Epidemiology in Africa

• Common in infants (congenital nasolacrimal duct obstruction).
• In adults, more common in women and in individuals >40 years.
• Rural factors that increase risk include: 
  • Limited access to early care
  • Chronic sinusitis
  • Facial trauma
  • Untreated nasal infections
  • Delayed referral to ophthalmology

 Clinical Features

Symptoms

• Sudden painful swelling at medial canthus
• Tearing (epiphora)
• Purulent discharge
• Fever in moderate–severe cases

Signs

• Tender, erythematous swelling over lacrimal sac
• Positive ROPLAS (reflux of pus on pressure)
• Abscess in advanced cases
• Conjunctival hyperemia

Red Flags

• Proptosis
• Vision change
• Restriction of extraocular movements
• Severe pain or systemic deterioration (suggests orbital cellulitis)

 Diagnosis

Clinical diagnosis is sufficient. No imaging is needed in most rural cases.

Optional when available:

• Gram stain and culture of expressed discharge
• Blood tests only if acutely ill
• Imaging only in trauma or suspected tumour (rare in rural practice)

 Treatment Protocol (Resource-Limited Setting)

Immediate Measures

• Warm compresses 3–4× daily
• Crigler massage (especially infants)
• Start empirical broad-spectrum antibiotics immediately

Oral Antibiotics (Adults)

• Amoxicillin–clavulanate 625–875 mg PO every 12 h for 7–10 days
• If penicillin-allergic: 
  • Ciprofloxacin 500 mg PO every 12 h

Oral Antibiotics (Children)

• Amoxicillin–clavulanate 20–40 mg/kg/day (amoxicillin component) divided every 8–12 h
• Severe cases: 
  • Ceftriaxone 50–80 mg/kg/day IV/IM

Severe or Toxic Patients (Adults)

• Ceftriaxone 1–2 g IV daily
• Add metronidazole if anaerobic coverage is needed.

Abscess Management

• Incision & drainage only if fluctuant
• Avoid incising lesions extending towards the orbit
• Give analgesia + continued antibiotics

After Acute Resolution

• Adults often need dacryocystorhinostomy (DCR)
• Infants: most congenital obstruction resolves spontaneously by 1 year → continue conservative therapy

When to Refer

Refer urgently if any of the following occur:

• Proptosis, ophthalmoplegia → suspected orbital cellulitis
• High fever / toxic appearance
• Recurrent episodes requiring DCR
• Failure to improve after 48–72 hours
• Children with persistent symptoms beyond 12 months
• Complications: 
  • Preseptal or orbital cellulitis
  • Meningitis
  • Cavernous sinus thrombosis
  • Persistent fistula

Conclusion

Key Points for Rural Doctors

• Diagnosis is clinical; do not delay treatment for tests.
• Oral antibiotics + warm compresses are usually effective.
• Always assess for early signs of orbital involvement.
• Abscesses can be drained safely in rural clinics if localized.
• Teach caregivers proper lacrimal sac massage technique.
• Adults with repeated infections require referral for DCR.
• Early treatment prevents life-threatening intracranial spread.