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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
  • 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
  • Microbiology
    • Staphylococcus aureus and Sepidermidis
    • Streptococcus pyogenes and Spneumoniae
    • Pseudomonas aeruginosa
    • Haemophilus influenzae
  • Prognosis
    • high success rate with surgical intervention (dacrtocystorhinostomy)
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
Complications
  • Ocular abscess
  • Orbital cellulitis

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Questions (3)
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(M2.OP.17.4867) A 17-year-old male presents to the emergency department for eye pain. The patient states that he has had left eye pain for the past week that has been steadily worsening. The patient denies any changes to his vision, trouble moving his left eye, or recent trauma. The patient smokes one pack of cigarettes a day, drinks alcohol socially, and has had unprotected sex with two males and four females this past month. His current medications include loratadine, nasal saline spray, and diphenhydramine. His temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 72/min, respirations are 11/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young man. Cardiopulmonary exam is within normal limits. His physical exam reveals the finding in Figure A. Which of the following is the most likely diagnosis?

QID: 109611
FIGURES:
1

Obstruction of the nasolacrimal duct

82%

(55/67)

2

Staphylococcus aureus infection of the inferior rectus

6%

(4/67)

3

Sexually transmitted infection

3%

(2/67)

4

Thrombosis of a major vessel

0%

(0/67)

5

Infection of a hair follicle

3%

(2/67)

M 6 C

Select Answer to see Preferred Response

(M2.OP.14.2) A 7-year-old girl presents to the emergency department with swelling around her eye. This has happened to her before but has never been this severe. The lesion started a few days ago but has become increasingly red and painful. Physical exam reveals the lesion in Figure A which is tender to palpation. Her cranial nerves are intact and there is no pain with extraocular movements. Which of the following is the most likely diagnosis?

QID: 105368
FIGURES:
1

Chalazion

66%

(33/50)

2

Dacryocystitis

12%

(6/50)

3

Hordeolum

0%

(0/50)

4

Orbital cellulitis

12%

(6/50)

5

Periorbital cellulitis

6%

(3/50)

M 6 E

Select Answer to see Preferred Response

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