Morning Conference

Meghan OConnor

Case Presentation
54 day old

SANDOVAL, ISABELLA (552680588)

2 day history of left eye erythema and swelling 1 day history of left eye bulging, fussiness, and decreased interest in breastfeeding.

History
PMHx: Nasolacrimal duct obstruction dx at 2 weeks Managed with nasolacrimal duct massage and warm compresses. Birth Hx: Term, AGA infant born via NSVD. Uncomplicated pregnancy. Prenatal screening all negative, including GBS, GC, and Chlamydia. Received VitK and erythromycin ointment at birth. Discharged at 48H of life.

History (continued)
Medications: None Allergies: None Family History: No immunodeciencies, inherited childhood diseases, or any children with chronic disease. Social History: Lives at home with mother, father, and 4yo sibling. No animals. No sick contacts. No one with skin infections or boils.

Review of Systems
Yes: As per HPI. No: No fever or hypothermia No photophobia, eye trauma, or recent purulent discharge No cough or congestion No vomiting or diarrhea

Physical Exam
Vitals: T 38.2 C HR 176 RR 48 Weight: 50%ile Gen: Irritable, but consolable CV, Lung, ABD/GU, EXT, MSK, and the remainder of the HEENT exam are normal.

Left Eye Exam

Unable to spontaneously open her left eye more than 2-3 mm Conjunctival chemosis Periorbital soft tissue erythema and edema most pronounced over the infero-medial NLD Tender to palpation and warm to the touch. +induration. - uctuance When NLD pressure is applied, purulent discharge is expressed at the medial punctum.

Physical Exam

Laboratory Evaluation
CBC: WBC 12 (51N 38L) HGB 11.1 PLTS 351 CRP: 3.3 CSF: WBC 1, RBC 1, GLUC 51, PROT 31, gram stain negative Blood Cx: Gram stain negative Routine Cx (eye discharge): Gram stain negative

Imaging
Head CT

Differential Diagnosis

54 day old infant with epiphora

Differential Dx- Epiphora

NLD obstruction Congenital eyelid abnormalities, such as ingrown eyelashes Chemical irritation Trauma Occult foreign body Congenital or early onset glaucoma Conjunctivitis, both horizontally and vertically acquired

Diagnosis

Dacryocystitis with abscessed left dacryocystocele Pre-septal and orbital cellulitis

Anatomy
Nasolacrimal duct

Nasolacrimal duct stenosis

Most common cause of excessive tearing in infants Affects up to 20% of infants Typically distal Clinical diagnosis Spontaneous resolution of 90% by 6 months of age Management: massage, warm compresses Only 1-2% require surgical intervention

Dacryocystocele
Rare (0.1% of total cases) Presentation: Typical NLD + swelling (often blueish) just inferior to the medial canthal fold 25% bilateral Differential: other paranasal masses such as hemangiomas, encephaloceles, gliomas, and dermoid and epidermoid cysts. Diagnosis: Physical exam and ultrasound Management: Optho referral Complications: dacryocystitis, respiratory distress caused by large cysts leading to intranasal obstruction, and astigmatism with threat of amblyopia, caused by a large cyst obstructing vision.

Acute Dacryocystitis
Acute onset of erythema, edema, warmth, and tenderness over the lacrimal sac More common on the left Complications: pre-septal & orbital cellulitis, meningitis, brain abscess, and sepsis Dx: H&P, CT to rule out complications

Acute Dacryocystitis
Etiology Most common: Alpha-hemolytic streptococcus, S. epidermidis, and S. aureaus GNR: E. coli and Haemophilus inuenzae Rarely anaerobes or fungi Treatment: IV 3rd generation cephalosporin + clinda/vancomycin Optho consultation Dacryoabscesses often require surgical intervention to prevent recurrence with dacryocystorhinostomy (stulization of the lacrimal sac into the nasal cavity) or daryocystectomy (removal of the external wall of the lacrimal sac).

References
Cavazza GL, Laf LL, Tassinari DD. Congenital dacryocystocele: diagnosis and treatment. Acta Otorhinolartyngologica Italica 2008; 28:298-301. 1. Nelson Textbook of Pediatrics, 19th Ed.; Chapter 626 - Orbital Infections. Pages 2182-2184 2. Robb RM. Congenital nasolacrimal duct obstruction. Ophthalmol Clin North Am 2001; 14:443 3. Cavazza GL, Laf LL, Tassinari DD. Congenital dacryocystocele: diagnosis and treatment. Acta Otorhinolartyngologica Italica 2008; 28:298-301. 4. Nelson Textbook of Pediatrics, 19th Ed.; Chapter 626 - Orbital Infections. Pages 2182-2184 5. Robb RM. Congenital nasolacrimal duct obstruction. Ophthalmol Clin North Am 2001; 14:443