SURVEY OF OPHTHALMOLOGY

VOLUME 56
NUMBER 4
JULYAUGUST 2011

MAJOR REVIEW

Primary and Secondary Lacrimal Canaliculitis:

A Review of Literature
Joshua R. Freedman, MS,1 Matthew S. Markert, MS,2 and Adam J. Cohen, MD, FACS3
1
3

Rush University Medical Center, Chicago, Illinois; 2University of Miami, Miller School of Medicine, Miami, Florida; and
Private Practice, The Art of Eyes Eyelid and Facial Plastic and Reconstructive Surgery, Skokie, Illinois, USA

Abstract. Canaliculitis is an uncommon inflammation of the proximal lacrimal drainage system that is
frequently misdiagnosed. It classically presents with symptoms of unilateral conjunctivitis, mucopurulent discharge, medial canthal inflammation, epiphora, and a red, pouting punctum. We summarize
the literature on canaliculitis published from antiquity to the modern era and explore therapeutic
options. (Surv Ophthalmol 56:336--347, 2011. 2011 Elsevier Inc. All rights reserved.)
Key words. actinomyces
actinomycosis
canaliculitis
canaliculostomy

canaliculotomy
chronic conjunctivitis
pouting
punctum
streptothricosis

I. Introduction

streptothrix

The clinical distinctions and treatment approach

separating primary canaliculitis and canaliculitis
secondary to plug insertion have not yet been
identified.32,39,58 We reviewed the case literature
on presentation, diagnosis, and treatment outcome,
and generate a differential diagnostic strategy for
the identification of primary canaliculitis, as well as
treatment recommendations for both primary and
secondary canaliculitis.

Canaliculitis is an uncommon inflammation of the

lacrimal canaliculi usually caused by infection5,6,9,28,73
or as a complication of punctal or intracanalicular
plug insertion35,58 or intubation.29,47 Canaliculitis
is often misdiagnosed as conjunctivitis.2,70
Described in Harrisons Principles of Internal
Medicine as the most misdiagnosed disease and
that no disease is so often missed by experienced
clinicians, primary canaliculitis is the result of an
infection of the canaliculus and proximal lacrimal
duct associated with eyelid thickening and/or
erythema, and/or the presence of a classic pouting
punctum.74 Recognition of canaliculitis as an infectious condition is attributed to Von Graefe
(1854).21 Actinomyces isrealli, then classified as
a fungus, was initially found to be the most common
causative organism. For this reason, canaliculitis was
originally known by the names of streptothrix
canaliculitis1,18,22 or streptothricosis.17,50

A. ANATOMY AND HISTOLOGY

The lacrimal canaliculi, also known as canals or

ducts, run vertically within the eyelids and converge
to form the common canaliculus. They begin as
branches of the lacrimal punctae and traverse the
eyelids for approximately 8 mm. The upper eyelid
canaliculi are shorter and narrower compared to the
lower canals. The upper canal travels at a sharp
angle before coalescing with lower canaliculus to
form the common canal. The lower canaliculi run
336

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doi:10.1016/j.survophthal.2010.12.001

337

PRIMARY AND SECONDARY LACRIMAL CANALICULITIS

almost completely horizontal before joining the

upper canaliculus, where the vertical components
become enshrouded by fibrous tissue to form the
punctum.
Canalicular obstructions may be anatomically
divided into proximal, mid-, or distal. Proximal
canalicular obstructions typically occur within the
first 2--3 mm of the canaliculi. Causes include
punctal stenosis, punctal occlusion, and swelling.
Mid-canalicular obstructions often follow injury or
are secondary to infection, canaliculiths, or medications. These obstructions occur 6--8 mm from the
punctal os. Distal obstructions are often congenital
malformations of the membrane (valve of Rosenmuller) where the common canaliculus opens into
the lacrimal sac. Lacrimal sac infections may also
result in distal canalicular obstruction. Distal obstructions occur more than 6--8 mm distal to the
eyelid punctum.
Case studies were analyzed for clinical presentation
reported, microbiological cause of infection, demographic data, and whether patients had previous
lacrimal plug insertion or canalicular intubation.

II. Epidemiology
In the last 20 years a number of case series of
canaliculitis have been reported, the majority of
which cited the prevalence of signs and symptoms.
The infrequency of canaliculitis limits statistical
analysis of reported cases. What an analysis of
reported cases does provide is a more qualitative
portrait of presenting clinical features, demonstrating a relatively consistent pattern when viewed
across the decades.
Demographic information from reviewed papers
is included in Table 1. Analysis of data obtained

from the literature indicates the most common

causative organisms of lacrimal canaliculitis are the
Actinomyces species (see Table 2). Other microorganisms known to be associated with canaliculitis are
listed in Table 3. Recent studies demonstrate greater
rates of infection with streptococcal, and staphyloccal species than Actinomyces.35,74
Lacrimal canaliculitis occurs at a mean age of 59
years, but has been reported in patients from 5--90
years of age. There is a 5:1 female:male ratio,
consistent with earlier studies.4 No racial or ethnic
association was found. Accurate measures of the
prevalence of primary canaliculitis in the general
population are unavailable, owing to the frequency
of misdiagnosis, relative rarity, and general underreporting of the disease. Historical incidence of
canaliculitis in ophthalmic records screened for
relevant symptoms ranged between 2% and 4%.16,74
Secondary canaliculitis is most commonly related
to punctal or intracanalicular plug placement.
Punctal occlusion to prevent tear drainage is the
most common non-pharmalogical treatment for dry
eye.12 Women represent 92% of secondary canaliculitis cases in the literature, likely because of the
preponderance of women treated with placement of
a plug for dry eye syndrome. A summary of case
reports in canaliculitis secondary to punctal and
intracanalicular plugs is included in Table 4. The
generalizability of these cases is difficult to measure,
and the first studies conducted especially to determine iatrogenic rates of lacrimal disease were
only recently published.25 Among 235 patients with
a total of 403 placed plugs from a single ophthalmology practice, the prevalence rate of canaliculitis
per patient was 7.23%, and per plug inserted was
4.73%. The study was limited to SmartPlug (Medennium, Inc., Irvine, CA) placement by a single
physician.

TABLE 1

Demographic Information from Literature Reviews and Case Reports

Sullivan, 1993
Anand, 2004
Pavilack and Freuh 1992
Zaldivar and Bradley 2009
Repp, 2009
Vecsei, Huber-Spitzy et al. 1994
Briscoe, Edelstein 2004
Berlin, 1980
Lee, 2009
Hill, 2009
Hussain, 1993
Lin, 2010
Information from Case Reports (see Table 4)
Means

Mean Age

Range

Female

Total

(%Fm)

52.0
69.6
51.0
60.0
70.6
52.3
71.7
60.3
61.5
64.0
49.9
64.0
45.7
59.4

14--86
45--87
10--84
22--86
50--87
26--82
43--90
n/a
29--77
41--88
n/a
30--89
5--80
14--90

13
13
8
15
9
25
4
6
23
15
5
24
24
184

18
15
11
23
11
40
7
9
30
17
7
34
29
251

72.2
86.7
72.7
65.2
81.8
62.5
57.1
66.0
76.7
88.2
71.4
70.6
82.8
73.31

338

Surv Ophthalmol 56 (4) July--August 2011

FREEDMAN ET AL

TABLE 2

Microorganism Prevalence
Organism

# Cases (188 Total)

67
52
26
22
11
15
2
32

30.3
21.8
11.8
9.9
4.9
6.7
0.9
14.4

Actinomyces
None Found
Strep
Staph
Fungus
Nonspecific gram()
Nonspecific gram()
Other

III. Clinical Presentation

The most commonly seen clinical presentation
among 29 case reports and 12 reviews (total 5 280
patients) of primary canaliculitis are described. The
typical patient is a post-menopausal woman who
presents with epiphora, lower eyelid erythema, and
a red, pouting punctum with yellowish, mucopurulent discharge. Massage or curretage of the canalicula frequently produces removable concretions
histologically positive for Actinomyces.

A. CLINICAL SYMPTOMS AND SIGNS

The classic presenting symptoms associated with

primary canaliculitis include epiphora, medial
canthal swelling, non-resolving or recurrent conjunctivitis, and a swollen, pouting punctum, with
or without yellowish or mucopurulent discharge.10,16,20,49,74 Also found is mattering on the
eyelids49,74 and sulfur granules, stones, or concretions expressed from the punctum by massage or
recovered during surgery.4,16,32,49,70
TABLE 3

All Known Organisms Associated with Canaliculitis

Actinomyces
Actinomyces israeli
Mycobacterium
Mycobacterium abcessus
Mycobacterium chelonae
Nocardia asteroides
Staphylococcus aureus
Streptococcus faecalis
Arcanaebacterium hemolytica
Streptothrix
Propionibacterium acnes
Cornyebacterium
Haemophilus influenza
Pseudomonas aeruoginosa
Fusobacterium
Citrobacter
Chryseobacterium
Proteus mirabellus
Bacteriodes fragillus

Cases of secondary canaliculitis have been associated with epiphora, conjunctivitis, eyelid induration
and erythema, pain, swelling, canalicular inflammation, inflammatory mass projecting from the
punctum, granuloma formation, intermittent
blood-stained tears, blood-tinged or mucopurulent
discharge, and the presence of canaliculiths and
dacryoliths.14,19,31,39,48,55,58
Vecsei et al reported that his groups in-office
diagnostic procedures included slit lamp examination of upper and lower eyelids, medial canthus,
conjunctival fornices, upper and lower lacrimal
puncta, and lacrimal syringing.69,70 They believe
lacrimal syringing allows for the assessment of
functional or mechanical stenosis and serves a therapeutic purpose when astringent or antibiotic drops
are administered.69
B. HISTORICAL USE OF EXAMINATION

Although no consensus exists, there is precedent

for making the presumptive diagnosis of canaliculitis based on the clinical symptoms
alone.4,16,32,36,49,70 Ellis et al reported the finding
of concretions as diagnostic.18 Demant et al stated
the presence of chronic unilateral conjunctivitis,
canalicular swelling, a pouting punctum, plical
congestion, and expression of discharge or stone
from the punctum were all suggestive of canaliculitis.16 Pavilack et al established the diagnosis
of chronic canaliculitis in 11 cases by the presence
of expressible canalicular concretions and signs of
pericanalicular inflammation, distinguishing it from
dacryocystitis by the absence of lacrimal sac involvement.49 Lee et al diagnosed 41 cases by swelling
and erythema of the affected punctum and canaliculus accompanied by purlulent discharge or concretions extruding from the punctum.32 Hill et al
defined canaliculitis in patients with epiphora or
mucopurulent conjunctivitis and swelling at the
medial ends of the upper or lower eyelids or reflux
of mucopurulent material with gentle compression
of the affected canaliculus.25 Zaldivar et al defined
primary canaliculitis as mucopurulent punctal regurgitation on palpation, no eyelid thickening or
erythema, or the presence of a classic pouting
punctum.74 Anand et al suggest that more elaborate
diagnostic methods such as dacryocystography are
not only unnecessary, but may predispose an already
inflamed canaliculus to scarring from the associated
iatrogenic trauma.4
Case series detailing the most prevalent presenting signs and symptoms differ. When these studies
are compared, there is no evidence to suggest
change over time in the presentation of canaliculitis.
Their differences most likely reflect normal

Case Report Information

a. Primary Canaliculitis
Leung et al 200634
Charles et al 200613
Fulmer et al 199920
Hatton and Durand 200824
Tost et al 200067
Serin et al 200760
Moscato and Sires 200845
Varma and Chang 200569
Varma and Chang 200569
Park et al 200448
Romano et al 197853
Sullivan et al 199365
Shauly et al 199361
McKellar and Aburn
199742
Liyanage and Wearne
200936
Abdul and
Sathiavakesan 19841
b. Secondary Canaliculitis
Fowler et al 200819
Fowler et al 200819
Fowler et al 200819
Scheepers et al 200758
Chen and Lee 200714
Chen and Lee 200714
Chen and Lee 200714
Ahn et al 20093
Lee and Flanagan 200131
Lee and Flanagan 200131
Gerding, Kuppers 200320a
Rumelt et al 199755

Age

Female

80
66
24
60
36
51
34
78
65
5
61
42
62
10

+
+
+
+
+
+
+

Plugs

Months
before
presentation

Punctal
Discharge

Upper
Eyelid

+
+

+
+

+
+

23

+
+
+

Reported
Concretions

Lasik

Sjogrens

Surgical
Treatment

+
+

+
+
+
+
+
+

+
+

+
+
+
+

+
+
+

+
+
+
+
+

+
+
+

+
+
+
+
+
+
+
+

Reported
Dry Eye

+
+

+
+

48

41
42
38
60
68
28
26
44
41
72
55
42

Lower
Eyelid

+
+
+
+
+
+
+
+
+
+
+
+

24
4
72
14
10
5
6
36
1
14
12
3

+
+
+

+
+
+

+
+
+

+
+
+
+
+
+
+
+

+
+

+
+
+
+
+
+
+
+
+

+
+
+

PRIMARY AND SECONDARY LACRIMAL CANALICULITIS

TABLE 4

+
+
+
+

+
+

+
+
+

+
+
339

340

Surv Ophthalmol 56 (4) July--August 2011

variability accentuated by a small number of

patients. Zaldivar et al found the most common
presenting symptoms to be epiphora and mattering,
and punctal regurgitation was the most common
clinical finding.74 Repp et al report a 73% prevalence of concretions.51 Mohan et al44 reported
epiphora, discharge, irritation, and recurrent conjunctivitis as the most common symptoms. Sixty
percent (60%) had punctal regurgitation, and all 12
cases had a pouting punctum, erythema, and
thickening of the medial aspect of the eyelid.44
The Smart Plug study group found that many of
their 17 cases presented with eyelid edema and
erythema, conjunctivitis, or an inflammatory mass
projecting from the punctum.39 Briscoe et al reported all of their patients had epiphora, chronic
conjunctivitis, thickened canaliculus, and yellow
discharge.10 The common findings in Anand
et als patients were mucopurulent discharge
(93.3%) and medial canthal inflammation
(66.6%), whereas epiphora was present in only
46.6%.4 Earlier cases corroborate high prevalence of
punctal regurgitation, concretions, medial eyelid
thickening and erythema, pouting punctum, and
expressible yellowish or bloody mucopurulent discharge among study populations.49,57,70
Regarding patients with punctal or intracanalicular plugs, silicone intubation, or any foreign body
in the eye, the literature consistently supports
a high index of suspicion for canaliculitis in any
patient with irritation, epiphora, and purulent
discharge.7,14,19,25,29,31,39,40,47,54,55,58

FREEDMAN ET AL

streptococcal and staphylococcal infection.4,35,70,74

Actinomyces was first cited by Harz in 1879 to
describe organisms found in the cattle. Their lesions
appeared radially arranged like fungal mycelia,
leading to the name Actinomyces (ray fungus).
Actinomyces species are now considered Gram
positive bacilli which occur singly, in pairs, or in
chains and are non-motile obligate or facultative
anaerobes. They are normal constituents of human
and cattle oral flora and are capable of causing
chronic granulomatous infections, typically spreading by direct extension. Actinomyces has been
reported to cause multiple forms of ocular infections, including canaliculitis, conjunctivitis,
dacryocystitis, keratitis, and endophthalmitis.28
Actinomyces characteristically appears as branching filaments on Gram stain. There is substantial
evidence that follow-up cultures will support an
alternative diagnosis, even when histopathological
analysis reveals actinomycotic concretions.10,16,52,74
The low success rate in isolation of organisms is
frequently attributed to the fastidious nature of
Actinomyces,18,28,42 the difficulty of culturing this
anaerobic organism, and high tendency for polymicrobial infection.24,28,44,48,59,63 Successful culture
of these organisms from concretions ranges from
11.1% to 71.4%.4,8,10,16,28,35,49,51,70 In spite of these
known problems, it is still common for clinicians
reporting cannaliculitis to base the diagnosis on
histopathology alone. One must keep in mind that
a lacrimal system neoplasm may present with
unilateral tearing and discharge.
A. MICROBIOLOGICAL CULTURE

IV. Diagnosis
Despite decades of literature detailing the constellation of clinical signs and symptoms, lacrimal
canaliculitis continues to be undiagnosed, misdiagnosed, and improperly treated.4,10,28,49,68,70 Because
of the variability of symptoms, coincidence of
symptomatology with other disorders of the eye,
and the possibility of canaliculitis presenting
without classic symptoms,45,60,61 more objective
measures should be used.
The majority of published studies and case
reports on canaliculitis detail an attempt to determine the causative organism, either by culture or
histopathological examination. Samples are taken
from tears, punctal discharge, concretions, or
particulate matter recovered via massage or
curettage.
Actinomyces israelli is often cited as the most
common pathogen of lacrimal canaliculitis,20,23,28,46,49,63,65 although studies published
within the last decade demonstrate higher rates of

Methods of obtaining culture include conjunctival swabbing,28,30,42 sampling of punctal discharge44,58,59 and conjunctival sac materials,
abscess culture,s and culture of particulate matter
and concretions.4,19,31,32,35 Some physicians choose
to send for only aerobic and anaerobic cultures,16
whereas others report culturing for bacteria, fungus,
and mycobacteria.19 Innoculums placed on blood
agar, chocolate agar, and Sabouraud dextrose agar
and incubated anaerobically have been successful in
identifying Actinomyces israelli from canalicular concretions.42 Urgent collection and transport methods
have been reported to improve yields, and delayed
processing may negatively affect results.28 Improved
detection rates have also been reported using a PD
Plus/F blood culture bottle (Beckton, Dickinson &
Co., Franklin Lakes, NJ).10
Less common organisms have been cultured by
a variety of means. Eikenella corrodens was identified
by the Vitek 1 system using the Neisseria/Haemophius identification card (BioMerieux, Marcy

341

PRIMARY AND SECONDARY LACRIMAL CANALICULITIS

lEtoile, France).34 Lactoccocus lactis cremoris has been

identified by the Rapid ID 32 Strep kit (BioMerieux).34 Some fungi like Pitysporum pacydermatitis
have required not just culture for identification, but
also analysis of sugar, ammonium, potassium, and
nitrogen assimilations.53 Because of the wide breath
of possible microbial pathogens when canaliculitis is
suspected, the microbiology lab should be informed
of the possible need for special testing.
B. HISTOPATHOLOGY

Histopathological examination is the most commonly reported diagnostic test performed on

canalicular concretions.10,16,32,51,57,70 The concretions found consistently in case series typically
portray the histopathological characteristics of
Actinomyces,10,70,74 although the success rate of
culturing these organisms is low.4,10,74
Sulfur granules, which have been described as
yellow, cheese-like granules with a gritty consistency,
are considered the pathologic hallmark of Actinomyces canaliculitis.20 On hematoxylin-eosin (H&E)
stain these are basophilic masses originating from
aggregated filamentous bacteria with peripheral
club-like eosinophilic structures.10 These actinomyotic granules typically show numerous, radially
oriented, Gram-positive, filamentous bacteria with
peripheral clubs that stain positively with Periodic
Acid-Schiff (PAS). Although highly suggestive of
Actinomycosis, they are also seen with Staphylococci,
Fusobacterium, Nocardiosis, Chromomycosis, and
Botryomycosis,11,32,72 so culture should always be
attempted. Filamentous bacteria demonstrating
a Gram-positive, acid-fast negative pattern are also
characteristic of propionibacterium.48
The typical findings associated with secondary
cases of canaliculitis can be centered about the
foreign body. Histopathologic examination of extracted foreign bodies shows inflammatory cells
infiltrated along the margins, as well as mass excisions
consistent with papillomas.3 Findings consistent with
pyogenic granuloma have also been reported.39
Histological methods that may aid in diagnosis
include H&E staining, Gomoris methenamine silver
stain, Brown and Brenn Gram-stain, and PAS. H&E
stain may be helpful in revealing the general
appearance and type of material present, whereas
Gram and PAS stains are more useful in making
a specific diagnosis.10 Gomori methenamine silver
stain can help to differentiate Actinomyces from
other microorganisms.11,32 Repp et al made a presumptive diagnosis from the presence of numerous
filamentous organisms on Gomorois methanamine
silver stain, if the organisms were also Gram positive
and clearly visible on PAS stain.51

Histopathological diagnosis may be misleading.

Weinberg et al reports three cases where Gram
stains show weakly Gram-positive branching filamentous organisms, thought to be Actinomyces.72
Aerobic cultures grew either a collection of Diphtheroids, Staphylococci, and Haemophilus, or nothing at all. Anaerobic cultures grew Fusobacterium,
Nucleatum, or Fusobacterium Necrophorum, but no
Actinomyces. The authors call attention to the fact
that the classic sulfur granules composed of
aggregates of filamentous branching microorganisms, typically associated with Actinomyces, are not
always present in Actinomyces infection and in fact
can be formed by other bacteria such as Staphyloccoccus
aureus. They point out that both Actinomyces
and Fusobacterium are anaerobic, non-sporeforming bacilli. Although Actinomyces should stain
Gram positive and Fusobacterium should stain
Gram negative, both are subject to irregularities in
this pattern, and the two can be confused
histopathologically.
C. GENETIC TESTING

Very limited reports of using polymerase chain

reaction to search for Actinomyces DNA exist. One
report details cases diagnosed by histopathology as
Actinomyces canaliculitis, having all yielded negative results for Actinomycotic DNA.4 An isolated
report demonstrates DNA in the concretion of
a suspected case of canaliculitis found positive for
human papillomavirus types 16, 18. In the event it
was evident on histopathology that this was in fact
carcinoma of the lacrimal sac.13 At present, there is
little evidence to support genetic testing in the
diagnostic work-up of suspected canaliculitis.
D. IMAGING

Imaging techniques can be used to confirm the

diagnosis of canaliculitis and provide information
that may facilitate surgical planning. Early imaging
was carried out with intubation macrodacryocystography (roentgenography), and more recently the
utility of ultrasound images has been explored. In
a case series identifying post-herpetic canaliculitis,
electron microscopy was used to image viral particles
in tissue samples, although the clinical use of such
techniques is uncommon.43
X-rays26 and, in rare cases, radioisotope lacrimal
scanning,27 have been used to aid in the diagnosis of
canaliculitis.4,16,33,57,65 Demant et al used x-rays to
depict non-filling of the involved canaliculus, or
marked dilatation and raggedness of the canaliculus
is associated with canaliculitis.16 They noted that
stones are not demonstrated by dacryocystography
because they are usually amorphous. Santhananthan

342

Surv Ophthalmol 56 (4) July--August 2011

et al designated filling defects of the lacrimal canaliculi as diagnostic of canaliculitis.57 Additional

findings associated with canaliculitis included
dilatation of the canaliculus, beading, and small
diverticuli.
More recently, ultrasound imaging has been used
in the diagnosis of canaliculitis.64,67 Ultrasonic
images of chronic canaliculitis showed ectasia of
the canaliculus and sulfur grains. High-resolution
ultrasonic examination of the lacrimal drainage
system demonstrated that a 20-MHz scanner is able
to show reflective structures such as sulfur granules
measuring 12 mm in diameter, which are pathognomic for canaliculitis. Scarce data are available to
support the practical utility of ultrasound as
a diagnostic measure at this time.
E. CANALICULAR PATENCY

Patency of the lacrimal drainage system to

syringing is typical in canaliculitis.18,28,44,52,57 Passage of a syringe into the canaliculus and fluid
expression ascertains patency of the nasolacrimal
drainage system and generally excludes dacryocystitis from the differential. Patency of the lacrimal
excretory passages to syringing does not suggest the
absence of stones, as stones in the canaliculi may still
allow saline flow.16 Similarly, co-morbidities may
exist that obstruct the system but do not exclude
canaliculitis, such as swelling and coexisting
obstructions of the tear sac.16
Anand et al4 conducted extensive lacrimal workups on patients, including complete adnexal and
anterior segment examination. They identified lid
position, punctal position, and any cause of reflex
epiphora including blepharitis or corneal surface
abnormalities, and reported tear film break-up time
and Schirmers test results. Lacrimal pump function
was assessed using the Jones dye disappearance test.
Lacrimal syringing and probing were used to
establish patency of the lacrimal system and the site
of any obstruction. These authors proposed that
detailed assessments would preclude the necessity of
invasive diagnostic imaging techniques. Other reports in the literature reflect similar drainage
assessment.43
F. MISDIAGNOSIS

Misdiagnosis and delayed diagnosis are frequent.

Physicians should suspect canaliculitis in patients
with chronic unilateral epiphora, chronic conjunctivitis, mucopurulent discharge, pouting punctum,
or concretions.4,10,16,42,49,70 If the literature accurately reflects clinical practice, it would appear that
it is more common to misdiagnose patients with
canaliculitis than to identify this condition. Case

FREEDMAN ET AL

studies of canaliculitis report percentages of patients

previously misdiagnosed as 45%,49 60%,4,70 and
100%,10 and one study noted that 33% of patients
had been previously misdiagnosed multiple times.4
Some patients have received empirical treatment
without any specific diagnosis.4 Speculations on why
canaliculitis is so frequently misdiagnosed include
its low prevalence, once cited as 2% of lacrimal
disease,16 or the atypical presentations which can
mimic conjunctivitis70 or dacryocystitis.60 Reported
misdiagnoses include chronic conjunctivitis,
chronic dacryocystitis, chalazion, mucoceles, and
blepharitis.4,49,68,70 The delay of diagnosis, or
amount of time from becoming symptomatic to
the eventual correct diagnosis, manifests a spectacular spectrum. Individual case reports of patients
have delays over 10, 15, and 20 years.10,52
Misdiagnosis results in inappropriate treatment,
often with broad spectrum topical antibiotics, which
may transiently alleviate the symptoms, but usually
do not result in a lasting cure.28 In other cases,
misdiagnosis results in unnecessary procedures,
often irrigation of lacrimal system, which can force
concretions into more distal portions of the
canaliculus.4,10,60 One report described a patient
previously diagnosed with acute dacryocystitis who
had undergone multiple irrigations, and finally
a one-snip punctoplasty, without complete resolution of symptoms. Several weeks after the surgery
the patient expressed a dozen dacryolyths.60 Analysis
of the stones demonstrated their composition to be
of previously formed canalicular concretions. The
authors suggest that misdiagnosis as dacryocystitis
led to unnecessary irrigations that may have pushed
previously formed concretions and granules into
more distal canalicular regions, explaining why
concretions were not evident during initial
compression or canaliculotomy.
Distinguishing canaliculitis from look-alike pathologies can be challenging. Differentiation of
canaliculitis from dacryocystitis is important to
prevent inappropriate treatment with irrigation that
can exacerbate symptoms. On exam, canaliculitis
can be distinguished from dacryocystitis by the lack
of lacrimal sac distention, nasolacrimal duct obstruction, and signs of lacrimal sac inflammation. In
contrast with the blennorrhea of dacryocystitis,
debris in canaliculitis is usually expressed with direct
massage of the involved canaliculus and not with
lacrimal sac compression.49

V. Treatment of Canaliculitis
Althought relatively little has changed in the
presentation or microbiological etiologies of

343

PRIMARY AND SECONDARY LACRIMAL CANALICULITIS

canaliculitis over the years,74 the treatment of

canaliculitis may in fact be evolving. Where it was
once believed that conservative treatment is ineffective in long-term treatment of canaliculitis,4,10,16,28,49,68,70 there are newer reports which
suggest increasing cure rates with non-surgical
approaches.44,74
A. MEDICAL MANAGEMENT

Conservative therapy includes warm compresses,

digital massage, topical and systemic antibiotics,
antifungals, corticosteroids, as well as some nonsurgical procedures such as irrigation and syringing.
It is widely reported that medical therapy is rarely
effective in clearing canalicular infections. The
concretions present may prevent antibiotics from
eradicating the bacterial source by virtue of obstruction to flow and protection of bacteria within the
stones.4,28,49,69,70 Others have postulated the thick
mucopurulent and particulate discharge and
abscess-like accumulation of infected debris are
responsible for resisting the penetration of topical
and systemic antibiotics.16,49 The thick granular
debris formation may cause a self-perpetuating cycle
of canalicular stasis and infection persisting for
many years.
Antibiotics may improve symptoms, even when
failing to achieve long term resolution.4,10,16,19,25,28
A recent study cites a 33% rate of recurrence in
conservatively treated patients.35 In many cases
conservative measures fail to provide any improvement,4,14,19 although case reports of resolution with
medical management exist.14,34,39,44,74 Rare cases of
secondary canaliculitis that resolve with medical
management are also described,39 but plug removal
should be a part of any treatment regimen.
Complete resolution with medical management is
typically limited to those patients who present early
in the course of the disease.16,34,69,70,74 A recent
series showed complete resolution without recurrence at an average of 150 days follow-up for those
treated within the first 30 days of symptoms.74
Symptomatic improvement has been noted with
systemic penicillin and topical neomycin, polymyxin, or bacitracin regardless of whether Actinomyces was cultured.16
A recent study demonstrated success in all
patients with combined topical antibiotic and
canalicular irrigation using fortified cefazolin solution, prepared at 50 mg/ml.44 Patients were again
irrigated at 48 hours if clinical improvement was not
evident. The number of irrigations necessary per
patient averaged 4.5 (range, 1--8); all patients had
excellent resolution of canaliculitis without the
need for surgical treatment.

Medical regimens not proven to give lasting

resolution include combinations of oral penicillins,
sulfamethoxazole-trimethoprim, tetracyclines, metronidazole, and indomethacin. Reported topical
combinations include penicillins; cephalosporins;
tetracyclines; chloramphenicol; macrolides; flouroquinolones; the antifungals fucithalmic, zinc and
adrenaline; neomycin; polymyxin; and bacitracin.4,10,16,28,44,69 Topical dexamethasone10 alone
was not successful but was efficacious when combined with tobramycin.14 Many studies use culture
sensitivities to guide their treatment regimen;however, this does not appear to improve response rates
to conservative therapy.
Lacrimal irrigation is sometimes effective in
resolving cases of canaliculitis secondary to intracanalicular plug placement. A notable risk of this
procedure, however, is the possibility of the plug
dislodging from its canalicular position and moving
distally into the lacrimal system, resulting in
permanent obstruction.39
Hyperbaric oxygen therapy was used by Shauly
et al61 treating an A. israelli canaliculitis that had
proven refractory to curettage and topical penicillin
for four weeks in a patient who refused further
surgery. The regimen included antibiotics and daily
90-minute sessions at 100% O2 at 2--2.5 atmospheres
6 days a week for 4 weeks. The patient noted gradual
improvement over this period, and complete resolution by 2 months, with no recurrence at 1 year
follow-up.
B. SURGICAL MANAGEMENT

Most studies support surgical management as the

definitive treatment for canaliculitis.10,16,35,49,70 Surgery removes concretions that serve as a reservoir
for bacteria. The least invasive methods involve
dilation of the punctum to facilitate curettage of the
stones.66 When dilatation is insufficient to allow
passage of the probe into the punctum or withdrawal of the concretions, various punctoplasty
techniques are shown to sufficiently widen the os.
Canaliculotomy allows greater access to the canaliculus, after which the incision can be left open or
closed with or without stent placement.
Syringing and probing can be used to determine
the presence and location of strictures in the
canalicular system. Length and patency of the
canaliculus can be determined in this fashion.
Dilation of the punctum followed by curettage of
the canaliculus has proven effective in primary
canaliculitis.49,51 This carries a low risk of scarring
the canaliculus, and the pump function is preserved
by avoiding canaliculotomy. Pavilack et al49 reported
high success rates treating patients with curettage,

344

Surv Ophthalmol 56 (4) July--August 2011

followed by a 10-day course of 10% sulfacetamide

sodium drops four times per day. If resolution of
symptoms had not occurred by two weeks, the
curettage and antibiosis regimen was repeated. In
this series all patients were successfully treated with
one (45%), two (45%), or three (10%) sessions of
curettage. Punctoplasty was first performed in the
study group to allow passage of the curette, but the
authors later found that dilation alone was sufficient
to allow curetting.
A more recent retrospective analysis of curettage
outcomes with the use of one snip punctoplasty in
thirty patients with primary canaliculitis demonstrated the successful resolution of symptoms in
83% of patients at their 3-week follow-up.32 Patients
with mild, persistent symptoms were treated with
continued antibiotics for one month, and their
infection resolved. Two patients required a second
curettage. Complications included formation of
canalicular strictures. Two-snip42 and three-snip43
punctoplasty procedures have been reported.
Risks of canaliculotomy include canalicular luminal narrowing or scarring, lacrimal pump dysfunction, canalicular fistula formation,4,39 failure to
diagnose and treat stones lodged deeper in the
canaliculus, and need for subsequent surgery,74 as
well as the standard risks associated with any surgical
procedure. Complications of the canaliculotomy
include the need to reconstruct the canaliculus,10
intubation,25 stent placement, canalicular fistula
formation,39 and orbital cellulitis and abscess
formation.24 Although continued epiphora in patients after canaliculotomy was considered a possible
sequela,70 Anand et al reported that long-term
follow-up did not reveal a direct relationship
between persistent epiphora and canaliculotomy.4
Canaliculotomy allows for greater access and
easier curettage of canalicular contents. It is widely
regarded at the procedure of choice for both
primary and secondary canaliculitis.4,10,14,16,25,36,
45,58,60,68,70,71,74
A canaliculotomy is performed by
passing a probe into the canaliculus and making
a horizontal incision through the eyelid margin to
open the canaliculus and expose the probe. The
incision should begin about 2 mm medial to the
ampula and is usually about 8 mm in length.66 Once
the canaliculus is opened, the probe is removed,
and the stones are extracted with a small curette.
The canaliculus may then be irrigated with antibiotic solution. At the surgeons discretion a canaliculostomy may be performed in which silicone
tubing stent such as a Mini-Monoka (FCI Ophthalmics, Pembroke, MA) is passed into the canaliculus,
and the wound is closed with small caliper absorbable sutures. The tube is usually removed in a few
weeks.

FREEDMAN ET AL

Some authors recommend irrigation of aqueous

penicillin or povidine iodine and meticulous repair
of the canaliculus.18,28 Others have found that, in
most cases, the canaliculus will return to its preinflammatory state when just left to heal.10,16
Silver nitrate cauterization following removal of
canalicular stones has been reported.16 This theoretically could cause injury to the epithelium, although
no evidence of this was noted. Multiple case reports
also detail patients where no reconstruction of the
canaliculus is undertaken, and full recovery with
patent syringing is seen on follow-up.20,52
Systemic Actinomyces involving other organs is
treated with high dose antimicrobial agents for
extended durations as a result of the tendency of
this pathogen to recur.56 Briscoe et al10 report no
recurrence in any of their patients with a regimen
that included an initial high-dose IV penicillin
therapy of 20 million units daily for at least 3 weeks,
followed by oral administration of 2 g per day for at
least 3 months.
Favorable treatment outcomes following canaliculotomy are reported among all case series on
canaliculitis, with complete resolution in the majority of primary canaliculitis patients.4,10,35,70 Resolution of canaliculitis occurs in between 80%69 and
100% of cases after canaliculotomy.4,10,16 Continued
symptoms of epiphora and recurrent canaliculitis
are reported.35,70 Intubation or stent placement is
employed in circumstances where patency of the
canaliculus is in question.14,19,25,51
In treatment of secondary canaliculitis following
SmartPlug insertion, an initial trial of topical and
broad-spectrum antibiotics followed by retrograde
massage is suggested should plug removal be indicated.39 Irrigation of the nasolacrimal duct is
recommended by the manufacturer, and this has
been demonstrated to resolve a number of SmartPlug
related cases.39 Irrigation is also thought to risk
dislodgement of the plug from its canalicular
position, causing permanent obstruction of the
lacrimal drainage system.41 Canaliculotomy with
removal of foreign body is frequently performed if
conservative therapy with medical management and/
or lacrimal irrigation fails to improve epiphora or
canaliculitis.25,39 If canaliculotomy fails to improve
the condition, dacryocystorhinostomy with intubation20 or placement of a Jones tube may be necessary.

VI. Prognosis
The long-term resolution of primary canaliculitis
treatment may be affected by the duration of
the disease prior to diagnosis, the management
employed, patient co-morbidities, and lesser

345

PRIMARY AND SECONDARY LACRIMAL CANALICULITIS

understood factors such as patient age, sex, the

presence of concretions, and microbiology.4,35,74
Acutely, treatment often progresses from conservative to surgical management until satisfactory
resolution is achieved.
In primary canaliculitis the presence of continued
symptoms varies with treatment modality. Successful
initial resolution with conservative treatments have
been reported in 0%,4 20%,70 ,26%,35 and
34.7%74with recurrence rates as high as 33%.35
Several authors have noted patients with acute
canaliculitis achieve higher success rates with
conservative treatment, whereas those with longer
disease courses typical fair better with surgical or
combination treatment.15,16,74 In the single case
series describing combination therapy with intracanalicular antibiotic irrigation and topical antibiotics, resolution was reported in all patients after
a mean of 4.5 treatments.44
Continued symptoms after canaliculotomysuch
as epiphora4,70 and mattering74occur in as many
as 27% of patients. Recurrence of canaliculitis after
canaliculotomy may develop in up to 21% of
patients undergoing canaliculotomy, with a mean
time of recurrence of 24 months.35 Some patients
have had recurrent canaliculitis in a previously
unaffected canaliculus.74 Pre-existing nasolacrimal
duct pathology or a history of inappropriate lacrimal
sac washout procedures may predispose to the
development of new, or the exacerbation of old,
nasolacrimal duct obstruction after canaliculotomy.4
Curettage success rates have been reported in as
many as 83.3% of patients at a mean follow-up of
10.76 weeks.32
With SmartPlug-related canaliculitis, topical and
systemic antibiotics are infrequently associated with
resolution. Lacrimal irrigation may resolve symptoms but is associated with the risk of lacrimal
system obstruction. Canaliculotomy is the definitive
therapy. Complete resolution of symptoms may not
always be achieved, however, and persistent epiphora following surgery has been reported.41

VII. Summary
In patients who present with epiphora, chronic or
recurrent unilateral conjunctivitis, a thickened canaliculus, pouting punctum, or expressible yellow
discharge, a diagnosis of canaliculitis should be
considered and evaluation and treatment instituted.
Manual expression of discharge or concretions
should be attempted. Microbiological investigation
of the expressed material should include histopathological examination and culture. Imaging may be
considered in situations where the diagnosis is not

clinically evident or where further information is

required for surgical planning. Ultrasound offers
a noninvasive means of identifying concretions;
intubation macrodacryocystography, however, remains the more well studied method for the
identification of filling defects in the lacrimal
drainage system.
Conservative medical therapy has a higher rate of
success with new onset canaliculitis and should be
considered as a first line treatment. Topical and/or
systemic antibiotic therapy may begin with broad
spectrum and then be tailored to the culture
sensitivity. Repeated intracanalicular antibiotic irrigation is suggested as an alternative to surgery and
demonstrates promising initial results, but has not
been widely reproduced or adopted at present.
Curettage of the punctum via dilation or punctoplasty may be successful in removal of concretions
and resolution of canaliculitis. Canaliculotomy remains the definitive therapy. Continued symptoms
of epiphora and mattering are common. Recurrent
canaliculitis occurs in approximately one-fifth of
patients 2 years after surgery. Patients should be
apprised of this possibility and advised to seek
treatment early if symptoms recur. Canaliculostomy
may be performed at the discretion of the surgeon.

VIII. Conclusion
There is a clear need for greater awareness among
clinicians, especially those in training, to recognize
canaliculitis. A higher index of suspicion would
prevent delays in diagnosis and unnecessary manipulation of the lacrimal system.4

IX. Method of Literature Search

A systematic review was conducted to survey all
published case reports of lacrimal canaliculitis, all
reviews of ophthalmic disease and surgical intervention where canaliculitis was recorded as an outcome
or described as a complication, and all previous
scientific studies on lacrimal canaliculitis. Search
was not limited to Medline or English-language
papers. A full-text search of the term canaliculitis in
the Cochran Collection yielded 2 of 608,405 records.37,38 A Medline search for ophthalmic streptothricosis yielded 409,770 results with no filters for
language or journal type. Adding the keyword
punctum reduced this number to 228, which were
each reviewed for relevance to canalicular disease
and additional references contained therein. An
independent Medline search for canaliculitis yielded
105 results, which were surveyed in a similar
manner. Identical search via Embase, OldMedline

346

Surv Ophthalmol 56 (4) July--August 2011

or ISI did not return additional citations. The

reference lists for relevant papers was reviewed,
and papers not electronically databased were individually acquired through library loan or a handreview of the historical journals collection of the
Rush University Medical Library, and the University
of Miami Norton Library, Bascom Palmer Eye
Center. Every effort was made to cite only original
sources, and to avoid secondary citations among
studies making more recent claims; for example, the
Norton library contains a rare print collection that
was useful for some of the less distributed
examples.17,18,22,50,62

X. Disclosure
The authors reported no proprietary or commercial interest in any product mentioned or concept
discussed in this article.

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Reprint address: Adam J. Cohen, MD, FACS, The Art of Eyes,
Concourse Office Plaza Tower IL, 12th Floor, 4709 Golf Road,
Skokie, IL 60076. e-mail: acohen@theartofeyes.com.

Outline
I. Introduction

D. Imaging
E. Canalicular patency
F. Misdiagnosis

A. Anatomy and histology

II. Epidemiology
III. Clinical presentation

V. Treatment of canaliculitis
A. Medical management
B. Surgical management

A. Clinical symptoms and signs

B. Historical use of examination
IV. Diagnosis
A. Microbiological culture
B. Histopathology
C. Genetic testing

VI.
VII.
VIII.
IX.
X.

Prognosis
Summary
Conclusion
Method of literature search
Disclosure