Evaluation should begin with a thorough history with emphasis on previous punctal plug placement and trauma. The examiner should inspect the medial eyelid margin paying close attention to the punctum and conjunctiva. The canalicular margin is usually swollen, erythematous, and tender to palpation. Gentle pressure should be placed along the medial eyelid margin looking for any punctal discharge. If any discharge or material is present, a culture should be taken. The lids should be everted to examine the palpebral conjunctiva and posterior surface of the tarsus. It remains controversial as to whether irrigation and probing should be performed. Some authors believe canalicular irrigation will only lodge current debris and concretions further distal into the lacrimal drainage system.

There are numerous treatment approaches for canaliculitis. These treatments can be broken down into medical versus surgical interventions. Conservative medical treatment with topical or systemic antibiotics can often achieve temporary success but has a high recurrence rate. Lack of eradication is thought to be due to a poor penetration of antibiotics secondary to the concretions that the bacteria form. Retained foreign bodies and stones are also a nidus for recurrence. Success from medical therapy is most likely to occur if treated early on in the course of infection and there is no foreign body or stone present. Other nonsurgical methods include canalicular irritation with antibiotics and/or steroids. However, this may take numerous sessions and in theory can push infected particles more distal into the lacrimal sac. In a recent study, irrigation with antibiotic and steroid solution was nearly 73% effective. This was more successful than conservative medical treatment but less successful than surgical intervention in the study [2]. Punctal dilation with curretage or “milking” of the canalicular system has been advocated by some authors but has reported high recurrence rate.

The most definitive treatment for canaliculitis is complete surgical removal of the canalicular contents. This is particularly important if there is any history of previous punctal plug placement. Punctoplasty with curretage or “milking” from distal to proximal to express canalicular contents has reported success. Epiphora is a possible side effect due to the distortion of the punctal anatomy.

Canaliculotomy with curretage is another option that provides excellent exposure while preserving punctal integrity [5]. This allows direct visualization to look for any foreign body or punctal plug and provides easy access to large stones or concretions that otherwise may be difficult to remove. There have been reports of scarring and stricture of the canalicular system following this procedure, but it is rare. Intubation of the lacrimal system can be performed at the time of canaliculotomy in hopes of preventing these complications but is usually not necessary. Postsurgical tearing is not usually a problem in patients who had plugs placed for dry eye symptoms. Canaliculotomy with curettage is the author’s procedure of choice and is described below.

The affected punctum is dilated with a punctal dilator. Local anesthetic is then injected to the area of concern. A #11 blade is used to make a punctal sparing incision medial to the punctum over the area of the canaliculus. Expression of any stone or foreign body is performed with cotton tip applicators and sent to the pathologist for further examination. Mucopurulent material should be cultured. The canaliculus is further examined more distally for any retained foreign body, especially a retained punctal plug. A Westcott scissors can be used to extend the incision distally if greater exposure is needed. A chalazion curette is used to explore the canalicular system. At the end of the case, the canalicular system can be irrigated with antibiotics if the surgeon so desires. The canaliculus is left to heal by secondary intention (Fig. 10.1).

Overall surgical treatment has an excellent prognosis with low rates of recurrence. However, this comes with the theoretical increased risk of damage to the canalicular system. If the canalicular system is damaged and nonfunctioning, patients may require a conjunctivodacryocystorhinostomy (CDCR) with insertion of a Jones tube to correct any postsurgical epiphora (Table 10.2).

Dacryocystitis is defined as an infection of the lacrimal sac. In adults, the most common cause of dacryocystitis is secondary to nasolacrimal duct obstruction. Nasolacrimal duct obstructions can be idiopathic in nature or caused by dacryoliths, sinus disease, trauma (including naso-orbital fractures), iatrogenic (sinus and nasal surgery), radioactive iodine, inflammatory disease, or neoplasm [1, 6, 7]. In pediatric cases, dacryocystitis is most commonly secondary to congenital nasolacrimal duct obstruction with a non-patent valve of Hasner. However, it can also be caused by dacryocystocele, tumors, congenital lacrimal system anomalies, sinusitis, foreign bodies, and post-traumatic nasolacrimal duct obstruction [8]. Despite the cause, the common factor for dacryocystitis is usually complete nasolacrimal duct obstruction that causes stasis and tear retention that lead to an infection of the lacrimal sac.