2.3 Dacryocystitis, Acute

Date of last review:

29/4/2026

Date of next review:

29/4/2028

Date of publication:

6/7/2026

Differential Diagnosis ⁽¹⁾

Facial cellulitis, preseptal cellulitis, or orbital cellulitis
Acute sinusitis
Infection following superficial trauma/skin abrasion
Lacrimal sac mucocoele (dacryocoele)
Chronic dacryocystitis

Possible management by optometrist

Advice

Do NOT probe the lacrimal system during acute infection (risk of spreading infection) ⁽¹⁾
For mild adult cases, use warm compresses and massage of the lacrimal sac to help drain purulent material through the puncta ⁽¹⁾
Consider non-pharmacological management first, prior to considering topical, then systemic pharmacological management ⁽⁷⁾

Treatment

For mild (non-febrile ⁽¹⁾) cases ⁽⁷⁾:
- Topical antibiotic: e.g. chloramphenicol drops/ointment for ≥5 days ⁽¹⁾
For more significant (non-febrile ⁽¹⁾) infection ⁽⁷⁾:
- Systemic antibiotic:
  - Co-amoxiclav ⁽¹⁾or flucloxacillin ⁽⁷⁾(refer to local formularies for preferred option ⁽⁷⁾)
  - If penicillin allergy: doxycycline ⁽⁷⁾
Poor response ^{(1, 7)}
- If symptoms do not improve (following above treatment ⁽⁷⁾) within 24–36 hours or patient is febrile, arrange urgent referral—may require IV antibiotics or incision and drainage.

NB all cases in children should be referred as an emergency⁽¹⁾

Typical adult dosage/duration

(Blue text = IP, black text = non-IP)

Chloramphenicol 0.5% eye drops ^(1,5) (POM, off-label): One drop every 2 waking hours for 48 hours. After this period, treatment should be every 4 hours during waking hours. Eye drops may be supplemented by 1% ointment at night. The course of treatment should be 5 days (even if symptoms improve)^(2,3)

Chloramphenicol 1% eye ointment ^(1,5) (POM, off-label): Apply at night (if eye drops used during the day), alternatively apply 3–4 times daily, if ointment used alone. The course of treatment should be 5 days (even if symptoms improve)^(2,3)

Co-Amoxiclav oral capsules ⁽⁶⁾ (POM): 500mg/125mg 3 times daily for 7 days ⁽⁶⁾

Flucloxacillin oral capsules ⁽⁶⁾ (POM): 500mg 4 times daily for 5-7 days ⁽⁶⁾

Doxycycline 100mg oral tablets/capsules ⁽⁷⁾(POM): 200mg in one dose on the first day then 100mg once daily for 5-7 days (in more serious infections can increase to 100mg twice daily for duration of treatment) ⁽⁶⁾

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and national guidance where available ⁽⁷⁾.

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾.

Further management options

Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate ⁽⁷⁾
Emergency referral ⁽¹⁾
- Severe cases (fever, systemic illness, or lacrimal sac abscess)
- All children
Urgent referral ⁽¹⁾
- Adult cases that are mild but not improving with systemic antibiotics after 24–36 hours.
- Maintain a low threshold for referral due to potential complications
Monitor ⁽¹⁾
- Mild, responsive cases: continue treatment and monitor for nasolacrimal duct obstruction (see chronic dacryocystitis guideline)
Manage to resolution ⁽¹⁾
- Where the condition resolves without long term effects.

Possible management in secondary care or local/community pathways where available

See Further management options ^(1,7)
Incision and drainage, where indicated ⁽¹⁾
Systemic/parenteral antibiotics for severe or unresponsive cases ⁽¹⁾
Investigation and treatment for nasolacrimal duct obstruction, usually via dacryocystorhinostomy (endoscopic or percutaneous) ⁽¹⁾
- Early surgical intervention improves outcomes ⁽¹⁾
In neonates/infants, co-management with paediatrics may be required ⁽¹⁾

College of Optometrists Clinical Management Guideline⁽¹⁾

Dacryocystitis (acute) - College of Optometrists *

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

Disclaimers

CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

Before reading the Eyecare Guidelines or making any management decisions based upon them, all users should read the ‘supporting information’ page which gives more detail around the content of the Guidelines and useful website links [link to Supporting Information page].

Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation, and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways.

Users should note that Guidelines which have not yet been updated should be considered with caution. Where the Eyecare Guidelines contain links to other sites and/or resources provided by third parties, these links are provided for information only.

Accordingly, to the maximum extent permitted by law, the Eyecare Guidelines are made available on the basis of excluding all representations, warranties, conditions and other terms (including, without limitation, the conditions implied by law of satisfactory quality, fitness for purpose and the use of reasonable care and skill) which, but for this disclaimer, might have effect in relation to the Eyecare Guidelines.

CEG disclaimer for updated guidelines:

Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

Updating the Eyecare Guidelines requires a continuous process; the date of the last review for each guideline will be clearly noted on each guideline. Users must consider these dates before using the guidance.

While the Common Services Agency (“PSD Scotland”) makes reasonable efforts to ensure that the information on the Eyecare Guidelines area of the Website is correct, the Website is provided ‘as is’ and PSD Scotland does not warrant the accuracy and completeness of the material on the Website. PSD Scotland may make changes to the Website at any time without notice. Some of the material on the Website may be out of date, and PSD Scotland makes no commitment to update such material. Users should note that some Eyecare Guidelines on the Website have not been updated for several years and should be considered with caution.

Where the Eyecare Guidelines section of the Website contains links to other sites and or resources provided by third parties, these links are provided for information only. PSD Scotland has no control over, and no liability in respect of, the content of these sites and resources.

Accordingly, to the maximum extent permitted by law, the Eyecare Guidelines area of the Website is made available by PSD Scotland on the basis that PSD Scotland excludes all representations, warranties, conditions and other terms (including, without limitation, the conditions implied by law of satisfactory quality, fitness for purpose and the use of reasonable care and skill) which, but for this disclaimer, might have effect in relation to the Website. 