CHRONIC DACRYOCYSTITIS CASE PRESENTATION

By MBBS Gang
PATIENT PARTICULARS
▸ Name: Mrs. XYZ
▸ Age: 40 years [Chronic DC seen in children or 40-60Yrs]
▸ Gender: Female [Chronic DC more common b/c of anatomy of NLD]
▸ Education: 10th standard
▸ Occupation: Home maker
▸ Address: Behind Poorna Prajna College, 5th cross, JP Nagar, Mysore, 570 001
▸ Socio-Economic status: Upper Lower class (Kuppuswamy scale)
▸ DOA: 1/7/2020
▸ DOE: 2/7/2020

CHIEF COMPLAINTS
Watering in the Left eye since the last 6 months
[Epiphora D/D – NLD Obstruction, Rhinitis/Polyp/Stenosis blocking NLD, Foreign
Object in Eye, Ectropion, Entropion, Trichiasis, Blepharitis, Allergic Conjunctivitis,
Keratitis, Reflex Tearing following Dry Eye, Lacrimal Pump Failure]

HISTORY OF PRESENTING ILLNESS

▸Patient was apparently normal 6 months back, later she noticed watering in the
left eye, insidious in onset.
▸ There is no history of any discharge [Note watering vs discharge]
▸There is no history of excoriation over the cheek skin.
▸ There is no other swellings found. [Look medial to inner canthus in lacrimal sac
area – encysted or plain mucocele, parotid gland swelling (Mikulicz Syndrome),
mumps]
▸ There is no history of pain (r/o Acute Inflammation)
▸ There is no history of rhinitis, sinusitis (inflammatory edema at the nasal end of
the nasolacrimal duct)
▸ There is no history of Itching (r/o Allergic Conjunctivitis)
▸ There is no history of redness (Keratitis, Epithelial Defect, Blepharitis)
▸ There is no history of trauma (r/o Canalicular Tear Injury)
▸ There is no history of Fever (r/o Acute DC, Uveoparotid fever)

OCULAR HISTORY
▸There is no history of surgery to the left eye. (Lid repair in canalicular tear)

PAST HISTORY
▸There is no history of similar complaints in the past. (Chronic DC Waxing and
Waning, Recurrence of Chronic DC after Sx
▸Patient is a known case of Diabetes Mellitus on regular medication (Metformin)
▸Patient is a known case of Hypertension on regular medication (Amlodipine)
▸No other chronic illnesses.

FAMILY HISTORY
No history of similar illness.

PERSONAL HISTORY
1. Diet Predominantly vegetarian.
2. Appetite Normal
3. Bowel and Bladder movements Regular
4. Sleep undisturbed
5. Addictions not present
6. Drug allergies not present

GENERAL PHYSICAL EXAMINATION

42 year old lady, who is moderately built and well-nourished is conscious,
cooperative, alert, oriented to time, place and person.
Weight: 70 Kg, Height: 165 cm, BMI: 27.3 Kg/m².
 No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
Vitals:
1. Pulse rate: 65 bpm [High in Acute cause]
2. Blood pressure: 128/80 mmHg measured in left arm, sitting position
3. Respiratory rate: 15 cycles per minute.
4. Temperature: Afebrile [High in Acute cause]

OCULAR EXAMINATION
1. Head posture erect
2. Facial symmetry symmetrical
[Ptosis > Frontalis Muscle overactive > Wrinkles on Forehead
Facial asymmetry- CN7 Palsy, Lacrimal Pump Failure (supplies Lacrimal part of
Orbicularis oculi, which drains tear with help of vavles of Hasner and Rosenmuller)
{check with Fluoroscein Dye}]
3. Ocular posture orthotropic.
Right eye Left eye
1. Visual acuity (Watering > RE
Changed > Blurring of Vision)
Distance vision Counting finger, more Counting finger, more
than 6 than 6
meters meters.
Near vision (know second Normal (or Not Checked) Normal (or Not
sightedness in nuclear cataract- Checked)
index myopia improve !!)
Perception of light (PL) ?? Present (can count Present (can count
fingers) fingers)
Projection of rays (PR) ?? Accurate in all Accurate in all
quadrants quadrants
Pinhole ?? No improvement No improvement
2. Eyebrows - Position Normal Normal
3. Eyelids (r/o blepharitis, Normal Normal (and no
entropion/ectropion, dystriciasis) ectropion/entropion)
Position Normal Normal
Palpebral aperture width Length: 30 mm, Height: Length: 30 mm,
(Lagophthalmos > Reflex tearing 10mm Height: 10mm
in early phase)
4. Lacrimal apparatus
Lacrimal Sac Normal Normal
Punctum (check both) [stenosis, Normal Increased watering
everted, inverted] from the eye is seen.
Skin over lacrimal sac (Scar in Normal Normal
previous DCR, Swelling in
inflammation/mucocele)
Regurgitation Test/ ROPLAS Negative Purulent Discharge
(no regurgitation in encysted
mucocele or pyocele)
Lacrimal gland Normal Normal
5. Eyeball (size, position, Normal Normal
movements of eyeball
uniocular movements, binocular
movements)
Eyelashes Normal Normal
6. Conjunctiva – Palpebral, Bulbar Normal Normal
and Fornices (r/o circumcorneal
congestion vs superficial
conjunctival congestion)
7. Cornea (Size, Shape, Surface, Normal in size (Know Normal in size
Sheen, Transparency) the normal dimensions Shape
!!) Transparency
Shape Regular surface
Transparency Sheen
Regular surface
Sheen (normal tear film,
what is sheen!!)
Purkinje images (1st & 2nd ) seen seen
Corneal Sensations Intact Intact (Both sided
corneal blink on
touching with cotton,
if absent in opposite
side- U/L CN7 palsy)
8. Sclera Normal Normal
9. Anterior chamber Normal depth (shallow Normal depth and
AC intumescent clear content
cataract

Deep AC Zonular

dehiscence,
Aphakia/pseudophakia)

Clear Content (R/O

Hyphema, hypopyon)
10. Iris – Color and Pattern Dark Brown in color (r/o Dark Brown in color
uveitic cataract, Fuchs Normal pattern
Uveitis Syndrome /
Fuchs Heterochromic
Iridocyclitis)
Normal pattern
11. Pupil Central, 3mm Round Central, 3mm Round
and Blackish and Blackish
Reactive to light
(intactness of anterior
visual pathway- good
post op vision
development)
Direct reflex Present briskly reactive Present briskly reactive
Indirect/Consensual reflex Present briskly reactive Present briskly reactive
Near reflex (Know the steps!!) Present (Constriction of Present
pupil, convergence of
eyeball present)
12. Lens – position, shape, color, Normal Normal
transparency

[*Intumescent Cataract with

Chronic DC – Cataract Sx may
cause Endophthalmitis as post-op
complication

First treat Chronic DC, then wait

for 2 weeks and do Cataract Sx]
Purkinje images (3rd & 4th) Seen Seen
13. Ocular Movements [Duction, Free and full in all Free and full in all
Version, Vergences] directions (Know all the directions
names of direction !!)
14. Digital Tonometry Firm and Fluctuant Firm and Fluctuant
(complications of Cataract Sx due (Normal) (Normal)
to high IOP!! )

SYSTEMIC EXAMINATION
1. CVS: S1 and S2 heard.
2. Respiratory system: B/L Normal Vesicular breath sounds heard.
3. CNS: No focal neurological deficits.
4. Per abdomen: Soft and non-tender.
SUMMARY
This is a case of 40 year old lady who is an home maker, a known case of DM and
HTN, who presented with the complaints of watering in left eye since the last 6
months.
PROVISIONAL DIAGNOSIS
After taking the history and doing the ocular examination, probable diagnosis can
be Chronic Dacryocystitis of the left eye, chronic suppurative stage.

DIFFERENTIAL DIAGNOSIS (do quick gross examination of nose)

1. Chronic Dacryocystitis.
2. Foreign Body in NLD.
3. Trauma to NLD or punctum or canaliculi.
4. Nasal Polyps.
5. Deviated Nasal Septum. (Do Septal Sx, this may resolve complains of epiphora)
6. Turbinate hypertrophy.
[Partial or Non-Canalisation of NLD will present at much younger age]

INVESTIGATIONS
Radiological – Macro-dacryo-cystography
MANAGEMENT
1) Chronic:
Syringing (repeated)
Antibiotics – Clindamycin (Mild Case)
Vancomycin, 3rd Gen Ceph (Severe Case)
Partial obstruction – Catheter Balloon Dilatation
Symptoms do not resolve > Go for DCR Sx
Relative C/Is: Old Age, Fibrosed & Shrunken Sac, DNS, Atrophic Rhinitis, HTN
or Deranged Blood Coagulation Profile (increased chance of bleeding),
Granulomatous Diseases (like Syphilis, Leprosy)

Kids:
Probing in Kids
 Less than 9 months – Crigler massage for Congenital NLD Obstruction and
Antibiotics
9 months to 4 years – Membranous obstruction: Do Bowman’s probing and
then syringing
Bony obstruction: Leave the baby and ask him/her to
come back at 3 years for DCR
2) Acute:

Oral Antibiotics
Anti-inflammatory
Analgesics
Hot fermentation

Complications: Fistula formation, Keratitis, Orbital Cellulitis, Mucocele

3) Punctal Stenosis / Common Canalicular Obstruction – Canaliculo-cysto-

rhinostomy
Partial Canalicular Obstruction – Stenting
4) Tube in Inferior Meatus to prevent epiphora after canalicular tear – mini-
Monoka’s stent
Know Jones I and Jones II Test (r/o anatomical obstructions), Syringing
procedure