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Gonococcal dacryoadenitis is uncommon, and its diagnosis may be delayed especially if there is a low index of clinical suspicion. Making an early diagnosis is extremely important because in some cases the organism may spread contiguously, leading to vision-threatening sequelae such as corneal perforation. The authors present a case report of a patient diagnosed with gonococcal dacryoadenitis complicated by orbital cellulitis. Our case demonstrates that in all cases of purulent dacryoadenitis, urgent evaluation, cultures and treatment is crucial, and it is prudent to consider gonococcal dacryoadenitis as a rare but possible differential in patients who are sexually active with an unexplained cause for dacryoadenitis.

Cutaneous squamous cell carcinoma (SCC) is a common malignancy of the skin, with the potential for local invasion and metastasis. Here, we present a case series of two patients with SCCs, suggesting radiological infiltration of the lacrimal gland on magnetic resonance imaging. However, histopathological examination revealed lymphoplasmacytic infiltration of the lacrimal gland consistent with dacryoadenitis, with no evidence of SCC infiltration. Our cases highlight the potential for peritumoural inflammation to cause dacryoadenitis and radiologically mimic tumour infiltration into the lacrimal gland.

Alternaria is a fungal genus that can cause opportunistic human infection in immunocompromised hosts. While the majority of clinical manifestations are cutaneous or subcutaneous infections, there are reports of oculomycosis, which is most commonly present as keratomycosis or endophthalmitis.Here, we present a rare case of Alternaria dacryocystitis with cutaneous fistula in a diabetic patient. The patient was referred with a non-healing medial canthal wound and an initial biopsy report showing "ruptured hair follicle;" re-examination of the biopsy specimen with fungal stains led to the diagnosis of alternariosis. The patient underwent surgical debridement and systemic antifungal treatment, with complete resolution of the infection. In order to initiate prompt treatment and prevent invasive disease, fungal infection should be considered in an immunocompromised patient with chronic dacryocystitis and cutaneous fistula or a nonhealing medial canthus wound.

VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is a newly recognised adult-onset multisystem autoinflammatory disease caused by a somatic mutation in the UBA1 gene in myeloid or erythroid precursor cells. This report describes an atypical presentation of recurrent dacryoadenitis associated with VEXAS syndrome and provides a review of the literature. A 68-year-old male presented with three episodes of unilateral alternating dacryoadenitis followed by bilateral involvement over a 4-year period. Each episode of orbital inflammation was characterised by upper lid swelling, oedema and enlarged lacrimal glands. In addition, he experienced intermittent flares of angioedema-like lesions involving the face and extremities, recurrent jaw aches, rash, progressive pulmonary fibrosis, and myelodysplastic syndrome. His inflammatory symptoms lessened with prednisolone but were refractory to methotrexate. Mycophenolate was subsequently trialled with a reasonable clinical response. Genetic testing established the diagnosis of VEXAS syndrome and tofacitinib, a JAK inhibitor, was commenced with resolution of inflammatory symptoms.

Purpose: Utilization of antibiotics for endoscopic dacryocystorhinostomy (endo-DCR) is largely dependent on individual surgeon preference. This study aimed to investigate prescribing practices of pre-, peri-, and postoperative antibiotics and effects on postoperative infection rates in patients who underwent endo-DCR., Methods: A retrospective chart review of institutional data at two academic centers of endo-DCR cases from 2015-2020 was performed. Postoperative infection rates for patients who received pre-, peri-, and postoperative antibiotics, individually or in combination, and those who did not, were compared via odds ratio and ANOVA linear regression., Results: 331 endo-DCR cases were included; 22 cases (6.6%) had a postoperative infection. There was no significant difference in the infection rates between patients without an active preoperative dacryocystitis who received different permutations of peri- and postoperative antibiotics. Patients who received preoperative antibiotics within two weeks of surgery for preexisting acute dacryocystitis, but did not receive peri- or postoperative antibiotics, had a higher rate of postoperative infections ( p  = 008)., Conclusions: Our data suggest antibiotics may be beneficial only when patients have a recent or active dacryocystitis prior to surgery. Otherwise, our data do not support the routine use of antibiotic prophylaxis in endo-DCR.

A 61-year-old man with no significant past medical history presented to a quaternary ophthalmic referral center with acute right-sided medial canthal pain, periorbital edema, and erythema despite oral antibiotic therapy. CT imaging confirmed the presence of right preseptal cellulitis and lacrimal sac aspiration identified Enterobacter cloacae . A diagnosis of acute right-sided dacryocystitis with preseptal cellulitis was made. He was successfully treated with broadening of antibiotic therapy to intravenous meropenem. Symptomatic resolution was noted on follow-up without evidence of disease recurrence. This unusual case of Enterobacter cloacae dacryocystitis and preseptal cellulitis highlights the increasing prevalence and challenges of treating these uncommon organisms.

Eosinophilic disease with orbital involvement is rare. We present two patients with dacryoadenitis associated with local and systemic eosinophilia. A 32-year-old man presented with episodic dacryoadenitis, lower respiratory inflammation and peripheral eosinophilia. Lung and lacrimal gland biopsies demonstrated eosinophilic infiltrate without granuloma, necrosis, or vasculitis. He improved with oral corticosteroids and Mepolizumab, an IL-5 inhibitor. The second case involved a 33-year-old man who similarly presented with episodic dacryoadenitis, pulmonary inflammation and pain/swelling in the hands and feet. Lacrimal gland biopsy demonstrated a predominantly eosinophilic infiltrate without granuloma or vasculitis. Symptoms improved with oral corticosteroids. Although neither patient was provided a definitive diagnosis, both were determined to have an eosinophilic condition on the spectrum of eosinophilic asthma or eosinophilic granulomatosis with polyangiitis.

We describe a retrospective case report of dacryoadenitis associated with orbital inflammatory disease in a patient with confirmed SARS-CoV-2 infection.A 22-year-old previously fit and healthy male presented with 4-day history of right ocular redness, eyelid swelling and blurred vision associated with discomfort and pain in the lacrimal gland area. He was found to have right acute dacryoadenitis based on clinical examination and orbital imaging. One day after initiation of oral antibiotic and non-steroidal anti-inflammatory therapy, he developed worsening of the orbital inflammation and partial ophthalmoplegia. Oral steroids were commenced resulting in rapid resolution of symptoms within a few days and clinical stability at 2 months.The patient did not have any systemic features of COVID-19 but he was in close contact with his mother and with his partner who both had respiratory symptoms and tested positive for SARS-CoV-2 antigen (PCR testing) 4 weeks prior. PCR testing from nasopharyngeal swab was negative for SARS-CoV-2 RNA; however, the serological test was positive for IgM/IgG SARS-CoV-2 antibodies. Extensive laboratory workup including infectious and autoimmune screening and chest x-ray were unremarkable.Orbital inflammatory disease due to infectious process or immunological response may potentially occur in COVID-19 patients, although the causal relationship remains uncertain.

Aim: The aim of the study is to describe intracanalicular antibiotic ointment loading as a treatment option for canaliculitis., Material and Methods: It was an interventional prospective study. The study was conducted over a 3 year period from June 2015 to June 2018. All patients of canaliculitis managed with intracanalicular antibiotic ointment loading and with a minimum follow up of 3 months were included in the study. The antibiotic ointment was loaded into the canaliculus based on the antibiotic sensitivity of the material expressed out from the canaliculus. Patients' demographics, clinical details, microbiological profile and management outcomes were evaluated., Results: A total of 24 patients were included in the study. Mean age at presentation was 58.41 ± 9.4 years. The right eye was involved in 15 (62.5%, p = .0424) cases. The incidence of lower canaliculus involvement (14, 58.33%, p = .022) was significantly higher as compared to the upper canaliculus (8, 33.33%). Staphylococcus epidermidis and Actinomyces israelii (6, 25%) were the most commonly isolated organisms. Mean number of intracanalicular antibiotic loading sessions required was 4.21 ± 1.69 (range 2-8). Complete resolution of canaliculitis was seen in all (100%) cases., Conclusion: Canalicular antibiotic ointment loading is a minimally invasive, safe, and effective procedure. It preserves the anatomy and function of the punctum and canaliculus and can be considered as one of the management options for canaliculitis.

Purpose: To compare the outcomes of patients with and without a history of dacryocystitis that undergo dacryocystorhinostomy without systemic intra- and post-operative antibiotics., Methods: A retrospective review was performed to identify all cases of patients that received surgery under this paradigm and had at least three months of follow up care. Key demographic and outcome data were captured, and a statistical analysis was performed via a dedicated software package (Microsoft Excel, Redmond, WA)., Results: For the study period, 83 patients without and 69 patients with a history of dacryocystitis were identified, and the two groups were not statistically significantly different in age, gender, or postoperative follow up duration (mean = 6.4 months for patients without and 6.3 months for those with dacryocystitis, respectively). No patient developed a postoperative infection or a recurrence of dacryocystitis during the follow up period., Discussion: While many surgeons routinely use systemic antibiotics in patients with a history of dacryocystitis who undergo dacryocystorhinostomy, these agents may not be necessary. As a result, patients may be able to avoid the complications and side effects inherent to systemic antibiotics. Large-scale, prospective studies will likely help to further clarify this issue.

Purpose: Recent studies suggest an increasing incidence of gram-negative bacteria and methicillin-resistant Staphylococcus aureus in dacryocystitis. Since patients are often treated empirically without culture data, a changing microbiologic profile will markedly affect the success of oral treatment. To provide current guidelines for the treatment of this common condition, we investigated the microbiology and antibiogram of dacryocystitis seen at our institution., Methods: The charts of all patients presenting with acute and/or chronic dacryocystitis in University Hospital, Newark, from 2007 to 2015 were reviewed. Patient demographics, culture isolates, and in vitro antimicrobial susceptibility data were collected. Additional sensitivity data were obtained from the Sanford Guide to Antimicrobial Therapy., Results: A total of 137 patients were included in the study. Of 205 samples collected, S. aureus was the most commonly isolated organism (46 of 156, 30%) followed by Pseudomonas species (19 of 156, 12%) and Propionibacterium acnes (15 of 156, 10%). Based on sensitivity data, the two oral antibiotics that would have been most effective in this population were levofloxacin and amoxicillin/clavulanate; however, even these antibiotics would have encountered at least one resistant organism in 16% and 32% of patients, and potentially in another 15% and 8% of patients, respectively., Conclusions: Given the broad range of causative organisms, routine treatment of dacryocystitis with any specific antibiotic may fail in up to one-third of patients. Obtaining a culture at the time empiric antibiotic treatment is initiated can prove extremely valuable when treating patients with dacryocystitis.

Acute dacryoadenitis with abscess formation has been rarely described. We describe four cases that resolved with incision and drainage. This includes a retrospective case series of four patients with radiologically confirmed lacrimal gland abscesses and a review of the reported cases in the literature. Computed tomography showed characteristic rim enhancing collections with central attenuation in all four cases. All patients presented with ptosis, upper eyelid erythema, and severe pain similar to scleritis. Injection of the conjunctiva and sclera was present in two patients, and a third patient presented with expression of purulent discharge onto the ocular surface upon palpation of the lacrimal gland. All patients were treated with intravenous antibiotics and underwent incision and drainage with subsequent improvement. All were monitored for 24 to 48 hours and discharged on oral antibiotics. There were no complications or recurrences. Lacrimal gland abscess formation is a rare complication of dacryoadenitis, and in our experience these patients respond well to incision and drainage in combination with systemic antibiotics.

Acute suppurative bacterial dacryoadenitis (ASBD) with abscess formation is rarely seen in clinical practice. A retrospective review of medical records in the past 8 years identified two unilateral cases in children, one developed presumably after methicillin-sensitive Staphylococcus aureus (MSSA) conjunctivitis and the other due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection. Computerized tomography scans showed globe indentation by the enlarged lacrimal glands with rim-enhancing lesions. After failing to respond to intravenous antibiotics, both abscesses resolved promptly with surgical drainage without any long-term sequelae.

The present report discusses a new case of dacryoadenitis with extraocular muscle inflammation associated with Acanthamoeba keratitis (AK) in a contact lens wearer. A 41-year-old male, who has worn silicone hydrogel contact lenses on an extended basis for about 10 years, attended with the complaints of vision disturbance, hyperemia, and pain in his right eye. His history revealed that 1.5 month ago, he had been diagnosed with allergic conjunctivitis and had used steroid eye drops. Biomicroscopic examination revealed eyelid edema, chemosis, and ring infiltration, radial keratoneuritis and an epithelial defect in the cornea. Magnetic resonance imaging demonstrated enlarged lacrimal gland with edematous changes consistent with inflammation due to dacryoadenitis. There were also thickening and edema of the right superior oblique and lateral rectus muscle. The treatment protocol for AK was applied with no specific treatment for dacryoadenitis. After 4 months of the treatment, dacryoadenitis and keratitis regressed. Dacryoadenitis and extraocular muscle inflammation may accompany AK more frequently than expected and previously known. The evaluation of the lacrimal gland and extraocular muscles in presence of AK might be beneficial for understanding better the exact clinical picture and course of the keratitis.

The aim of this report is to present a case of a patient with bilateral lacrimal gland abscesses in the course of dacryoadenitis. A 45-year-old female patient with a long history of cocaine abuse presented with bilateral bacterial dacryoadenitis and upper lid inflammation with purulent discharge from a palpebral wound of the right upper lid. The diagnosis was confirmed with microbiology culture and an orbital CT scan, which revealed lacrimal gland abscesses. The patient admitted to vigorous eye scratching, which we believe was the mechanism responsible for the process. The infection resolved on targeted antibiotic therapy. This is the first reported case of bilateral infectious dacryoadenitis produced in a self-inflicted mechanism in a cocaine addict.

A previously healthy 23-month-old girl was admitted for the management of an acute unilateral dacryocystitis following accidental contact with dog faeces. No periocular trauma was reported. Microbiological investigation showed a multiresistant strain of Pantoea species to be the responsible pathogen. The infection responded to a course of oral Clindamycin and Ciprofloxacin, in combination with Chloramphenicol eye drops. This is the first report of an acute dacryocystitis sustained by this microorganism.

Acute dacryocystitis is a rare complication of infectious mononucleosis with only three previous reports in the English literature. We present two further children with acute dacryocystitis and clinical and laboratory features of Epstein-Barr Virus related infectious mononucleosis. Both were treated with systemic antibiotics and one child additionally required surgical drainage of a lacrimal sac abscess. Both children made a complete recovery without any lacrimal symptoms. Acute dacryocystitis is uncommon in children without a history of congenital nasolacrimal duct obstruction, and an underlying systemic condition such as infectious mononucleosis should be suspected. In such patients, dacryocystitis can be expected to resolve without symptoms of nasolacrimal duct obstruction and dacryocystorhinostomy is seldom required.

We report a case of a rare fungal orbital infection in an infant presenting with dacryocystitis. The causative organism was Conidiobolus sp. of the order Entomophthorales. There is no standard treatment for entomophthoramycosis. Our patient responded well to combined antifungal therapy without aggressive surgical débridement.

Purpose: Unusual intranasal conditions may increase the rate of complications and affect success rate of endonasal dacryocystorhinostomy (DCR) surgery. The purpose of this study was to find the influence of endonasal abnormalities on outcome of endonasal DCR surgery and to find the role of topical mitomycin C (MMC) as a postoperative adjunct to endonasal dacryocystorhinostomy in these patients., Methods: A total of 23 patients (19 males and 4 females) of bilateral chronic dacryocystitis in the age range of 18-60 years, having endonasal anatomical variants were included in this study. After endonasal DCR, the right side of nasal cavity was packed with 0.05% MMC nasal pack and left side of nasal cavity was packed with normal saline pack for 48 hours. During postoperative visits, the patients were checked for improvement in clinical symptoms and watched for complications including formation of adhesions and/or synechaie. The statistical association between endonasal pathologies and 3 dichotomous outcome variables (clinical features, adhesions, synechaie) was assessed by applying Fisher's Exact Test., Results: Postoperative retention of nasal packs for 48 hours after endonasal DCR, did not cause any side effect in our patients. An improvement in clinical symptoms (23/23 = 100%) was seen in all the patients on side with 0.05% MMC soaked nasal pack, while 10/23 i.e., 43.47% patients did not show improvement in symptoms on side of saline nasal pack. Postoperatively, the MMC nasal pack side nasal cavity had a healthy nasal mucosa during the entire follow up, while the saline nasal pack side nasal cavity had synechiae in 15/23 (65.2%) patients and adhesions in 15/23 (65.2%) patients. In our study, none of the anatomical endonasal variants had a statistically significant association with either formation of adhesion or formation of synechiae, as the p-value was > 0.05 in all these instances., Conclusions: The patients with endonasal anatomical variants have a higher incidence of complications like formation of adhesions and synechaie after endonasal DCR than other patients. Topical MMC is safe and effective agent to decrease the rate of complications when used as an adjunct in endonasal DCR in patients with endonasal anatomical variants.

Purpose: To examine the current spectrum of bacterial isolates in cases of chronic dacryocystitis and dacryoabcess and to determine their antibiotic sensitivities., Materials and Methods: We carried out a prospective study in which 39 patients who presented to the outpatient clinic with chronic purulent dacryocystitis or acute dacryoabscess had cultures taken. All patients were antibiotic-free for at least one week prior to culturing., Results: The 39 positive cultures grew 41 bacterial isolates, as two patients grew two species of bacteria. Sixteen isolates (39%) were Gram positive and 25 (61%) were Gram negative. The most common isolates were Pseudomonas (22%), Staphylococcus aureus (13%), Enterobacter (10%), Citrobacter (10%), Streptococcus pneumoniae, Escherichia coli, and Enterococcus (7%). Uncommon Gram-negative bacteria were also cultured: Alcaligenes in 2 cases (5%) and one case of Stenotrophomonas maltophilia (2.5%). No anaerobic bacteria were isolated. Gram-negative isolates were sensitive to ceftazidime in 95%, ciprofloxacin in 86% and cefuroxime in 50%, with a sensitivity of less than 30% to cefalexin and ampicillin in those tested. All Pseudomonas isolates (100%) were sensitive to ceftazidime, 86% were sensitive to ciprofloxacin, while only 20% were sensitive to ampicillin and 14% to cefalexin. Alcaligenes was resistant to all antibiotics tested with the exception of ceftazidime., Conclusion: This study demonstrates a significant change in bacterial flora and antibiotic treatment requirements of purulent dacryocystitis from previously published data. A higher incidence of Gram-negative organisms, particularly Pseudomonas, with resistance to commonly used antibiotics was found. The emergence of rarer, highly resistant, Gram-negative microorganisms may also indicate a trend in lacrimal sac infections. These findings suggest that the antibiotic treatment protocol before and after lacrimal surgery should be reconsidered in this subgroup of patients.

Objective: To examine the current spectrum of bacterial isolates in cases of chronic dacryocystitis and dacryoabcess and to determine their antibiotic sensitivities., Materials and Methods: We carried out a prospective study in which 39 patients who presented to the outpatient clinic with chronic purulent dacryocystitis or acute dacryoabscess had cultures taken. All patients were antibiotic-free for at least one week prior to culturing., Results: The 39 positive cultures grew 41 bacterial isolates, as two patients grew two species of bacteria; 16 isolates (39%) were Gram-positive and 25 (61%) were Gram-negative. The most common isolates were Pseudomonas (22%), Staphylococcus aureus (13%), Enterobacter (10%), Citrobacter (10%), Streptococcus pneumoniae, E. coli, and Enterococcus (7%). Uncommon Gram-negative bacteria were also cultured: Alcaligenes in two cases (5%), and one case of Stenotrophomonas maltophilia (2.5%). No anaerobic bacteria were isolated. Gram-negative isolates were sensitive to ceftazidime in 95%, ciproxin in 86%, and cefuroxime in 50% of cases, with sensitivity of less than 30% to cephalexin and ampicillin in those tested. All Pseudomonas isolates (100%) were sensitive to ceftazidine, 86% were sensitive to ciprofloxacin, with only 20% being sensitive to ampicillin and 14% to cephalexin. Alcaligenes was resistant to all antibiotics tested with the exception of ceftazidine., Conclusion: This study demonstrates a significant change in bacterial flora and antibiotic treatment requirements of purulent dacryocystitis from previously published data. A higher incidence of Gram-negative organisms, particularly Pseudomonas, with resistance to commonly used antibiotics was found. The emergence of rarer highly resistant Gram-negative microorganisms may also indicate a trend in lacrimal sac infections. These findings suggest that the antibiotic treatment protocol before and after lacrimal surgery should be reconsidered in this subgroup of patients.

A 26-year-old woman presented with a painful skin eruption which led to the diagnosis of acute myeloid leukemia. During chemotherapy, she developed an unusual orbital inflammation. Careful observation of the clinical course, computed tomography, and orbital biopsy were necessary to establish the diagnosis of dacryoadenitis associated with subcutaneous Sweet's syndrome. The skin eruption and the dacryoadenitis resolved rapidly with corticosteroid therapy. This is the first report of dacryoadenitis in the course of subcutaneous Sweet's syndrome.