Dacryocystitis sounds obscure until you see it, and then it is unmistakable: a red, tender, swollen lump at the inner corner of the eye in someone who has been putting up with a watery eye for months. This article explains what the tear sac is, why it becomes infected, how the acute and chronic forms differ, what treatment involves and which features make it urgent.
Tears drain from small openings at the inner edge of each eyelid into a short channel, then into the lacrimal sac, a small reservoir tucked against the bone beside the nose. From there they pass down the nasolacrimal duct into the nasal cavity. The system works because tears keep moving.
Dacryocystitis is what happens when they stop. If the duct below the sac becomes narrowed or blocked, tears and mucus collect and stagnate, and stagnant fluid in a warm enclosed space eventually becomes infected. This is why dacryocystitis is rarely an isolated event: it is a complication of obstruction, which I describe in more detail on my page about adult nasolacrimal duct obstruction.
The acute form develops over hours to a couple of days. There is a painful, red, warm swelling below the inner corner of the eye. The location matters diagnostically: the sac sits below the tendon that anchors the eyelids to the nasal bone, so swelling centred below that line points to the sac, while swelling above it usually suggests something else.
Patients often have discharge, a sticky eye and marked tenderness. Gentle pressure over the swelling may bring mucopurulent material back up through the tear openings. Some feel generally unwell or feverish. If the swelling becomes fluctuant, an abscess has formed, and occasionally it discharges through the skin and leaves a small persistent fistula.
Chronic dacryocystitis is far less dramatic and far more often ignored. The dominant symptom is a watering eye that never quite resolves, with recurrent stickiness and repeated episodes described as conjunctivitis. The sac may be distended with mucus, forming a soft, painless swelling, and pressing on it produces a return of clear or cloudy mucus at the corner of the eye.
Because it is not painful, people live with it for years. The problem is that a chronically infected sac is a reservoir. It maintains a low-grade surface infection, and it can flare into the acute form at any time. It is also a genuine risk if the patient later needs intraocular surgery, which is one reason I ask about watering before cataract surgery.
The diagnosis is largely clinical: the location and character of the swelling usually make it clear. Beyond that, I examine lid position and the tear openings, check the ocular surface, and look for signs that the infection has spread beyond the sac into surrounding tissue.
Once the acute episode has settled, the drainage system itself is assessed, typically by gently irrigating it with a fine cannula to establish whether and where it is blocked. Endoscopic examination of the nose is often part of this, and imaging is used when the anatomy is unclear or when a mass is suspected. Crucially, probing or syringing is not done during an active infection, because it can push infection into the surrounding tissues. The wider group of drainage problems is covered on my page about lacrimal system disorders.
Acute dacryocystitis is treated with systemic antibiotics chosen and prescribed by the treating doctor, together with warm compresses and analgesia. Most cases settle over several days. A collection that has formed a defined abscess may need drainage, and patients who are systemically unwell, immunosuppressed, very young or not improving may need intravenous treatment in hospital.
What antibiotics do not do is fix the reason it happened. The obstruction is still there when the redness fades, which is why so many patients describe a series of episodes over months or years, each treated as a fresh infection.
Restoring drainage is the only way to stop the cycle. The standard operation is dacryocystorhinostomy, which does not attempt to reopen the blocked duct but creates a new passage directly between the lacrimal sac and the nasal cavity. A small window is made in the bone, the linings of the sac and nose are joined, and a fine silicone tube is often left in place for a period while the new passage matures.
It can be done through a small incision beside the nose, which gives direct access and allows tissue to be sampled if anything looks atypical, or endoscopically through the nose without a skin incision, which is convenient when there is coexisting nasal disease. Surgery is normally scheduled once the acute inflammation has settled rather than during it. Recognised risks include nosebleed, a skin scar with the external approach, infection, problems related to the silicone tube, adhesions inside the nose and the possibility that the new passage narrows again over time.
Congenital duct obstruction is common in infants and most cases resolve during the first year with massage and observation. Infection in that setting is treated differently from an adult, and more urgently, because babies are more vulnerable to infection spreading around the eye.
A tense bluish swelling at the inner corner present from birth suggests a distended sac and needs specialist assessment rather than watchful waiting. Any newborn with a red, swollen, tender inner corner should be seen the same day.
In the short video below I explain what the bluish swelling at a newborn's inner corner is, and why a dacryocystocele needs to be examined rather than watched.
See a doctor the same day for a painful red swelling at the inner corner of the eye. Attend an emergency department without delay if there is fever, if redness is spreading across the lids and cheek, if the lids are swollen shut, if eye movement is restricted or painful, if there is double vision, or if vision is reduced. These features suggest the infection is extending into the orbit, which is a serious condition requiring inpatient treatment.
Outside those situations, the message is simpler. A persistently watering, sticky eye is not something to tolerate indefinitely. It usually means the drainage system is not working, and identifying where it is blocked is what prevents the painful episode that brings most patients to me in the first place.
It is an infection of the lacrimal sac, the small reservoir that collects tears at the inner corner of the eye before they drain into the nose. It almost always develops because the duct below the sac is blocked, so tears and mucus stagnate there and become infected.
The classic finding is a tender, red swelling just below the inner corner of the eye, below the level of the tendon that anchors the lids to the nose. Swelling that sits above that level usually has a different cause. Pressure over the area may produce mucus or pus at the corner of the eye.
It needs to be seen the same day. Most cases respond to systemic antibiotics, but the infection can spread into the tissues around the eye. Fever, spreading redness, swelling of the lids, double vision, restricted eye movement or reduced vision all mean urgent assessment.
Antibiotics treat the episode, not the cause. Because the underlying problem is a blocked duct, infections tend to recur until drainage is restored. That is why surgery is usually recommended once the acute inflammation has settled.
No. Probing or syringing an acutely infected sac risks spreading the infection into surrounding tissue. The inflammation is treated first, and the drainage system is assessed and dealt with afterwards.
In babies this is treated seriously and urgently. A distended, bluish swelling at the inner corner present from birth, or an infected sac in a newborn, requires prompt specialist assessment rather than watchful waiting, because infants are more vulnerable to spreading infection.
The standard operation is dacryocystorhinostomy, which creates a new passage between the lacrimal sac and the nasal cavity, bypassing the blocked duct. It can be performed through a small skin incision beside the nose or endoscopically through the nose, and it is normally scheduled after the acute infection has settled.
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