Dr. Nisar Sonam Poonam Dr. M Shahid Alam, Dr.Kirthi Koka
INTRODUCTION:
Canaliculitis is a rare infection of the canaliculus, which accounts for 2% of all lacrimal diseases1. It is often misdiagnosed as chronic conjunctivitis, dacryocystitis, chronic blepharitis,chalazion despite classic clinical findings like inflamed medial canthus, pouting puncta, mucopurulent discharge or concretions on expression from the canaliclus. Therefore, it has a longer and a chronic course2.
Von Graefe, in 1854 was one of the first to identify actinomyces as the causative agent for intracanaliculardacryoliths.Most cases reported in literature are sporadic without any recognizable predisposing factors. However, stasis secondary to lacrimal obstruction or a diverticula can promote anerobic growth which can cause canaliculitis2,4.
Transient symptomatic relief may be achieved with conservative management and topical antibiotics, however it has been associated with high recurrence rates5. Curettage of the canalicular contents through punctoplasty or canaliculotomy has been effective with higher success rates4,5,6,7. However, canalicular stenosis, scarring , lacrimal pump failure and post op epiphora has been reported as a sequalae of surgical intervention4,5,6,7.
Our study aimed at analyzing the long term post operative outcomes of canaliculotomy and factors responsible for recurrence of canaliculitis. We also analyzed the demographic, clinical and microbiological profile of all patients who underwent canaliculotomy for canaliculitis.
METHODS AND MATERIALS:
The clinical records of all patients who underwent canaliculotomy for canaliculitis, at the Orbit and Oculoplasty clinic at our tertiary care centre between January 2000 to January 2016 were reviewed retrospectively. We analyzed the demographic, clinical and microbiological profile, long term outcomes of canaliculotomy and complications of the procedure. Pre operatively, the mucopurulent discharge or the concretions expressed from the canaliculus was sent for microbiology evaluation. Initially, all patients were treated conservatively with either topical antibiotics or intra canalicular syringing with gentamcin followed by topical fortified cefazolin or fortified gentamycin eye drops. Those who showed no improvement with the conservative management were then taken up for canaliculotomy or punctoplasty plus curettage.
Under local anesthesia, Bowmans probe was passed into the canaliculus and using a 11 no. blade canaliclus was incised horizontally uptill the puncta. 3 snip punctoplasty was performed with Vannus scissors. Canalicular curettage was done in all cases with a chalazion curette and repeated till no further debris or granules were seen. At the end of the procedure lacrimal sac syringing with gentamycin was done. Post operatively all patients were started on topical antibiotic eye drops (based on the culture sensitivity report) for 1 week.
Post operative epiphora and lacrimal passage patency was assessed taking into account lacrimal sac syringing, florescein dye disappearance test (FDDT) and MUNK score.
Complete resolution of signs and symptoms was defined as good outcome and no improvement in signs and symptoms post operatively was defined as poor outcome. Recurrence was defined as new episode of signs and symptoms after complete resolution.
The study strictly adhered to the declaration of Helsinki.
RESULTS:
A total of 40 patients [21 (52.5%), males and 19(47.5%) females] were included in the study. Mean age at presentation was 53± 15.4 years (17-89 years). Only 8 (20%) patients were less than 45 years of age, while remaining 32 [80%, (p=0.02)] were over 45 years of age. The most common presenting symptoms was increased watering (34, 85%) followed by redness of the eye (26, 65%), discharge and watering from the eye (14, 35%), foreign body sensation (5, 12.5%) and swelling over the medial canthal area (4, 10%). Mean duration of symptoms prior to definitive diagnosis was 8.12 months (0.5- 60 months). Five (12.5%) patients had history of similar episodes in the past. Chronic dacryocystitis (8, 20%) was the most frequent misdiagnosis, followed by conjunctivitis (5, 12.5%), hardeolum externum (2, 5%). Three (7.5%) patients underwent dacryocystorhinostomy and one had undergone incision and drainage elsewhere for the same. Co existing hypertension was seen in 10 (25%) patients, diabetes mellitus in16 (40%) and one (2.5%) was a known case of pulmonary tuberculosis. Pouting angry puncta (32, 80%) was the most frequently occurring clinical sign followed by medial canthal inflammation or swelling (28, 70%), mucopurulent discharge (21,52.5%), concretion expression on pressing over the canaliculus (20,50%) and conjunctival congestion medially (8,20%).
All (100%) patients in our study had unilateral involvement. Right eye was involved in 19 (47.5%) while left was involved in 21(52.5%) patients. Thirty three (82.5%) patients had involvement of only one canaliculus, lower canaliculus being more commonly affected (22, 55%). Upper canaliculus involvement seen in 11 (27.5%) patients and involvement of both puncta was seen is7 (17.5%) patients.
The discharge or concretions expressed was sent for microbiological evaluation in all cases. Polymicrobial growth was seen in 18 (45%) patients, fungal aspergillus canaliculitis was seen in one (2.5%) patient. Most commonly isolated bacteria on culture was staphylococcus epidermidis (16, 40%) followed by actinomyces (14, 34%) and corneybacterium species (5, 12.5%).
We divided patients into two group, depending upon the presence or absence of the concretions, twenty, in each group. (Table no. 5) Mean age in the concretion group was 53.67 ± 8.87 years, while in the no concretrions group was55.05 ± 16.29 years. No specific gender predilection was seen in either groups. Microbiological profile identified Actinomyces as the microbe, most commonly causing concretions (13, 65%) followed by Staphylococcus species 9 (45%), followed by streptococcus species (2, 5%) and Corneybacterium species (2, 5%). Polymicrobial growth was identified in 6 (30%) cases onl 1y in the concretions group. The most common isolated causative microbe in the non concretions group was Staphylococcus (9,45%) followed by Steptococcus species (3,15%) and Corneybacterium species (3,15%).
Microbiological profile of the concretions group revealed 92.8% patients
Thirty one (77.5%) patients received intracanalicular gentamycin syringing for 3 days followed by topical cephazoline and fortified gentamycin eye drops for 2 weeks before the surgery.
All (40, 100%) patients underwent canaliculotomy with curettage of the canalicular contents. Mini monoka was inserted post canaliculotmy in one (2.5%) patient.
Post canalicultomy,complete resolution of canaliculitis was seen in all (100%) patients. Mean duration of follow up post op was 20.63 months (1 – 180 months). Long term results were analyzed and good outcome was achieved in 34 (85%) patients. Six (15%) patients complained of persistent epiphora, which included 3 patients from the recurrence group and all three developed canalicular block (2 lower canalicular, 1 upper canalicular), one developed punctal ectropion and one had punctual stenosis.
Recurrence was seen in 6 (15%) patients. Mean duration of recurrence was 17 months (2-36 months). Four (66.67%) were males, 2 (33.33%) females and five (83.33%) of the six patients were above 60 years of age. Four (66.67%) of the six patients had associated diabetics and 2 (33.33%) were hypertensives. Five (83.33%) patients who had recurrence showed presence of concretions in the canaliculus. All (6,100%) showed single bacteria growth on culture at the time of recurrence. Five (83.33%) patients improved with intracanalicular antibiotic syringing followed by topical antibiotics, however, one patient despite a repeat canaliculotomy and currettage had persistent canaliculitis.
DISCUSSION:
Canaliculitis is an uncommon disease. Despite the classical features being described in literature, rarity of canaliculitis often accounts for a delay in diagnosis. Mean duration of symptoms prior to an established diagnosis in our study was 8.12 months , ranging from 0.5- 60 months depiciting the difficulty in initial diagnosis by clinician. This finding was similar to the other two South Indian studies by Kim UR9 et al and Kalki S4 et al (8,10 months respectively). This delay can be minimized by understanding the peculiar clinical features, having a higher index of speculation,a good history taking and a detailed clinical evaluation.
Dacryocystography and ultra biomicroscopy2 have been described as diagnostic tools for confirming the diagnosis of canaliculitis, however we diagnosed all patients based on clinical features alone as described by other studies 2,4,5,7,9. A higher prevalence of canaliculitis amongst elderly women has been reported in the s though prevalence amongst males was slightly higher (52.5%) in our study similar to Kim U R 9 et al (51.61%) and Kalki S 4 et al (46%). This could either be due to a referral bias or a geographic variation indicating that prevalence of canaliculitis is higher amongst south Indian males.
Pathophysiology of primary canaliculitis is still unknown.5 It has been hypothesized that presence canalicular diverticuli, decreased tear production can cause stasis promoting bacterial growth causing canaliculitis2,5,9.Gullian11 et al have suggested a higher prevalence of dry eye in general population aged over 45 years and decreased tear production has been hypothesized as one of the factors for canalculitis. Mean age at presentation in our study was 53± 15.4 years (17-89 years).Though we did not specifically test all patients for dry eye, 80% (p=0.02) of our patients were above 45years. There could be an association between dry eye and canaliculitis and, further prospective studies are required to confirm the same.
We also found higher prevalence of lower canaliculus involvement (55%) , similar to other studies 2,4,8. Watering and discharge from the eye were the most commonly reported complaints by other studies 2,4,8,9,10.Eighty five percent of our patients presented with chief complaints of watering followed by redness and discharge. The classical pouting puncta was seen in 80% patients in our study slightly higher as compared to Lin S C8 (59%) et al, Zaldívar RA10(50%)et al and Kalki S4 (34%) et al.
Pavilack7 et al have reported presence of concretions in all (11, 100%) patients. We found concretions in 80% patients higher than that reported by other studies2,8. Initially, concretions were thought to be pathologic of Actinomyces, however, many other organisms have been associated with the presence of concretions as reported by various other studies 2,4,8,9,10.
We compared both the concretion and the non concretion group, however did not notice any significant difference between the demographic profile of the two groups. A strong association of concretions and Actinomyces was noted (p=0.002). We also observed a slightly longer duration of symptoms in the no concretion group as compared to the concretion group, however this was not statisitically significant (p=0.79). This comparison has not been reported by any study till date.
The discharge or concretions from all (100%) patients were sent for microbiology evaluation and all (100%) samples were culture positivity as documented by Varma D 12 et al and Mohan E 13 et al. Polymicrobial growth was seen in 45% samples similar to another study10,13 (58%) .This is contrary to many other studies, which have majorly isolated a single causative microorganism2,5,7,8,9,12. In concordance with other recent studies, Staphlyococcus species (55%) was the most commonly isolated in our study as well 2,4, while many other studies have reported Streptococcus as the most common causative microorganism 6,8,9,10.
No specific protocol for the management of canaliculitis has been described in literature. Conservative management has been reported to have high recurrences5,7.
This is probably due to inability of the antibiotics to penetrate through the concretions and debris2. A thorough canalicular curettage of the infected debris and concretions following a canaliculotomy or punctoplasty has shown promising results with higher rates of resolution. Vécsei VP et al5 have described canaliculotmy as the procedure of choice for canaliculitis.
Canaliculotomy with thorough curettage of the canalicular contents was performed in all cases. Complete resolution of canaliculitis post op was noted in all (100%) patients, identical to that reported by Anand 2 et al and Varma D 12 et al. Long term efficacy of canaliculotomy was assessed and good outcome was observed in 85% patients in our study similar to other studies2,5,10.
Presence of concretion and male gender has been described by Lin S C 8 et al as a prognostic factor for recurrence. We observed a higher prevalence of recurrence amongst elderly men, diabetics and those with presence of concretions. We could not associate the presence of a specific micro organism with recurrence.
Vécsei VP5 et al and Anand2 et al have reported an incidence of post canaliculotomy epipohora to be 20% and 27% respectively. We observed a slightly lesser incidence (15%) of post op epiphora. Three patients with epiphora, had recurrent episode of canaliculitis and developed canalicular block probably secondary to scarring and fibrosis due to repeated manipulation. We can conclude that recurrence of the disease may be associated with higher incidence of epiphora and canalicular stricture. Anand2 et al, had a long follow up of (mean: 26 months), yet found no direct correlation between epiphora and canaliculotomy. They observed pre- exisiting canalicular block and nasolacrimal duct obstruction (NLDO) in 50% cases and the remaining 50% developed NLDO post operatively. They observed, these patients to have history of multiple lacrimal sac syringing and delayed diagnosis and, attribute these factors to be the probable cause for NLDO. Though, majority (77.5%) patients in our study received intracanalicular antibiotic syringing before the surgery, we did not find any NLDO in any of our patients at follow up. Vécsei VP5 et al had a shorter follow up (3 months) and reported persistent epiphora in 26.67% despite patent lacrimal passage. They attributed this to either surgical manipulation or secondary to inflammation. We noticed similar finding in one patient who had a patent lacrimal passage but a MUNK score of 2 and FDDT grade 2.
The limitation of our study is that it is retrospective in nature. Also there was no comparative study amongst different treatment modalities and surgical techniques. Also the data analyzed was at a tertiary care centre, thus a referral bias and recalcitrant cases could have affected the outcome. Besides, surgery was done by different surgeons and that could again alter the final outcome.
CONCLUSION:
A delay in the diagnosis of canaliculitis can be troublesome and traumatizing for the patient. A higher prevalence of canaliculitis amongst elder south Indian men was seen in our study. We did not noticed a strong association between presence of concretions and and actinomyces in our study. Elderly men, diabetics and presence of concretions was associated with higher risk of recurrence in our study. Post canaliculotomy epiphora was seen in only 15% patients and we conclude that canaliculotmy with proper curettage is a safe and efficacious mode of management for canaliculitis.
CANALICULOTOMY TABLES:
Table no. 2
| Demographic profile (n=40) | |
| Age | 53± 15.4 years (17-89 years) |
| Sex
Male Females |
21, 52.5% 19, 47.5% |
| Laterality
Right eye involvement Left eye involvement |
19, 47.5% 21, 52.5% |
| Canaliculus involved
Upper Lower Both |
11 , 27.5% 22, 55% 7 , 17.5% |
Table no. 2
| Microbiological profile (n=40) | P – Value | |
| Staphylococcus epidermidis | 16 (40%) | 0.0016 |
| Staphylococcus aureus | 4 (10%) | 0.1138 |
| Methicillin resistant staphylococcus aureus | 1 (2.5%) | 0.201 |
| Streptococcus viridians | 5 (12.5%) | 0.2358 |
| Actinomyces | 14 ( 35%) | 0.0177 |
| Corneybacterium species | 5 (12.5%) | 0.2358 |
| Enterococcus fecalis | 4 (10%) | 0.1138 |
| Enterobacter aerogenes | 1 (2.5%) | 0.201 |
| Haemophilus para infuenzae | 3 (7.5%) | 0.1840 |
| Chlamydia tachomatis | 1 (2.5%) | 0.201 |
| Pseudomonas aeriginosa | 1 (2.5%) | 0.201 |
| Prevotella Nigrescen | 1 (2.5%) | 0.201 |
| Proteus Mirabilis | 1 (2.5%) | 0.201 |
| Acinobacter calcoaceticus | 1 (2.5%) | 0.201 |
| E. coli | 1 (2.5%) | 0.201 |
| Aspergilllus | 1 (2.5%) | 0.201 |
Table no 3
| Recurrence (n=6) | ||||||||
| Sr. no | Age (years) | Sex | Duration of symptoms (months) | Associated systemic conditions | Concretions | Microbiology | Duration of recurrence
(months) |
Microbiology at the time of recurrence |
| 1 | 68 | F | 2 | DM, HTN | Present | Streptococcus viridians, Enterococcus fecalis | 5 | Actinomyces |
| 2 | 62 | M | 8 | DM, HTN | Present | Chlamydia trachomatis | 18 | Corneybacterium species |
| 3 | 77 | M | 3 | – | Present | Actinomyces | 36 | Actinomyces |
| 4 | 46 | M | 4 | – | Absent | Prevotella Nigrescen | 15 | Staphylococcus epidermidis |
| 5 | 67 | M | 6 | DM | Present | Staphylococcus epidermidis, Enterococcus fecalis | 26 | Corneybacterium species |
| 6 | 61 | F | 5 | DM | Present | Actinomyces | 2 | Actinomyces |
DM- Diabetes Mellitus, HTN- Hypertension
Table no 4
| Post canaliculitis epiphora (n=6) | FDDT | MUNK | SYRINGING | P – value | |
| Canalicular block | 3 (50%) | 3 | 3 | Not patent | 0.066 |
| Lower lid punctual ectropion | 1 (16.67%) | 2 | 2 | Patent | 0.84 |
| Punctal stenosis | 1 (16.67%) | 2 | 2 | Patent | 0.84 |
| Partial patent lacrimal passage | 1 (16.67%) | 2 | 2 | Partially patent | 0.84 |
Table no 5
| Parameters | Concretions group (n= 20) | No concretions group (n= 20) | P – value |
| Mean age (years) | 53.67 ± 8.87 | 55.05 ± 16.29 | 0.749 |
| Sex | Male: 10 (47.6%)
Female: 11 (52.4%) |
Male: 11 (57.9%)
Female: 8 (42.1%) |
0.516 |
| Mean duration of symptoms | 6.13 ± 5.4 | 10.24 ± 13.99 | 0.243 |
| Canaliclus affected | Lower: 12 (60%)
Upper: 7 (35%) Both: 3(15%) |
Lower: 10(50%)
Upper: 4 (20%) Both: 4 (20%) |
0.505 |
| Microbiological profile | Actinomyces : 13 (65%)
Staphylococcus species : 9 (45%) |
Staphylococcus species: 9 (45%)
Streptococcus species: 3(15%) |
0.002 |
| DM | 10 (50%) | 6 (30%) | |
| Recurrence | Yes: 3 (14.3%)
No: 18 (85.7%) |
Yes: 3 (15.8%)
No: 16 (84.2%) |
0.894 |
Table no 6
| Parameters | Recurrence (n= 6) | No Recurrence (N = 34) | P – value |
| Age < 60 years
≥ 60 years |
2 (33.3%)
4 (66.7%) |
24 (70.6%)
10 (29.4%) |
0.078 |
| Sex | Male: 4 (66.67%)
Female: 2 (33.33%) |
Male: 18 (52.9%)
Female: 16 (47.1%) |
0.894 |
| Mean duration of symptoms (months) | 4.83 ± 2.23 | 8.73 ± 11.37 | 0.413 |
| Canaliclus affected | Lower: 1 (16.7%)
Upper: 4 (66.7%) Both: 1 (16.7%) |
Lower: 10 (30.3%)
Upper: 17 (51.5%) Both: 6 (18.2%) |
0.757 |
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