Bilateral acute lacrimal sac abscess in a newborn infant
Dhan Krishna Sen
Department of Ophthalmology, Maulana Azad Medical College and associated Guru Nanak Eye Centre, New Delhi, India
Department of Ophthalmology, Maulana Azad Medical College and associated Guru Nanak Eye Centre, New Delhi
Sen DK. Bilateral acute lacrimal sac abscess in a newborn infant.Indian J Ophthalmol 1984;32:25-27
Sen DK. Bilateral acute lacrimal sac abscess in a newborn infant. Indian J Ophthalmol [serial online] 1984 [cited 2021 Jan 15 ];32:25-27
Available from: https://www.ijo.in/text.asp?1984/32/1/25/27363
Although large series of cases of chronic dacryocystitis in infancy have been recorded in the literature[1],[2] acute dacryocystitis during the first year of life has been observed only rarely[3]. The incidence of acute dacryocystitis at or shortly after birth is all the more rare and its main complication, formation of lacrimal sac abscess, is exceptional.
The case reported here is of interest be­cause acute dacryocystitis occurred on the day of birth, it was bilateral, and the condition quickly progressed to form lacrimal sac abscess on both the sides at the same time.
A female infant was brought to our out= patient department on the fifth day after birth with a red and acutely inflamed swelling near the inner canthus of each eye. Her mother and other relatives had observed the red inflamed swelling on both the sides on the day of birth of the infant. Delivery was at a remote village with a history of prolonged and difficult labour but the delivery was unaided. The parents on their own tried some home remedies which gave no relief and the swell­ing and the redness rapidly increased on both the sides. On examination. The infant was full-term and well-nourished. A tense fluctuating acute inflammatory swelling was found in the region of the lacrimal sac on both the sides; there was oedema and erythema of the adjoining skin and eyelids [Figure 1]. The size of the lacrimal sac abscess was 1.5X1.0 cm on the right and 1.5X 1.5 cm on the left side. The child was having fever and mild con­stitutional disturbances. Preauricular and neck glands were not palpable. Examination of the nasal cavity showed no abnormality and no discharge. The mother was advised to get the infant admitted to the hospital immediately but she returned with the infant only after two days and by that time the skin overlying the abscess had become completely necrotic on both the sides [Figure 2]. The child was immediately put on Erythromycin orally.
As the abscesses were on the verge of ruptur­ing the pus was drained by a small incision on both the sides. The wounds were dressed with a broad-spectrum antibiotic. Bacteriological investigations of pus revealed the growth of staphylococcus aureus and streptococcus viridans. The acute inflammation gradually resolved and on eighteenth day after birth both the nasolacrimal ducts were probed with a solid probe, 0.4 mm in diameter, under open ether general anaesthesia. A block at the lowermost end of the nasolacrimal duct was found on both the sides .-1iich offered con­siderable resistance. The block appeared to be caused by a membrane which could be per­forated only by rubbing the tip of the probe against a periosteal elevator introduced into the inferior meatus of the nasal cavity beneath the anterior tip of the inferior turbinate. Pre­sence of the tip of the probe in the nasal cavity was confirmed by direct visualisation using a nasal speculum and a head lamp. It was immediately followed by syringing with air through lower canaliculus. Thereafter, the infant was treated with antibiotic drops and massage. There was no regurgitation on pre­ssure over the region of the lacrimal sac but epiphora persisted on both the sides. The pro­bing was repeated after a period of one month which cured the condition. The child was followed-up for a period of four years. There was no epiphora or any other complaint.
Mayou[4] in 1908 reported 8 cases of lac­rimal abscess in infants. Thereafter, only a few reports of isolated cases appeared in the literature until 1961 when Ffooks[5] reported a small series of 7 cases. Amongst the cases of lacrimal sac abscess published there were only two cases where the condition was bil­ateral. In the case described by Riser[1] the con­dition occurred at the age of 2 weeks but the child was brought for treatment at the age of 2 months and in the case reported by Blankstein[6] the condition occurred again at the age of 2 weeks but the child was presented for treatment only at the age of 29 months. In the patient reported here acute dacryocystitis occurred on the day of birth and quickly pro­gressed to form acute lacrimal sac abscess; occurrence of the condition on both the sides at the same time is another interesting feature; and moreover, the infant was brought for treatment within the first week after birth.
Travia[7] believes that acute dacryocystitis is accompanied by the poor health of the infant. However, this infant was full-term, well nourished, and otherwise healthy.
In cases of chronic dacryocystitis in infants one usually defers probing upto the age of 4 to 6 months and treats the child conservatively with the hope that spontaneous opening of the nasolacrimal duct may occur by that age. However, the cases of acute dacryocystitis with or without the formation of lacrimal abscess should be placed in a different category from treatment point of view. In these cases we do not lose time with conserva­tive treatment and prefer to probe the nasolacrimal duct under systemic antibiotic coverage as soon as the signs and symptoms of acute inflammation subside with antibiotic therapy; because the condition may be dif­ficult to cure by a simple procedure like prob­ing if it is delayed much after the first acute attack and a major surgery like dacryocys­torhinostomy may be required to achieve a cure[6]. If the first probing fails or if symptoms persist as happened in this case, the probing can be safely repeated 3 to 4 times at the inter­val of 1 to 2 months before a decision to do dacryocystorhinostomy is taken. While prob­ing a mucous membrane causing the block at the lowermost end of the nasolacrimal duct may get stretched giving a false impression that the membrane is perforated and the probe has entered the nasal cavity. We, therefore, always aim at direct visualisation of the end of the probe in the nasal cavity, but if it proves to be difficult then we introduce another solid probe of large diameter into the inferior meatus of the nose beneath the anterior tip of the inferior turbinate and elicit metal-to-metal contact.
Riser[1] and Zentmayer[8] advocated probing without a general anaesthesia by wrapping the child in a sheet of cloth and holding the head forcibly but our experience is that a general anaesthesia is necessary for a safe and satisfactory probing of the nasolacrimal duct.
A case of bilateral acute dacryocystitis beginning on the day of birth and quickly pro­gressing-to from acute lacrimal abscess on both the sides is reported. The infant was brought for treatment within a week after birth. Complete recovery followed incision and drainage of the lacrimal abscesses under systemic antibiotic coverage and probing of the nasolacrimal ducts. Role of early probing of the nasolacrimal duct in cases of acute dac­ryocystitis has been discussed.
1 Riser, R.O., 1935, Amer. J. Ophthalmol., 18:1116.
2 Hooks, O.C., 1962, Brit. J. Ophthalmol., 46:422.
3 Radnot, M. and Bolts, S., 1971, The Lacrimal Sys­tem. Proc. First Internat. Symp. ed. Veirs, E.R., C.V. Mos­by, Saint Louis, p. 126.
4 Mayou, M.S., 1908, Lon. Ophthalmol. Hosp., 17:246.
5 Hooks, O.O., 1961, Brit. J. Ophthalmol., 45:562.
6 Blankstein; S.S., 1952, Arch. Ophthalmol., 48:322.
7 Travia, A., 1967, Ann. Ottal., 93:583.
8 Zentmayer, W.,-1937, Arch. Ophthalmol., 17:1152.