Lacrimal Canaliculitis, A Case Report - KSOS

December 2008 M. Chakrabarti et al. - Ocular Contusion Injury 421
Lacrimal Canaliculitis, A Case Report
Dr. Bindu N. Das MS, Dr. Sisira MS
Introduction
Canaliculitis is a chronic unilateral infection of the
lacrimal canaliculus which is often overlooked and
treated unsatisfactorily. Bacteria, fungi and viruses may
all produce such infection , the most common agents
reported being actinomyces. Here we report a case of
culture positive bilateral actinomyces canaliculitis
involving both upper and lower puncti.
Case Report
A 40 year old male patient presented to us with
complaints of watering and purulent discharge from
left eye of 1 year duration, pain and swelling of the left
eyelids for 2 months. On examination his vision was
6/6 in right eye and 6/12 in left eye. Examination of
left eye showed a tender fusiform swelling in the medial
one third of left upper and lower eyelids. The
neighbouring part of the conjunctiva was inflammed.
(Fig.1) There was no tenderness and swelling in the
lacrimal sac area. The upper and lower puncti were
found to be pouting with expression of tenacious pus
on pressure over the swelling. The right eye also showed
pouting of lower puncta though it did not show
swelling. Patient was asymptomatic in the right eye.
Rest of the anterior and posterior segment was normal.
He was a known diabetic on irregular treatment.
The punctum was split under topical anaesthesia using
a fine scissors taking aseptic precautions and a thick,
tenacious purulent material was expressed from the
canaliculus. (Fig.2) The casts were removed by
performing a 3- snip procedure (Fig.3) followed by
irrigation with penicillin solution (100, 000 units). The
patient was also treated with fortified penicillin eye
drops and a course of oral penicillin. The casts collected
were sent for microbiological investigations. Repeated
irrigation with crystalline penicillin drops was done in
the right eye. A portion of collected material was
inoculated on blood agar and brain heart infusion broth.
On Gram staining the organisms appeared as gram-
Fig. 1. showing conjunctival
inflammation
Fig. 2a-b showing thick tenacious purulent material expressed
from canaliculus
Dept of Ophthalmology, Kozhikode Medical College, Kozhikode Fig. 3. The casts removed after 3-snip procedure
C A S E
REPORT

422 Kerala Journal of Ophthalmology Vol. XX, No. 4
Fig. 4. showing positive
beaded, coccoid, thin
branching filaments
on gram staining
positive beaded, coccoid, thin branching filaments.
(Fig.4) The patient recovered rapidly and was left with
a slit punctum and adjoining canaliculus. The remaining
portion of the lower canaliculus was intact and was
patent. Post-operatively, the swelling, conjunctivitis and
discharge disappeared (Fig.5).
Discussion
Fig. 5. P ost-operative
appearance of the eye
Actinomyces israelii species is a gram-positive, castforming,
non–acid-fast, non–spore-forming anaerobic
bacillus. Its filamentous growth and mycelia like
colonies have a striking resemblance to fungi. They are
soil organisms, often found in decaying organic matter
(eg, wet hay, straw). It is primarily a commensal
microbe found in normal oral cavities, in tonsillar
crypts, in dental plaques, and in caries teeth and enters
the lacrimal system through the nasal passage or
indirectly by means of saliva into the conjunctiva. The
anaerobic environment also helps in the growth of the
Actinomyces in the canaliculus.
Other ocular manifestations include keratitis,
conjunctivitis, blepharitis, dacryocystitis, postsurgical
endophthalmitis, and infected porous orbital implant.
Cervico-facial actinomycosis has also been reported.
Canaliculitis usually presents as chronic watering,
redness and discharge from eye. A pouted punctum is
clinically diagnostic, although it occurs in less than
50 % of all patients who are affected. Typically, the
discharge is particulate and contains concretions.The
plica may be swollen and congested, and canalicular
swelling and overlying lid erythema are often
present.The lower lid is more commonly affected, and
the lacrimal sac and the duct are usually not
involved.The disease is most commonly unilateral.
Among the reported cases almost all were unilateral,
involving the lower lid. Bilateral and upperlid
involvement as in this case is a rare presentation.
Concretions on the lacrimal canaliculus can also be due
to Candida albicans , Aspergillus niger , Fusobacterium
species, and Nocardia asteroids.
Lab Studies
Canalicular discharge and canaliculiths may be sent for
the following studies:
Gram stain/Giemsa stain
Culture and sensitivity (ie, blood agar, Sabouraud,
anaerobic media)
Special stains (ie, calcofluor white)
Treatment
Actinomycetes are usually susceptible to penicillins and
cephalosporins.
Surgical Care
Failure of resolution of canaliculitis by topical treatment
necessitates surgical exploration of the canalicular
system and removal of any casts. Extensive surgery is
not always required. A 2-snip punctoplasty, cast
removal, curettage, and probing is usually done.
Subsequent lacrimal irrigation with 1 MU of penicillin
in 10 mL of sterile water may be helpful.
References
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External Disease: Clinical Diagnosis and Management.
Krachmer JH, Mannis MJ, Holland EJ, Eds. (St. Louis,
Mosby). 1997;687-693.
2. Richards WW. Actinomycotic lacrimal canaliculitis.
American J Ophthalmol 1975;75:155-157.
3. Pine L, Hardin H, Turner L, Roberts SS. Actinomycotic
lacrimal canaliculitis - A report of two cases with a
review of the characteristics which identify the causal
organism. American J Ophthalmol 1960;49:1278-1298.
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Ocular Nocardia infections with special emphasis on
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