|Year : 2014 | Volume
| Issue : 1 | Page : 1-5
A clinico-bateriological study of chronic dacryocystitis
Khevna Patel, Renu Magdum, Sarika Sethia, Abhay Lune, Atreyee Pradhan, RN Misra
Department of Ophthalmology, R N Misra Department of MicroBiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||16-Aug-2014|
Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune - 411 018, Maharashtra
Aim: This hospital-based study was conducted to identify common bacterial organisms and the antibiotic susceptibility of these organisms and to study the demographic profiles of patients with chronic dacryocystitis. Materials and Methods: A total of 100 patients above the age of 40 years were examined. Patients complaining of epiphora and nasolacrimal duct block on syringing were selected. Demographic factors such as age, sex, occupation and social status were recorded. Samples were collected by applying pressure over the lacrimal sac and allowing the purulent material to reflux through the lacrimal punctum, or by irrigating the lacrimal drainage system with sterile saline and collecting the refluxing material. Samples were sent for microbiological investigation and antibiotic sensitivity pattern. Results: One hundred patients were included in the study, of which the majority of patients were in the age group of 50-60 years (43%); female (52%) were more commonly affected. Majority of the patients belong to low socioeconomic status (64%) and majority were housewives (39%), and the left eye was more commonly involved (56%). All patients presented with epiphora (100%), and majority of them had mucopurulent regurgitant (71%) on sac-syringing. Of 100 clinical samples, 83% were culture positive and the remaining were reported as having no growth (17%). Among the Gram-positive organisms isolated, Staphylococcus aureus (41%) was the most common organism (1%). Most of the isolates of S. aureus were sensitive to ciprofloxacin (82.9%). Conclusion: It is important to know about microbial organisms responsible for chronic dacryocystitis as it is one of the important predisposing factors for postoperative endophthalmitis, especially due to the large volume of cataract surgery performed nowadays. Knowledge of common bacteria causing chronic dacryocystitis and their antibiotic sensitivity may help in deciding the appropriate antibiotic coverage for ocular surgery.
Keywords: Chronic dacryocystitis, epiphora, nasolacrimal duct obstruction
|How to cite this article:|
Patel K, Magdum R, Sethia S, Lune A, Pradhan A, Misra R N. A clinico-bateriological study of chronic dacryocystitis. Sudanese J Ophthalmol 2014;6:1-5
|How to cite this URL:|
Patel K, Magdum R, Sethia S, Lune A, Pradhan A, Misra R N. A clinico-bateriological study of chronic dacryocystitis. Sudanese J Ophthalmol [serial online] 2014 [cited 2019 Dec 16];6:1-5. Available from: http://www.sjopthal.net/text.asp?2014/6/1/1/138842
| Introduction|| |
Chronic dacryocystitisis is a chronic inflammation of the lacrimal sac due to obstruction of the nasolacrimal duct. It is an essential cause of ocular morbidity both in children and in adults.  It is the most frequent cause of epiphora.  It has been reported as being more common between the age group of 40 and 60 years, with females (80%) being more commonly affected than males probably due to the narrow lumen of the bony canal.  The disease is more predominant in the low socioeconomic group and in patients with poor personal hygiene. The source of infection is mainly due to infection from the conjunctiva, nasal cavity (retrograde spread) or paranasal sinus, allergic rhinitis or deviated nasal septum. Usual reported causative organisms are Staphylococcus species (spp), Pneumococcus spp, Streptococcus spp and Pseudomonas spp. Rarely, chronic granulomatous infection like tuberculosis, syphilis, leprosy and, occasionally, rhinosporidiosis may also cause dacryocystitis. Each year, 1.6-1.9 million cataract operations are performed throughout India,  many in "camps" or rural peripheral centers. In most centers, preoperative syringing of the nasolacrimal system is routinely performed prior to cataract surgery; the aim is to exclude chronic dacryocystitis, a major risk factor for postoperative endophthalmitis. Panophthalmitis can occur if any intraocular operation is undertaken due to unrecognized dacryocystitis.  Lacrimal syringing is a debatable issue because recent studies have reported that sac syringing is not essential for every patient undergoing cataract surgery.  If ROPLAS is negative, one can go ahead with surgery, but most prefer sac syringing prior to cataract surgery; use of antibiotics drops preoperatively and 5% betadine drops on the table are universally followed to exclude sight threatening complication.
The bacteriological investigations in chronic dacryocystitis would contribute to the choice of effective antimicrobial agents and would also help in reducing the unnecessary load of anti-microbial agents  prior to surgery. Hence, this study was conducted to identify the common bacterial organisms and the antibiotic susceptibility of these organisms and to study the demographic profiles of patient with chronic dacryocystitis.
| Materials and methods|| |
One hundred consecutive patients attending the outpatient department (OPD) of a tertiary care center in Western Maharashtra of age above 40 years were included in the study between July 2011 and September 2013. Patients complaining of epiphora, swelling at medial canthus (a nasolacrimal duct block), on syringing were included in the study. An informed consent was taken prior to investigating procedures. Demographic factors like age, sex, occupation and social status were recorded. Complete eye examination was performed with special importance to the medial canthal and sac areas. Clinical examination included evaluation of the nature of the discharge, presence of fullness in the lacrimal sac area and lacrimal sac patency. The nature of regurgitation on pressure over the lacrimal sac and during sac syringing was examined.
Collection of the samples was performed by applying pressure over the lacrimal sac and allowing the purulent material to reflux through the lacrimal punctum, or by irrigating the lacrimal drainage system with sterile saline and collecting the sample from the refluxing material. The samples were collected with sterile cotton wool swabs, ensuring that the lid margins or the conjunctiva were not touched. None of the patients had used either antibiotic eye drops or systemic antibiotics for at least 1 week before their visit to the OPD.
After the collection of the samples, they were immediately sent to a microbiology laboratory to carry out the isolation and identification of the pathogens. The first swab was used for Gram staining and KOH mount and the second for inoculation into culture media like Blood agar, Chocolate agar, MacConkey's agar, Nutrient agar and Sabaurauds Dextrose agar.
The specimens were cultured immediately in the following manner. The swab was rolled over Blood agar, Chocolate agar, Nutrient agar and MacConkey's agar plates and incubated at 37°C for 24-48 hours. Examination of the Blood agar and Chocolate agar plates were performed after 24 and 48 h of incubation. The plates were observed for the number and types of colonies formed. Colony characteristics were noted down. Gram staining was performed to identify whether the organisms grown were Gram positive or Gram negative. The organisms were further identified to the genus and species levels depending on motility and biochemical reactions. Also, antibiotic susceptibility testing was performed. Identification of the microorganisms was carried out using various biochemical reactions as well as routine tests. Biochemical tests were included in order to identify Gram positive (catalase, coagulase, etc.) and Gram negative bacteria (catalase, oxidase, indole, MR-VP, urease, citrate, TSI, O/F, etc.).
| Results|| |
One hundred patients were included in the study, of which the majority of patients were in the age group of 50-60 (43%) years; females (52%) were more commonly affected than males (48%). Majority of the patients belonged to low socioeconomic status (64%) and a majority were housewives (39%), and the left eye was more commonly involved (56%). One hundred percent of the patients complained of epiphora and had mucopurulent regurgitant (71%) on sac-syringing. Majority of the patients had associated nasal pathology. Of 100 clinical samples, 83% were culture positive and the remaining were reported as having no growth (17%). Gram-positive and Gram-negative organisms were both isolated. Among the Gram-positive organisms, Staphylococcus aureus (41%) was the most common organism isolated, followed by Streptococcus pneumoniae (9%). Among the Gram-negative organisms were Escherichia coli (17%), Pseudomonas aeruginosa (12%), Klebsiella pneumoniae (3%) and Haemophilus spp (1%). Most of the isolates of S. aureus were sensitive to ciprofloxacin (82.9%). Streptococci pneumoniae cultures were sensitive to gentamycin (88.9%). The sensitivity among E. coli was for ceftazidime-tazobactum (CAT) (70.6%). Most of the isolates of P. aeruginosa showed utmost sensitivity to CAT (83.3%). K. pneumoniae was sensitive to gentamycin (100%) and Haemophilus spp were sensitive to ciprofloxacin (100%).
| Discussion|| |
Our study included 100 cases of chronic dacryocystitis. Various demographic factors were studied, such as age, sex, occupation and laterality. Our findings were more or less similar to those of other studies. In our study, majority of the patients were in the age group of 50-60 (43%) years, followed by 40-50 (39%) years and 60-70 (18%) years [Table 1]. Other studies have also reported similar findings. ,
Females showed a higher incidence [Figure 1]. Hartikainen et al. in 1997 found a female to male ratio of 79%:21%.  In a series of 662 patients, Badhu et al. reported that 67.6% of the patients were female.  Chaudhry et al. in 2005 studied 118 patients of diagnosed chronic dacryocystitis, which had a predominant female patient population (65.4%). 
|Figure 1: Pie diagram of sex-wise distribution of cases in the study group|
Click here to view
The incidences of chronic dacryocystitis were more among the housewives (39%), followed by farmers (29%), service holders (24%) and drivers (8%). Majority of patients belonged to the lower class (64%), followed by middle class (36%), due to lack of relative hygienic habits and education.
In our study, none of the patients showed bilateral disease and dacryocystitis was more commonly seen on the left side (56%). Ghose et al. found that there was a relatively high incidence of the disease on the left side (40%) as compared with that on the right side (32%). Similar findings were noted by Brook et al. In general, the disease had a predilection to the left side, especially in females, because of their narrow bony canal. The nasolacrimal duct and the lacrimal fossa formed a greater angle on the right side than on the left side.  All patients complained of epiphora (100%). Seventy percent of the patients had complaints of mucopurulent discharge and 30% presented with swelling over the lacrimal sac along with epiphora (38%) [Figure 2]. Sood et al. found epiphora as the presenting complaint (49.3%), and 17.1% had pus regurgitation on pressing the inner canthus.
|Figure 2: Bar diagram of presenting complaint-wise distribution of cases in the study group|
Click here to view
In this study, 51% of the patients had complete naso-lacrimal duct obstruction on sac syringing while 49% had partial naso-lacrimal duct obstruction. Similar results were found in a study carried out in 2008. 
On the basis of regurgitant on sac-syringing, 71% patients had mucopurulent discharge, 19% had clear discharge and the remaining 10% had purulent discharge.
Of the 100 clinical samples evaluated, 83 (83%) were culture positive and the remaining were reported as having no growth 17 (17%). Among all Gram-positive growths, S. aureus was encountered as the most common isolate (49%) [Figure 4], followed by Streptococcus pneumoniae (11%), while among the Gram-negative organisms, E. coli (21%), P. aeruginosa (14%), K. pneumoniae (4%) and Haemophilus spp (1%) were predominant [Table 2][Figure 3]. The antibiotic susceptibility pattern varies from region to region and with communities. This is because of the emergence of resistant strains as a result of the indiscriminate use of antibiotics.
|Figure 3: Pie diagram of percentage of bacteriological isolate-wise distribution of cases in the study group|
Click here to view
|Figure 4: Photograph of S. aureus on Blood agar. The picture also shows beta hemolysis around the colonies|
Click here to view
|Table 2: Bacteriological isolate-wise distribution of|
cases in the study group
Click here to view
Most of the isolates of S. aureus were sensitive to ciprofloxacin (82.9%) [Figure 5], followed by cefuroxime (60.98%) and clindamycin (58.54%). Streptococci pneumoniae showed the highest sensitivity to gentamycin (88.9%), followed by vancomycin (44.44%). The sensitivity among E. coli was highest for CAT (70.6%), followed by imepenem (64.7%). Most of the isolates of P. aeruginosa showed utmost sensitivity to CAT (83.3%), followed by gentamycin (75%). All the isolates of K. pneumoniae were sensitive to gentamycin (100%) and all the isolates of Haemophilus spp were sensitive to ciprofloxacin (100%).
|Figure 5: Photograph shows the antibiotic sensitivity pattern of Grampositive cocci|
Click here to view
In a study conducted in 2008, 56 adults patients of chronic dacryocystitis were evaluated for causative organisms; S. aureus (40%) was found to be the most common Gram = positive organism, followed by S. epidermidis (10%) and Streptococcus pneumoniae (10%). Among the Gram-negative organisms, P. aeruginosa (16.6%) was the most common, followed by K. pneumoniae (6%) and Haemophilus influenzae (6%). Most organisms were resistant to penicillin. Chloramphenicol was found to be effective against most Gram-positive organism. Aminoglycosides, tobramycin in particular, was most effective against S. epidermidis. Fluoroquinolones, namely ciprofloxacin and ofloxacin, were sensitive to P. aeruginosa and K. pneumoniae.
In a study conducted in 2011 involving 100 patients, both Gram-positive and Gram-negative bacteria were found to be equally distributed in the study. The most common organism was again S. aureus. The antibacterial sensitivity showed more effectiveness toward Gram-positive isolates than Gram negative isolates. 
In a recent study conducted in 2012 on 83 patients of chronic dacryocystitis, it was found that S. aureus (26), Streptococcus pneumoniae (22) and P. aeruginosa (14) were the most common isolates. The Gram-positive isolates were most sensitive to vancomycin (100%), tobramycin and linezolid (99.36%). The Gram-negative organisms were most sensitive to tobramycin and gentamicin (100%), followed by cefepime (98.79%) and choramphenicol (97.1%). 
Majority of the patients (79%) had associated nasal pathology, 69% of the patients had deviated nasal septum, 9% had atrophic rhinitis and 2% had inferior turbinate hypertrophy. Similar results were found in a study conducted by Mandal and co-workers.  Nasal pathology, like hypertrophied inferior turbinate, deviated nasal septum, nasal polyp and allergic rhinitis, was found in 19.6% of the patients.
| Conclusion|| |
Indiscriminate use of antibiotics can give rise to the emergence of resistant strains. At the same time, preoperative antibiotic prophylaxis is important in large-volume cataract surgeries as widely practiced in our country. Our study revealed the highest incidence of S. aureus isolates with maximum sensitivity to ciprofloxacin.
| References|| |
|1.||Ghose S, Nayak N, Satpathy G. Current microbial correlates of the eye and nose in dacryocystitis - Their clinical significance. AIOC Proc 2005;437-9. |
|2.||Jacob HB. Symptomatic Epiphora. Br J Ophthalmol 1959;43:415-34. |
|3.||Duke Elder S, Cook C. Diseases of the lacrimal passages. In: Duke-Elder S, editor. System of Ophthalmology, Vol. 13 , Part II. St. Louis, CV: Mosby Elsevier; 1974. p. 675-724. |
|4.||Thomas R, Thomas S, Braganza A, Muliyil J. Evaluation of the role of sayringing prior to cataract surgery. Indian J Ophthalmol 1997;45:211-4. |
|5.||Sihota R, Tandon R. Parsons' Diseases of the Eye; 20 th ed. New Delhi: Elsevier; 2007. p. 447. |
|6.||Jose R, Bachani D. World Bank assisted cataract blindness control project. Indian J Ophthalmol 1995;43:35-43. |
|7.||Chaudhary M, Bhattarai A, Adhikari SK, Bhatta DR. Bacteriology and antimicrobial susceptibility of adult chronic dacryocystitis. Nepal J Ophthalmol 2010;2:105-13. |
|8.||Sood NN, Ratnaraj A, Balaraman G, Madhavan HN. Chronic dacryocystitis-clinicobacteriological study. J All India Ophthalmol Soc 1967;15:107-10. |
|9.||Bhuyan J, Das S. A clinicobacteriological study on chronic dacryocystitis. AIOC Proc 2010;392-3. |
|10.||Hartikainen J, Lehtonen OP, Saari KM. Bacteriology of lacrimal duct obstruction in adults. Br J Ophthalmol 1997;81:37-40. |
|11.||Badhu B, Dulal S, Kumar S, Thakur SK, Sood A, Das H, et al. Epidemiology of chronic dacryocystitis and success rate of external dacryocystorhinostomy in Nepal. Orbit 2005;24:79-82. |
|12.||Chaudhary IA, Shamsi FA, Al-Rashed W. Bacteriology of chronic dacryocystitis in a tertiary eye care centre. Ophthalmic Plast Rec 2005;21:207-10. |
|13.||Brook I, Frazier EH. Aerobic & Anaerobic Microbiology of Dacryocystitis. Am J Opthalmol 1998;125:552-4. |
|14.||Mandal R, Banerjee AR, Biswas MC, Mondal A, Kundu PK, Sasmal NK. Clinico-bacteriological study of chronic dacryocystitis in adults. J Indian Med Assoc 2008;106:296-8. |
|15.||Shah CP et al, Santani D. Bacteriology of dacryocystitis. Nepal J Ophthalmol 2011;3:134-9. |
|16.||Prakash R, Girish Babu RJ, Nagaraj ER, Prashanth HV, Shah J. A bacteriological study of dacryocystitis. J Clin Diagn Res 2012;5:652-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]