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 Table of Contents    
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 169-172  

A prospective study on epidemiology of dacryocystitis at a tertiary eye care center in Northern India


1 Shankara Eye Hospital, Coimbatore, Tamil Nadu, India
2 Department of Ophthalmology, Oculoplasty and Ocular Oncology Services, Al Nahdha Hospital, Ministry of Health, Muscat, Sultanate of Oman
3 Department of Ophthalmology, Jawaharlal Nehru Medical College, AMU, Aligarh, Uttar Pradesh, India
4 Department of Orbit Oculoplasty, Reconstructive and Aesthetic Service, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India

Date of Submission13-Mar-2021
Date of Decision02-Jul-2021
Date of Acceptance04-Jul-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Prof. Syed Ali Raza Rizvi
Department of Ophthalmology, Oculoplasty and Ocular Oncology Services, Al Nahdha Hospital, Ministry of Health, Muscat
Sultanate of Oman
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ojo.ojo_80_21

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   Abstract 


AIM: The aim of this study is to study the prevalence, incidence, and the epidemiological characteristics of the patients of acquired dacryocystitis at a tertiary eye care center of Northern India.
MATERIALS AND METHODS: It was a prospective, cross-sectional study carried out over a period of 2 years (July 2016–July 2018). The prevalence, incidence, and the epidemiological characteristics of acquired dacryocystitis were studied and analyzed. Chi-square test was used to test the qualitative distribution.
RESULTS: A total of 212 cases were included in the study. The prevalence rate of dacryocystitis was 19.5 cases per 10,000 patients, and the incidence rate was 15 cases per 10,000 patients. Chronic dacryocystitis (183; 86.30%) was more commonly encountered clinical type than acute dacryocystitis. Majority of cases (204; 96.23%) were due to the primary acquired nasolacrimal duct (NLD) obstruction, whereas eight cases (3.78%) were due to the secondary acquired NLD obstruction. Females were more commonly affected (156; 73.58%). The mean age was 44.44 ± 18.95 (range: 12–86) years. Majority of the patients 108 (50.94%) belonged to 3rd–6th decades of life. The disease was more prevalent in people belonging to lower-middle socioeconomic class (92; 43.40%) living in rural areas (130; 61.32%) and the majority of them were housewives (125; 59%).
CONCLUSIONS: The incidence and prevalence of acquired dacryocystitis were 15 and 19.5 cases per 10,000 patients. It was much more common in females of lower socioeconomic status and is seen commonly in the 3rd to 6th decades of life.

Keywords: Dacryocystitis, epidemiology, Northern India


How to cite this article:
Khatoon J, Raza Rizvi SA, Gupta Y, Alam MS. A prospective study on epidemiology of dacryocystitis at a tertiary eye care center in Northern India. Oman J Ophthalmol 2021;14:169-72

How to cite this URL:
Khatoon J, Raza Rizvi SA, Gupta Y, Alam MS. A prospective study on epidemiology of dacryocystitis at a tertiary eye care center in Northern India. Oman J Ophthalmol [serial online] 2021 [cited 2021 Dec 8];14:169-72. Available from: https://www.ojoonline.org/text.asp?2021/14/3/169/328616




   Introduction Top


Normal drainage of tear from the conjunctival sac into the nose is dependent on patency of the nasolacrimal passage which includes the lacrimal puncta, the lacrimal canaliculi, the lacrimal sac, and nasolacrimal duct (NLD). NLD obstruction is the obstruction of NLD which leads to excess overflow of tears called epiphora.[1]

Congenital blockage of the lacrimal drainage system usually occurs due to imperforate valve of Hasner which covers the end of the NLD, and it occurs in 2%–6% of newborn infants, in which spontaneous resolution is seen in 80%–96% of infants by 1 year.[2]

In 1986, Linberg and McCormick coined the term “primary acquired nasolacrimal duct obstruction (PANDO)” to describe a NLD obstruction caused by inflammation of unknown cause that eventually leads to occlusive fibrosis of the NLD.[3]

Bartley proposed an obstruction of NLD which was secondary to well-identified and known pathologies and termed it secondary acquired lacrimal duct obstruction (SALDO) based on his published case series.[4] SALDO may result from a wide variety of causes including infection, inflammation, neoplasm, and trauma.

Dacryocystitis is the inflammation of the lacrimal sac which usually occurs because of NLD obstruction. It generally affects two age groups, infant and adult females over 40 years of age. Congenital dacryocystitis is almost always chronic, while acquired dacryocystitis may be acute or chronic. Chronic dacryocystitis is commonly attributed to effects of stricture of the NLD arising from chronic inflammation. Obstruction to the lower end of NLD may also be caused by the pressure of nasal polypi, a hypertrophied inferior turbinate, or extreme deviation of the septum. The accumulation of secretions and tear within the lacrimal sac is easily infected. Untreated chronic dacryocystitis never undergoes spontaneous resolution. The condition tends to progress and the walls of the sac ultimately become atonic, the contents never being evacuated except by external pressure. An acute inflammation may arise at any time, leading to lacrimal abscess.[1]

If untreated, it may cause unilateral chronic conjunctivitis, corneal ulcer, lacrimal abscess, lacrimal fistula, and orbital cellulitis; cavernous sinus thrombosis and panophthalmitis may occur if any intraocular surgery is performed in the presence of unrecognized dacryocystitis.[1]

Several epidemiological studies have been carried out in the past with a focus on epidemiology of acute and chronic dacryocystitis, but there is a dearth of literature from the Indian subcontinent. The present study was conducted to know the prevalence, incidence, and the epidemiological characteristics in the patients of dacryocystitis in the Indian subcontinent.


   Materials and Methods Top


It was a prospective, cross-sectional study carried out over a period of 2 years (July 2016–July 2018). Institutional review board approval and ethical clearance were obtained, and the study adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all the patients willing to participate in the study. All patients of acute and chronic dacryocystitis were included in the study. Cases of congenital NLD obstruction, patients <12 years of age, and those unwilling to participate in the study were excluded.

Name, age, sex, occupation, residential distribution, i.e., rural or urban, and socioeconomic status were recorded. Socioeconomic status was recorded using modified BG Prasad classification.[5] This classification can be applied to both urban and rural population and it is based on per capita income which is simple to calculate. All the patients were subjected to detailed history and clinical examination, which included duration and nature of symptom, laterality, history of trauma, and previous medical treatment or surgical treatment. Clinical examination included tear meniscus height, position of puncta, fluorescein dye disappearance test, regurgitation on pressure over lacrimal sac, and lacrimal sac irrigation. Investigations included nasal endoscopy and imaging in the form of computed tomography, magnetic resonance imaging, and dacryocystography wherever required.

Statistical analysis

Chi-square test for the distribution was used to test the qualitative distribution. A P < 0.05 was considered a significant association between the variables which were tested. The statistical software IBM SPSS 23 (SPSS Inc, Chicago, Delaware, United States ) was used for the analysis of the data.

The following formulae were used for calculating the incidence and prevalence rate.

Incidence rate



Prevalence rate



Hence, all recently diagnosed cases of acute and chronic dacryocystitis were categorized as new cases, while follow-up cases were categorized as old/existing cases.

Denominator population for the calculation of incidence and prevalence in our study was all patients who visited to our ophthalmology outpatient department and oculoplasty clinic during the study period.


   Results Top


A total of 212 patients were included in the study. The prevalence rate of acquired dacryocystitis was 19.5 cases per 10,000 patients (95% confidence interval [CI]: 0.19% ± 0.03%) and incidence rate of dacryocystitis was 15 cases per 10,000 patients (95% CI: 0.15% ± 0.02%).

Majority of cases (39; 18.40%) were in the age group of 41–50 years followed by 31–40-year age group (36; 17%). The minimum age was 12 years (which was the cutoff limit for inclusion) and the maximum age was 86 years. The mean age was 44.44 ± 18.95. The mean age for acute dacryocystitis was 40 ± 13.74 years as compared to 45.09 ± 19.60 years for chronic dacryocystitis (P = 0.2, 95% CI: 2.63–12.28) [Table 1].
Table 1: Epidemiological features of dacryocystitis

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Females comprised 156 (73.58%) and males comprised 56 (26.41%) of the total number of cases. The gender distribution was compared among acute and chronic dacryocystitis cases, and it was found to be statistically insignificant (P = 0.83). The number of acute and chronic dacryocystitis cases were 29 (13.7%) and 183 (86.32%), respectively [Table 1].

The left side (107; 50.47%) was more commonly involved than the right (78; 36.79%). Bilateral involvement was seen in 27 (12.73%) cases. The distribution of laterality was compared among acute and chronic dacryocystitis cases which was statistically insignificant (P = 0.09). In the current study, majority of cases (135; 63.70%) belonged to lower socioeconomic class, i.e., Class IV and V, 57 cases (26.9%) were from middle class, i.e., Class III, whereas 20 (9.4%) cases were of upper class, i.e., Class I and II [Table 1].

Majority of patients (125; 59%) were housewives by occupation, followed by students (23; 10.8%), farmers (22; 10.4%), laborers (20; 9.9%), self-employed (13; 6.1%), and teachers (8; 3.8%). Most of the patients (130; 61.32%) belonged to rural area, whereas 82 (38.68%) patients were from urban area [Table 1].

In our study of 212 cases, 148 (69.82%) cases were not associated with any nasal pathology and 64 cases (30.18%) were associated with nasal pathology. Deviated nasal septum (DNS) (44; 20.75%) and inferior turbinate hypertrophy (13; 6.13%) to the side of dacryocystitis were the most common nasal pathologies seen. Five (2.36%) cases had both DNS and inferior turbinate hypertrophy, while allergic rhinitis was seen in two (0.94%) cases [Table 1].

A total of 204 cases (96.23%) of dacryocystitis were due to primary acquired NLD obstruction, whereas eight cases (3.3%) were due to secondary acquired NLD obstruction. In this study, 163 (76.88%) cases were newly diagnosed cases of dacryocystitis, whereas 49 (23.11%) cases were existing cases which included follow-up cases having a history of medical or surgical treatment, and among these, 27 (12.74%) cases were having a history of dacryocystorhinostomy on the affected side. The most common ocular complication resulting from acquired dacryocystitis was conjunctivitis, which was seen in 28 (13.2%) cases, whereas five (2.3%) had lacrimal fistula, four (1.9%) had preseptal cellulitis, and one each had orbital cellulitis and lacrimal sac abscess [Table 1].


   Discussion Top


Our aim was to study the prevalence, incidence, and the epidemiological characteristics of the patients of acquired dacryocystitis at a tertiary eye care center of Northern India. Woog reported the incidence of NLD obstruction as 20.24 per 100,000 population.[6] In our study, we found the prevalence rate of dacryocystitis as 19.5 cases per 10,000 patients (95% CI: 0.19% ± 0.03%) and incidence rate as 15 cases per 10,000 patients (95% CI: 0.15% ± 0.02%). The rates seen in our study, however, cannot be extrapolated to the community since it is a hospital-based study.

Chronic dacryocystitis (183; 86.32%) was more common mode of presentation as compared to acute dacryocystitis in our study. It is in concordance to the previous studies wherein the rate of chronic dacryocystitis ranges from 60% to 70% as compared to the acute cases.[7],[8]

Majority of the patients in our study, 108 (50.94%), belonged to 3rd–6th decades of life with maximum incidence in 41–50 years (39, 18.4%) age group, which to is in concordance with previous studies.[9],[10] Around 3/4th of the study population in the present case series were females. Many previous studies have noted a similar gender predilection.[9],[10],[11],[12] A narrower bony nasolacrimal canal and hormonal factors in females have been proposed to be the plausible causes for this gender preponderance.[13]

Our study showed a more common involvement of left side (107; 50.47%) which is comparable with reports in literature.[12] This is probably because the NLD and the lacrimal fossa form a greater angle on the right than on the left side.[13]

Our majority of cases, 204 (96.23%), were due to primary acquired NLD obstruction and only eight cases (3.78%) were due to secondary acquired NLD obstruction which is correlating with the fact that idiopathic inflammatory obstruction is the primary cause of dacryocystitis in population.[3]

Socioeconomic status plays an important role in epidemiology of dacryocystitis. As people belonging to poor socioeconomic status often have to work in factories without proper protective measures and get exposed to lot of smoke, fumes, and irritants and also have poor hygiene. Poor socioeconomic status directly affects their poor affordability to health facilities. It also contributes to their poor knowledge regarding disease condition and awareness regarding maintaining good hygiene.

Our observation showed that majority of cases (135; 63.70%) belonged to lower socioeconomic Class (IV, V). Similar observation was noted in literature by Duggal et al.[9] and Majidaee et al.[12]

In our study, majority of patients (125; 59%) were housewives by occupation. Similar result was reported in literature.[12] These can be attributed to the fact that the majority of them came from the lower socioeconomic groups which can be correlated to poor ocular hygiene and knowledge of disease condition, less affordability to health care facilities, and exposure to lots and smokes while cooking using woods and cow dung cakes.

Majority of our patients belonged to rural area (130; 61.32%) which is comparable with reports in literature.[9],[12] As in our tertiary care center, most of the patients who came for seeking treatment were from rural areas and the majority of them were belonging to lower socioeconomic class.


   Conclusions Top


Hence, to conclude, dacryocystitis is a common ocular condition which was much more common in females of lower socioeconomic status and is seen commonly in the 3rd–6th decades of life. Females' predominance can be explained by anatomical and hormonal factors. Left-sided involvement was seen in the majority of cases which can be attributed to anatomical factors. Socioeconomic factors play a very important role as it affects awareness among people regarding nature of disease condition, ocular hygiene, occupation associated health risk, and health status of patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Sihota R, Ton R. Disease of the Lacrimal Apparatus Parson's Disease of Eye. 22nd ed. New Delhi: Elsevier; 2015. p. 475-7.  Back to cited text no. 1
    
2.
Nesi FA, Lishman RD, Levine MR. Ophthalmic Plastic and Reconstructive Surgery. 2nd ed. St. Louis: Mosby-Year Book, Inc.; 1998.  Back to cited text no. 2
    
3.
Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique. Ophthalmology 1986;93:1055-63.  Back to cited text no. 3
    
4.
Bartley GB. Acquired lacrimal obstruction: An etiologic classification system, case report, and a review of the literature. Part 1. Ophthal Plast Reconstr Surg 1992;8:237-42.  Back to cited text no. 4
    
5.
Mangal A, Kumar V, Panesar S, Talwar R, Raut D, Singh S. Updated BG Prasad socioeconomic classification, 2014: A commentary. Indian J Public Health 2015;59:42-4.  Back to cited text no. 5
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6.
Woog JJ. The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota, 1976-2000 (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2007;105:649-66.  Back to cited text no. 6
    
7.
Bharathi MJ, Ramakrishnan R, Maneksha V, Shivakumar C, Nithya V, Mittal S. Comparative bacteriology of acute and chronic dacryocystitis. Eye (Lond) 2008;22:953-60.  Back to cited text no. 7
    
8.
Eshraghi B, Abdi P, Akbari M, Fard MA. Microbiologic spectrum of acute and chronic dacryocystitis. Int J Ophthalmol 2014;7:864-7.  Back to cited text no. 8
    
9.
Duggal P, Chakravorty S, Azad RK, Mohan C. An epidemiological study on patients undergoing dacryocystorhinostomy. Indian J Otolaryngol Head Neck Surg 2006;58:349-51.  Back to cited text no. 9
    
10.
Badhu B, Dulal S, Kumar S, Thakur SK, Sood A, Das H. Epidemiology of chronic dacryocystitis and success rate of external dacryocystorhinostomy in Nepal. Orbit 2005;24:79-82.  Back to cited text no. 10
    
11.
Hartikainen J, Lehtonen OP, Saari KM. Bacteriology of lacrimal duct obstruction in adults. Br J Ophthalmol 1997;81:37-40.  Back to cited text no. 11
    
12.
Majidaee M, Mohammadi M, Sheikh MR, Khademlu M, Gorji MH. Patients undergoing dacryocystorhinostomy surgery in northern Iran: An epidemiologic study. Ann Med Health Sci Res 2014;4:365-8.  Back to cited text no. 12
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13.
Dacryocystitis GG. In: Agarwal S, Agarwal A, Apple DJ, Buratto L, Alio JL, Pandey SK, et al., editors. Textbook of Ophthalmology. 1st ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2002. p. 705-12.  Back to cited text no. 13
    



 
 
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