modified lacrimal sac decompression through probing. The findings of this case will provide clinicians with a valuable alterative for the effective treatment of infantile acute dacryocystitis and giant lacrimal abscess.