10-year-old girl presents with eye swelling
A previously healthy 10-year-old female presents to your office with some painful swelling with erythema about the left eye. Although she was previously healthy, a detailed review of her past medical history revealed that she had been diagnosed with left-sided lacrimal duct stenosis as an infant, which spontaneously resolved by 1 year of age but still periodically recurs. It manifested as excessive tearing for a few days to weeks at a time. Since it never bothered her, it was never pursued. She denies any injury or past episodes of pain or erythema. She otherwise feels well and has had no sick contacts, including anyone with “pink eye.” Her immunizations are up to date.
On examination, her vital signs are normal, and the only abnormal finding is that about the left eye, with some painful swelling and diffuse erythema surrounding the eye, as shown in Figures 1 and 2. There also appears to be additional discrete swelling just inferior to the medial canthus, with a dark spot from which a small amount of material drained. Upon further questioning, the patient admitted to picking at the area, resulting in the small scab before the more diffuse redness and swelling occurred. The rest of her facial and ocular exam was normal.
What’s your diagnosis?
A. Preseptal cellulitis
B. Dacryocystitis with secondary cellulitis
D. Choices A and B
Answer and discussion:
The correct answer is both preseptal cellulitis and acute dacryocystitis (choice D). Preseptal cellulitis is simply a descriptive term meaning inflammation or an infection that is contained to the anterior portion of the orbital septum, a membrane that separates the orbital contents from the outer structures (Figure 3). It may be due to the spread of a sinus infection, injury, hematogenous seeding of the area or, as in this case, spread beyond an infection within the lacrimal sac, likely with the help of picking at the spot. When due to the latter, the responsible organism is usually Staphylococcus aureus or a streptococcal species, but it can be mixed. The typical finding is swelling in the area of the lacrimal sac, just medial and inferior to the medial canthus. There may be a history of mucopurulent material occasionally getting into the eye by retrograde movement. An abscess can develop, which may get large enough to result in spontaneous drainage, but this is unlikely.
Management is almost always left to an ophthalmologist, especially if any drainage is to be attempted (Figure 4). However, medical management may be all that is needed. Warm compresses may be tried, along with an oral anti-staph/anti-strep antimicrobial. If there is any material that can easily be expressed, it should be cultured. However, firm pressure should be avoided, as the anatomic structures are fairly delicate and can be damaged. In recurrent cases, even with successful medical management, referral to an ophthalmologist is always recommended for more definitive management.
Dacryoadenitis describes inflammation of the lacrimal gland, not the lacrimal sac or duct. The gland resides in the superior-lateral aspect of the upper lid area. Therefore, with dacryoadenitis, one would expect to see swelling and/or erythema of the lateral area of the upper lid, which typically results in an “S” shape configuration to the edge of the upper lid (Figure 5).
Over the years, I have shown other case s of dacryoadenitis (in December 1989, August 2005 and April 2015), in case you want to look back. The important thing to remember is that dacryocystitis can usually be managed in the office with an oral anti-staph antimicrobial. Some may recommend a gentle massage of the duct. I would caution against that due to the delicate nature of the anatomy. Additionally, when an abscess clearly complicates the picture, I recommend referral to an ophthalmologist. The patient may also end up needing the ophthalmologist to probe the lacrimal duct to keep it open. I used to say that I recommend what I would do for my own child. Now I say that I recommend what I would do for my own grandchild, and referral of a problem like this about the eye is what I recommend. Preseptal cellulitis management, which is often complicated by sinusitis, will be for another time.
For more information:
Brien is a member of the Infectious Diseases in Children and Infectious Disease News Editorial Boards, and an adjunct professor of pediatric infectious diseases at McLane Children's Hospital, Baylor Scott & White Health, in Temple, Texas. He can be reached at firstname.lastname@example.org.