Acute dacryocystitis usually induces preseptal infection. In rare instances the infection that is confined to the lacrimal sac can extend to the orbital contents resulting in orbital cellulitis. We present a case of intraconal abscess secondary to acute dacryocystitis and review the literature of orbital cellulitis resulting from acute lacrimal sac infection.A dacriocistite aguda comumente evolui para infecção pré-septal. Raramente a infecção localizada no saco lacrimal pode estender-se ao conteúdo orbitário resultando em celulite orbitária. Apresentamos um caso de abscesso orbitário intraconal secundário à dacriocistite aguda e uma revisão de literatura de celulite orbitária causada por infecção aguda do saco lacrimal

AKAISHI, Patrícia Mitiko Santello

CRUZ, Antonio Augusto Velasco e

MARTINS, Marcia Clivati

RICARDO, José Reinaldo da Silva

Universidade de São Paulo

Arquivos Brasileiros de Oftalmologia

Abscesso orbitário secundário à dacriocistite aguda: relato de caso

Biblioteca Digital da Produção Intelectual da Universidade de São Paulo (BDPI/USP)

Arq Bras Oftalmol. 2008;71(4):576-8
Abscesso orbitário secundário à dacriocistite aguda: relato de caso
Trabalho realizado no Departamento de Oftalmologia,
Otorrinolaringologia e Cirurgia de Cabeça e Pescoço da
Faculdade de Medicina de Ribeirão Preto - Universida-
de de São Paulo.
1 Médica Residente do Hospital das Clínicas da Universi-
dade de São Paulo - USP - Ribeirão Preto (SP) - Brasil.
2 Médico Residente do Hospital das Clínicas da USP -
Ribeirão Preto (SP) - Brasil.
3  Médica contratada do Setor de Oculoplástica. Hospital
das Clínicas USP - Ribeirão Preto (SP) - Brasil.
4 Professor Titular e Chefe do Setor de Oculoplástica do
Hospital das Clínicas da USP - Ribeirão Preto (SP) -
Brasil.
Endereço para correspondência: Antonio Augusto Ve-
lasco e Cruz. Departamento de Oftalmologia, Otorrinola-
ringologia e Cirurgia de Cabeça e Pescoço, Hospital das
Clínicas - Campus. Av. Bandeirantes, 3900 - Ribeirão
Preto (SP) CEP 14049-900
E-mail: aavecruz@fmrp.usp.br
Recebido para publicação em 22.07.2007
Aprovação em 18.11.2007
Nota Editorial: Depois de concluída a análise do artigo
sob sigilo editorial e com a anuência da Dra. Joelice dos
Santos Araújo sobre a divulgação de seu nome como
revisora, agradecemos sua participação neste processo.
Marcia Clivati Martins1 
José Reinaldo da Silva Ricardo2 
Patrícia Mitiko Santello Akaishi3 
Antonio Augusto Velasco e Cruz4
Orbital abscess secondary to acute dacryocystitis:
case report
Keywords: Lacrimal apparatus diseases; Dacryocystitis/complications; Orbital diseases/
etiology; Cellulitis; Abscess; Bacterial infections; Case reports [Publication type]
Acute dacryocystitis usually induces preseptal infection. In rare instances
the infection that is confined to the lacrimal sac can extend to the orbital
contents resulting in orbital cellulitis. We present a case of intraconal
abscess secondary to acute dacryocystitis and review the literature of
orbital cellulitis resulting from acute lacrimal sac infection.
ABSTRACT
RELATOS DE CASOS
INTRODUCTION
The immediate consequence of nasolacrimal duct obstruction is epipho-
ra. In chronic cases conjunctivitis and mucoid discharge ensue. Acute da-
cryocystitis may develop when significant bacterial growth occurs in the
stagnant fluid of the lacrimal sac. The main complication of acute dacryo-
cystitis is lacrimal sac abscess that often leads to draining fistulas to the
skin. The infection can also spread to the lower eyelid tissues, becoming a
preseptal cellulitis. Orbital extension rarely can occur(1-10) and may result in
intraconal abscess formation(2-5,8). We present a case of intraconal abscess
secondary to acute dacryocystitis and review the literature of orbital cellu-
litis caused by acute dacryocystitis.
CASE REPORT
A 39-year-old, otherwise healthy woman presented to the emergency
department of the “Hospital Clinicas Faculdade Medicina Ribeirão Preto -
Universidade de São Paulo - HCFMRP-USP” with fever and a history of
yellowish discharge, eyelid swelling, pain, redness, and reduced vision in
the left eye. She reported epiphora in the last six months and denied any
sinus disease, periocular trauma or prior infections. She had been using
500 mg oral cephalexin every 6 hours in the last days. Her visual acuity
was 20/20 in the right eye and 20/100 in the left. The pupils were equal, with
normal reflexes. She presented with a clear abscess on the lower eyelid, with
pus drainage occurring upon external pressure. The left eye was proptotic
with an important degree of chemosis and extraocular motility limitation
(Figure 1). The patient was admitted to the hospital and intravenous the-
rapy was started with 1 g ceftriaxone every 12 hours. Her leukocyte count
was 15.6 x 109/L, with 84% segmented neutrophils and 16% lymphocytes. A
computed tomography (CT) scan of the orbits showed left proptosis, seve-
re soft tissue edema and intraconal abscesses, with no signs of rhinosinu-
sitis (Figure 2). The patient was submitted to orbital drainage under general
71(4)02.pmd 31/7/2008, 16:28576
Arq Bras Oftalmol. 2008;71(4):576-8
 577Orbital abscess secondary to acute dacryocystitis: case report
anesthesia. The orbit was approached through a subciliary inci-
sion. The abscess was located and drained, releasing a large
amount of pus. After drainage of the abscess, irrigation of the
lacrimal sac through the lower canaliculus clearly demonstrated
that the sac was ruptured. The skin was closed and a small
Penrose drain was left in the wound. On the third postoperative
day the patient was afebrile, with a marked decrease in eyelid
swelling and improved ocular motility of the left eye. Culture of
the tissues grew strictly anaerobic bacteria (Peptostreptococcus
prevotii and Prevotella melaninogenica). After resolution of
the infection her final visual acuity was 20/20 in both eyes and an
external dacryocystorhinostomy (DCR) was performed.
DISCUSSION
Dacryocystitis is a rare cause of orbital infection. A litera-
ture search using the Medline data base showed only 10
reports of orbital cellulitis (13 cases) caused by acute dacryo-
cystitis (Table 1). For 7 patients (53.8%) the infection reached
the intraconal space forming an abscess. The rarity of orbital
extension has been attributed to the fact that the lacrimal sac
is a preseptal structure. In fact, the orbital septum inserts
posteriorly at the lacrimal crest, acting as an anatomic barrier.
In addition, other anatomical elements such as the lacrimal
fascia, the posterior limb of the medial canthal ligament, and
deep heads of the pretarsal and preseptal orbicularis muscles
(Horner muscle) also act as a barrier to posterior extension.
Once the infection ruptures the lacrimal sac the posterior
barriers may be overcome by the infection, leading to orbital
cellulitis. Because of the anterior and inferior location of the
lacrimal sac a channel of communication can be formed bet-
ween the medial and inferior rectus muscles directly to the
intraconal space, leading to an intraconal abscess(2-3,5).
Table 1 shows that the microorganisms found in dacryo-
cystitis-induced orbital cellulitis do not differ from the germs
found in uncomplicated dacryocystitis. In most cases (53.8%)
single isolates of gram-positive bacteria are found. There were
only four polymicrobial infections (30.8%), with strictly anae-
robic bacteria in two of them.
Orbital abscess formation can occur even in patients using
oral antibiotics and can rapidly lead to visual loss(2). Intrave-
nous antibiotic therapy is necessary in all cases of orbital
cellulitis; because of its bacteriology we consider the use of
intravenous oxacillin, 2 g every 6 hours, and ceftriaxone, 2 g
every 12 hours, as the first empirical option.
Although intravenous antibiotic therapy is necessary, sur-
gical drainage of the abscess is mandatory for the resolution
of the acute orbital picture. DCR can be delayed until complete
resolution of the acute infectious disease.
The present report demonstrates that acute dacryocystitis
can be added to the list of causes of orbital abscess and may
be a cause of visual loss. In view of this type of complication,
we conclude that patients with acute infection of the lacrimal
sac should be carefully monitored.
RESUMO
A dacriocistite aguda comumente evolui para infecção pré-
septal. Raramente a infecção localizada no saco lacrimal pode
estender-se ao conteúdo orbitário resultando em celulite orbi-
tária. Apresentamos um caso de abscesso orbitário intraconal
secundário à dacriocistite aguda e uma revisão de literatura de
celulite orbitária causada por infecção aguda do saco lacrimal.
Descritores: Doenças do aparelho lacrimal; Dacriocistite/com-
plicações; Doenças orbitárias/etiologia; Celulite; Abscesso;
Infecções bacterianas; Relatos de casos [Tipo de publicação]
Figure 1 - Clinical aspect at presentation. Note non axial proptosis and
 chemosis.
Figure 2 - Coronal computed tomographic scan showing a left lacrimal
sac abscess adjacent to an extra- and intraconal orbital abscess pu-
 shing globe laterally and outward
71(4)02.pmd 31/7/2008, 16:28577
578 Orbital abscess secondary to acute dacryocystitis: case report
Arq Bras Oftalmol. 2008;71(4):576-8
Table 1. Orbital cellulitis secondary to acute dacryocystitis
Author, year Age Sex Imaging Orbital infection Management Culture FVA
category
Schmitt et al., 2005(1) 71 y M CT, MRI Diffuse cellulitis IV Antib, DCR Staph. aureus 20/25
Kikkawa et al., 2002(2) 38 y F CT Extraconal abscess IV Antib, AD, DCR Staph. aureus NLP
64 y F CT Intraconal abscess IV Antib, AD, DCR Nonenterococcal group D NLP
with silicone stents strep. Strep. viridans,
Strep. intermedius
62 y F CT Intraconal abscess IV Antib, AD, DCR Strep. viridans, Strep. 20/25
with silicone stents intermedius, Veillonella parvula
51 y M CT Intraconal abscess IV Antib, Endo-DCR Negative 20/20
with silicone stents
Ataulla et al., 2002(3) 60 y F CT Intraconal abscess IV Antib, AD, DCR Strep. spp 20/60
recommended
Ntountas et al., 1997(4) 38 y M CT, Intraconal abscess IV Antib, AD, DCR Strep. anginosus, 20/20
MRI, Peptostreptococcus,
US Anaerobic gram-negative
rods
Mauriello et al., 1996(5) 84 y F CT Intraconal abscess IV Antib, AD, Staph. aureus NS
Dacryocystectomy
Warrak et al., 1996(6) 62 y M CT Subperiosteal abscess IV Antib, AD, DCR Morganella morganii NS
Weiss et al., 1993(7) 15 d F CT Intraconal abscess IV Antib, AD Staph. aureus NS
Molgat et al., 1993(8) 40 y M CT Extraconal abscess IV Antib, AD, DCR Strep. viridans 20/20
Allen et al., 1985(9) 57 y F CT, Diffuse cellulitis IV Antib Eikenella corrodens, 20/20
US Enterobacter aerogenes
Ahrens-Pallumbo et al., 1982 (10) 60 y F CT Extraconal abscess IV Antib, DCR Staph. epidermidis 20/20
Present report 39 y F CT Intraconal abscess IV Antib, AD, DCR later Peptostreptococcus 20/20
prevotii, Prevotella
melaninogenica
FVA= final visual acuity; y= years; d= days; CT= computed tomography; MRI= magnetic resonance imaging; US= ultrasonography; IV Antib.= intravenous antibiotic
therapy; DCR= external dacryocystorhinostomy; AD= abscess drainage; Endo-DCR= endonasal dacryocystorhinostomy; Staph.= Staphylococcus; Strep.=
Streptococcus; NLP= no light perception; NS= not stated
REFERENCES
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in a patient with dacryocystitis-induced orbital cellulitis. Ophthal Plast Re-
constr Surg. 2005;21(5):387-9.
2. Kikkawa DO, Heinz GW, Martin RT, Nunery WN, Eiseman AS. Orbital cellulitis
and abscess secondary to dacryocystitis. Arch Ophthalmol. 2002;120(8):1096-9.
3. Ataullah S, Sloan B. Acute dacryocystitis presenting as an orbital abscess.
Clin Experiment Ophthalmol. 2002;30(1):44-6.
4. Ntountas I, Morschbacher R, Pratt D, Patel BC, Anderson RL, McCann JD.
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71(4)02.pmd 31/7/2008, 16:28578


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Abscesso orbitário secundário à dacriocistite aguda: relato de caso

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