December 2012 Online Photo Diagnosis

By William Townsend, OD, FAAO

A 67-year-old male presented with a history of unilateral (left) epiphoria, ocular injection, and discharge. He was initially hopeful that it would clear spontaneously, but after two weeks without improvement, and at the insistence of his spouse, he presented to our office. His ocular health history was significant for bilateral cataract surgery and retinal detachment repair in his left eye. These occurred several years prior to the present condition. There was no history of trauma to either eye. There was no prior history of epiphoria with discharge.

Presenting visual acuities were 20/20 OD and OS. Gross examination revealed a profuse mucopurulent discharge from the left lower and upper puncta. The corneas were clear OD and OS, but there was grade 1 injection of the left conjunctiva. We tentatively diagnosed the patient with upper and lower canaliculitis of the left eyelid pending additional testing.

Definitive diagnosis of canaliculitis is based on history, patency of the lacrimal outflow system, and laboratory analysis for pathogens.¹ Individuals who report previous presentations and treatment have a higher index of suspicion for chronic or recurring canaliculitis. The average latency between onset and diagnosis is 10 months.² Chronic disease may unfortunately lead to scarring and anatomic obstruction of the lacrimal outflow system.

Dilation and irrigation of the upper and lower canaliculi help determine the location(s) of the obstruction, and in many cases are therapeutic.¹ If neither is occluded, the blockage is located in the common canaliculus or lacrimal sac. One complication of this procedure is that if there are concretions in the canaliculi, forceful irrigation may drive them deeper into the system, potentially worsening the blockage.¹ Dacryocystitis can cause some signs and symptoms that mimic canaliculitis, but also presents with pain, edema, and redness in the medial canthal region.¹

Laboratory cultures are useful, but not essential in diagnosing canaliculitis. Actinomyces species have historically been the primary causative agent in this condition, but recent studies suggest that Streptococcus and Staphylococcus are increasingly identified as the agents that cause canaliculitis.²

Our management of this case consisted of independently irrigating first the upper and then the lower canaliculi; we determined that the obstruction was in the common canaliculus. After repeated irrigation, we dislodged the obstruction, and saline freely passed into the lacrimal sac and nasopharynx. We irrigated the canaliculus with a topical ophthalmic antibiotic solution and prescribed a long-term course of topically instilled antibiotics. This approach is gaining acceptance as an alternative to surgery.³ In some instances, systemic antibiotics are also prescribed as an adjunct to the topical medication.⁴

References

• Freedman JR, Markert MS, Cohen AJ. Primary and secondary lacrimal canaliculitis: a review of literature. Surv Ophthalmol. 2011 Jul-Aug;56(4):336-47
• Kaliki S, Ali MJ, Honavar SG, Chandrasekhar G, Naik MN. Primary canaliculitis: clinical features, microbiological profile, and management outcome. Ophthal Plast Reconstr Surg. 2012 Sep-Oct;28(5):355-60.
• Mohan ER, Kabra S, Udhay P, Madhavan HN. Intracanalicular antibiotics may obviate the need for surgical management of chronic suppurative canaliculitis. Indian J Ophthalmol. 2008 Jul-Aug;56(4):338-40.
• Fulmer NL, Neal JG, Bussard GM, Edlich RF. Lacrimal canaliculitis. Am J Emerg Med. 1999 Jul;17(4):385-6.