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Surgeon's Corner
A Lacrimal Sac Abscess Incision and Drainage Technique
Patrick Roland Boulos, MD, FRCSC;
Peter A. D. Rubin, MD
Arch Ophthalmol. 2008;126(9):1297-1300.
ABSTRACT
A comfortable, anatomically based lacrimal sac abscess incision and drainage technique is described. The records of 52 patients were reviewed. The procedure was relieving and well tolerated because of adequate infraorbital and anterior ethmoidal nerve blocks. To promote rapid resolution, both components of the abscess were drained: the distended lacrimal sac and its associated submuscular pocket. The contiguous cavities were packed and allowed to heal by secondary intention. Of 49 cases, 39 (79.6%) were done as outpatient procedures and 41 (83.7%) were performed under locoregional anesthesia. Edema completely resolved by a median of 7 days. A repeat drainage procedure within 1 month was required in only 4 of 48 cases (8.3%). Fistulas and ectropion were not found. Four of 16 patients (25.0%) who did not eventually receive a definitive procedure (dacryocystorhinostomy or dacryocystectomy) developed a recurrent lacrimal sac abscess after complete resolution of the primary episode.
INTRODUCTION
Dacryocystitis, or inflammation of the lacrimal sac, is almost always secondary to nasolacrimal duct obstruction.1 In fact, up to 10% of adults aged 40 years or older have obstruction of the lacrimal drainage system. This percentage increases with age.2 Tear stasis promotes secondary bacterial infection that may cause an erythematous and very tender distention of the lacrimal sac below the medial canthal tendon. Like abscesses in other infectious conditions, it forms an environment where antibiotic penetration is inadequate and progression of infection is favored.3
Standard surgical care dictates that a pointing abscess should be drained.1, 4 Curiously, this principle is often violated in cases of lacrimal sac abscesses. Some of the stated origins of reluctance include giving antibiotics a chance, fear of causing a fistula, fear of inducing orbital cellulitis, patient pain due to ineffective local anesthesia, and potential for inducing cicatricial ectropion.
A technique of anesthesia and lacrimal sac incision and drainage that is very safe, is comfortable, and promotes rapid resolution of infection without complications is described.
METHODS
Data were collected through a retrospective record review of all of the patients with acute dacryocystitis as well as lacrimal sac abscesses treated surgically between July 17, 1994, and March 14, 2005, at our institution. The study was carried out with approval from the institutional review board at the Massachusetts Eye and Ear Infirmary and is in accord with regulations of the Health Insurance Portability and Accountability Act of 1996. The data were used for descriptive statistics.
After orbital cellulitis was ruled out, all of the patients received systemic antibiotics. Incision, drainage, and packing of the abscess cavity as well as the lacrimal sac were performed when there was evidence of a pointing abscess associated with dacryocystitis.
ANESTHESIA TECHNIQUE
Patients first received a topical instillation of proparacaine hydrochloride, 0.5%, in each eye. An infraorbital nerve block was performed by palpating the nerve's foramen 1 cm below the junction of the medial one-third and lateral two-thirds of the inferior orbital rim. Approximately 1.5 mL of lidocaine, 2%, with epinephrine (dilution, 1:100 000) was injected with a 30-gauge, 0.5-inch needle just over the foramen without penetrating it.
A transconjunctival anterior ethmoidal nerve block was performed with a 25-gauge, 1.5-in needle inserted at the lateral aspect of the caruncle (Figure 1). The needle was angled 10° toward the medial orbital wall and redirected posteriorly every time bone was met until it reached a distance of 24 mm from the anterior lacrimal crest, or two-thirds of the needle length. A total of 1.5 mL was injected at that site. At each site before injection, aspiration of the syringe was performed to confirm that the needle was not positioned intravascularly.
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Figure 1. Anterior ethmoidal block. The needle is angled 10° toward the medial wall and inserted to 24 mm from the anterior lacrimal crest.
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SURGICAL TECHNIQUE
A BD Bard-Parker number 11 blade (BD Medical Systems, Franklin Lakes, New Jersey) was used to make a transcutaneous stab incision. The incision was made over the apex of the pointing abscess, typically just inferior to the medial canthal ligament and directed toward the nasal ala. Great care was taken to drain the abscess's 2 components, present in most patients: its submuscular pocket and the distended lacrimal sac (Figure 2). A fine-tipped hemostat or a chalazion curette was used to lyse any loculations in the submuscular pocket of the abscess. This portion was drained completely. The curette was used to penetrate through the anterior face of the lacrimal sac where the second collection could be found. The lacrimal sac was then suctioned completely. To confirm penetration of the lacrimal sac, its mucosa should be visualized. Alternatively, a lacrimal probe can be placed into the sac through a canaliculus and visualized through the anterior sac incision. Any extruding pus was cultured and a microscope slide was smeared for Gram staining.
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Figure 2. Axial computed tomographic scan of the lacrimal sac abscess's 2 components. Most often, a submuscular pocket and a distended lacrimal sac are found.
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Once the contiguous cavities were copiously irrigated with saline, 0.9%, they were packed with iodoform gauze (0.25 inches) and allowed to heal by secondary intention. Usually at least 10 cm of gauze was packed into the wound. One centimeter of its distal end was left out as a wick and covered with a steristrip to prevent accidental extrusion. Antibiotic irrigation was not necessary.
All of the patients were followed up at 3- to 7-day intervals (or sooner if there was evidence of immunosuppression or a more aggressive infection). Every time, the gauze was pulled and several centimeters were cut away until it had been completely removed, which usually took about 3 visits.
If the abscess recurred, patients were offered a second incision and drainage procedure or a dacryocystectomy (mostly in elderly patients with dry eyes). Once the acute episode was resolved, a dacryocystectomy or dacryocystorhinostomy was offered as a definitive procedure to address the nasolacrimal duct obstruction.
RESULTS
Fifty-two cases of lacrimal sac abscesses secondary to acute dacryocystitis were treated with the incision and drainage technique described here. Patients were followed up for a mean (SD) of 8.5 (10.9) months. The mean (SD) age of the patients was 57.8 (29.9) years (range, 2.5-100 years). There were only 4 patients younger than 21 years. The female to male ratio was 1.6:1 (32 females, 20 males).
Patients found the procedure comfortable, with 39 of 49 cases (79.6%) done as outpatient procedures and 41 of 49 cases (83.7%) performed under locoregional anesthesia. Eight were done under general anesthesia (pediatric or mentally challenged patients).
The median (SD) number of days to complete resolution of edema was 7 (6.7) days (range, 2-35 days). A repeat drainage procedure within 1 month was required in only 4 of 48 cases (8.3%). Fistulas and ectropion were not found (Figure 3).
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Figure 3. Patient with a lacrimal sac abscess, shown preoperatively (A) and 1 month after incision and drainage of the abscess's 2 components (B). The incision healed well and was inconspicuous, with absence of cicatricial ectropion or fistula.
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Ultimately, whether it was planned or performed, definitive treatment of the nasolacrimal duct obstruction was dacryocystorhinostomy in 32 of 48 cases (66.7%) and dacryocystectomy in 8 of 48 cases (16.7%). Dacryocystectomy was chosen in older patients with no history of epiphora when dry eyes were confirmed on Schirmer testing. In 8 of 48 cases (16.7%), patients refused further treatment. Of 16 patients whose lacrimal sac abscess was incised and drained and who either refused a definitive procedure (dacryocystorhinostomy or dacryocystectomy) or were awaiting surgery at the end of the study period, 4 (25.0%) developed a new lacrimal sac abscess after complete resolution of the primary episode. Only new abscesses beyond 1 month from the initial episode were taken into account to distinguish the 2 episodes. The mean (SD) follow-up for these 16 patients was 7.0 (10.5) months. The mean (SD) delay before recurrence of new pain and swelling was 19.1 (16.1) months.
COMMENT
As demonstrated, early incision and drainage of a lacrimal sac abscess is a simple, comfortable procedure that results in immediate resolution of pain and promotes rapid healing from infection.3 Many of the arguments against this procedure have been dispelled.
Allowing systemic antibiotics to act before incising the abscess is probably futile because the cavity allows only poor penetration of the drug. When the abscess is opened, the reduced bacterial load facilitates resolution as well as antibacterial action.3 In fact, in this study edema and inflammation resolved quickly (around 7 days) and a repeat drainage procedure was required in only 4 of 48 cases (8.3%).
Very few cases of orbital cellulitis secondary to dacryocystitis have been described,5-10 probably because the lacrimal sac is located in a preseptal location. Medially, the orbital septum divides into 3 layers, 2 of which lie posterior to the sac (Figure 4).1, 12
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Figure 4. Axial anatomy of the lacrimal sac (S) and orbital septum. The anterior septum layer (1) inserts on the anterior lacrimal crest. A thicker intermediate layer (2) inserts on the posterior lacrimal crest. The thinnest posterior layer (3) lies behind the Horner muscle (H). Adapted from Dutton11 with permission from Elsevier.
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As a general rule, patients with dacryocystitis should not have orbital findings (proptosis, globe displacement, restricted ocular motility, pain on eye movement, optic nerve dysfunction, or retinal venous congestion). If orbital signs are present or if there is a history of surgery or trauma, a computed tomographic scan is advised prior to drainage of the sac to ensure that there is no anomalous extension posteriorly. If manipulations are limited to the submuscular pocket and the lacrimal sac, the orbital septum should remain intact (Figure 4).1
When the lacrimal sac becomes distended with pus, it expands anterolaterally and inferiorly because several structures that protect the sac posteromedially and superiorly are absent in these areas.1, 5, 12-13 Once the pus breaks through, it fills a suborbicularis pocket, which is often the most prominent portion seen clinically. It is likely that there is a spectrum of manifestations and that some abscesses may be limited to the lacrimal sac, but if present, both pockets should be thoroughly drained.
Although effective, the incision and drainage technique is sometimes deferred because it is thought to be a painful procedure. Two locoregional blocks were used in this series to avoid injection over the incision site, which is indeed inflamed and painful. They provided excellent pain relief. The anterior ethmoidal nerve block via a transcaruncular approach is safe because the needle follows a path that is posterior to the Horner muscle and the posterior lacrimal crest and avoids lacrimal sac penetration.
At the end of the procedure, the surgical wound is allowed to heal by secondary intention. One concern is that this may lead to excessive scarring and cicatricial ectropion. This was not observed in any of the patients described here. Generally, incisions healed well and were inconspicuous (Figure 3).
In addition, there were no cases of cutaneolacrimal iatrogenic fistulas in this series. In fact, fear of this complication is largely unfounded and has been shown not to occur when acute dacryocystitis is treated with incision and drainage.14
Data suggest that after an acute lacrimal sac abscess is drained, a definitive treatment such as a dacryocystorhinostomy or a dacryocystectomy is warranted. As shown, of 16 patients who refused a definitive procedure or were awaiting surgery at the end of the study period, 4 (25.0%) developed a new lacrimal sac abscess after complete resolution of the primary episode. Assuming that some patients may have visited other locations for treatment of the recurrence, this percentage could be even higher. The picture might also be different for patients with nasolacrimal duct obstruction who have never developed a lacrimal sac abscess requiring drainage. A prospective study could probably clarify these issues.
Although this study is retrospective and comparison with other managements is therefore difficult, the technique of anesthesia and lacrimal sac incision and drainage described here remains simple and comfortable. It results in immediate resolution of pain and promotes rapid healing from infection with rare recurrence.
AUTHOR INFORMATION
Correspondence: Peter A. D. Rubin, MD, Eye Plastics Consultants, 44 Washington St, Brookline, MA 02445 (padrmd{at}aol.com).
Submitted for Publication: November 26, 2006; final revision received March 24, 2008; accepted March 24, 2008.
Author Contributions: Drs Boulos and Rubin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosure: None reported.
Author Affiliations: Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston. Dr Boulos is now with the Oculofacial Surgery Service, Department of Ophthalmology, Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada. Dr Rubin is now with Eye Plastics Consultants, Brookline, Massachusetts, and the Department of Ophthalmology, University of Tennessee Health Science Center, Memphis.
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