4-Week Old Infant With Unilateral Ocular Pain and Swelling

August 22, 2011

The parents of a previously healthy 4-week-old girl brought her to the ED on the recommendation of a pediatric ophthalmologist who had seen her several hours earlier. Concern centered on a bluish pimple at the corner of the child’s left eye that had appeared 2 days earlier. The mother had applied warm compresses and tried to gently manipulate the pimple, but it had not improved. The eye became swollen and the infant had become increasingly irritable and fussy.

The parents of a previously healthy 4-week-old girl brought her to the ED on the recommendation of a pediatric ophthalmologist who had seen her several hours earlier. Concern centered on a bluish pimple at the corner of the child’s left eye that had appeared 2 days earlier. The mother had applied warm compresses and tried to gently manipulate the pimple, but it had not improved. The eye became swollen and the infant had become increasingly irritable and fussy.

In the ED, the child’s temperature was normal and she had no symptoms of a respiratory infection. The parents said she had not vomited or had diarrhea and there had been no change in her feeding habits. Her past medical history included dacryostenosis, which had been diagnosed during the first follow-up pediatrician visit after birth. The condition was managed with supportive care (ie, warm compresses) and gentle digital manipulation of the lacrimal gland. The left lacrimal sac was swollen and erythematous and there was a 0.5 x 1-cm area of induration overlying the nasolacrimal sac (Figure). The left sclera and conjunctiva appeared normal without icterus, injection, or discharge. The right eye was not affected.

The ophthalmologist’s report described a purulent yellow discharge from the left lacrimal duct that was not seen in the ED. No sample had been taken for culture. The ophthalmologist recommended empiric antibiotic therapy.

There was no preauricular or cervical lymphadenopathy, no nasal discharge, and mucous membranes were moist. The remainder of the physical examination was normal.

Laboratory studies found an elevated CRP level of 2.5 mg/dL (normal range, <0.5 mg/dL). CBC values were normal, with no evidence of lymphocytosis or bandemia. A blood sample was sent for culture.

What's Your Diagnosis?

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ANSWER:  Acute dacryocystitis likely secondary to dacryostenosis.  

A clinical diagnosis of acute dacryocystitis likely secondary to dacryostenosis was made in the ED. The most common organisms isolated from children with acute dacryocystitis include alpha-hemolytic Streptococci, Staphylococcus epidermidis, and Staphylococcus aureus.1,2 Based on suspicion of the causative organisms, the known prevalence of MRSA in the local community, and the potential for serious complications (abscess formation, cavernous sinus thrombosis, sepsis, and death) the patient was admitted for IV clindamycin therapy. Blood cultures were monitored for bacteremia.2,3

On day 2 of antibiotic therapy, swelling and erythema had significantly decreased and the child was resting more comfortably. She remained afebrile. Warm compresses were applied to facilitate drainage from the affected eye. After 48 hours of negative blood cultures, the child was switched to a 10-day course of oral clindamycin to be continued at home. Final results of blood culture were negative after 7 days. The parents were instructed to follow up with a pediatric ophthalmologist after completion of the antibiotic therapy for further evaluation and nasolacrimal probing. 

Acute Dacryocystitis
Bacterial infection secondary to prolonged obstruction of the nasolacrimal duct is usually responsible for the inflammation of the mucous and submucous membranes of the nasolacrimal sac. The common isolates are Staph epidermidis followed by Staph aureus.1,4 Acute dacryocystitis is characterized by sudden onset of signs of discomfort and a warm, erythematous swelling of the area overlying the lacrimal sac. Inflammation is generally most pronounced over the lower lid near the bridge of the nose.1,2 Other common findings include fever (not seen in this patient), epiphora, purulent discharge from the puncta, and a palpable mass just below the medial canthal tendon.5 Anecdotally, the condition has been described more frequently on the left side, although the reason for this is not well understood.

The infection may occasionally extend to the surrounding connective tissue and cause periorbital cellulitis. Case reports of serious complications of untreated acute dacryocystitis include extension into the orbit with abscess formation, sepsis, meningitis, blindness, cavernous sinus thrombosis, and death.2,3 

Selection of treatment depends on the clinical picture, but should include hospitalization for IV antibiotics and close monitoring.6  Warm compresses can help facilitate drainage. Probing of the nasolacrimal duct has been shown to be safe and successful for treating dacryocystitis and underlying dacrostenosis.7 The risk of recurrence is decreased if the procedure is done after antibiotic therapy is completed.1
 

 

References:

References

1. Faden HS. Dacryocystitis in children. Clinical Pediatrics. 2006;45:567-569.

2. Robb RM. Nasolacrimal duct obstruction in children. Focal Points. 2004;22:1-10.

3. Baskin DE, Reddy AK, Chu YI, Coats DK. The timing of antibiotic administration in the management of infant dacryocystitis. J AAPOS. 2008;12:456-459.

4. Brook I, Frazier EH. Aerobic and anaerobic microbiology of dacryocystitis. Am J Ophthalmol. 1998;125:552-4.

5. Fooks O. Dacryocystitis in infancy. Br J Ophthalmol. 1962;46:422-434.

6. Campolattaro BN, Lueder GT, Tychsen L. Spectrum of pediatric dacryocystitis: medical and surgical management of 54 cases. J Pediatr Ophthalmol Strabismus. 1997;34:143-153.

7. Pollard ZF. Treatment of acute dacryocystitis in neonates. J Pediatric Ophthalmol Strabismus. 1991;28:341-343.