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 . 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 . 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).
Canaliculotomy . (a) Right upper eyelid canaliculitis. (b) Erythema and edema over right upper canalicular system. (c) Punctal dilation. (d) Injection of local anesthetic. (e) #11 blade used to make a punctal sparing incision over the area of the canaliculus. (f) Incision carried distally to expose canalicular stone. (g) Expression of canalicular stone. (h) Canaliculus further explored more distally using chalazion curette. (i) Additional stones removed with curette. (j) Lid inspection at end of case
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).
Canaliculitis treatment options
– Topical antibiotics
– Systemic antibiotics
– Intracanalicular antibiotics
– Intracanalicular antibiotics and steroids
– Punctal dilation with canalicular curettage
– Punctoplasty with curettage
– Canaliculotomy with curettage
Lacrimal Sac Infections: Dacryocystitis
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 . 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.
Dacryocystitis can be grouped into acute and chronic disease. Patients with acute disease generally present with rapid onset of painful swelling over the lacrimal sac and medial canthal area. Classically, the erythema and edema of the lacrimal sac is below the medial canthal tendon. There is often mucopurulent material expressed with digital pressure on the lacrimal sac. In severe cases there can be an associated localized abscess of the lacrimal sac or cellulitis of the periorbital and facial soft tissues. Although uncommon, orbital cellulitis is another potential complication that would require immediate intervention. In contrast, patients with chronic dacryocystitis present with less profound symptoms thought to be due to an incompetent valve of Rosenmuller. Although tearing and swelling of the lacrimal sac occur, there is typically much less pain and a more indolent course. Mucopurulent discharge is expressed with palpation of the sac or with irrigation of the lacrimal system. These patients often have an elevated tear lake on exam  (see Table 10.3).
Dacryocystitis presenting signs and symptoms
Pain and redness in medial canthal area
Swelling over the lacrimal sac
Lacrimal sac discharge with palpation
Numerous organisms can be pathogenic in dacryocystitis. Gram-positive organisms (staphylococcus and streptococcus) are the most common in acute dacryocystitis followed by gram-negative and anaerobic organisms . Fungi have also been reported but are much less common. Gram-negative bacteria tend to be more common in patients with chronic dacryocystitis or in immunocompromised patients [7, 8].
A thorough history should be taken followed by a slit lamp examination. Digital palpation should be placed over the lacrimal sac to look for any mucopurulent discharge. If the lacrimal sac and surrounding tissue is not severely swollen, probing and irrigation can be performed. However, this should be avoided in adult patients with clinical evidence of acute dacryocystitis. Any discharge produced with palpation or irrigation should be cultured for organisms and sensitivities. If there is a localized abscess, the lacrimal sac should be incised and drained while taking appropriate cultures. Special attention should be given to any history or evidence of bloody discharge on exam that could suggest possible malignancy (lymphoma/squamous cell carcinoma). Imaging should be considered in post-traumatic, suspected sinusitis, or patients with orbital signs. Pediatric patients should have a nasal exam to exclude an intranasal cyst from possible congenital dacryocystocele with concurrent dacryocystitis.