Although primary lacrimal canaliculitis accounts for only 2% to 4% of lid pathologies, it is important to recognize, as misdiagnosis may result in delayed treatment and worsening infection.¹ 

Patients commonly present with localized pain, persistent unilateral epiphora, recurrent or non-resolving conjunctivitis and chronic discharge.^1,2 The condition has a 5:1 predilection for females, and the inferior canaliculus is affected in two-thirds of cases.^1,3 Classic signs consist of a “pouting” punctum, yellowing of the surrounding skin and localized hyperemia.^1,2 Actinomycetaceae organisms are the common infectious agent, although other bacterial, fungal or viral entities can be culprits.² With time, they clump together in yellowish clusters of sulfur granules or concretions. 

Topical and oral antibiotics, warm compresses and digital manipulation are common initial therapy, although the time between presentation and accurate diagnosis often leads to concretions deep within the canaliculus.³ Complete removal of the infection and any concretions requires surgical intervention.¹

Under the Knife

Prior to surgery, a topical anesthetic is applied to the affected eye and an injection of lidocaine 1% with 1:100,000 epinephrine is administered to the pericanalicular tissues. The area is prepped with povidone iodine and draped. After confirming anesthetic effect, a plastic corneal shield is placed to protect the globe. 

The surgeon makes an incision along the longitudinal aspect of the eyelid canaliculi, sparing the puncta, and expresses the canaliculi contents. Any expressed concretions should be sent to pathology. The surgeon then passes a dilating probe through the puncta to check for patency. Curettage on the inner lining of the canaliculi and the adjacent areas ensures complete removal of concretions and ensures no pyogenic granuloma is present. If the surgeon finds a pyogenic granuloma, it is excised and also sent to pathology. 

An antibiotic (e.g., moxifloxacin ophthalmic solution 0.5%) is then injected through the canalicular system and into the lacrimal sac using a tuberculin syringe and lacrimal catheter. After control of hemostasis with digital pressure, the plastic corneal shield is removed and an additional drop of topical antibiotic is applied to the corneal surface. 

Recovery Road

The patient uses topical antibiotics QID in the affected eye for one week and should continue any previously prescribed oral antibiotics and return for follow-up in one week. Ice packs on the eyelids and over-the-counter pain medications are appropriate as needed. Patients experience minimal postoperative pain and achieve good cosmetic appearance once the edema resolves.

Comanaging clinicians should review the pathology and microbiology results to determine if the causative organism is susceptible to the prescribed antibiotics. If so, the patient should continue the treatment for an additional week. If not, switch the patient to a treatment therapy based on the results of the culture and continue the regimen for one to two weeks.¹

Dr. Skorin is an ophthalmologist at the Mayo Clinic Health System in Albert Lea, Minn.

Dr. Toldo is a recent graduate of Pacific University College of Optometry. 

Mr. Baker is a nurse practitioner participating in the Mayo Clinic Emergency Medicine Fellowship program.

1. Freedman JR, Markert MS, Cohen AJ. Primary and secondary lacrimal canaliculitis: A review of literature. Surv of Ophthalmol. 2011;56:336-47.  2.  Bagheri N, Wajda B. Canaliculitis. In: The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7th ed. Philadelphia: Wolters Kluwer; 2017;138-9. 3. Kaliki S, Ali MJ, Honavar SG, et al. Primary canaliculitis: clinical features, microbiological profile, and management outcome. Ophthal Plast Reconstr Surg. 2012;28(5):355-60.