Mohammad Javed Ali
Dr. Mohammad Javed Ali currently leads The Institute of Dacryology at the LV Prasad Eye Institute. Javed described two new diseases of the lacrimal system along with their classifications and clinicopathologic profiles. He is one among the rare recipients of The Experienced Researcher – Alexander Von Humbold Fellowship Award, one of the pinnacle awards in the research world. He was honored by the 2015 ASOPRS Merrill Reeh Award for his path-breaking work on etiopathogenesis of punctal stenosis. His textbook Principles and Practice of Lacrimal Surgery is considered to be the most comprehensive treatise on the subject. He is a section editor for 3 journals and reviewer for 16 major journals. He has to his credit a total of 203 publications, of which 141 are peer reviewed and 30 are non peer reviewed, 32 book chapters, 21 instruction courses, 3 keynote addresses, 214 conference presentations, 12 live surgical workshops, and 26 awards.
Introduction
The canaliculi and the lacrimal sac are the regions of lacrimal drainage system, which are prone for infections. Canaliculitis is an infection of the canalicular part of lacrimal drainage system (Fig. 40.1) [1]. This chapter would describe the epidemiology, etiology, clinical presentations, microbiological profiles, diagnosis, management, and outcomes of canaliculitis along with a brief discussion on intracanalicular foreign bodies.
Fig. 40.1
Clinical presentation of canaliculitis
Epidemiology
It accounts for only 2 % of all patients with lacrimal diseases [2]. Canaliculitis affects the lower eyelid more than the upper eyelid and women more than men [3]. This female preponderance is thought to be partly due to physiological or hormonal changes during menopause, which may cause decreased tear production and reduced protection against infections [4]. Furthermore, cosmetic products may occlude the canaliculus and promote bacterial growth, predisposing to canaliculitis [5].
Etiology
Most of the cases are idiopathic in nature. Few rare predisposing factors include diverticulum or obstruction of the canaliculus which promote anaerobic bacterial growth secondary to stasis of tear and use of cosmetics.
Microbiological Profile
Most published case series report Actinomyces and Nocardia species, prominent among them being Actinomyces israelii and Nocardia asteroides as the common pathogenic organisms [6–16]. There are only isolated case reports of canaliculitis due to other various organisms like Mycobacterium chelonae, Lactococcus lactis, Eikenella corrodens, Enterobacter cloacae, Fusobacterium, and Kocuria rosea, viruses like Herpes simplex, and fungal organisms like Pityrosporum pachydermatis and Candida albicans [17–25]. However, in one of the largest studies in literature from the author’s institution, the culture-positive rates were 91 % with Staphylococcus species being the most common isolate (39 %) (Fig. 40.2) followed by Streptococcus species (29 %) and Actinomyces (10 %) [3].
Fig. 40.2
Gram-positive organisms on a smear
Clinical Presentation
Common presenting symptoms include epiphora, swelling of the eyelid, pain, or redness (Fig. 40.1). Kaliki S et al. [3] in a very large series showed epiphora as the most common symptom (85 %) followed by swelling of the canalicular portion of the eyelid (32 %) and pain in 27 % of the cases. Rarely patient may even be asymptomatic [3].
Diagnosis
Although canalicular imaging by dacryocystography and ultrasound biomicroscopy has been described for diagnosis and documentation of canaliculitis, a thorough clinical examination is sufficient for the diagnosis in most cases [26, 27].
The rarity of this disease may be attributed to the high rate of missed and delayed diagnosis. Furthermore, it may have atypical presentations, leading to additional difficulties in diagnosis [4, 28–30]. Canaliculitis can be misdiagnosed as chronic conjunctivitis, chalazion, hordeolum internum, or chronic dacryocystitis, causing a further delay in the initiation of effective treatment [3, 4, 31–33].
Management
Various modalities of treatment have been described for canaliculitis [2–33]. Conservative measures include oral and topical antibiotics, punctal dilatation, and canalicular expression or canalicular irrigation with antibiotics [6–8]. Surgical measures include punctoplasty and canalicular curettage, canaliculotomy with canalicular curettage, or canaliculostomy [2, 3, 10–33].
However, with any of the modality of treatment, it is important to send the material for a meticulous microbiological examination.
Conservative Medical Therapy
Initially, punctal dilatation with expression of canalicular discharge is performed under strict aseptic precautions under topical anesthesia. After instilling a drop of 0.5 % proparacaine hydrochloride in the conjunctival cul-de-sac, dilatation of the punctum is performed with Nettleship punctum dilator and manual expression of canalicular contents by a milking movement toward the punctum (Fig. 40.3). Mechanical expression is repeated until no further contents are expressed. The expressed contents are collected on a sterile cotton-tipped applicator and sent for microbiological workup. Broad-spectrum antibiotics can be started as dictated by regional isolates and their sensitivity, followed by specific antibiotics guided by patient-specific isolates. Conservative treatment in one of the largest series has shown to be effective in 59 % of the patients with a high rate or recurrence [3].
Fig. 40.3
Late phase of canalicular milking
Surgical Treatment
Surgical modalities include punctoplasty alone or in conjunction with canalicular curettage, performed under strict aseptic precautions, under local infiltrative anesthesia with 2 % lignocaine hydrochloride. A three-snip punctoplasty or the surgeon-preferred punctoplasty is performed with a small, straight Vannas scissors. To this a small canaliculotomy can be added (Fig. 40.4), and a 1-mm chalazion curette is used to curette out the granular material, concretions, or mucoid debris (Fig. 40.4). It is a good practice to evaluate walls of the ampulla, since concretions have a tendency to stack up and accumulate there. The curettage is repeated until there are no further contents. It is of utmost importance to avoid any damage to canalicular mucosa during this procedure. The curetted material is collected on a sterile surface or cotton-tipped applicator and sent for microbiological culture and sensitivity.
Fig. 40.4
Pouting of concretions following canaliculotomy
Following any of the two interventions, the patient is prescribed a broad-spectrum antibiotic eye drop (e.g., 0.3 % ciprofloxacin four times per day) and is subsequently altered according to the results of the microbiology culture and sensitivity report.
Conservative treatment with topical antibiotics is associated with a high recurrence rate as high as 41 % [3, 4]. Canalicular curettage after canaliculotomy or punctoplasty carries a high-resolution rate and is the procedure of choice [2–4, 10, 31, 33]. Occasionally a repeat procedure may be required to manage recurrences. However, canaliculotomy can result in canalicular luminal narrowing or scarring, lacrimal pump dysfunction, and canalicular fistula formation [6, 31, 33]. In contrast, curettage through the punctum is a less-invasive procedure and preserves the lacrimal pump function [31, 33].
Intracanalicular Foreign Bodies
Intracanalicular foreign bodies although rarely encountered can present as an ophthalmic emergency. Occasionally a broken cilia may enter the punctum and the canaliculus (Fig. 40.5). Careful removal under high magnification with a fine forceps is the usual management. The use of punctal plugs in the treatment of dry eye is well established [34, 35]. Collared silicone plugs of various sizes are available for managing dry eye on a semipermanent or permanent basis. Migrated punctal plugs into the canaliculus can cause infection, granulomas, fibrosis, and canalicular obstructions [36]. Dacryoendoscopy has shown few typical features of migrated punctal plugs within a canaliculus [37]. If the plug is situated parallel to the canaliculus, the intracanalicular space is occluded along with granulomas and heavy debris. In contrast if the migrated plug is perpendicular to the intracanalicular space, it is not completely occluded and little granulation tissue and debris are found.
