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(Data acquisition - Description of abnormalities)

This is an external photo showing a smooth, well-demarcated mass that is below the medial canthal tendon.  There is some erythema of the surrounding skin.  The tear lake appears quite abundant and contains fluorescein dye.

(Data acquisition - History to obtain)

I would ask the patient if this was his first episode of experiencing this swelling; whether it was painful; whether he has had chronic tearing in the past; and whether he has past issues with ear, nose, throat, or sinus infections.  I would ask if he has expressed any material from this mass and whether this discharge was purulent.  I would ask if he was feeling febrile and whether his vision was being affected or he was experiencing any double vision.  I would ask a complete medical history including whether he had diabetes or other causes of immunosuppression.  I would also want to know if the patient resided in a nursing home or other skilled nursing facility.

(Data acquisition - Exam data to seek out)

I would perform a comprehensive exam of both eyes.  In particular, I would confirm the location of the mass being below the medial canthal tendon.  I would test extraocular movements to determine if there was any restriction and test for the presence of an afferent pupillary defect.  I would perform Hertel exophthalmometry to determine if there was any proptosis of the right eye.  I would perform a slit-lamp exam to see if there were any corneal infiltrates.  I would perform a dilated fundus exam to rule-out the presence of optic disc swelling.  I would gently press on this mass to see if any discharge refluxed through the lower punctum.

(Diagnosis -- Focused differential diagnosis)

My focused differential diagnosis for this mass in the region of the lacrimal sac is:

• Dacryocystitis
• Facial cellulitis involving the medial canthus
• Acute ethmoid sinusitis
• Lacrimal gland tumor
• Dacryocystocele
• Frontal sinus mucocele or mucopyocele

Given the patient’s relatively-acute presentation, he most likely has dacryocystitis.

(Diagnosis - what lab or other tests would you want to order to narrow DDx?)

What other tests would you want to order for this patient?

This patient’s clinical presentation is relatively straightforward for a diagnosis of dacryocystitis.  However, I would consider a CT scan of the orbits and sinuses if the presentation was atypical or worsened despite appropriate treatment.  If purulent discharge could be expressed from the punctum, I would send this discharge for culture and sensitivities.

(Management -- appropriate plan for medical or surgical management of condition)

If this patient was afebrile, reliable, and there was no concern for orbital cellulitis, I would prescribe oral antibiotics; for example, cephalexin 500 mg po four times a day.  If this patient was febrile, unreliable, or there were orbital signs indicative of orbital cellulitis, then I would hospitalize the patient and administer intravenous antibiotics (for example, cefazolin 1 gram every 8 hours).  I would administer an analgesic to help with the likely pain and also instruct the patient to use warm compresses and gentle massage to the medial canthal area.  Since a pyoecele appears to be approaching the skin surface, I could also offer incision and drainage of the abscess and pack it open to heal by secondary intention.  However, I would only offer this treatment if more conservative measures failed since incision and drainage could possibly lead to a chronically-draining fistula.

(Management -- prognosis and/or therapeutic complications)

I would counsel the patient that most cases of dacryocystitis resolve with oral antibiotics alone.  However, I would examine the patient daily until improvement occurs, and would have a low threshold to administer intravenous antibiotics if his condition worsened.  I would educate the patient that dacryocystitis is almost always due to acquired nasolacrimal duct obstruction.  I would inform him that he is at risk for recurrent episodes of dacryocystitis as long as his nasolacrimal duct obstruction existed.  Thus, after his acute dacryocystitis was resolved, I would offer him a dacryocystorhinostomy to resolve his nasolacrimal duct obstruction.