Predominantly unilateral tearing or discharge, red eye, and mild tenderness over the nasal aspect of the lower or upper eyelid.

(see Figure 6.10.1.)

Figure 6.10.1: Canaliculitis.

Critical

Erythematous “pouting” of the punctum (turned outward) and erythema of the surrounding skin. Expression of mucopurulent discharge or concretions from the punctum is diagnostic.

Other

Recurrent conjunctivitis confined to the nasal aspect of the eye, gritty sensation on probing of the canaliculus, and focal injection of the nasal conjunctiva. 

• Dacryocystitis: Infection of the lacrimal sac with more lacrimal sac swelling, tenderness, and pain than canaliculitis. See 6.11, Dacryocystitis/Inflammation of the Lacrimal Sac.

• Chalazion: Focal inflammatory eyelid nodule without discharge from punctum. See 6.7, Chalazion/Hordeolum.

• Nasolacrimal duct obstruction: Tearing, minimal-to-no erythema or tenderness around the punctum. See 8.10, Congenital Nasolacrimal Duct Obstruction.

• Conjunctivitis: Often bilateral, depending on the etiology. Does not present with focal tenderness; rather diffuse injection, tearing or discharge. See 5.1, Acute Conjunctivitis and 5.2, Chronic Conjunctivitis.

• Actinomyces israelii (streptothrix): Most common. Anaerobic gram-positive rod with fine, branching filaments. Produces sulfur-rich stones.

• Other bacteria (e.g., Fusobacterium and Nocardia species).

• Fungal (e.g., Candida, Fusarium, and Aspergillus species).

• Viral (e.g., herpes simplex and varicella zoster).

• Retained punctal plug or foreign body.

1. Apply gentle pressure over the lacrimal sac and canaliculus with a cotton-tipped swab and roll it toward the punctum while observing for mucopurulent discharge or concretions.

2. Smears and cultures of the material expressed from the punctum, including slides for Gram stain and Giemsa stain. Consider thioglycolate and Sabouraud cultures.

3. Ask about a history of punctal plugs.

1. Apply warm compresses to the punctal area for 5 to 10 minutes q.i.d.

2. Remove obstructing concretions or retained plug. Concretions may be expressed through the punctum at the slit lamp. A canaliculotomy is usually required for complete removal or in the setting of a retained punctal plug. If necessary, marsupialize the horizontal canaliculus from a conjunctival approach and allow the incision to heal by secondary intention. Consider placing a temporary silicone stent to prevent postoperative canalicular scarring.

3. If concretions are removed, consider irrigating the canaliculus with an antibiotic solution (e.g., trimethoprim sulfate/polymyxin B, moxifloxacin, penicillin G solution 100,000 units/mL, iodine 1% solution). The patient is irrigated while in the upright position, so the solution drains out of the nose and not into the nasopharynx.

4. Treat the patient with antibiotic drops (e.g., trimethoprim sulfate/polymyxin B or moxifloxacin q.i.d.) and oral antibiotics for 1 to 2 weeks (e.g., doxycycline 100 mg b.i.d.).

5. If a fungus is found on smears and cultures, nystatin 1:20,000 drops t.i.d. and nystatin 1:20,000 solution irrigation several times per week may be effective.

One to 2 weeks depending on severity. This is usually not an urgent condition.