Primary and Secondary Lacrimal Canaliculitis: A Review of Literature

Lacrimal Canaliculitis: A Major Review

Lacrimal canaliculitis is an inflammation of the proximal lacrimal drainage system. It classically presents with symptoms of redness, mucopurulent discharge, medial canthal swelling, epiphora, and pouting punctum. Despite having classical clinical characteristics it is frequently misdiagnosed. The cause can be primarily due to various infectious agents or secondary mostly due to the use of punctal plugs. There are no universally accepted guidelines for the management of canaliculitis but different medical and surgical options have been employed with varying success rates and it is notorious for recurrences and failure to therapy. The present review summarizes the existing literature on lacrimal canaliculitis published over the past 15 years to provide an overview of this uncommon condition. A total of 100 articles published in the literature were anlaysed during this period. The mean age at diagnosis was 57.09 ± 16.91 years with a female preponderance. Misdiagnosis was common with many patients misdiagnosed as conjunctivitis and dacryocystitis. Primary canaliculitis was found to be more frequent than secondary with inferior canaliculus involved more commonly than the superior. Staphylococcus, Streptococcus, and Actinomyces were the most common microbes isolated. Surgical management was employed in 74.25% of cases while medical management was done in 20.82% of cases. The review presents an insight into the complexities of canaliculitis, its diagnosis, and management which will further help to improve the understanding of this uncommon infection of the lacrimal system.

[Concrements of the lacrimal apparatus]

Concrements of the lacrimal apparatus, known as dacryoliths, can occur at different localizations and can cause a variety of symptoms. A common clinical sign is chronic inflammation, possibly exhibiting acute exacerbation. Based on a literature review and descriptive clinical cases with histopathological correlations, this contribution summarises the most important information concerning epidemiology, aetiopathogenesis, composition, histology, and therapy of lacrimal concrements. Furthermore, factors known to affect lacrimal lithogenesis are addressed. Concrements of the lacrimal gland cause a swelling at the lateral canthus. With only mild pain, this manifests as circumscribed conjunctival hyperaemia. Histologically, the gland tissue is characterised by acute-erosive to chronic inflammation. The concrements consist of amorphic material. Inflammatory infiltration is dominated by neutrophil granulocytes. Canalicular concrements are highly correlated with chronic canaliculitis. Besides epiphora, patients present with purulent discharge at the affected canaliculus. Actinomyces are frequently found inside these deposits and form drusen-like formations. The surrounding tissue reacts with plasma-cellular and granulocytic inflammation. Dacryoliths (concrements of the lacrimal sac) are associated with dacryocystitis, whereby acute and chronic types are common. Stones can be found in up to 18% of patients undergoing dacryocystorhinostomy or dacryoendoscopy. Preoperative diagnostic testing is challenging, as many lacrimal sac stones cannot be reliably visualised by diagnostic procedures. Recurring episodes of epiphora, mucopurulent discharge, and dacryocystitis are common indicators of dacryoliths. Lacrimal syringing is often possible and shows that total blockage is not present. Histology of the lacrimal mucosa reveals lymphocytic infiltration and submucosal fibrosis. The immediate vicinity of the dacryoliths shows acute inflammation. Therapy consists of stone extraction and improving lacrimal drainage, as the latter is recognised as the main risk factor for dacryolith formation.

Actinomycotic primary canaliculitis: Predisposing factors, clinical characteristics, and treatment outcomes

OBJECTIVE

Ocular actinomycosis is an uncommon progressive infection. The study aims to investigate the predisposing factors, clinical characteristics and treatment outcomes of culture-proven cases of Actinomycotic primary canaliculitis.

METHODS

Single-center, retrospective, interventional case series. Culture-proven cases of Actinomyces-associated primary canaliculitis diagnosed and treated between January 2017 and December 2021 at the Beijing Tongren Eye Center, Capital Medical University were identified and reviewed for ocular and systemic risk factors, clinical presentations, microbiological profile, treatment modalities and outcomes.

RESULTS

Of the 201 patients diagnosed with primary canaliculitis, 22 (10.9%) were caused by Actinomyces. The mean age at onset of 22 patients (21 women and one men) was 54 years. The lower canaliculus was most commonly involved (54.6%). The most frequent symptom was mattering without epiphora (77.3%) and clinical signs were punctal regurgitation of purulent discharge (100%) and expressible concretions (95.5%). Dry eye co-existed in 77.3% of patients, whereas no obvious systemic factors were found. Among 19 cases (86.0%) of identified Actinomyces species, A. odontolyticus (43.5%) was the predominant causative microorganism. There were 50% of patients with polymicrobial infection and the most common additional bacteria isolated were Streptococcus species. Conservative therapy combining repeated canalicular expression and irrigation with susceptible topical antibiotics achieved complete resolution in 86.4% of patients.

CONCLUSIONS

Dry eye was identified in the vast majority of patients with Actinomycotic canaliculitis. Most cases are odontogenic in origin and the infection occurs in immunocompetent individuals. The conservative method combining canalicular expression and irrigation with topical susceptible antibiotics is recommendable as initial therapy.

A prospective study comparing mini-invasive and conventional canaliculotomy of punctum-sparing canaliculotomy for primary canaliculitis treatment

PURPOSE

To compare outcomes of mini-invasive canaliculotomy with those of conventional canaliculotomy conducted using the punctum-sparing approach for the treatment of primary canaliculitis.

METHODS

A prospective, comparative, and interventional case series study was conducted on 118 individuals with unilateral inferior primary canaliculitis. These patients were randomly divided into two groups, each with 59 cases. Group A underwent mini-invasive canaliculotomy (minor incision ~3 mm), whereas group B received conventional canaliculotomy (long incision ~6-8 mm). Punctum-sparing and canaliculus-reconstructing procedure was used to treat all patients. Both groups had silicone tube intubations and were retained in the lacrimal passages for one month. Both groups' surgical success rates and postoperative complications were measured at the last follow-up of 12 months after surgery.

RESULTS

A total of 108 patients were finally included in the study, 53 in group A and 55 in group B. There were 79 females and 29 males with a median age of 57 ± 13.4 years. The anatomical success rates for groups A and B were 96.2% and 92.7% (P = 0.679), respectively. Functional success rate was accomplished by considerably more patients in group A (50/53, 94.3%) compared to group B (45/55, 81.8%) (P = 0.046). No recurrences were seen during follow-up visits in any of the participants.

CONCLUSIONS

The two procedures employed in this study to treat primary canaliculitis achieves excellent clinical effects with no incidence of recurrence. The mini-invasive canaliculotomy is worthy to be recommended for its higher functional success rate with mini-invasion of canaliculus and intact lacrimal punctum.

Clinical diagnosis, treatment and microbiological profiles of primary canaliculitis

The present study aimed to examine the clinical and pathogenic characteristics, diagnosis and treatment of primary canaliculitis to provide further guidance for its clinical management. The present prospective study enrolled 50 patients (50 eyes) diagnosed with primary canaliculitis between May 2018 and April 2021 at Department of Ophthalmology, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China. The patients' general clinicopathological information, clinical characteristics, microbiological profiles and treatment outcomes were analyzed and summarized. All the patients presented with persistent red eyes and eye discharge. Examination of discharge smears revealed that 96% of patients tested positive for Actinomyces and all smears were negative for fungi. Microbial cultures indicated that 82% of cases were positive for bacteria. A total of 51 bacterial strains were cultured; of these, 27.5% were aerobes, 35.3% were anaerobes and 37.2% were facultative anaerobes. A total of 56.9% of strains were gram-positive and 43.1% were gram-negative. The three most common bacteria, including Streptococcus spp., Capnocytophaga spp. and Propionibacterium, were analyzed. Only 3 cases (6%) of microbial cultures were positive for Actinomyces and all cases were negative for fungi in microbial cultures. Among the 50 cases, 45 were cured with conservative treatment [intracanalicular ointment infiltration (IOI)]. Five patients responded poorly to conservative treatment; however, they were cured with surgical treatment. In the current study, the majority of canaliculitis cases were caused by mixed infections, predominantly Actinomyces. The results revealed that the culture positivity rate of Actinomyces was low; however, the smear staining positivity rate was high. Fungus was smear- and culture-negative in all cases. In conclusion, patients with canaliculitis had a good prognosis after timely diagnosis and treatment.

Chronic canaliculitis with canaliculoliths due to Providencia stuartii infection

Canaliculitis, inflammation of the lacrimal canaliculi, can be caused by numerous pathogens, most commonly bacteria from the genera Actinomyces, Streptococcus, and Staphylococcus. Primary canaliculitis often requires surgical canaliculolith removal and appropriate antibiotic coverage. The authors report a case of a 77-year-old woman with a history of punctal plugs who presented with chronic canaliculitis with canaliculoliths that grew Providencia stuartii. P. stuartii has not previously been described as a cause of primary canaliculitis. This case highlights a new organism that causes canaliculitis with canaliculoliths and stresses the importance of speciation and antibiotic sensitivity testing following canaliculotomy and curettage. P. stuartii should be considered in the differential for bacterial canaliculitis with canaliculoliths, especially in patients with persistent symptoms on topical antibiotic therapy without canaliculotomy.

Concrements of the Lacrimal Apparatus

Concrements of the lacrimal apparatus, known as dacryoliths, can occur at different localizations and can cause a variety of symptoms. A common clinical sign is chronic inflammation, possibly exhibiting acute exacerbation. Based on a literature review and descriptive clinical cases with histopathological correlations, this contribution summarises the most important information concerning epidemiology, aetiopathogenesis, composition, histology, and therapy of lacrimal concrements. Furthermore, factors known to affect lacrimal lithogenesis are addressed. Concrements of the lacrimal gland cause a swelling at the lateral canthus. With only mild pain, this manifests as circumscribed conjunctival hyperaemia. Histologically, the gland tissue is characterised by acute-erosive to chronic inflammation. The concrements consist of amorphic material. Inflammatory infiltration is dominated by neutrophil granulocytes. Canalicular concrements are highly correlated with chronic canaliculitis. Besides epiphora, patients present with purulent discharge at the affected canaliculus. Actinomyces are frequently found inside these deposits and form drusen-like formations. The surrounding tissue reacts with plasma-cellular and granulocytic inflammation. Dacryoliths (concrements of the lacrimal sac) are associated with dacryocystitis, whereby acute and chronic types are common. Stones can be found in up to 18% of patients undergoing dacryocystorhinostomy or dacryoendoscopy. Preoperative diagnostic testing is challenging, as many lacrimal sac stones cannot be reliably visualised by diagnostic procedures. Recurring episodes of epiphora, mucopurulent discharge, and dacryocystitis are common indicators of dacryoliths. Lacrimal syringing is often possible and shows that total blockage is not present. Histology of the lacrimal mucosa reveals lymphocytic infiltration and submucosal fibrosis. The immediate vicinity of the dacryoliths shows acute inflammation. Therapy consists of stone extraction and improving lacrimal drainage, as the latter is recognised as the main risk factor for dacryolith formation.

Anterior Segment Optical Coherence Tomography for Canaliculitis

Canaliculitis is an uncommon inflammation of the lacrimal canaliculi, and it is often misdiagnosed as conjunctivitis or dacryocystitis. There are no gold-standard methods to diagnose canaliculitis, therefore newer methods such as ulrasound biomicroscopy are being introduced. Anterior segment optical coherence tomography (OCT) is being utilized to evaluate punctum and canaliculus, but no previous study has applied anterior OCT for canaliculitis. One case of canaliculitis with canaliculith was diagnosed by anterior segment OCT noninvasively, by successful detection of canaliculith. Pouting of the punctum and detection of canaliculith as hyper-reflective signals by OCT were checked, which was impossible with other conventional methods. Surgical incision and drainage confirmed the presence of stones. This article is meaningful as a first study about the diagnosis of canaliculitis with canaliculith using anterior segment OCT. Presence of canaliculith in vertical canaliculus, and the status of punctal epithelium and canalicular mucosa was possible in this study.

A "Clinical Tetrad" for Easy Diagnosis of Lacrimal Canaliculitis

Purpose

To study the clinical presentation and highlight the "diagnostic clinical features" in patients having lacrimal canaliculitis (LC).

Methods

A retrospective analysis of all patients diagnosed with primary and secondary LC was performed. A detailed slit-lamp examination of the conjunctiva, lacrimal punctum, canalicular region, and lacrimal sac was performed. Common and coexisting clinical features were highlighted. The posttreatment sequence of resolution of clinical features was also noted.

Results

Forty eyes of 36 patients (28 females, 77.78%) with a mean age of 59.5 years were included in the study. Thirty eyes (75%) had primary LC, whereas 10 had a secondary type. Previous misdiagnoses were noted in 34 (85%) eyes. The highlighting clinical features were medial eyelid edema (n = 40, 100%), pouting and hyperemia of lacrimal punctum (n = 36, 90%), yellowish canalicular hue (n = 35, 87.5%), and canalicular distention and expressible discharge (n = 32, 80%). None had features suggestive of nasolacrimal duct obstruction. Thirty-two eyes (80%) showed all four clinical features of LC, a tetrad. At a mean follow-up of 14.5 months, the complete resolution was noted in 36 (90%) eyes.

Conclusions

We propose a "clinical tetrad" of 1. medial eyelid edema, 2. pouting and hyperemia of lacrimal punctum, 3. yellowish canalicular hue and, 4. canalicular distention, and expressible discharge, for the easier clinical diagnosis of LC. The authors believe that using this clinical tetrad may be helpful for the diagnosis of LC.

Long-Term Outcomes of Canaliculotomy with Silicone Tube Intubation in the Management of Canaliculitis

As a rare and often misdiagnosed disease of the lacrimal apparatus, only limited data exist on long-term outcomes of surgical methods for the treatment of primary canaliculitis. The aim of this study was to evaluate canaliculotomy with silicone tube intubation (STI) as a surgical procedure for canaliculitis in a long-term follow-up setting. A total of 25 eyes of 25 patients with canaliculitis treated with canaliculotomy and STI at the University of Muenster Medical Center, Germany, from 2015 to 2021 were included in this study. Data analysis involved clinical symptoms, complications, duration of STI and rate of recurrence. Mean patient age was 63.7 ± 17.2 years. After a follow-up time of 3.7 ± 1.5 years, 88% of cases showed no recurrence of inflammation. The mean duration of STI was 5.8 ± 3.4 months. Complications such as post-operative hemorrhage, spread of infection, obstruction of the canaliculus or migration of the STI were not observed in any of the patients. However, tube dislocation occurred in four cases, a pyogenic granuloma in two cases and a fistula formation in one case. The management of canaliculitis by canaliculotomy with STI showed very good postoperative outcomes and low complication rates in the long-term and can therefore be considered a safe and successful surgical approach.

Microbiological profile of canaliculitis and their antibiotic susceptibility patterns: A 11-year review at a referral eye care centre

PURPOSE

To analyze the microbiological profile and in vitro antibiotic susceptibility patterns of bacterial isolates in canaliculitis, an infection of the lacrimal drainage system of the eye.

METHODS

The laboratory records of patients presenting with canaliculitis from whom specimens were obtained for microbiological investigations at our tertiary eye care centre in South India from January 2010 to December 2020, were reviewed.

RESULTS

A total of 130 canalicular pus samples were collected from 112 patients and submitted for microbiological studies during the study period. A total of 183 micro-organisms were isolated from 115 culture-positive specimens. The micro-organisms isolated were predominantly aerobic Gram-positive bacteria (83.44%), with Coagulase-negative Staphylococci (CoNS/Other Staphylococcus spp) (31.69%), Corynebacterium spp (15.3%), Staphylococcus aureus (9.84%) and Viridans Streptococci (9.84%) accounting for a majority of the isolates. Actinomycesspp (6.56%) was the most common anaerobic bacterium isolated. Our study revealed several bacteria not previously associated with canaliculitis namely Ottowia spp, Elizabethkingiameningoseptica, Aeromonassalmonicida, Capnocytophagaochracea and Campylobacter gracilis. Polymicrobial aetiology was observed in 39.13% of culture-positive samples. Analysis of antibiotic susceptibility patterns of the isolates revealed a high proportion of Gram-positive bacteria susceptible to chloramphenicol (90.16%) compared to fluoroquinolones including ciprofloxacin (74.42%), norfloxacin (64.15%) and gatifloxacin (60.49%).

CONCLUSION

This study represents the largest series of canaliculitis reporting the microbiological profile and antibiotic susceptibilities of the isolated micro-organisms, till date. Gram-positive bacteria accounted for a majority of isolates, predominated by Staphylococcus spp. The increasing resistance of Gram-positive bacteria to fluoroquinolones warrants antibiotic treatment in canaliculitis is based on in vitro antimicrobial susceptibility patterns.

Metagenomics of infective canaliculitis: The Lacriome paper 3

PURPOSE

To study the metagenomics of the microbes isolated from the canaliculus of patients with infective canaliculitis.

METHODS

A prospective study was performed on five consecutive canalicular samples obtained for the metagenomic analysis from the patients with infective canaliculitis who underwent non-incisional canalicular curettage at a tertiary care Dacryology service. The canalicular concretions were collected intraoperatively soon after a canalicular curettage and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina™ platform. The downstream processing and bioinformatics of the samples were performed using multiple software packaged in SqueezeMeta™ pipeline or MG-RAST™ pipeline.

RESULTS

The taxonomic hit distribution across the samples showed that bacteria were the most common isolates (mean-80.5%), followed by viruses (mean-0.74%), and archaea (0.01%). The five major phyla identified across the samples of infective canaliculitis were, Fusobacteria, Bacteroidetes, Proteobacteria, Actinobacteria, and Firmicutes. The prevalent organisms include Fusobacterium nucelatum, Fusobacterium periodonticum, Parvimonas micra, Prevotella oris, Selonomonas noxia, Pseudopropionobacterium propoinicum, Campylobacter showae, and Streptococcus anginosus, amongst few others. Actinomycetes israelii was noted in all the samples, though it was not the most abundant. The microbial gene mapping and protein prediction demonstrated proteins with known functions to range from 69.91% to 87.09% across the samples. The functional subsystem profiling demonstrated genes associated with carbohydrate, amino acid, and co-enzyme transport and metabolism, cell wall or cell membrane biogenesis, energy production and conversion, transcription, translation, and cellular communications.

CONCLUSION

This is the first whole metagenome sequencing of infective canaliculitis. Infected canaliculi harbor diverse microbial communities, including bacteria, viruses, and archaea. Functional analysis has provided newer insights into the ecosystem dynamics and strategies of microbial communities.

Evaluation of Ultrasound Biomicroscopy Combined with Color Doppler Flow Imaging in the Diagnosis of Primary Lacrimal Canaliculitis

Purpose: To explore the performance of ultrasound biomicroscopy (UBM) and color Doppler flow imaging (CDFI) in the diagnosis of primary lacrimal canaliculitis.Methods: Subjects with relevant symptoms of canaliculitis were prospectively recruited. UBM and CDFI were performed for presumptive diagnosis. Microbiology and histopathology were performed for definitive diagnosis.Results: A total of 37 cases were recruited, including 25 cases of canaliculitis and 12 cases of non-canaliculitis. Pathogens were isolated in 13 canaliculitis cases, and the leading pathogens were Actinomyces (4 cases) and Streptococcus (4 cases). UBM and CDFI identified 24 canaliculitis cases (sensitivity = 96%) and 11 non-canaliculitis cases (specificity = 92%). The predictive factors for canaliculitis were lumen wall thickness >0.25 mm (P = .019) and intracanalicular concretions (P = .010). Other typical features were enlarged lumen (2.16 ± 0.25 mm) and hot-wheel sign-on CDFI (84%). These image findings were congruent with histopathologic changes.Conclusion: Ultrasonography is a valuable tool to assist the diagnosis of canaliculitis.(Clinical trial registration number: ChiCTR1900025411).

Utility of 80-MHz Ultrasound Biomicroscopy and Lacrimal Endoscopy in Chronic Lacrimal Canaliculitis

Lacrimal canaliculitis (LC) is a rare infection of lacrimal passage, which is usually late diagnosed or misdiagnosed. Traditional lacrimal system tests barely provide a clear and definite understanding of the pathological changes in lacrimal passage. We presented three patients with asymptomatic and atypical symptoms who were misdiagnosed and were eventually diagnosed with chronic LC with assistance of 80-MHz ultrasound biomicroscopy (80-MHz UBM) and lacrimal endoscopy. To our knowledge, the mutual assistance of above two techniques diagnosing LC has never been reported, it can provide better images and observations of the canaliculus from the inside out and can guide the differential diagnosis.

Isolation of unusual bacteria in canaliculitis: A series of four cases

With increased availability of sophisticated microbiological techniques for isolation, growth and identification of micro-organisms the spectrum of organisms is rapidly. Herein we report four cases of canaliculitis with unusual organisms and highlight their clinical significance. To the best of our knowledge, there are no reports of isolation of Brucella melitensis and Leuconostoc species reported in English literature; and only one report of isolation of Myroides species from canaliculitis exists. Sphingomonas paucimobilis, is an uncommon isolate in canaliculitis. Extremes of age and occupational exposure may be possible risk factors for infection with uncommon organisms. Clinical features at presentation do not vary greatly with uncommon or multi drug resistant organisms' hence sampling and microbiological assessment is warranted. The benefit of curettage in canaliculitis is manifold. Unusual organisms and opportunistic pathogens can be multi-drug resistant and determination of antibiotic susceptibility is important to initiate targeted therapy to ensure disease cure and prevent recurrences.

Intracanalicular antibiotic ointment loading as a management option for canaliculitis

AIM

The aim of the study is to describe intracanalicular antibiotic ointment loading as a treatment option for canaliculitis.

MATERIAL AND METHODS

It was an interventional prospective study. The study was conducted over a 3 year period from June 2015 to June 2018. All patients of canaliculitis managed with intracanalicular antibiotic ointment loading and with a minimum follow up of 3 months were included in the study. The antibiotic ointment was loaded into the canaliculus based on the antibiotic sensitivity of the material expressed out from the canaliculus. Patients' demographics, clinical details, microbiological profile and management outcomes were evaluated.

RESULTS

A total of 24 patients were included in the study. Mean age at presentation was 58.41 ± 9.4 years. The right eye was involved in 15 (62.5%, p = .0424) cases. The incidence of lower canaliculus involvement (14, 58.33%, p = .022) was significantly higher as compared to the upper canaliculus (8, 33.33%). Staphylococcus epidermidis and Actinomyces israelii (6, 25%) were the most commonly isolated organisms. Mean number of intracanalicular antibiotic loading sessions required was 4.21 ± 1.69 (range 2-8). Complete resolution of canaliculitis was seen in all (100%) cases.

CONCLUSION

Canalicular antibiotic ointment loading is a minimally invasive, safe, and effective procedure. It preserves the anatomy and function of the punctum and canaliculus and can be considered as one of the management options for canaliculitis.

Outcomes of Canaliculotomy with and without Silicone Tube Intubation in Management of Primary Canaliculitis

PURPOSE

To compare the outcomes of canaliculotomy and curettage with and without silicone tube intubation in the treatment of primary canaliculitis.

METHODS

A prospective, randomized, interventional case series was performed. Fifty patients diagnosed with unilateral inferior primary canaliculitis underwent canaliculotomy with curettage and were randomly divided into two groups depending on silicone tube intubation. Twenty-five patients were recruited in group A (without intubation) and 25 patients were recruited in group B (with intubation). The resolution of infection, the success rate and postoperative complications observed in both groups were analyzed with a minimum follow-up of 1 year.

RESULTS

Forty-seven patients were finally included in the study consisting of 23 patients in group A and 24 patients in group B. There were 33 females and 14 males with a median age of 57 ± 13.9 years (range 29-89 years). All patients recorded complete resolution of canaliculitis and no recurrent infections were observed in the 2 groups during follow-up. A significantly higher number of anatomical and functional successes were achieved in patients in group B (100%, 87.5%) than in group A (78.3%, 60.9%) (P < .05,). The surgical complication of canalicular obstruction was significantly higher in patients in group A (21.7%, 5/23) compared to group B (0/24)(P < .05).

CONCLUSION

Canaliculotomy with curettage gives excellent clinical outcomes in the treatment of patients with primary canaliculitis and a higher success rate can be achieved when silicone tube intubation is performed during the procedure. The use of silicone tube intubation may be a necessary choice in canaliculotomy to avoid post-operative canalicular obstruction.

Metagenomic Shotgun Sequencing Analysis of Canalicular Concretions in Lacrimal Canaliculitis Cases

Lacrimal canaliculitis is a rare infection of the lacrimal canaliculi with canalicular concretions formed by aggregation of organisms. Metagenomic shotgun sequencing analysis using next-generation sequencing has been used to detect pathogens directly from clinical samples. Using this technology, we report cases of successful pathogen detection of canalicular concretions in lacrimal canaliculitis cases. We investigated patients with primary lacrimal canaliculitis examined in the eye clinics of four hospitals from February 2015 to July 2017. Eighteen canalicular concretion specimens collected from 18 eyes of 17 patients were analyzed by shotgun metagenomics sequencing using the MiSeq platform (Illumina). Taxonomic classification was performed using the GenBank NT database. The canalicular concretion diversity was characterized using the Shannon diversity index. This study included 18 eyes (17 patients, 77.1 ± 6.1 years): 82.4% were women with lacrimal canaliculitis; canalicular concretions were obtained from 12 eyes using lacrimal endoscopy and six eyes using canaliculotomy with curettage. Sequencing analysis detected bacteria in all samples (Shannon diversity index, 0.05–1.47). The following genera of anaerobic bacteria (>1% abundance) were identified: Actinomyces spp. in 15 eyes, Propionibacterium spp., Parvimonas spp. in 11 eyes, Prevotella spp. in 9 eyes, Fusobacterium spp. in 6 eyes, Selenomonas spp. in 5 eyes, Aggregatibacter spp. in 3 eyes, facultative and aerobic bacteria such as Streptococcus spp. in 13 eyes, Campylobacter spp. in 6 eyes, and Haemophilus spp. in 3 eyes. The most common combinations were Actinomyces spp. and Streptococcus spp. and Parvinomonas spp. and Streptococcus spp., found in 10 cases. Pathogens were identified successfully using metagenomic shotgun sequencing analysis in patients with canalicular concretions. Canalicular concretions are polymicrobial with anaerobic and facultative, aerobic bacteria.

Plug-related canaliculitis: a rare or underdiagnosed disease?

CLINICAL RELEVANCE

Conjunctivitis, chalazion and blepharitis are routinely managed by optometrists. However, it is especially important to consider the diagnosis of canaliculitis in patients with chronic or recurrent conditions.

BACKGROUND

This study aimed to report the clinical features, radiological findings and treatment outcomes in patients with plug-related canaliculitis.

METHODS

This retrospective study included patients with canaliculitis secondary to plug insertion between 2007 and 2020. All data regarding epidemiological characteristics, clinical presentation, isolated microorganisms, computed tomography imaging findings, treatment, and outcomes were analysed.

RESULTS

A total of 20 plug-related canaliculitis from 19 patients (18.3%) among all 109 cases of canaliculitis were identified. All patients with plug-related canaliculitis were females with a past history of lacrimal plug insertion for dry eye (mean age: 58.2 years). Most patients were initially treated as conjunctivitis with the mean time lapse to a diagnosis of 5.2 months. The average time from plug insertion to onset of symptoms was 5.1 years. Eighteen patients underwent canaliculotomy, and one patient received lacrimal irrigation. Plugs were identified in 18 cases, with SmartPlug in 13 cases (72%), followed by EaglePlugTM (two cases), Herrick Lacrimal Plug (two cases), and migrated FCI Painless Plug (1 case). Cultures of discharge, concretions, and/or infected plugs mostly revealed Pseudomonas aeruginosa (42%). Orbital computed tomography in four cases with SmartPlug revealed central radiolucency with surrounding soft-tissue enhancement. No recurrent canaliculitis was observed throughout a mean follow-up period of 13.7 months. No patient needed re-plugging after canaliculotomy and plug removal, with only one required additional lubricants for recurrent dry eye.

CONCLUSION

Plug-related canaliculitis is often underdiagnosed due to late onset and similar symptoms to common ocular diseases. Awareness of plug insertion history as well as meticulous removal of the plug, concretion and/or granulation tissue is important for early diagnosis and to ensure a good outcome.

Campylobacter concisus as a pathogen of primary canaliculitis: a case report

A 73-year-old woman presented to our hospital with a 1-year history of epiphora associated with discharge on the left eye. On the first examination, there was a swelling in the medial part of the left lower eyelid associated with a cystic change along the lacrimal canaliculus. On digital compression, there was an expression of a yellow mucopurulent discharge from the left-lower punctum. A culture test of the discharge showed Campylobacter concisus (1+), Gemella morbillorum (1+), Fusobacterium nucleatum (1+), and Porphyromonas gingivalis (2+). Complete removal of the canaliculoliths was done with a curette. Dacryoendoscopic examination showed a substantially dilated horizontal canaliculus accompanied with granulation and fibrous tissues on the left-lower side. An ofloxacin ointment-coated bicanalicular tube was inserted. Also, an oral antibiotic was administered for 14 days after surgery. At a 3-month follow-up, the patient did not have any symptoms associated with canaliculitis.

Surgical procedure of canaliculoplasty in the treatment of primary canaliculitis associated with canalicular dilatation

Background

Primary canaliculitis is a chronic infection of the proximal lacrimal pathway. We aimed to evaluate surgical outcomes of a canaliculoplasty procedure for primary canaliculitis associated with canalicular dilatation.

Methods

This study enrolled 42 primary canaliculitis patients with canalicular dilatation who underwent canaliculoplasty. All patients were treated with canaliculotomy, curettage of canalicular contents and canaliculoplasty with stent placement. Patients’ demographics, clinical features, and follow-up outcomes were evaluated.

Results

There were 12 males and 30 females with a mean age of 66.1 ± 13.9 years. The mean duration time from the first onset of signs/symptoms to diagnosis was 30.6 ± 39.5 months. Epiphora (90.5%) and mucopurulent discharge from punctum (85.7%) were the most common signs. Thirty-three out of 42 patients (78.6%) achieved complete remission with a mean follow-up time of 25.3 ± 12.9 months. There were 3 patients found to have canalicular stenosis due to obstruction after surgery.

Conclusion

Canalicular dilatation is a severe condition of primary canaliculitis, probably due to a combined result of long standing disease and the presence of concretions. The surgical procedure of canaliculoplasty can be a highly effective treatment for primary canaliculitis associated with canalicular dilatation.

Punctal dilatation and non-incisional canalicular curettage in the management of infectious canaliculitis

OBJECTIVE

To describe the outcomes of punctal dilatation and non-incisional canalicular curettage in patients with infectious canaliculitis.

METHODS

A retrospective analysis of 53 canaliculi of 47 eyes of 46 consecutive patients diagnosed with canaliculitis was performed from November 2015 to December 2018. All patients were treated with punctal dilatation and a non-incisional canalicular curettage. Parameters studied include demographics, clinical presentation, microbiological analysis, management and treatment outcomes. The outcome measures were clinical resolution of canaliculitis and resolution of epiphora.

RESULTS

The mean age at presentation was 59.34 years with female preponderance (M:F = 19:28). Left eye was more affected (64%, n = 30) as compared to the right (36%, n = 17). Only one patient presented bilaterally. Lower canaliculus was most commonly involved (68%, n = 32). Six eyes showed involvement of both upper and lower canaliculus. Presenting symptoms include discharge (81%), swelling of the eyelids (64%), watering (55%), redness (51%) and pain (39%). Punctal dilatation and non-incisional canalicular curettage were performed using punctum dilator and a small chalazion scoop (1 mm Meyhoefer chalazion curette). Of the 53 involved canaliculi, 14 canaliculi of 14 eyes underwent a repeat curettage for complete resolution and 1 canaliculus underwent the same procedure thrice. The most common micro-organisms isolated were Streptococci species (28% cases). At a mean follow-up of 6.8 months, resolution of canaliculitis was achieved in all patients; however, epiphora persisted in two eyes (4%).

CONCLUSION

Non-incisional canalicular curettage is a minimally invasive technique with good preservation of the punctal and canalicular anatomy. It also facilitates good anatomical and functional outcomes in infectious canaliculitis.

Long-term Outcome of Incision and Curettage Treatment in Patients with Lacrimal Gland Ductulitis

Purpose

To describe the effects and long-term outcomes of incision and curettage treatment in patients with lacrimal gland ductulitis.

Methods

Twenty-four patients (24 eyes) with lacrimal gland ductulitis who were treated at Saevit Eye Hospital from June 2010 to November 2016. All patients underwent incision and curettage through the lacrimal ductule, and granules or concretions were removed. After the procedure, oral and topical antibiotics, oral anti-inflammatory agent were used for a week. Clinical presentations of the patients were analyzed. The resolution of symptoms and inflammatory signs and recurrence were evaluated more than 12 months after the procedure including telephone follow-up by a specialist nurse.

Results

Common symptoms were a painful, swelling mass with mucous discharge (17 eyes) and conjunctival injection (7 eyes) at the lateral canthal area. During the procedure, 22 patients (91.7%) had typical sulfur granule of Actinomyces, and 10 patients (41.7%) had many cilia in the expressed debris from the ductule. Twenty-three of 24 patients had resolution of symptoms after the procedure and all but one patient (95.8%) showed no recurrence.

Conclusions

Incision and curettage is a simple and less invasive procedure that may be considered as a first treatment option for lacrimal gland ductulitis. Furthermore, incision and curettage of the affected lacrimal ductule has been shown to be effective at minimizing long-term recurrence of lacrimal ductulitis.

Infectious keratitis secondary to canaliculitis with concretions: A case report

RATIONALE

Canaliculitis is a frequently overlooked and misdiagnosed disease. Concurrent corneal ulceration with canaliculitis is uncommon. We report such a case.

PATIENT CONCERNS

An 87-year-old woman complained of swelling and pain of the right eye after acute angle closure glaucoma attack. Slit-lamp examination was compatible with the features of infectious keratitis, and the cultures from corneal scrapings grew Streptococcus anginosus later. Hourly topical vancomycin (25 mg/ml) was instilled, then the corneal ulceration improved initially but became stationary after 1-week treatment.

DIAGNOSIS

Discharge from the upper punctum was noted subsequently and canalicular concretions were found through curettage. The cultures from canalicular discharge and concretions also revealed the presence of S. anginosus. Thus, infectious keratitis secondary to canaliculitis was diagnosed.

INTERVENTIONS

Canaliculotomy was performed to remove the large concretion and vancomycin was injected locally.

OUTCOMES

The corneal ulceration resolved after canaliculitis was appropriately treated.

LESSONS

Canaliculitis could be a reservoir for organisms that may make compromised corneas liable to infections. Only the appropriate diagnosis and aggressive treatment of canaliculitis leads to the eradication of associated corneal infections.

Long-term results of maintenance of lacrimal silicone stent in patients with functional epiphora after external dacryocystorhinostomy

PURPOSE

To evaluate long-term outcomes of maintenance of lacrimal silicone stent for the management of functional epiphora after anatomically patent external dacryocystorhinostomy (DCR).

METHODS

We retrospectively reviewed the medical records of 101 eyes of 75 patients who were diagnosed to have functional epiphora after external DCR from 2005 to 2014. Functional epiphora was defined as epiphora that persisted or recurred even after patent DCR confirmed by a lacrimal irrigation test. Secondary silicone intubation was indicated when the patients wanted a further intervention. The stent was intended to be kept in situ unless there was a stent-related complication or the patient wanted removal.

RESULTS

In total, 34 of 75 patients (45.3%, 52 eyes) who agreed to the intervention underwent secondary silicone intubation. The success rates at 1, 3, and 5 years after surgery were 96.2%, 75.5%, and 70.2%, respectively. At the final follow-up (mean 72.7 ± 26.4 months), 32 (61.5%) eyes chose to retain the silicone tube: silicone stent was well maintained without epiphora and complications once inserted in 18 eyes (34.6%), whereas tube replacement was needed in 14 eyes (26.9%) because of nasal crust or whitish plaque formation on the tube surface. In 13 cases (25.0%), silicone stent was removed because of tube-related complications, and the most common complication was canaliculitis (n = 8, 15.4%).

CONCLUSIONS

Secondary intubation and maintenance of the stent is an effective and simple procedure for functional epiphora. The main obstacle to long-term maintenance is tube-associated canaliculitis.

Application of lacrimal endoscopy in the diagnosis and treatment of primary canaliculitis: Practical technique and graphic presentation

To investigate the efficacy of lacrimal endoscopy in the diagnosis and treatment of primary canaliculitis.This is a retrospective, interventional study. Fifteen patients diagnosed as primary canaliculitis were investigated, who underwent surgery with lacrimal endoscopy from January 2015 to December 2017 at Zhejiang Provincial People's Hospital. Patients were subsequently followed post-operatively for at least 6 months. Pre- and post-operative main measurement included ocular surface symptoms, signs of canaliculitis, intraoperative images, treatment response and complications.Twelve patients (12 eyes) were enrolled. Endoscopy was successful in revealing the residual concretion and pathological change of lacrimal duct. With its unique direct vision and micro drill, all concretions got removed and lacrimal ducts got patent. On postoperative month 6, all of the patients got cured with no signs of redness, swelling of the punctum and eyelid, epiphora with discharge and pain. None serious complications such as false canalicular passage were observed.Lacrimal endoscopy is indispensable in diagnosis, treatment and follows up of primary canaliculitis. With less iatrogenic injury, higher resolution rate and direct observation of canalicular mucosa, lacrimal endoscopy should be widely applied in the management of lacrimal diseases.

Pediatric Canaliculitis: A Case Report

Canaliculitis is a rare disease that relapses when not properly diagnosed and treated. It usually occurs in middle-age and advanced age. It is extremely rare in children and infants. A healthy 12-year-old girl presented with lower eyelid swelling and watery discharge in her right eye. During the last 2 years, the patient had been examined several times for the same complaints but there was no improvement despite treatment. Examination showed that the lower punctum had a pouting punctum appearance, and applying pressure to the lacrimal sac area resulted in purulent discharge. Lavage showed that the lacrimal passage was patent. In light of these clinical findings, the patient was diagnosed with canaliculitis. Punctoplasty with surgical curettage of the dacryoliths were performed. After the surgical procedure, a topical antibiotic was prescribed. Histopathological examination of the dacryoliths revealed that the infective cause was Actinomyces. No recurrence or complications were observed during 12 months follow-up.

Outcomes of canaliculotomy in recalcitrant canaliculitis

Purpose

To evaluate outcomes of canaliculotomy in cases of recalcitrant canaliculitis.

Methods

All cases diagnosed with canaliculitis who subsequently underwent canaliculotomy over a 15 year period were included in the study. We reviewed and analyzed demographic data, clinical presentation, microbiological profile and management outcomes.

Results

Out of 40 patients, 21 (52.5%) were males. Age range was 17–89 years. Lower canaliculus was affected most commonly (53.81%). Mean duration of symptoms was 8 months (range- 0.5–60 months, median 6 months). The most common presenting symptom was watering (34, 85%) while pouting puncta (32, 80%) was the most frequently documented clinical sign. Concretions were seen in 20 (50%) patients and Actinomyces was the most commonly isolated micro organism in the concretion group. Polymicrobial growth was seen in 18 (45%) patients. Commonly isolated bacteria on culture were Staphylococcus epidermidis (16, 40%) followed by Actinomyces (14, 34%) and Corynebacterium species (5, 12.5%). Complete resolution was seen in 39 cases post-operatively (97.5%, p = 0.0002). Mean follow up period was 21 months (range- 3–180 months).

Recurrence was noted in 6(15%) cases, of which 4 were males (66.67%, p = 0.069) Four (66.67%, p = 0.069) patients had associated diabetes and 5 (83.33%, p = 0.046) had associated concretions. Six (15%) patients complained of persistent epiphora.

Conclusion

Canaliculotomy is a safe and effective method for management of recalcitrant canaliculitis with a success rate of 85%. Presence of concretions was associated with higher risk of recurrence in our study.

A case report on complete cure of recurrent primary canaliculitis by 4-snip punctoplasty and canalicular curettage

RATIONALE

For the treatment of primary canaliculitis, 1,2,3-snip punctoplasty and canalicular curettage are commonly used; however, a recurrence rate of 6.6% to 22% has been reported. Herein, we describe a case of recurrent primary canaliculitis that was completely cured by 4-snip punctoplasty and canalicular curettage.

PATIENT CONCERNS

A 53-year-old woman was admitted to our hospital with chief complaints of epiphora, discharge, eyelid flare up, and swelling near the inferior lacrimal punctum in the left eye, which initially presented 6 months earlier.

DIAGNOSIS

Based on the aforementioned symptoms, the patient was initially diagnosed with bacterial conjunctivitis at a local ophthalmologic clinic and used antibiotic eye drops for 6 months. However, her symptoms did not improve and they worsened at 2 weeks prior to admission. She was subsequently diagnosed with chronic dacryocystitis and referred to our hospital for surgical treatment. Slit lamp examination results showed conjunctival congestion in the inner corner of the left eye, along with eyelid flare up, swelling near the inferior lacrimal punctum, and yellowish discharge and concretion from the lacrimal punctal orifice. Furthermore, punctal regurgitation was not observed in the lacrimal sac compression test. Thus, the patient was diagnosed with primary canaliculitis on the basis of her clinical symptoms and laboratory findings.

INTERVENTIONS

Based on the diagnosis of primary canaliculitis, 1-snip punctoplasty and canalicular curettage were performed, and the patient was prescribed oral antibiotics for 2 weeks together with topical antibiotics for 4 weeks. Overall, the patient's symptoms improved after surgery, but epiphora and yellowish discharge from the lacrimal punctal orifice developed again 2 months after surgery during outpatient follow-up. Based on the diagnosis of recurrent primary canaliculitis, 4-snip punctoplasty and canalicular curettage were performed, and the patient was prescribed oral antibiotics for 2 weeks together with topical antibiotics for 4 weeks.

OUTCOMES

Over a 6-month follow-up period, the symptoms disappeared completely and no other findings were observed.

LESSONS

Four-snip punctoplasty and canalicular curettage are simple clinical procedures that can minimize the recurrence rate of primary canaliculitis. Hence, 4-snip punctoplasty and canalicular curettage should be considered as the 1st-line treatment for primary canaliculitis and recurrent cases.

Primary lacrimal canaliculitis - A clinical entity often misdiagnosed

Purpose

Primary lacrimal canaliculitis (PLC) is a unique disorder which often gets misdiagnosed by the general as well as speciality-trained ophthalmologists. Elderly patients with history of chronic or recurrent epiphora with discharge, often get mislead towards chronic dacryocystitis. The aim of our report is to discuss the misleading diseases in our PLC patients and to revisit this hidden disease.

Methods

The patients of PLC who were previously misdiagnosed were studied. The clinical history, presenting clinical features, misdiagnosis, and final management of the patients is described.

Results

There were 5 misdiagnosed female patients. A history of chronic redness, watering, discharge, and medial canthal region edema lead to the misdiagnosis of chronic dacryocystitis in 3 (60%) and medial marginal chalazion in 2 (40%) cases. Slit-lamp examination revealed localized hyperemia (n = 5), classical pouting of lacrimal punctum (n = 3), and expressible purulent discharge (n = 3). Two patients without punctum pouting had an explicit yellowish hue/discoloration of the canalicular region. Our patients had a mean 4 visits before an accurate diagnosis. Three-snip punctoplasty with canalicular curettage was performed in three while two were managed conservatively. At last follow-up, all patients were symptom-free with punctum and canalicular scarring in three, who underwent surgery.

Conclusion

PLC is a frequently misdiagnosed clinical entity which delays the initiation of appropriate treatment. A succinct magnified examination of punctum and canalicular region can provide sufficient clues pivotal for accurate diagnosis.

Clinical features and surgical outcomes of primary canaliculitis with concretions

The purpose of our study is to analyze the clinical, ultrasonic, microbiologic, and histopathologic characteristics, management, and outcomes in a series of primary canaliculitis with concretions patients who underwent canaliculotomy with curettage.Thirty-six patients were reviewed for age, sex, location and laterality, duration of symptoms, clinical symptoms, ultrasonic signs, result of microbiologic culture and histopathologic examination, treatment, and outcomes. Main outcomes were the clinical, ultrasonic, and microbiological characteristics of the canalicular concretions; the histopathologic profiles; and the treatment effect.Thirty-six patients were identified with concretions in all 37 cases of the patients with canaliculitis. There were 30 (83.3%) female patients with a mean age of 54.2 years. Twenty-eight (77.8%) patients were misdiagnosed or delayed diagnosed, and the mean duration was 17.1 months. The common most clinical presentations were discharge (100%), epiphora (66.7%), erythema (52.8%), and swelling (47.2%), and concretions were found in 31 of 37 patients by typical clinical manifestations and in 5 of 6 patients by ultrasonic. Actinomyces was found in 8 of 13 histopathologic specimens, and microbiological cultures were positive in 13 of 24 patients. All patients underwent canaliculotomy with curettage to completely remove all concretions and contents; 35 of 36 patients' symptoms improved and 1 recurred after treatment at a median of 21.7 months follow-up according to the telephonic questionnaires.Canalicular concretions play an important role in primary canaliculitis. Canaliculotomy with curettage is a standard therapy with canalicular concretions, and the surgical removal of all possible concretions is essential for cure.

Is routine histopathological examination of dacryocystorhinostomy/dacryocystectomy specimens necessary? A tertiary eye hospital experience

PURPOSE

Limited literature documenting the incidence of unsuspected malignant neoplasm among dacryocystorhinostomy/Dacryocystectomy (DCR/DCT) specimens is reviewed to determine if routine biopsy of all the patients undergoing such procedures is required. We are evaluating if sending lacrimal sac specimens for histopathological examination is necessary as a routine patient's care standard.

STUDY DESIGN

This is a retrospective study of all lacrimal sac specimens received for histopathological examination in a tertiary eye hospital over a period of 12 years.

PARTICIPANTS

This is an institutional study of all patients who underwent lacrimal sac drainage procedure and/or lacrimal sac biopsy during the 12-years period.

METHODS

498 samples from 459 patients were included for review of the histopathological findings and tissue diagnosis. The files were checked for demographic data collection, preoperative clinical diagnosis and suspicion of malignancy.

RESULTS

Out of the 459 patients initially included, the mean age was 51.63 ± 17.8 years. Female patients constituted 70.8% while male patients accounted for 29.2%. Malignancy was suspected before surgery in 3 cases of the 498 specimens reviewed (0.6%). The remaining 495 specimens analyzed, 17 cases (3.43%) had unsuspected tissue diagnosis (other than chronic dacryocystitis) including Oncocytoma in 7, dacryolith in 7 and granulomas in 3. However, no case of malignant neoplasm was identified.

CONCLUSIONS

There were no unsuspected malignant cases in the current series. Therefore routine histopathological examination of DCR specimens is not considered to be essential. It should be reserved only for selected suspicious cases. Careful intra-operative assessment in these cases is also warranted.

Aggregatibacter aphrophilus chronic lacrimal canaliculitis: a case report

Background

Chronic canaliculitis is often misdiagnosed as conjunctivitis, delaying proper documentation and management. Aggregatibacter aphrophillus has not been implicated in chronic canaliculitis.

Case presentation

We report a case of unilateral chronic epiphora associated with chronic lacrimal canaliculitis resistant to prolonged topical antibiotic treatment in a 65-year-old woman without notable medical history. Canaculotomy, curettage with removal of concretions and tubing with silicone stent for six weeks resolved this chronic infection. Culturing lacrimal secretions and concretions yielded Aggregatibacter aphrophilus in pure culture. Histological analyses showed elongated seed clusters surrounded by neutrophils. Fluorescence in Situ Hybridization confirmed the presence of bacteria in two distinctive concretions.

Conclusion

This first documented case of A. aphrophilus chronic lacrimal canaliculitis illustrates that optimal surgical management of chronic lacrimal canaliculitis allows for both accurate microbiological diagnosis and treatment.

A Pathological Analysis of Canaliculitis Concretions: More Than Just Actinomyces

Purpose. Canaliculitis is classically associated with Actinomyces species, which are filamentous bacteria; the purpose of this study was to evaluate the extent to which nonfilamentous bacteria colonize canalicular concretions by using graded histopathological analysis. Methods. This is a series of 16 cases. The percentage of Gram-positive/Gomori's methenamine silver-positive filamentous bacteria (Actinomyces) versus the total bacteria identified was graded, and the types of bacteria seen were recorded. Nonfilamentous bacteria were categorized based upon Gram stain (positive or negative) and morphology (cocci or rods). Results. There were 11 females and 5 males. Nonfilamentous bacteria were identified in 16 of 16 (100%) specimens and filamentous bacteria were identified in 15 of 16 (94%) specimens. The mean percentage of filamentous bacteria relative to total bacteria was 57%. Regarding the nonfilamentous bacteria present, 69% of specimens had Gram-positive cocci only, 25% had Gram-positive and Gram-negative cocci, and 6% had Gram-positive cocci and Gram-positive rods. Conclusion. In the current study, there was a mix of filamentous and nonfilamentous bacteria in almost all canalicular concretions analyzed. Nonfilamentous bacteria may contribute to the pathogenesis of canaliculitis. In addition, the success of bacterial culture can be variable; therefore, pathological analysis can assist in determining the etiology.

Clinical features, microbiological profiles and treatment outcome of lacrimal plug-related canaliculitis compared with those of primary canaliculitis

AIMS

To compare the clinical features and treatment outcome between lacrimal plug-related canaliculitis and primary canaliculitis.

METHODS

Patients with plug-related canaliculitis and primary canaliculitis between 2007 and 2014 in a medical centre were collected. Charts were reviewed for clinical features, microbiological profiles, time lapse between plug insertion and symptom onset, type of plug and outcomes.

RESULTS

Of 76 eligible cases collected, 13 were plug-related canaliculitis and 63 were primary canaliculitis. The most common presenting symptom was discharge in both groups (85% and 79%, respectively). The average time interval from plug insertion to symptoms onset was 5.5 years. Most canaliculitis developed in women, especially for plug-related canaliculitis, when compared with primary canaliculitis (100% vs 65.1%; p=0.015). The most common isolated microorganism was Pseudomonas aeruginosa in plug-related canaliculitis (46%) and Streptococcus in primary canaliculitis (28%), respectively. Isolation of Pseudomonas was significantly higher in plug-related canaliculitis than in primary canaliculitis (46% vs 12%; p=0.029). Most plug-related canaliculitis resolved after removal of plugs by canaliculotomy (12 cases, 93%). Most identified plug was SmartPlug (seven cases), followed by EaglePlug (two cases) and Herrick Lacrimal Plug (two cases). There was no recurrence in patients with plug-related canaliculitis, however, recurrence developed in seven patients (11%) with primary canaliculitis.

CONCLUSIONS

In comparison with primary canaliculitis, plug-related canaliculitis appear to be more prevalent in women and show a different microbiological profile. Retrieval of infected plug by canaliculotomy and adequate antibiotics can achieve a good outcome. Long-term follow-up is required because canaliculitis may develop several years after plug insertion.

Primary canaliculitis: The incidence, clinical features, outcome and long-term epiphora after snip-punctoplasty and curettage

Purpose

To study the incidence, clinical features and outcome of primary canaliculitis with special reference to long-term epiphora after Snip–punctoplasty and curettage.

Methods

Single center, retrospective, telephonic questionnaire study. The medical records of patients who visited Orbit and Oculoplasty clinic, Tertiary Eye Hospital, India from 01 July 2011 to 31 June 2012 were analyzed. Records of the patients with primary canaliculitis were reviewed for clinical profile and management. Post-surgical patients thus identified were telephonically contacted in December 2012. Questionnaire was used to assess the postsurgical epiphora. Symptomatic patients were given clinic appointment, reassessed and managed.

Results

2245 patients visited Orbit and Oculoplasty clinic during the study period. The incidence of primary canaliculitis was 1.4% (31 patients). The median age of the patients with canaliculitis was 65 years (range, 14–80 yrs). Sixteen patients were male. All cases were unilateral and four eyes showed both upper and lower canalicular involvement. The commonest clinical presentations were pus or concretion from punctum (28), mucous discharge (23), epiphora (18) and conjunctival injection (18). Three snip punctoplasty and canalicular curettage was performed in 30 of these patients. Twenty of the 25 available culture results were positive and streptococcus species was the most common isolated organism. Records revealed that five (22%) of these patients had persistence of symptoms. Twenty-three patients could be contacted telephonically. The median follow-up of these patients was 11 months. On telephonic communication we found that two (8.7%) patients had epiphora. Munk epiphora score in these patients was three and one respectively.

Conclusions

Incidence of canaliculitis was 1.4%. Most common isolate was streptococcus species. Snip–punctoplasty and curettage is a safe and efficacious modality of treatment of canaliculitis. Post-operative epiphora occurred in 8.7% patients.

Novel Therapy for Primary Canaliculitis: A Pilot Study of Intracanalicular Ophthalmic Corticosteroid/Antibiotic Combination Ointment Infiltration

In patients with primary canaliculitis, conservative medical therapy is associated with a high recurrence rate. Surgical treatments carry a great resolution rate but sometimes can result in the lacrimal pump dysfunction and canalicular scarring. The aim of this study is to introduce a minimally invasive approach, intracanalicular ophthalmic corticosteroid/antibiotic combination ointment infiltration (IOI, intracanalicular ointment infiltration), and to report our preliminary results for treating primary canaliculitis. In this retrospective, interventional case series, 68 consecutive patients with newly developed primary canaliculitis at a major tertiary eye center between January 2012 and January 2015. Thirty-six patients received conservative medical treatment alone (group 1; 36 eyes). Twenty-two patients and 10 medically uncontrolled patients from group 1 underwent IOI therapy (group 2; 32 eyes). Ten patients and 26 recurrent patients from group 1 and group 2 underwent surgery (group 3; 36 eyes). Patients were followed-up for at least 8 weeks. Clinical characteristics and outcomes were analyzed and compared. In this study, patients' age, sex, onset location, and durations of disease among 3 groups showed no significant difference. The resolution rate in group 2 was 72.7% (16/22) for new patients and 68.8% (22/32) for gross patients, respectively, both of which are higher than that of group 1 (22.2%, 10/36) but lower than that of group 3 (100%, 36/36). Of group 3, 2 patients received 2 surgical interventions and resolved finally. Microbiological workup was available in 51 patients. The most common isolates were staphylococcus species (27.9%) and streptococcus species (20%). Canalicular laceration developed in 1 patient during the IOI procedure and 1 patient undergoing surgery. Only 2 had postoperative lacrimal pump dysfunction and 1 had canalicular scarring in group 3. The IOI may be an effective and minimally invasive technique for treating primary canaliculitis and obviate the need for further intensive surgery.

Clinical characteristics, treatment patterns, and outcomes of primary canaliculitis among patients in Beijing, China

Background. Canaliculitis may cause punctal or canalicular swelling, discharge, erythema, and sometimes concretions. This study examined the clinical characteristics, treatment patterns, and outcomes of primary canaliculitis from patients at a top-rated hospital in Beijing, China. Methods. Medical records of 16 patients (retrospective case series) were studied. Results. This study included four males and twelve females with a median age of 72.5 years. The mean and the median follow-up time were 10.4 months and 6 months, respectively. The mostly observed clinical symptoms were epiphora with discharge (94%), while the mostly observed signs included pouting punctum (75%) and punctal regurgitation of concretions under syringing (75%). Only the symptoms of one patient among those with conservative therapy completely resolved within two-year follow-up. Curettage therapy was found to partly resolve the clinical symptoms and signs within the follow-up of four weeks. Fifteen patients finally received curettage with punctoplasty, and symptoms completely resolved in fourteen patients after one surgery. Conclusions. Syringing with pressing of lacrimal sac area may help better diagnosis of canaliculitis. Additionally, curettage with punctoplasty is recommended for thorough removal of concretions and complete resolution of canaliculitis.