Acute Vision Loss From Dacryocystitis: JAMA
A 59-year-old woman presented with 2 days of left orbital pain. Medical history was significant for hypertension controlled with lisinopril and several months of epiphora without prior dacryocystitis. Examination revealed acuity of 20/25 OD and 20/400 OS, edematous, hyperemic left eyelids, diffuse limitation in extraocular movements in the left eye, normal intraocular pressure, and normal fundi on both sides.

Computed tomography with contrast revealed a left-sided lacrimal sac abscess with postseptal fat stranding largely limited to the extraconal space, minimal sinus mucosal thickening, and opacification of both nasolacrimal ducts (Figure 1A). Urgent, bedside transcutaneous incision and drainage yielded copious pus. No packing was placed, and intravenous ampicillin-sulbactam and vancomycin were started. Next-day cultures isolated gram-positive cocci in chains, visual acuity in the left eye improved to 20/70, and intraocular pressure was 17 mm Hg in each eye.

Two days after drainage, visual acuity remained 20/70, but with worsening eyelid edema and no improvement in extraocular movements. Repeated contrast-enhanced computed tomography revealed increased abscess size with globe compression (Figure 1B). There was minimal intraconal fat stranding, and the optic nerve was unremarkable in appearance.

Intraocular pressure remained normal in each eye. The next day, the patient had intraoperative repeated incision and drainage, bacitracin washout, and surgical drain placement. On postoperative day 1, edema and pain were improved, but visual acuity in the left eye was no light perception, with a 4+ relative afferent pupillary defect and new disc edema. Intraocular pressure was within normal limits.

Same-day magnetic resonance angiography demonstrated a patent ophthalmic artery; however, diffusion-weighted imaging showed acute injury to the entire orbital segment of the left optic nerve (Figure 2). Cultures from the initial drainage grew pan-susceptible Streptococcus pyogenes.

Antibiotics were narrowed 5 days after original incision and drainage to complete 2 weeks of ceftriaxone. She underwent an external dacryocystorhinostomy 1 month later. At 6 months, visual acuity in the left eye remained no light perception.

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