• Written By: Shimon Rumelt, MD
    Oculoplastics/Orbit

    This retrospective case series describes the clinical characteristics and management of patients with chronic unilateral mucopurulent conjunctivitis probably due to Actinomyces infection of the lacrimal gland ductules. The authors suggest calling this new entity Actinomyces ductulitis or Actinomyces ductular dacryoadenitis.

    This appears to be the first report of patients with lacrimal gland ductulitis due to probable Actinomyces infection. The authors say this rare condition should be included in the differential diagnosis for any patient with a long history of a very sticky eye that does not resolve with topical therapy, especially in the presence of a localized temporal episcleritis.

    The study included seven patients who presented to a lacrimal clinic in London. Six cases were treated with surgical excision of the infective focus. In the remaining case, fenestration and expression of infective debris from the affected lacrimal gland ductule, typically the most inferolateral of the ductules, was performed.

    All cases settled rapidly after surgery, which was followed by a short course of postoperative topical antibiotics to prevent proliferation of any bacteria spilled during surgery. The authors have observed no recurrences.

    They report that there was often a major delay in diagnosis, with patients having symptoms for between two and 42 months before referral. Five patients received prolonged or ineffectual topical medical therapy before referral. Although one patient was cured without formal excision, they note that chronic Actinomyces canaliculitis is unlikely to be cured by medical therapy alone.

    It would be interesting to know what percentage of the authors' oculoplastics patients were affected. It is unclear how patients were identified and whether all cases seen during the study period were included. Also it is unclear how the authors diagnosed the disease, how patients were referred and what previous medical treatment they received.

    Still, a differential diagnosis should include dacryoadenitis, pyogenic granuloma and a secreting chalazion. Although the authors say the lacrimal gland was intact during their excisional biopsies, some cases may have been extensions of dacryoadenitis. In addition, the involvement of the lacrimal drainage system was not excluded. A simple digital massage and obtaining cultures would exclude such involvement.

    They note that Actinomyces is the same infective agent found in canaliculitis. Mucus stasis may result in relative hypo-oxygenation that may facilitate the proliferation in such compact spaces of these microorganisms. Still, cultures should have been obtained to exclude other infective agents and co-infection.

    The most important conclusion from this report is that in cases of chronic conjunctivitis that do not respond to medical treatment, the evaluation should include everting the upper eyelid and searching for a nidus, as is done when searching for other more common sources.