Mark Awad, John Awad
Background
Canaliculitis is an uncommon condition caused by chronic infection of the lacrimal canaliculus, a key part of the lacrimal drainage system (1). It is typically a unilateral condition and is associated with a variety of signs including discharge, epiphora, swelling of the eyelid and punctum pouting (2). Primary lacrimal canaliculitis (PLC) occurs mainly secondary to infection, most commonly due to actinomyces, staphylococcus, and streptococcus (2). Secondary canaliculitis, on the other hand, occurs as a complication of inter-canalicular or punctal plug insertion for the treatment of dry eye (1). Management can be conservative, with warm compress, topical and systemic antibiotics, irrigation, and syringing, or surgical, including punctoplasty, canaliculotomy, canalicular curettage, and silicone tube intubation.
Misdiagnosis is common, even amongst specialty ophthalmologists with many patients misdiagnosed as blepharitis, conjunctivitis, chalazion and dacryocystitis (3). A recent review of existing literature on canaliculitis found misdiagnosis was common, occurring in almost 10% of published cases (2). A high degree of suspicion is therefore needed to facilitate early diagnosis which can be vital for complete cure. Chronic cases are more likely to have complications and poorer prognosis (1). In this article, we describe two cases of canaliculitis where there was a delay in diagnosis subjecting patients to incorrect treatments and potentially avoidable surgeries.
Case presentation
Case 1 – Mr X
Patient 1 presented to ophthalmology clinic for review in 2023 with a left upper eyelid lesion associated with watery eyes and a yellow/green discharge.
On examination, there was mild conjunctival hyperaemia in the left eye with discharge. There was evidence of a fleshy growth extending from the punctum with an associated history of ipsilateral intermittent epistaxis for months. The patient at the time believed this to be unrelated. Left eye vision was 6/9 unaided. With suspicion high for a sinus or lacrimal sac tumour, he was listed for incisional biopsy and commenced on 0.5% chloramphenicol eye drops in the meantime.
Excision biopsy one month later showed inflamed granulation tissue. MRI of the orbits was arranged to rule out a malignant cause of the lesion. This showed features suggestive of dacrocystitis and a possible stone but no concerning evidence of orbital or nasal malignancy. Consequently, he was listed for a further biopsy of the left superior punctum lesion. Five months from initial presentation, he underwent punctum biopsy during which a large dacrolith was expressed. He was discharged with co-amoxiclav for five days. Post-op appointment in March 24 showed complete resolution of symptoms and he was discharged with PIFU.
Case 2 – Mrs Y
Patient 2, a middle-aged female who was initially seen in the dry eyes video assessment clinic in 2022 for severe dry eyes despite optimal conservative treatment with liquid paraffin Xalin night eye ointment, eye mask overnight and lid wipes. She was subsequently invited for review in dry eyes clinic and treated with bilateral punctual cautery.
She re-presented to ophthalmology a year later with watery eyes and recent development of a ‘stye’ on the inferior lower lid of the right eye which had not resolved. Seen by specialist optometrist, and prescribed dexamethasone + neomycin + polymyxin B Maxitrol eye ointment and hydrocortisone softacort eye drops and referred to ophthalmologist to consider reversal of punctual cautery.
Re-presented to ophthalmology again, two years following initial presentation due to an ongoing growth in medial corner of lower lid of right eye, now discharging pus and passing blood in her tears. She was prescribed co-amoxiclav and chloramphenicol for a week. Conjunctival swabs were taken, and she was referred to oculo-plastics for further review. Examination of the eyes revealed 6/6 vision in both eyes with glasses and a fleshy looking growth from inferior punctum right eye. The canaliculus appeared red and inflamed. She was listed for 3-snip right inferior punctoplasty and exploration and biopsy.
Discussion
Canaliculitis is an uncommon condition, accounting for 2-4% of lacrimal diseases. It is commonly diagnosed late or misdiagnosed due to subtle, non-specific symptoms and high degree of suspicion is needed to facilitate early diagnosis which can be vital for complete cure. Chronic cases are more likely to have complications and poorer prognosis (1).
A recent review of the published literature by Pal & Alam reported canaliculitis onset at a mean age of 57 years (range 10 months – 88 years), with a female predominance (male to female ratio of 1: 2.4). The review identified mucopurulent discharge as the most common presenting sign, present in 44% of cases, followed by medial canthal swelling, observed in ~40% of cases (2). Other studies have also sighted peri-punctum hyperaemia and pouting of the lacrimal punctum as classic signs (4). One study described the typical patient as a post-menopausal woman, presenting with epiphora, lower eyelid erythema with a red, pouting punctum with yellowish, mucopurulent discharge (5).
Singh et al have described a clinical tetrad of lacrimal canaliculitis including (4):
1. Medial eyelid oedema
2. Pouting and hyperaemia of the lacrimal punctum
3. Yellow-ish hue over the canaliculus
4. Canalicular distention with expressible canalicular discharge
If suspecting canalicular disease, the following tests may be considered. Firstly, the expression test, where manual pressure is gently applied to the canaliculi near the punctum. The test is positive if mucopurulent discharge is released from the punctum. Secondly, slit lamp examination can be performed to inspect the punctal area for inflammation, swelling, or punctal stenosis or scarring. Discharge smear swabs can also be taken for gram staining and culture to assess for bacterial or fungal growth. Both polymicrobial and monomicrobial causes well documented and the most commonly isolated organisms are actinomyces, staphylococcus, and streptococcus (2).
However, despite well documented signs, misdiagnosis of the condition is common as the clinical signs can often mimic other conditions affecting the eye.(2) Pal & Alam’s review of all published literature on canaliculitis in the last 15 years revealed the most common misdiagnosis was conjunctivitis in 39% of cases, followed by dacryocystitis and nasolacrimal duct obstruction (2).
We reviewed the NICE CKS guidelines for the management of conjunctivitis. While discussion with or referral to ophthalmology is advised for recurrent or persistent conjunctivitis, the guidelines do not make any reference to lacrimal involvement (6). Our cases highlight the importance of considering canaliculitis as a differential in persistent conjunctivitis: patients with recurrent unilateral discharge and epiphora following brief improvement with topical antibiotics, e.g. for conjunctivitis should undergo a more detailed examination of the canaliculi, keeping canaliculitis as part of the differential diagnosis. Other cases of canaliculitis being treated as recurrent or chronic conjunctivitis have in fact also been well documented (7).
In our second case, the patient was incorrectly diagnosed as having a ‘stye.’ Discharge from the eye is not a typical feature of meibomian cyst. Further, the location of the swelling should provide clues to the aetiology: meibomian cysts are found along the eyelid margin, however swellings in atypical locations, i.e. medial to the lacrimal punctum should raise suspicions for canalicular disease as there are no meibomian glands located here (8).
The management of lacrimal canaliculitis can be medical or surgical: medical management includes topical and systemic antibiotics, canalicular expression and warm compress whereas surgical management options include punctoplasty, canaliculotomy, and canalicular curettage. However, conservative therapies alone have been found to be inferior to surgical treatment with one study even finding 100% resolution with surgical treatment compared to only 69% with medical treatment (9). Canaliculotomy with curettage is considered the gold standard for treatment of lacrimal canaliculitis (10).
Learning points
- Lacrimal canaliculitis is an uncommon condition that that is challenging to diagnose due to subtle, non-specific symptoms (discharge, epiphora and erythema) that can often mimic other conditions. It is often misdiagnosed as conjunctivitis, blepharitis, dacryocystitis and even chalazion.
- Patients with recurrent unilateral discharge and epiphora following brief improvement with topical antibiotics, e.g. for conjunctivitis should undergo a more detailed examination of the canaliculi, keeping canaliculitis as part of the differential diagnosis
- Meibomian cysts in atypical locations, i.e. medial to the lacrimal punctum should raise suspicions for canalicular disease.
References
1. Feroze KB, Patel BC. Canaliculitis. Encyclopedia of Ophthalmology [Internet]. 2023 Jul 31 [cited 2024 Oct 25];1–2. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441922/
2. Pal SS, Alam MS. Lacrimal Canaliculitis: A Major Review. Semin Ophthalmol [Internet]. 2024 Nov 16 [cited 2024 Oct 25]; Available from: https://www.tandfonline.com/doi/abs/10.1080/08820538.2024.2354689
3. Singh M, Gautam N, Agarwal A, Kaur M. Primary lacrimal canaliculitis – A clinical entity often misdiagnosed. J Curr Ophthalmol. 2018 Mar 1;30(1):87–90.
4. Singh M, Mehta A, Sharma M, Kaur M, Gupta P. A “Clinical Tetrad” for Easy Diagnosis of Lacrimal Canaliculitis. J Curr Ophthalmol [Internet]. 2022 Jul [cited 2024 Oct 25];34(3):347. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC9832468/
5. Freedman JR, Markert MS, Cohen AJ. Primary and Secondary Lacrimal Canaliculitis: A Review of Literature. Surv Ophthalmol. 2011 Jul 1;56(4):336–47.
6. Scenario: Who should I refer to ophthalmology? | Management | Conjunctivitis – infective | CKS | NICE [Internet]. [cited 2024 Oct 25]. Available from: https://cks.nice.org.uk/topics/conjunctivitis-infective/management/who-should-i-refer-to-ophthalmology/
7. Liyanage SE, Wearne M. Lacrimal canaliculitis as a cause of recurrent conjunctivitis. Optometry – Journal of the American Optometric Association. 2009 Sep 1;80(9):479–80.
8. Singh M, Gautam N, Agarwal A, Kaur M. Primary lacrimal canaliculitis – A clinical entity often misdiagnosed. J Curr Ophthalmol. 2018 Mar 1;30(1):87–90.
9. Kaliki S, Ali MJ, Honavar SG, Chandrasekhar G, Naik MN. Primary canaliculitis: Clinical features, microbiological profile, and management outcome. Ophthalmic Plast Reconstr Surg [Internet]. 2012 Sep [cited 2024 Oct 25];28(5):355–60. Available from: https://journals.lww.com/op-rs/fulltext/2012/09000/primary_canaliculitis__clinical_features,.10.aspx
10. Wang M, Ma Y, Tu Y, Wu W, Yu B. A prospective study comparing mini-invasive and conventional canaliculotomy of punctum-sparing canaliculotomy for primary canaliculitis treatment. [cited 2024 Oct 25]; Available from: https://doi.org/10.1038/s41433-022-02333-7