Conservative management of paediatric dacryocystitis: a collection of clinical experiences highlighting effectiveness and parental satisfaction

Abstract

Paediatric dacryocystitis, often linked to congenital nasolacrimal duct obstruction, may require surgical intervention if local conservative treatment is ineffective. This case series evaluated a local conservative treatment approach in five infants (1–12 months). Patients received Crigler massages twice daily, a 0.01% hypochlorous acid-based disinfectant spray and moxifloxacin eye drops during acute episodes. Symptoms progressively improved, with complete resolution within 6–9 months and no recurrence. The regimen was well tolerated and no surgical intervention was needed. These findings suggest that this local conservative strategy may serve as an effective first-line treatment, potentially reducing the need for invasive procedures in paediatric dacryocystitis management.

Introduction

Dacryocystitis, an infection of the lacrimal sac, is a relatively rare condition in paediatric populations (1 in 3,884 live births) but poses significant clinical challenges due to its potential complications and impact on patient quality of life.1,2 In children, it is typically associated with congenital nasolacrimal duct obstruction (CNLDO), which affects approximately 6% of newborns and often presents with symptoms such as excessive tearing, discharge, and occasional swelling or redness in the medial canthal region.2,3

Early diagnosis and appropriate conservative treatment are essential to prevent chronic complications and avoid the need for surgical intervention.4 In particular, the primary goal of conservative therapy is to relieve obstruction, promote tear drainage and control infection, thereby minimizing the need for surgical procedures.5 Hydrostatic Crigler massage is a widely employed technique that involves the application of gentle pressure over the lacrimal sac to encourage clearance of the obstruction and facilitate the drainage of purulent or mucoid material.6 Topical therapies, including disinfectant products, help maintain eyelid hygiene and reduce the microbial load around the affected area. Topical antibiotic treatments can be added to counteract acute bacterial infections and prevent their progression. In particular, the use of tobramycin eye drops, alone or in combination with dexamethasone, along with the tear duct probing procedure, represents a widespread approach.7

Whilst the obstruction spontaneously resolves in most infants, it persists in up to 25% of affected children.8 Patients who fail conservative treatment often undergo additional surgical interventions such as stenting, balloon dacryoplasty and dacryocystorhinostomy (DCR), which can be performed percutaneously (external DCR) or endoscopically (endonasal DCR).9–11

To date, limited literature exists on the effectiveness of conservative measures in resolving dacryocystitis in paediatric populations, particularly in infants under 18 months of age. Furthermore, the optimal combination and duration of conservative treatments have not yet been standardized, leaving clinicians with variable practices guided by anecdotal experience. Moreover, increasing resistance amongst ocular isolates to aminoglycosides (e.g. tobramycin) and previous-generation fluoroquinolones (e.g. ofloxacin and ciprofloxacin) has been documented, highlighting the need for novel antibacterial approaches.12,13

This collection of clinical experiences in infants aims to provide case descriptions and valuable insights into the outcomes of an innovative local conservative approach with three components: Crigler massages, a hypochlorous acid-based ocular spray and moxifloxacin eye drops. The findings support the role of this regimen in avoiding surgical procedures.

Patients and methods

Clinical cases involving paediatric patients diagnosed with dacryocystitis between January 2023 and March 2024 were retrospectively reviewed and described. Treatment regimens were based on the physician’s routine clinical practice, with an innovative approach consisting of hydrostatic Crigler massages, the application of a 0.01% hypochlorous acid-based disinfectant ocular spray (Ocudox™, marketed in Italy by Alfa Intes) and moxifloxacin eye drops (Quimox, Alfa Intes, single-dose administration). These local conservative treatments were prescribed in combination to control and resolve clinical signs and symptoms and avoid surgical intervention. Specifically, the rationale behind this approach was the usefulness of the antiseptic for cleansing the periocular region, limiting contamination from the skin, eyelashes and eyebrows, whilst also exerting a mechanical washing action and diluting the bacterial load and mucopurulent secretions. The addition of a latest-generation antibiotic, moxifloxacin, helped control bacterial replication in the affected tissues (conjunctiva and lacrimal ducts).

The included patients were aged ≤18 months and had a clinically confirmed diagnosis of dacryocystitis, with no prior surgical intervention. All cases were secondary to CNLDO. Ocular outcomes and treatment responses are reported on a patient-by-patient basis. Because of the retrospective nature of the study, treatment regimens and follow-up intervals were not standardized. The study was conducted in accordance with the ethical principles of the revised Declaration of Helsinki (52nd WMA General Assembly, Edinburgh, Scotland, October 2000). Informed consent for treatment and publication of clinical data was obtained from the patients’ parents or legal guardians. Ethics committee approval was not required in accordance with Italian national guidelines, which do not mandate ethics review for retrospective case series, provided no experimental interventions are performed and only routine clinical data are collected (ref. Ministerial Decree of August 2024).

Results

The authors retrospectively identified and documented the clinical experiences of five paediatric patients diagnosed with dacryocystitis. The five cases were consecutively included; however, they were collected over different periods during routine outpatient visits. A detailed account of each case is provided in Table 1.

Table 1.

Summary of patient characteristics and treatment protocols.

Patient ID	Age at diagnosis (months)	Eye affected	Key symptoms	Massage	Disinfectant spray	Antibiotic drops	Total treatment duration (months)	Outcome
1	5	Right	Tearing, purulent discharge	Twice daily for 6 months	Twice daily for 6 months	Three times daily for 7 days, as needed for 3 months	6	Complete resolution
2	3	Right	Tearing, purulent discharge	Twice daily for 6 months	Twice daily for 6 months	Three times daily for 14 days, as needed for 3 months	6	Complete resolution
3	6	Right	Tearing, purulent discharge	Twice daily for 7 months	Twice daily for 7 months	Three times daily for 7 days, as needed for 1 month	7	Complete resolution
4	12	Right	Tearing, purulent discharge	Twice daily for 6 months	Twice daily for 6 months	Three times daily for 7 days, as needed for 2 months	6	Complete resolution
5	1	Left	Tearing, purulent discharge	Twice daily for 9 months	Twice daily for 9 months	Three times daily for 7 days, as needed for 3 months	9	Complete resolution

The five paediatric patients were aged 1–12 months at the time of diagnosis with dacryocystitis associated with CNLDO, with symptom onset from birth. All cases involved the right eye except one patient with left-sided involvement. Clinical presentations included persistent tearing, mucoid or purulent discharge, and regurgitation of fluid upon lacrimal sac compression.

The conservative management protocol comprised twice-daily hydrostatic Crigler massages, twice-daily application of a 0.01% hypochlorous acid-based disinfectant ocular spray throughout the treatment period, and moxifloxacin eye drops administered three times daily during the acute phase, with durations ranging from 7 to 14 days per course and repeated as needed for a maximum of 3 months (Table 1).

Overall, the total duration of treatment varied from 6 to 9 months (Table 1). Patients were followed up periodically, and all showed progressive improvement, characterized by a decrease in discharge severity and a transition from purulent to serous regurgitation.

By the end of the treatment period, complete symptom resolution was documented in all cases, with no discharge observed upon lacrimal sac compression (Figure 1). No patient required surgical intervention, and all achieved full recovery within the specified follow-up timeframe.

Figure 1.

Pre- and post-treatment representative images.

A. Persistent tearing and mucoid discharge from the medial canthus of the right eye at presentation. B. Symptom resolution after 6 months of combined therapy with hydrostatic Crigler massages, disinfectant ocular spray and moxifloxacin eye drops.

The treatment regimen was well tolerated and easily administered by caregivers, contributing to its successful implementation in all cases.

Discussion

This case series highlights the success of an innovative local conservative therapeutic approach for the treatment of paediatric dacryocystitis associated with CNLDO. The findings show that a non-surgical regimen combining hydrostatic Crigler massages, a hypochlorous acid-based disinfectant ocular spray and moxifloxacin eye drops effectively resolved the condition in all patients without the need for probing or surgical intervention. Moreover, the consistent use of the antiseptic spray throughout the treatment period allowed the antibiotic to be used in cycles (as needed, e.g. during episodes of red eye) rather than continuously. These results are significant, as DCR and other invasive procedures, whilst effective for refractory cases, pose considerable risks in young children due to the necessity of general anaesthesia and the potential for post-operative complications.

The effectiveness of hydrostatic Crigler massages, a well-established technique in managing CNLDO, was a cornerstone of the treatment regimen in this study. By applying gentle pressure to the lacrimal sac, the massages promoted the clearance of obstructions and improved tear drainage, contributing to symptom resolution in all cases. The findings align with previous research emphasizing the efficacy of this method in facilitating resolution in infants and young children.14

Another essential component of the regimen was the use of a hypochlorous acid-based disinfectant ocular spray, which provided a non-invasive solution for maintaining eyelid hygiene and reducing the local microbial load. The use of 0.01% hypochlorous acid also offered several advantages over other antiseptic products. Notably, it demonstrated an immediate microbicidal effect on all tested organisms compared to commonly used, highly concentrated skin antiseptics (e.g. 70% isopropyl alcohol, 5% povidone-iodine and 4% chlorhexidine gluconate).15,16 Moreover, the low concentration of hypochlorous acid supported the favourable tolerability of the product, and the ease of application likely enhanced adherence and contributed to successful outcomes, in line with previous literature evidence.17 Its antiseptic properties aided infection control whilst minimizing inflammation, complementing the mechanical relief achieved through massage.

The inclusion of moxifloxacin eye drops further bolstered the conservative approach, addressing the infectious component of dacryocystitis. Moxifloxacin, a fourth-generation fluoroquinolone, is known for its broad-spectrum activity against common pathogens implicated in the condition such as Staphylococcus aureus and Haemophilus influenzae.18 The choice of moxifloxacin was guided by its favourable pharmacokinetic properties, particularly its ability to achieve high tissue penetration when administered topically. Another crucial aspect of moxifloxacin is its low potential to induce bacterial resistance, a major concern in ophthalmic antibiotic therapy. Unlike older fluoroquinolones, moxifloxacin exerts dual inhibition on bacterial DNA synthesis by targeting both DNA gyrase and topoisomerase IV, significantly reducing the likelihood of single-step resistance development.18 This feature was particularly relevant in the present treatment protocol, which required multiple antibiotic courses as needed, with no observed loss of clinical efficacy. Moreover, moxifloxacin has a well-established safety profile in paediatric populations, making it an appropriate choice for infants.18 The preservative-free, single-dose formulation offered an added advantage, reducing the risk of irritation and ensuring better tolerability in paediatric patients. The combination of these treatments proved highly effective in resolving the signs and symptoms of dacryocystitis within 9 months, allowing all patients to avoid surgical intervention and minimize long-term antibiotic exposure.

Larger, prospective studies are warranted to support these observations and establish standardized treatment protocols. Furthermore, integrating microbial culture data could provide insights into pathogen-specific responses and guide targeted antibiotic use. Such research could further refine the conservative approach and ensure its broader applicability in clinical practice.

Conclusion

This collection of clinical experiences supports the effectiveness of local conservative management in resolving paediatric dacryocystitis, avoiding the need for surgical intervention in all cases. The combination of hydrostatic Crigler massages, a hypochlorous acid-based disinfectant spray and moxifloxacin eye drops provides a practical, well-tolerated and effective treatment approach. These findings reinforce the value of conservative therapy as a first-line treatment for dacryocystitis in paediatric patients.

Data availability

All relevant data are presented within this paper. Additional information can be requested from the corresponding author upon reasonable request.