Snapshot A 47-year-old woman presents to the emergency department with severe eye pain. Approximately 3 days ago, she experienced a hit to the face by a football. She feels a mass around her eye that is warm and painful to the touch. Physical examination demonstrates an enlarged mass over the nasolacrimal sac that is erythematous and tender to palpation. Introduction Overview inflammation of the nasolacrimal sac can be acute, chronic, or congenital congenital dacrocystitis carries significant morbidity and mortality because it can result in orbital cellulitis brain abscess meningitis sepsis Microbiology Staphylococcus aureus and S. epidermidis Streptococcus pyogenes and S. pneumoniae Pseudomonas aeruginosa Haemophilus influenzae Epidemiology Demographics woman > men infants and adults > 40 years of age Risk factors nasolacrimal sac obstruction female gender nasal septum deviation rhinitis Pathophysiology Obstruction of the nasolarcimal duct causes include idiopathic inflammatory stenosis of the duct trauma malignancy infection mechanical Presentation Symptoms/physical exam acute dacrocystitis acute pain, erythema, and swelling over the nasolacrimal sac may rupture and create a fistula through the skin may have conjunctival injection may be associated with preseptal cellulitis chronic dacrocystitis tearing (most common) eye discharge Differential Chalazion differentiating factor focal, firm, and painless nodule over the eyelid Hordeolum (stye) differentiating factor focal and tender nodule over the eyelid Treatment Medical antibiotics indications oral antibiotics in mild cases intravenous antibiotics in severe cases medications 1st generation cephalosporin penicillinase-resistant synthetic penicillin Surgical dacryocystorhinostomy indication chronic dacryocystisis resolved acute dacryocystitis Prognosis High success rate with surgical intervention (dacrtocystorhinostomy)