Diagnosis & Treatment of Canaliculitis

BY WILLIAM TOWNSEND, O.D.
APR. 1996

Melissa, a 38-year-old patient, presented with a history of unilateral ocular discharge for two weeks. Her primary care physician treated her with gentamycin drops but the red eye and discharge persisted. She also complained of epiphora on the side of the affected eye. Slit lamp examination showed a scant mucopurulent discharge and grade II+ conjunctival injection. Scattered papillae were present in the lower tarsus. The cornea was clear of infiltrates and did not stain with fluorescein. Expression of the canaliculus produced regurgitation of white, mucopurulent material with an unusual consistency. The discharge was less "ropey" than usually seen in ocular inflammation. The contralateral eye showed no infection or inflammation.

EXPRESSION OF THIS PATIENT'S CANALICULUS PRODUCED A WHITE DISCHARGE COMMON TO ACTINOMYCES ISRAELII CANALICULITIS

Because Melissa was using a topical antibiotic, we decided against culturing, and her primary care physician started her on oral penicillin. We used a lacrimal cannula to irrigate the canaliculus and lacrimal sac. We then prescribed tetracycline drops to be used in conjunction with the oral antibiotic. Her condition steadily improved and after two weeks of treatment, we discontinued her medications. We advised Melissa to report any recurrence of these signs or symptoms immediately.

DIAGNOSIS

Canaliculitis is a relatively uncommon presentation that can be caused by a variety of agents. Younger individuals frequently develop this condition in association with primary herpetic infections. Allergic canalicular obstruction may also occur, which is characterized by itching, chemosis and intermittent epiphora.

Bacterial canaliculitis usually presents with a mucopurulent discharge. Stenosis of the canal due to edema or physical blockage causes intermittent epiphora and can be confirmed by lacrimal dilation and irrigation. Expression of the canaliculus results in expulsion of mucopurulent material. Clumps of branching bacterial filaments and resulting sulfur granules may adhere to the canal walls and cause obstruction.

Differential diagnostic considerations in lacrimal disease include congenital partial or complete stenosis of the canaliculus, dacryocystitis, allergic canaliculitis and viral canaliculitis. Tear flow through the system should be evaluated by the Jones I and II tests. If fluorescein introduced into the tear film cannot be recovered from the nose, attempt lacrimal irrigation and dilation.

TREATMENT

To treat viral canaliculitis, you must maintain patency of the canal through dilation and irrigation until the inflammation resolves. Failure to do so may lead to scarring of the canaliculus and necessitate dacryocystorhinostomy. Treat allergic canaliculitis with topical antihistamines and mast cell stabilizers.

The most common cause of canaliculitis in adults is Actinomyces israelii. This filamentous bacteria resembles fungi morphologically.

The condition is best treated with systemic antibiotics. Penicillin G or ampicillin are the drugs of choice for managing actinomycetes canaliculitis. Patients who are allergic to these medications may be treated with oral clindamycin or tetracycline.

Topical antibiotics are of limited value as an adjunct to systemic therapy. Bacitracin-Neomycin-Polymyxin B preparation is relatively effective against Actinomyces but, because the product is available only in ointment form, it's difficult to apply the drug to the site of infection. Tetracyclines have good activity against Actinomyces, and may be used as drops instilled directly into the canal using a lacrimal canula.

Fortunately, Melissa responded well to conservative therapy. Canaliculitis is often resistant to all forms of medical therapy. Those cases that fail to respond to topical or systemic therapy may require surgical procedures such as canaliculostomy or silicone ring intubation to prevent permanent closure of the lacrimal pathways. CLS

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center.