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Dacrocystitis: Diagnosis and Management

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This seminar outlines modalities to diagnose and manage dacrocystitis.

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Dacrocystitis: Diagnosis and Management

  1. 1. Dacrocystitis: Diagnosis and Management Presented By: Dr Sahil Thakur Moderated By: Dr Amit Raj
  2. 2. Introduction • Dacryocystitis is commonly encountered by an ophthalmologist accounting for 87% of epiphora, which causes social embarrassment due to chronic watering from eyes. • It commonly affects females over 40 years of age with peak incidence in 60 to 70 years. • It has higher incidence among people of lower socioeconomic status. • The prevalence of chronic dacryocystitis in cataract population has been reported as 6.6%. It has also been reported as an important cause of endophthalmitis thus it is imperative to evaluate the patient for this condition before surgery. Thomas R, Thomas S, Braganza A, Muliyil J. Evaluation of the role of syringing prior to cataract surgery. Indian J Ophthalmol 1997;45:211-4 Mal R, Banerjee AR, Biswas MC, Mondal A, Kundu PK, Sasmal NK. Clinico bacteriological study of chronic dacryocystitis in adults.J Indian Med Assoc. 2008.
  3. 3. SchematicsofSeminar • Anatomy • Dacrocystitis: Definition/ Types • Risk Factors • Etiology • Clinical Tests • Imaging • Management Outline for Acute/Chronic Dacrocystitis • Surgical Options • Recent Advances • Conclusion
  4. 4. Anatomy
  5. 5. Dacrocystitis:Definition • Dacryocystitis is an infection of the lacrimal sac, secondary to obstruction of the nasolacrimal duct at the junction of lacrimal sac. • The term derives from the Greek dákryon (tear), cysta (sac), and -itis (inflammation). • Signs and symptoms may differ according to the etiology of the clinical picture. • Under normal conditions, the mucosa of the lacrimal sac is highly resistant to infection. However, infections of the tear duct may develop, triggered by functional problems. • Although there are several causes, the main mechanism for the occurrence of dacryocystitis is distal obstruction of the nasolacrimal duct, which leads to the retention of tears and detritus at the bottom of the conjunctival sac at the level of the lacrimal sac. • A “critical mass” of bacteria may be reached, overwhelming the anti- infection response of the lacrimal sac mucosa, leading to an acute or chronic infection.
  6. 6. Dacrocystitis:Classification Dacrocystitis Acquired Congenital Acute Chronic Acute on Chronic
  7. 7. AcuteDacrocystitis • Acute dacryocystitis consists of inflammation of the lacrimal sac, in general caused by infection. This pathology is predominantly found in adult women, while it is also relatively common in young infants. • The most notable common signs and symptoms are reddening, oedema and the presence of a painful area of induration overlying the nasolacrimal sac, specifically just below the anatomical boundary of the medial canthal ligament. • Epiphora and discharge may also be observed. In particular, when pressure is applied to the inflamed tear duct, purulent material may be expressed through the lacrimal punctum. • Frequently, patients may present conjunctivitis and preseptal cellulitis. Rarely, the infection extends beyond the septum, and causes orbital cellulitis.
  8. 8. ChronicDacrocystitis • This is more common than acute dacryocystitis and there are several stages of presentation: Catarrhal: there is intermittent conjunctival hyperaemia and epiphora, with mucoid discharge that is normally sterile. Lacrimal sac mucocele: stagnant tears collect and there is dilation of the lacrimal sac, with mucoid content. Chronic suppurative: epiphora and chronic conjunctivitis are observed, with erythema of the lacrimal sac. There is reflux of purulent material with pressure, and microorganisms are often isolated.
  9. 9. DacrocystitisinChildren • Dacryocystitis is rare in children and, when it occurs, it is almost always associated with congenital nasolacrimal duct obstruction. It has been reported that up to 6% of healthy newborns have this type of obstruction but, of these, only 2.9% develop acute dacryocystitis. • The rate is around 60% in those with congenital dacryocoele. • The diagnosis is clinical and must be differentiated from preseptal cellulitis and mucocele, by the presence of hardening, inflammation and/or hyperaemia at the level of the medial canthal ligament, associated with the presence of mucopurulent material that drains through the lacrimal punctum and epiphora.
  10. 10. RiskFactors •Most common risk factor is Nasolacrimal duct obstruction. •Higher rates of both acute and chronic dacryocystitis have been reported among women even 70% in some case series. •Upto 28.6% have associated nasal pathology like DNS, rhinitis, inferior turbinate hypertrophy. •Dacroliths seen in 6 to 18 % patients undergoing DCR. These have been shown to have a relationship with makeup/cosmetics and Candida hyphae. Pinar-Sueiro, S., Sota, M., Lerchundi, TX. et al. Curr Infect Dis Rep (2012) 14: 137. doi:10.1007/s11908-012-0238-8
  11. 11. Etiology • Staphylococcus aureus and Streptococcus pneumoniae being the most common among Gram-positive and Haemophilus influenzae, Serratia marcescens and Pseudomonas aeruginosa among Gram-negative bacteria. • Anaerobic microorganisms have been isolated in as many as 15.7% of the positive cultures, in some studies, the most common genus being Bacteroides (5.7%). • As for fungi, they have been reported to be present in 4% to 7% of cases, the most commonly isolated genus being Candida, although Aspergillus and Mucor may also be found.
  12. 12. Pinar-Sueiro, S., Sota, M., Lerchundi, TX. et al. Curr Infect Dis Rep (2012) 14: 137. doi:10.1007/s11908-012-0238-8
  13. 13. ClinicalTests To evaluate patient for dacrocystitis we need to perform the following tests: 1. Examination of adnexa and puncta 2. ROPLAS 3. Snap back test/ Pinch test and Examination of Lids 4. Fluorescein Dye Disappearance Test 5. Tear Film Break up Time 6. Jones Dye Test 7. Syringing and Probing 8. Schirmer’s Test ASSESS LACRIMAL DYSFUNCTION ASSESS LACRIMAL DRAINAGE FUNCTION AND PATENCY ASSESS LEVEL OF OBSTRUCTION ASSESS TEAR PRODUCTION
  14. 14. ROPLAS • Technique: The anterior lacrimal crest is identified by tracing the inferior orbital margin medially and superiorly. The index finger is then directed behind the crest and used to apply pressure on the sac area in an upward and medial direction so as to express the contents of the lacrimal sac into the conjunctiva. Any reflux of fluid or purulent material from the puncta is noted. • ROPLAS has a sensitivity of 88.9% and specificity of 99.0% as compared to syringing when used for cataract patients. Thomas R, Thomas S, Braganza A, Muliyil J. Evaluation of the role of syringing prior to cataract surgery. Indian J Ophthalmol 1997;45:211-4
  15. 15. FluoresceinDyeDisappearance Test
  16. 16. Schirmer’sTest
  17. 17. SyringingTest Syringing Pressure Syringing
  18. 18. IMAGING The following imaging modalities are available to us that further supplement the clinical tests: •Dacryocystography (DCG) •Nuclear lacrimal scintigraphy •Computed Tomography (CT) •Magnetic Resonance Imaging (MRI)
  19. 19. DCG • Dacryocystography is an anatomical investigation and is indicated if there is a block on syringing in the lacrimal system, and thus it can help in creating an image of how the internal anatomy of the lacrimal system looks. • Indications of DCG: 1. Complete obstructions: the size of the sac determination of the exact location of an obstruction (common canaliculus, sac) 2. Incomplete obstructions and intermitent tearing: location of the stenosis; diverticuli; stones; and no anatomical pathology (functional disorders) 3. Failed lacrimal surgery: size of the sac 4. Suspicion of sac tumors, traumatic injury to the face
  20. 20. DCG Radiological Criteria of Lacrimal Pathology: 1. Regurgitation of (radio-opaque) fluid into the conjunctival sac (retention of fluid, absence of fluid in the nose, fluctuation of lumen of lacrimal system) 2. Irregularity in contrast 3. Cystic dilation and aneurysm 4. Deformation and drawing of the lacrimal sac
  21. 21. NuclearLacrimalScintigraphy •Nuclear lacrimal scintigraphy is a simple, non- invasive physiological test that evaluates patency of the lacrimal system. •Scintigraphy uses a radiotracer (technetium-99m pertechnetate), which is very easily detectable with a gamma camera.
  22. 22. CTScan •CT is required in the following situations: 1. Following trauma 2. To evaluate a patient with a suspected lacrimal sac malignancy 3. To evaluate the infant with a medial canthal mass
  23. 23. MRIandMRDCG • Magnetic resonance imaging combined with contrast agent offers many advantages over other imaging studies. Here lacrimal system is not cannulated and is not under increased hydrostatic pressure, which gives a true functional status of nasolacrimal drainage system. • Gadolinium is used as topical solution (1:10–1:100 in normal saline)—one drop per minute for 5 minutes. • MRI is reserved in cases where tumors are suspected. ADVANTAGE
  24. 24. Management:Acute Dacrocystitis • In adults, the most widely recommended treatment for the management of people with acute dacryocystitis consists of the application of heat with massage, systemic antibiotics (oral or intravenous administration, as appropriate) and percutaneous abscess drainage. • On the other hand, for cases that course with a clear abscess, drainage by puncture and aspiration of the lacrimal sac seems to be the technique of choice for treatment, as well as for the diagnostic information it provides. • Sometimes it is not possible to drain sufficient mucopurulent material from the sac, leading to recurrent and prolonged inflammation, the formation of lacrimal cutaneous fistulae adjacent to the medial canthal ligament, and of fibrous and granulation tissue in the lacrimal sac.
  25. 25. Management:Acute Dacrocystitis • Classically, surgical intervention has not been considered an option for the treatment of purulent acute dacryocystitis due to the risk of clinical worsening and spread of the infection. • However, there is a growing interest in the role of transcanalicular endoscopic laser-assisted dacryocystorhinostomy and nasal endoscopic surgery for the management of this type of infection. • This allows simultaneous diagnosis and treatment of the nasal abnormality underlying the infection (nasal septum deviation, middle turbinate hypertrophy, or chronic ethmoid sinusitis. • Recent studies show that endoscopic technique can be treatment of choice from the start, since it is more effective than conservative treatment and achieves earlier resolution of the condition than with external dacryocystorhinostomy (3.4±1 and 8.3±1.3 days, respectively) Cahill KV, Burns JA. Management of acute dacryocystitis in adults. Ophthal Plast Reconstr Surg. 1993;9:38–41. Wu W, et al.: Primary treatment of acute dacryocystitis by endoscopic DCR with silicone intubation guided by a soft probe. Ophthalmology 2009.
  26. 26. Pinar-Sueiro, S., Sota, M., Lerchundi, TX. et al. Curr Infect Dis Rep (2012) 14: 137. doi:10.1007/s11908-012-0238-8
  27. 27. AcuteDacrocystitis:Children • In the particular case of pediatric patients with acute dacryocystitis, there is an association with a higher rate of intranasal mucocele, preseptal cellulitis and retrobulbar abscesses. • Intubation of the nasolacrimal duct, hospital admission and the use of intravenous antibiotics have been recommended. • Given this risk, of systemic spread in up to 17.5% of patients who undergo intubation prior administration of systemic antibiotics 24h before surgery is recommended. Jones LT,Wobig JL, eds.: Surgery of the eyelids and lacrimal system. Birmingham, AL: Aesculapius Publishing Co, 1976: 185–93. Walland MJ, Rose GE. Soft tissue infections after open lacrimal surgery. Ophthalmology. 1994;101:608–11.
  28. 28. Pinar-Sueiro, S., Sota, M., Lerchundi, TX. et al. Curr Infect Dis Rep (2012) 14: 137. doi:10.1007/s11908-012-0238-8
  29. 29. Management:Chronic Dacrocystitis • Management of chronic dacryocystitis varies according to the age of patients. • In adults, it has been proposed that patients with lacrimal sac swelling and suspicion of obstruction of the lacrimal drainage system associated with tear stones should be treated conservatively; using lacrimal sac massage and lacrimal irrigation until symptoms improve, reserving surgery for cases refractory to these techniques. • If surgery is planned, studies recommend the use of prophylactic antibiotics for dacryocystorhinostomy especially in patients who have had prior episodes of mucocele, mucopyocele, or acute dacryocystitis.
  30. 30. ChronicDacrocystitis:Pediatric Patient • If clinical signs are suggestive of congenital nasolacrimal duct obstruction, being the patient less than 12 months of age, conservative treatment is recommended as more than 90% of these patients experience spontaneous resolution. • Early surgery (nasolacrimal intubation) should be indicated if the patient associates a dacryocele or episodes of acute dacryocystitis. Between 12 and 18 months of age nasolacrimal probing is recommended. • Patients between 18 and 36 months could benefit of nasolacrimal dilation or intubation. • Patients older than 3 years of age, dacryocystorhinostomy is indicated. Antibiotic prophylaxis during or after surgery is not essential, unless the patient has mucopurulent collection in conjunctival sac after expression of the lacrimal sac.
  31. 31. Pinar-Sueiro, S., Sota, M., Lerchundi, TX. et al. Curr Infect Dis Rep (2012) 14: 137. doi:10.1007/s11908-012-0238-8
  32. 32. There are four markings at 10 mm intervals. • When the first mark at 10 mm approaches the punctum, tip of the probe enters the lacrimal sac. • As 20 mm approaches the punctum, tip of the probe is at the level of the upper end of the nasolacrimal opening. • As 30 mm approaches the punctum, tip of the probe is at valve of Hasner. • Beyond 30 mm probe is in the nasal cavity, in the inferior meatus. • At 40 mm tip of the probe is on the floor of the nose, which gives an indication to stop further probing. • Probing was first practiced by Anel in 1713 and popularized by Bowman in 1857. • Probing is indicated between 6 months and 13 months of age. Probing
  33. 33. WhatifProbingFails? Takahashi, Y., Kakizaki, H., Chan, W. O. and Selva, D. (2010), Management of congenital nasolacrimal duct obstruction. Acta Ophthalmologica, 88: 506–513.
  34. 34. SiliconTubeIntubation Takahashi, Y., Kakizaki, H., Chan, W. O. and Selva, D. (2010), Management of congenital nasolacrimal duct obstruction. Acta Ophthalmologica, 88: 506–513.
  35. 35. SurgicalOptions •DCR External Endonasal •Conjunctivodacryocystorhinostomy (CDCR) •Minimal Invasive Lacrimal Surgery Balloon Dacroplasty 9mm Balloon assisted DCR
  36. 36. •Dacryocystorhinostomy (DCR) introduced by Toti in 1904 is a lacrimal drainage operation in which a fistula is created between the lacrimal sac and the nasal cavity in order to bypass an obstruction in the nasolacrimal duct. •The procedure can be performed via an external skin incision (external DCR) or through the nose (endoscopic DCR), either under local anesthesia, with or without intravenous sedation, or under general anesthesia. DCR
  37. 37. ExternalDCR • Indications 1. Chronic epiphora due to a nasolacrimal duct obstruction 2. Recurrent or chronic dacryocystitis 3. Failed probings and silicone intubations in a child 4. Proposed intraocular surgery in the presence of nasolacrimal duct obstruction • Contraindications 1. Acute dacryocystitis 2. Malignant lacrimal sac tumor
  38. 38. ExternalDCR Surgical Procedure The operation consists of four parts: 1. Skin incision, retraction of the wound, and exposure of the lacrimal fossa 2. The osteotomy 3. The mucosal flaps and stent placement 4. The wound closure
  39. 39. ExternalDCR:Incision
  40. 40. ExternalDCR:Landmarks
  41. 41. ExternalDCR:Osteotomy
  42. 42. ExternalDCR:Osteotomy Extent of osteotomy should be as follows: Posteriorly: Till lamina papyracea. Superiorly: At or slightly above level of MPL. Anteriorly and Inferiorly: As much as possible
  43. 43. ExternalDCR:Lacrimaland NasalMucosaFlaps
  44. 44. ExternalDCR:FlapClosure
  45. 45. ExternalDCR:Modifications Modifications in DCR: 1) Single flap: There seems to be no difference in outcome of the surgery if the posterior flaps are excised and only the anterior flaps are sutured. 2) Mitomycin C: Use of Mitomycin C, an anti-proliferative agent in a concentration of 0.2 to 0.4 mg/ml of has been reported increase the success rate of DCR to around 95%.The technique involves placing a sponge soaked in Mitomycin C over the anastomosed posterior flaps and osteotomy site for 30 minutes. Serin D,et al. External Dacryocystorhinostomy: Double-Flap Anastomosis or Excision of the Posterior Flaps. Ophthal Plastic and Reconst Surg; 23(1) 28–31. Liao SL, Kao SCS, Tseng JHS, Chen MS, Hou PK. Results of intraoperative mitomycin C application in dacryocystorhinostomy. Br J Ophthalmol 2000;84:903–906.
  46. 46. ExternalDCR:Modifications 3) Silicone tube intubation: Bicanalicular silicone tube intubation is useful in cases with associated canalicular stenosis, post traumatic nasolacrimal duct obstruction and treating previously failed DCR. The use of silicone intubation along with DCR has reportedly increased the success rate to 95%. Kashkouli MB, Parvaresh MM, Modarreszadeh M, Hashemi M, Beigi B. Factors affecting the success of external dacryocystorhinostomy. Orbit 2015; 22(4): 247-55.
  47. 47. ExternalDCR:Modifications 4) Fistulectomy: In cases of fistula formation additional fistulectomy is required with DCR. Sometimes infected lacrimal sac along with necrotic tissue is to be extensively removed and such cases require lacrimal intubation along with DCR to make sure that the newer tract remains patent. Systemic antibiotics are essential to prevent relapse.
  48. 48. ExternalDCR:Complications Early complications include wound dehiscence, wound infection, tube displacement, excessive rhinostomy crusting and intranasal synechiae.
  49. 49. ExternalDCR:Complications Intermediate complications include granulomas at the rhinostomy site, tube displacements, intranasal synechiae, punctal cheese-wiring, prominent facial scar and nonfunctional DCR.
  50. 50. ExternalDCR:Complications Late complications include rhinostomy fibrosis, webbed facial scar, medial canthal distortion, and failed DCR. 1. Fistula formation 2. Lacrimal abscess 3. Orbital cellulitis 4. Meningitis 5. Cavernous sinus thrombosis RARESEQUELAE
  51. 51. EndonasalDCR The operation consists of four parts: 1. The fashioning of a nasal mucosal flap 2. The osteotomy 3. The opening of the lacrimal sac and the creation of anterior and posterior flaps 4. The manipulation and replacement of the nasal mucosal flap and placement of the silicone stent
  52. 52. EndonasalDCR:MucosalFlap
  53. 53. EndonasalDCR:Osteotomy
  54. 54. EndonasalDCR:Osteotomy
  55. 55. EndonasalDCR:LacrimalFlap
  56. 56. EndonasalDCR:Intubation
  57. 57. EndonasalDCR
  58. 58. EndonasalDCR:PostOpCare • Irrigation of the nose at least twice a day to remove dried clots and debris for a minimum period of 2 weeks postoperatively. • Steroid nasal spray and a decongestant nasal spray nasal are prescribed for 5 days. • Gentle syringing of the lacrimal drainage system is undertaken 1 week following the surgery. • Endoscopic examination to remove excessive intranasal debris. • Stent removed in clinic endoscopically 6 to 8 weeks postoperatively. • Topical or systemic antibiotics are only used in patients who have had previous dacryocystitis or who are diabetic or immuno- compromised.
  59. 59. LaserassistedEndonasalDCR • In an attempt to achieve precise bone removal with meticulous hemostasis, the laser DCR was developed and first described by Massaro et al in 1990. • The Ho:YAG laser fibers have multiple use specification and this can potentially reduce the cost per procedure. The major disadvantage is the splattering of tissue with soiling of the lens, requiring frequent cleaning and more collateral damage when compared with the KTP laser. • The KTP/532 with its star-pulse mode is most suitable as it vaporizes the bone effortlessly and without splattering. The major disadvantage of the KTP is that the optical fiber is marketed for single use and therefore the cost per procedure for these lasers is significantly higher.
  60. 60. LaserassistedEndonasalDCR • Literature reports success rates for the various lasers of around 60–80%. • Conventional DCR has better surgical outcome than Endonasal DCR with laser because of a wider bony opening and it obviates the thermal damage caused by the laser which produces more fibrosis and occlusion at the rhinostomy site. Weber, et al. Atlas of Lacrimal Surgery, Springer, 2009.
  61. 61. EndonasalDCR:Advantages 1. Short operating time (30 to 45 min) 2. Minimal postoperative morbidity 3. Minimal disruption of adjacent structures 4. No cutaneous scarring 5. High patient acceptance 6. Easy revision surgery 7. Ideal for the patient with a bleeding diathesis or who is using anti-coagulants 8. Nasal pathology can be treated simultaneously
  62. 62. •Conjunctivodacryocystorhinostomy (CDCR) is the creation of a passage for drainage of tears from the conjunctival culde-sac, at the medial canthus, to the middle meatus of the nose. •To maintain the patency, a pyrex glass or other tube is inserted in the fistula. •The procedure was first described by Lester Jones in 1965, and the standard glass tubes are named Jones tubes. Conjunctivodacryocystorhinostomy (CDCR)
  63. 63. Conjunctivodacryocystorhinostomy (CDCR)
  64. 64. Conjunctivodacryocystorhinostomy (CDCR)
  65. 65. •Literature reports over 90% of patients free of symptoms of watering after insertion of the Jones tube. •Tube extrusion, malposition or migration is the most common complication after surgery. The rate may be as high as 50% or more of the patients. •The high rate of complications, maintenance, and secondary procedures required may cause dissatisfaction even in patients with a successful functioning CDCR. Conjunctivodacryocystorhinostomy (CDCR) Zilelioglu G, Gündüz K.Conjunctivodacryocystorhinostomy with Jones tube. A 10-year study. Doc Ophthalmol. 1996-1997; 92(2):97-105.
  66. 66. SmartProbe
  67. 67. BalloonDacroplasty • Balloon dacryoplasty is a term used for a set of minimally invasive lacrimal procedures that utilizes specially designed balloons, targeted at different points in the lacrimal system for a wide range of indications. • Balloons were first used by Becker and Berry in 1989. • A 2 mm balloon is used for patients less than 30 months of age and 3 mm for children more than 30 months of age. Also available are 4mm and 5mm balloons. • The indications of balloon dacryoplasty for CNLDOs are:  Failed probing  Failed intubation  Older children (> 12 months of age)  Down’s syndrome or any syndromic association with CNLDO.
  68. 68. BalloonDacroplasty
  69. 69. 9mmBalloonassistedDCR • Primary endoscopic DCR using the 9 mm nasal balloon catheter is a good alternative to an external or endoscopic DCR. It was introduced and popularized by Silbert DI. • The advantages of this procedure include:  Reduced operative trauma  Less bleeding  Faster and less time consuming  No need for powered endoscopic instruments  Less postoperative morbidity  Early rehabilitation  High success rates.
  70. 70. • Balloon dacryoplasty for CNLDO is a very effective treatment modality. • The success rates range from 76% to 83% in various large case series. • The results of primary endoscopic 9 mm balloon DCR’s in adults in long term are also appearing to be quite encouraging. Silbert DI in a large case series of 97 patients showed a success rate of 92%. BalloonDacroplasty:Results Silbert DI, Matta NS. Outcomes of 9 mm balloon-assisted endoscopic dacryocystorhinostomy: retrospective review of 97 cases. Orbit. 2010. Yuksel D, Ceylan K, Erden O, et al. Balloon dilatation for treatment of congenital nasolacrimal duct obstruction. Eur J Ophthalmol. 2005.
  71. 71. EndonasalDCR:What'sNew? Combined Transcanalicular Endonasal Diode Laser Dacryocystorhinostomy 85.4% of 125 cases had complete resolution of their symptoms. The functional success rate decreased to 67.7% at 6 months, to 63.3% at first year, and to 60.3% at second year, while the patency of the lacrimal drainage system was restored in 93.1%, 74.6%, 69.5%, and 68.2% of the cases, respectively.
  72. 72. CONVENTIONAL TEACHING CURRENT SCENARIO
  73. 73. TheDCRConundrum:Externalor Endonasal • There is an overall result favoring external DCR with a success rate of 84% (897/1068) for END-DCR and 87% (863/993) for EXT-DCR, but when (Endonasal with Drill) EM-DCR and (Endonasal with Laser) EL-DCR are separately compared to EXT-DCR, the success rates of EM-DCR are comparable to EXT-DCR (87%; 624/714), while the results of EL-DCR (77%; 273/354) clearly favor EXT-DCR. • The metanalysis recommends Endonasal DCR with mechanical drill as the procedure of choice among the three. Orbit, 2015
  74. 74. Conclusion
  75. 75. Conclusion
  76. 76. Summary • Dacrocystitis is an important disease that an ophthalmologist may come across often in daily practice. • It is direct relationship with cataract surgery outcome and hence needs to be timely diagnosed and managed. • CNLDO is an important cause of dacrocystitis in children and can be easily managed with proper care.
  77. 77. Summary • Silicon tube intubation can be used in cases of failed probing. • In adults DCR is an effective way to manage dacrocystitis. The scale is tipping towards endoscopic approach but external DCR is still the gold standard. • Newer modalities like balloon dacroplasty can be tried in children where probing fails and adult patients who prefer cosmesis.

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