Etiology
Primary canaliculitis
- Infection secondary to bacteria, fungus, or virus
- Most commonly due to Actinomyces species
- A number of other bacteria have also been implicated: Nocardia, Mycobacterium species, Staphylococcus, Streptococcus (Freedman, Surv Ophthalmol 2011; Zaldivar OPRS 2009).
- Bacteria are often among concretions, which are basophilic masses of amorphous material.
- Classic Actinomyces "sulfur" granules have an eosinophilic periphery with club-like structures (filamentous bacteria) (Freedman, Surv Ophthalmol 2011).
- Actinomyces is a facultative anaerobe; anaerobic cultures are required for isolation.
- Rarely, patients are found to have a canalicular diverticulum that can cause stasis and the propagation of bacteria (Adjemian, OPRS 2000).
- Staphylococcus is the most common organism cultured from specimens of canaliculitis (Anand, Orbit 2004; Vecsei, Ophthalmologica 1994).
Secondary canaliculitis
- Secondary infection after punctal or intracanalicular plug placement
- 8% incidence of canaliculitis with intra-canalicular plugs (Marcet, Ophthalmology 2015)
- Plugs can cause canalicular stasis.
- Organisms isolated are often similar to primary canaliculitis (Freedman, Surv Ophthalmol 2011).
Epidemiology
- Mean age at presentation is approximately 60 years.
- 5:1 female to male ratio
- In 1 study risk of canaliculitis after intracanalicular plug placement was about 5%.
- Most often affects the lower eyelid (Vecsei, Ophthalmologica 1994)
History
Patients often have months to years of chronic symptoms, including discharge and irritation of the eye.
Determine whether patient has a history of punctal or intracanalicular plugs.
Clinical features
- Classic presenting signs (Figures 1–3)
- Epiphora
- Medial canthal edema
- Nonresolving conjunctivitis
- Occasionally patients are found to have a mass emanating from the punctum (papilloma or pyogenic granuloma) (Perumal, OPRS in press).
Figure 1. Canaliculitis stone. Courtesy Michael J. Hawes, MD.
Figure 2. Canaliculitis. Courtesy Gregory J. Griepentrog, MD.
Figure 3. Canaliculitis. Courtesy Gregory J. Griepentrog, MD.
Testing
- Slit-lamp examination: Edema of the medial eyelid, pouting punctum with discharge emanating from the punctum
- Attempt to express discharge from the punctum through compression over the medial eyelid
- Canalicular probe and irrigation
- Initial probe can be "gritty" secondary to canalicular concretions.
- There may be some component of resistance to probing.
- Irrigation often demonstrates a stenotic distal end of the canaliculus.
- If classic signs of canaliculitis are present, probing and irrigation are likely not necessary.
- Discharge can be sent for culture and/or histopathological analysis.
- Culture of punctal discharge
- Recommend culture be sent in separate aerobic and anaerobic transport media; Actinomyces is a facultative anaerobe.
- Urgent transport of the material may increase yield
- Consider specifying culture for mycobacteria and fungi as well.
- Histopathology of concretions or foreign body
- Consider hematoxylin and eosin (HE), Gram, Gomori's methenamine silver (GMS), and Periodic acid-Schiff (PAS) stains to help identify the presence of granules and various bacteria and fungi (Repp, Ophthalmology 2009)
- Dacryocystography may be useful in atypical cases, potentially to diagnose a true canalicular diverticulum (Adjemian, OPRS 2000).