Fig. 15.1
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, makeup and cosmetics 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 (Fig. 15.2) and Nocardia asteroides as the common pathogenic organisms [6–16]. There are only isolated case reports of canaliculitis due to other various other organisms like Mycobacterium chelonae, Lactococcus lactis, Eikenella corrodens, Enterobacter cloacae, Fusobacterium, and Kocuria rosea; viruses like Herpes simplex; and fungal organisms like Malassezia 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. 15.3) followed by Streptococcus species (29 %) and Actinomyces (10 %) [3].
Fig. 15.2
Microbiological smear of Actinomyces
Fig. 15.3
Gram-positive organisms on a smear
Clinical Presentation
Common presenting symptoms include epiphora, swelling of the eyelid, pain, and redness (Fig. 15.1). Kaliki 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, and 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. 15.4). Mechanical expression is repeated (Fig. 15.5) 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. 15.4
Early phase of milking canalicular contents
Fig. 15.5
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 3-snip punctoplasty or the surgeon-preferred punctoplasty is performed with a small, straight Vannas scissors (Figs. 15.6 and 15.7). To this, a small canaliculotomy can be added (Fig. 15.8), and a 1-mm chalazion curette is used to curette out the granular material, concretions, or mucoid debris (Figs. 15.9 and 15.10). It is a good practice to evaluate the walls of the ampulla, since concretions have a tendency to stack up and accumulate there (Fig. 15.11). The curettage is repeated until there are no further contents (Fig. 15.12). It is of utmost importance to avoid any damage to canalicular mucosa during this procedure. The curetted material is collected on a sterile surface (Fig. 15.13) or cotton-tipped applicator and sent for microbiological culture and sensitivity.
Fig. 15.6
Punctoplasty
Fig. 15.7
Completed punctoplasty
Fig. 15.8
Canaliculotomy
Fig. 15.9
Pouting of concretions following canaliculotomy
Fig. 15.10
Canalicular curettage
Fig. 15.11
Remnant concretions in the ampulla and proximal canalicular floor
Fig. 15.12
Complete expression of concretions
Fig. 15.13
Canalicular concretions on a sterile surface
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].
In conclusion, a high index of suspicion is needed for the diagnosis of canaliculitis. The microbiological profile of canaliculitis seems to be evolving with staphylococcus emerging as the most common isolated species in Southeast Asia. Punctal dilatation with canalicular expression, though is effective in few patients, is more commonly associated with persistence of the disease. Punctoplasty with canalicular curettage is more efficacious with high success rates. In recurrent and persistent cases, conservative treatment is best avoided, and canalicular curettage should be done in all such cases to achieve a complete resolution.
Acute Dacryocystitis
Dacryocystitis is inflammation of the lacrimal sac which can be chronic or can present as an acute condition due to secondary infection of the stagnant tear secretions [34, 35]. Dacryocystitis is generally due to obstruction of the nasolacrimal duct, which can be congenital or acquired. However, it is uncommon to have acute dacryocystitis associated with congenital nasolacrimal duct obstructions. Rarely a dacryopyocele may be the presenting feature. Details of these infections have been dealt with in the Chap. 12.
In this section, we shall discuss acute infective dacryocystitis.
Definition
Acute dacryocystitis can be defined as “a medical urgency which is clinically characterized by rapid onset of pain, erythema and swelling, classically below the medial canthal tendon with or without preexisting epiphora mainly resulting from the acute infection of the lacrimal sac and perisac tissues” [34] (Fig. 15.14).
Fig. 15.14
Clinical presentation of acute dacryocystitis
Epidemiology
Epidemiology of acute dacryocystitis is not very well known. It constitutes 2.4 % of all lacrimal disorders with a female preponderance (2:1), usually noted in the 3rd–5th decade, although it can affect any age and is predominantly unilateral (91.6 %) [34].
Microbiological Profile
Although many microbiological studies are available for chronic dacryocystitis, very few looked at the acute ones [36–38]. The microbiologic spectrum of acute dacryocystitis in 21 patients found gram-positive organisms to be the most common with Staphylococcus aureus as the most common organism isolated from cultures [36]. In contrast, Razavi et al. [37] concluded that there are significant differences in the isolates between acute dacryocystitis and chronic dacryocystitis, although the study did not show much difference and the sample size of acute cases was only 12 patients. In the largest study on microbiological profile of lacrimal abscess (n = 100) [38], gram-positive cocci (GPC) were the most common isolates (56 %) followed by gram-negative bacilli (GNB) (30 %) (Figs. 15.15 and 15.16) and gram-positive bacilli (3 %). Among the gram-positive cocci, the most common isolates were Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes. Haemophilus influenza, Escherichia coli, and Pseudomonas aeruginosa were the common gram-negative bacilli [38]. Occasionally rare organisms like Cardiobacterium hominis had been implicated in the pathogenesis of acute dacryocystitis [39].
