BASICS

DESCRIPTION

Acute or chronic isolated inflammation of the canalicular system

EPIDEMIOLOGY

Incidence

• 6:1 female:male

• 93% lower canaliculus

Prevalence

• Rare, varies with populations

• More common in adults

RISK FACTORS

• Canalicular plugs

• Recurrent conjunctivitis

• Dacryocystitis

GENERAL PREVENTION

• Ocular hygiene

• Avoid intracanalicular plugs

PATHOPHYSIOLOGY

Canalicular obstruction with subsequent infection and inflammation of the canalicular system

ETIOLOGY

• Streptococcus/staphylococcus species

• Actinomyces/propionibacterium

• Mixed organisms

COMMONLY ASSOCIATED CONDITIONS

• Chronic conjunctivitis

• Recurrent dacryocystitis

• History of dry eyes

DIAGNOSIS

HISTORY

• Epiphora

• Localized pain and swelling at or medial to punctum

• Mucopurulent discharge

PHYSICAL EXAM

• Purulent material at punctum

• Edematous dilated punctum

• Tender erythematous canaliculus

• Mild to severe swelling of the canaliculus

• Slit-lamp exam shows dilated punctum with discharge and tender canaliculus.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

• Culture and sensitivity

• Fungal cultures

Follow-up & special considerations

Curettage of the infected canaliculus with a small chalazion curette

Imaging

Follow-up & special considerations

Dacryocystogram (DCG) to rule out dacryoliths or lacrimal sac foreign bodies if problem extends beyond the canaliculus

Diagnostic Procedures/Other

• Canalicular probing with recovery of concretions is diagnostic

• Intracanalicular plug may also be found

Pathological Findings

Concretions with or without pathologic organisms

DIFFERENTIAL DIAGNOSIS

• Dacryocystitis

• Chalazion

• Mucopurulent conjunctivitis

TREATMENT

MEDICATION

First Line

• Penicillin eyedrop 100,000 units/mL q.i.d. for 2 weeks. This must be formulated by the pharmacy each week and placed in a brown ultraviolet protected bottle.

• Alternative: Sodium sulfacetamide 10% 1ggt q.i.d. for 2 weeks (if penicillin eyedrops are not available).

• Warm compresses q.i.d.

Second Line

Surgery, see below

ADDITIONAL TREATMENT

General Measures

Broad spectrum antibiotic eye drops q.i.d. for 1 week postoperative canaliculotomy

Issues for Referral

Patients should follow up with ophthalmologist in 1 week, 1 month, then p.r.n.

SURGERY/OTHER PROCEDURES

• Removal of all concretions from the involved canaliculus is essential for cure. An incision into the horizontal canaliculus from the conjunctival surface, leaving the punctum intact, provides excellent exposure for removal of canaliculitis.

• The canaliculotomy is left open.

ONGOING CARE

PATIENT EDUCATION

Canaliculoplasty is safe and effective in the treatment of lacrimal canaliculitis.

PROGNOSIS

Nearly 100% cure, if all concretions are removed.

COMPLICATIONS

• Recurrence, if all concretions are not removed

• Rarely patient may have tearing from obstruction and scarring of canaliculus

ADDITIONAL READING

• Zaldivar RA, Bradley EA, Primary canaliculitis. Ophthal Plast Reconstr Surg 2009;25(6):481–484.

• Ahn HB, Seo JW, Roh MS, et al. Canaliculitis with a papilloma-like mass caused by a temporary punctal plug. Ophthal Plast Reconstr Surg 2009;25(5):413–414.

• Lin SC, Kao SC, Tsai CC, et al. Clinical characteristics and factors assositaed the outcome of lacrimal canaliculitis. Acta Ophthalmol 2010. [Epub ahead of print].

• Anand S.Hollingworth K, Kumar V, et al. Canaliculitis: The incidence of long-term epiphora following canaliculotomy. Orbit 2004;23(10):19–26.

CODES

ICD9

• 375.30 Dacryocystitis, unspecified

• 375.31 Acute canaliculitis, lacrimal

• 375.41 Chronic canaliculitis

CLINICAL PEARLS

• More common in lower canaliculus

• Complete removal of concretions (canaliculolithes) necessary for cure

• Must be considered in the differential diagnosis of chronic conjunctivitis

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