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Signs and symptoms: Canaliculitis is a relatively rare disorder that predominantly affects individuals over age 50. Complaints center on a chronic, recalcitrant unilateral red eye, and often epiphora. The discharge may range from a simple watery consistency to full-blown mucopurulence. In many cases, the patient will report previous therapy with topical antibiotics, but to no avail. Recurrent episodes are not uncommon.

Biomicroscopic inspection reveals a classic "pouting punctum" in the involved eye--that is, the punctal orifice is red, swollen and turned outward, like pouting lips. The involved area is often tender to touch. Digital manipulation of the punctum and/or canaliculi may express discharge and/or concretions. Other important signs include erythema and swelling of the lid and adnexal tissue, and a conjunctivitis that is most pronounced inferiorly and nasally.

Lacrimal probing reveals additional diagnostic signs. You will encounter a "soft stop" while probing the canaliculus. This blockage indicates the presence of concretions within the drainage system. Concurrent with this finding is the so-called "wrinkle sign"; as your probe meets resistance, the overlying skin of the medial canthus may compress and wrinkle. The Jones test for fluorescein dye disappearance is inherently negative.

Pathophysiology: Canaliculitis results from an infection of the canaliculus. Most often a bacterial pathogen causes this, though it can also result from fungal or viral infection. In older individuals, Actinomyces israelii is the primary etiology. Those under age 20 who present with canaliculitis are more likely to manifest primary herpetic infections. Other less common etiologies include Fusobacterium, Nocardia, Candida, Fusarium and Aspergillus species.

Infections within the canaliculi cause dacryoliths--small stones or concretions that further impede lacrimal drainage--to form. These concretions help to form "pockets" in which the infection flourishes, not subject to the antimicrobial properties of the precorneal tear film. Foreign bodies that lodge within the canaliculus can produce a similar presentation.

Management: Management of canaliculitis is twofold, consisting of physical removal of associated foreign matter and vigorous antimicrobial therapy. Small dacryoliths and other debris may be expressed through the punctum with direct manipulation using a cotton-tipped applicator. Larger or numerous stones often require surgical canaliculotomy.

Institute antimicrobial therapy only after alleviating the blockage. Treatment options depend on the offending agent. Obtain smears and cultures from the extruded canalicular material. In cases of bacterial infection, irrigate the canaliculus with penicillin G solution (100,000 units/ml). Usually, you will then follow-up with topical therapy (Polytrim or Neosporin ophthalmic solution) and systemic antibiosis (penicillin or ampicillin) for 1-2 weeks. Treatment for herpetic infection consists of topical trifluridine 1% five times daily for 2-3 weeks. Address fungal infections by using nystatin 1:20,000 ophthalmic solution tid, as well as biweekly nystatin irrigation.

Clinical Pearls:

  • Differentiate canaliculitis from dacryocystitis; the latter presents more acutely and with greater pain and swelling in the canthus region.
  • Herpetic canaliculitis often follows herpes simplex blepharoconjunctivitis. Consider this in cases that manifest persistent epiphora after resolution of the herpes vesicles.
  • If treatment fails to eradicate the problem, or if canalicular patency cannot be restored, a dacryocystorhinostomy may be required.

Other reports in this section

Eyelids & Eyelashes | Conjunctiva & Sclera | Cornea
Uvea | Vitreous & Retina | Optic Nerve & Brain | Oculosystemic Disease

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