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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 2  |  Page : 89-92

Punctotomy augmented by the use of perforated punctal plugs for the management of canaliculitis


Department of Ophthalmology, Ophthalmic Center, Mansoura University, Mansoura, Egypt

Date of Submission04-Apr-2015
Date of Acceptance13-Jun-2015
Date of Web Publication28-Oct-2015

Correspondence Address:
Ayman Abd El Ghafar
Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University, Elgomhoria Street, Mansoura 35516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9173.168537

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  Abstract 

Purpose
The aim of this study was to evaluate the use of perforated punctal plugs with punctotomy for the management of canaliculitis with preservation of punctal and canalicular patency.
Patients and methods
This was a prospective interventional case series including 12 consecutive patients with unilateral canaliculitis. Punctotomy was performed for all cases with curettage of canalicular contents followed by application of a perforated punctal plug. Plugs were removed after 3 months and all patients were followed up for 6 months.
Results
This study included 12 cases of canaliculitis, eight female (66.7%) and four male (33.3%), with a mean age of 60.33 ± 4.6 years (ranging from 48 to 73 years). The lower canaliculus was affected in 83.33% of cases, whereas the upper canaliculus was affected in 16.67% of cases. Sulfur granules were present in six cases (50%) and six cases (50%) were negative. Gram staining of the expressed contents revealed the following: 50% Actinomyces israelii, 30% Staphylococcus aureus, and 20% mixed infection. Improvement in inflammation and epiphora occurred in 11 cases (91.67%), whereas persistence of epiphora occurred in one case (8.33%). One case (8.33%) showed inflammatory granuloma at the site of punctotomy and one case (8.33%) showed extrusion of the plug after 1 month of surgery.
Conclusion
This study showed that punctotomy combined with implantation of perforated punctal plug is an effective technique for the management of canaliculitis, with improvement in manifestations and preservation of punctal and canalicular patency.

Keywords: canaliculitis, perforated punctal plugs, punctotomy


How to cite this article:
Abd El Ghafar A, Al-Sharkawy H. Punctotomy augmented by the use of perforated punctal plugs for the management of canaliculitis. Delta J Ophthalmol 2015;16:89-92

How to cite this URL:
Abd El Ghafar A, Al-Sharkawy H. Punctotomy augmented by the use of perforated punctal plugs for the management of canaliculitis. Delta J Ophthalmol [serial online] 2015 [cited 2017 Dec 12];16:89-92. Available from: http://www.djo.eg.net/text.asp?2015/16/2/89/168537


  Introduction Top


Canaliculitis is a chronic inflammation of the lacrimal canaliculi caused by infection [1] . It is often misdiagnosed, thus leading to a delay in diagnosis. Canaliculitis is generally a unilateral condition. Symptoms associated with canaliculitis include chronic conjunctivitis, watering, a swollen pouting punctum, or purulent discharge. Additional findings include an inflammatory mass projecting from the punctum, or intermittent blood-stained tears [2],[3],[4],[5],[6],[7],[8] . Other findings include sulfur granules or canaliculiths extruded from the punctum through massage, or discovered during canaliculotomy [6],[8] . Canaliculitis should be considered as a possible etiology in cases of persistent conjunctivitis [9],[10] .

Actinomyces israelii is classically cited as the most common causative organism of canaliculitis. Branching filaments during Gram staining are characteristic of Actinomyces spp. Characteristics of Actinomyces spp. on histopathology include filamentous gram positive bacteria with sulfur granules [4],[11] . Other recent studies, however, have demonstrated higher rates of streptococcal and staphylococcal species as causative organisms [12],[13] .

Medical management - namely, antibiotics - may temporarily improve symptoms; however, recurrence or persistence of disease is common [4],[14] . Obstruction may block antibiotics from eradicating bacteria from its source, especially when concretions and stones are present [11] .

Antibiotics shown to achieve symptomatic improvement include systemic penicillin and topical neomycin, polymyxin, or bacitracin [6] .

Surgical management is generally considered the definitive treatment for canaliculitis. Curettage of stones after dilation of the punctum is a method that is generally effective in canaliculitis. Punctoplasty can be performed to allow passage of the curette. Canaliculotomy, although more invasive, allows more direct access to the canaliculus [15] .

The majority of patients with canaliculitis treated with canaliculotomy report complete resolution; however, it may be complicated by scarring and dysfunction of the lacrimal pump [16] . In addition strictures, obstruction, continued epiphora, and mattering after canaliculotomy have been reported [17] .

Recent studies reviewed techniques such as canaliculotomy with intubation to avoid postcanaliculotomy sequelae. This technique successfully cures the disease process, avoids risk of scarring of the lacrimal system, and prevents stasis in the canalicular system that can lead to recurrence [17] .

In this study, punctotomy and canalicular curettage were performed followed by insertion of a perforated punctal plug to treat canaliculitis and prevent postoperative punctal stenosis.


  Patients and methods Top


This was a prospective interventional case series including 12 consecutive patients attending Mansoura Ophthalmic Center, Mansoura, Egypt, from August 2013 to June 2014 presenting with canaliculitis. All patients presented with chronic mucopurulent conjunctivitis and epiphora.

Full ophthalmological examination was performed in all cases, particularly for other causes of mucopurulent discharge and epiphora (conjunctivitis, chronic dacryocystitis, post-trachomatous concretions (PTCs), rubbing lashes). A regurge test was performed to exclude dacryocystitis.

Slit-lamp examination revealed swollen canaliculus, erythema, mucopurulent discharge, pouting punctum (swollen and everted), and pressure upon the swelling expressing pus and sometimes sulfur granules [Figure 1] and [Figure 2].
Figure 1: Left upper lid canaliculitis

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Figure 2: Lower lid canaliculitis with expression of the contents using a chalazion forceps

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Surgical techniques

After taking written consent from all patients, patients were operated under infilteration anesthesia using xylocaine 2% around the affected canaliculus. A Nettleship punctal dilator was used to dilate the affected punctum and then a Bowman probe was applied to the affected canaliculus and the punctum was incised over the probe on the conjunctival side using No. 15 surgical blade. Thereafter, a chalazion curette was applied and all contents of the canaliculus were gently removed to avoid injury of the mucosa and avoid subsequent scarring [Figure 3].
Figure 3: Expression of sulfur granules from lower canaliculus after punctotomy

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The canal was washed with povidone iodine 5% and then a perforated punctal plug (FCI Ophthalmics, Issy-les-moulineaux Cedex, France, [Figure 4] was applied. It was supplied loaded on its applicator and it is designed to be used for cases of punctual stenosis.

As the punctum was already incised, dilatation before application of the plug was not needed. The tip of the applicator over which the plug is loaded was inserted in the affected punctum, the plug was injected, and the applicator was removed [Figure 4].
Figure 4: Perforated punctal plug (FCI Ophthalmics)

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Expressed contents were sent for microbiological study. Topical antibiotic eye drops (neomycin+polymexin+dexamethasone) were applied for 1 week.

Patients were followed up at 1 week, 1 month, 3 months, and 6 months, and punctal plugs were removed after 3 months of surgery.


  Results Top


This study was conducted in Mansoura Ophthalmic Center, Mansoura, Egypt, from August 2013 to June 2014 on 12 cases presenting with canaliculitis.

The study included eight female (66.7%) and four male patients (33.3%) with a mean age of 60.33±4.6 years (ranging from 48 to 73 years).

The lower canaliculus was affected in 10 cases (83.33%), whereas the upper canaliculus was affected in two cases (16.67%).

Sulfur granules, which are characteristic for A. israelii, were present in six cases (50%), and six cases (50%) were negative. Gram staining of the expressed contents revealed the following: 50% A. israelii, 30% Staphylococcus aureus, and 20% mixed infection.

Improvement in inflammation and epiphora occurred in 11 cases (91.67%), whereas persistence of epiphora occurred in one case (8.33%). In this case the perforated punctal plug was extruded after 1 month of surgery.

As regards complications, one case (8.33%) showed inflammatory granuloma at the site of punctotomy. This granuloma was excised and cautery was applied at its bed to avoid recurrence.

Another case (8.33%) showed extrusion of the plug after 1 month of surgery followed by punctal stenosis. For this case, dilatation of the affected punctum and reapplication of a perforated plug was performed after 6 months of the first surgery due to persistence of epiphora, and it was removed after 3 months of the second application.


  Discussion Top


Canaliculitis is generally a unilateral chronic inflammatory condition. Most cases are unilateral, although bilateral phenomena have been documented [3] . It is a relatively rare disorder that typically affects older adults. In one recent series, patients ranged from 43 to 90 years of age. A study suggests that canaliculitis is more common in postmenopausal women [6],[15] . This is in agreement with our results in which the disease was more common in women (66.7%), predominant in older age (mean age was 60.33 years), and all cases showed unilateral involvement.

Most of the studies revealed that A. israelii is the most common pathogen in canaliculitis [4],[11],[12] .

In this study, expression of sulfur granules, which are pathognomonic for A. israelii, occurred in 50% of cases, and gram staining of expressed contents revealed the same results.

Various types of medical management have been used to treat canaliculitis. Warm compresses, local massage, and topical and systemic antibiotics are common therapies. Irrigation or syringing is also used. Generally speaking, medical management - namely, antibiotics - may temporarily improve symptoms; however, recurrence or persistence of the disease is common [17],[18],[19] .

Surgical management is generally considered a definitive treatment for canaliculitis. Curettage of stones after dilation of the punctum is a method that is generally effective in canaliculitis [15],[20] . Punctoplasty can be performed to allow the passage of the curette. However, one study concluded that dilation alone was sufficient to allow passage of the curette. Topical antibiotic therapy with punctoplasty and canalicular curettage is considered the gold standard of treatment because punctal dilation with expression and drainage of canaliculiths alone often leads to persistence or recurrence of the disease [20] .

Complications of the surgery include scarring and dysfunction of the lacrimal pump, the need for intubation or stent placement, recurrent infection, or need for reoperation. In addition, strictures, obstruction, and continued watering after canaliculotomy have been reported [7] .

Recent studies reviewed techniques that augment the results of punctoplasty and canaliculotomy, such as canaliculoplasty with silicon intubation to avoid postcanaliculotomy sequelae. This technique successfully cures the disease process and avoids the risk of scarring [16] .

In this study we used punctotomy instead of canaliculotomy to be more conservative and still have a space to apply the curette and remove the canalicular contents. This will avoid postoperative canalicular scarring and avoid the need for another surgery to restore patency. However, punctotomy may be followed by punctal occlusion and so we used perforated punctal plugs as a temporary stent that were removed after 3 months. This achieved an improvement in 91.67% of cases.

To our knowledge, this is the first technique to use perforated punctal plugs instead of silicon tube to avoid postpunctoplasty complications to treat canaliculitis.We believe that this is an effective yet more conservative technique in the management of canaliculitis, thus avoiding postoperative epiphora.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Baldursdottir E, Sigurdsson H, Jonasson L, Gottfredsson M Actinomycotic canaliculitis: resolution following surgery and short topical antibiotic treatment. Acta Ophthalmol 2010; 88:367-370.  Back to cited text no. 1
    
2.
Smartplug Study Group. Management of complications after insertion of the SmartPlug punctal plug: a study of 28 patients. Ophthalmology 2006; 113:1859.e1-1859.e6.  Back to cited text no. 2
    
3.
Scheepers M, Pearson A, Michaelides M. Bilateral canaliculitis following SmartPLUG insertion for dry eye syndrome post LASIK surgery. Graefes Arch Clin Exp Ophthalmol 2007; 245:895-897.  Back to cited text no. 3
    
4.
Fulmer NL, Neal JG, Bussard GM, Edlich RF Lacrimal canaliculitis. Am J Emerg Med 1999; 17:385-386.  Back to cited text no. 4
    
5.
Kaliki S, Ali MJ, Honavar SG, Chandrasekhar G, Naik MN Primary canaliculitis: clinical features, microbiological profile, and management outcome. Ophthal Plast Reconstr Surg 2012; 28:355-360.  Back to cited text no. 5
    
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Demant E, Hurwitz JJ. Canaliculitis: review of 12 cases. Can J Ophthalmol 1980; 15:73-75.  Back to cited text no. 6
    
7.
Zaldivar RA, Bradley EA. Primary canaliculitis. Ophthal Plast Reconstr Surg 2009; 25:481-484.  Back to cited text no. 7
    
8.
Park A, Morgenstern KE, Kahwash SB, Foster JA Pediatric canaliculitis and stone formation. Ophthal Plast Reconstr Surg 2004; 20(3): 243-246.  Back to cited text no. 8
    
9.
Almaliotis D, Nakos E, Siempis T,et al. A para-canalicular abscess resembling an inflammed chalazion. Case Rep Ophthalmol Med 2013; 20:10-13.  Back to cited text no. 9
    
10.
Takemura M, Yokoi N, Nakamura Y, et al. Canaliculitis caused by Actinomyces in a case of dry eye punctual plug occlusion. Nihon Ganka Gakkai Zasshi 2002; 106:416-419.  Back to cited text no. 10
    
11.
Hussain I, Bonshek RE, Loudon K, Armstrong M, Tullo AB Canalicular infection caused by Actinomyces. Eye (Lond) 1993; 7 :( Pt 4):542-544.  Back to cited text no. 11
    
12.
Sullivan TJ, Hakin KN, Sathananthan N. Chronic canaliculitis. Aust NZ J Ophthalmol 1993; 21:273-274.  Back to cited text no. 12
    
13.
Lin SC, Kao SC, Tsai CC, Cheng CY, Kau HC, Hsu WM, Lee SM Clinical characteristics and factors associated the outcome of lacrimal canaliculitis. Acta Ophthalmol 2011; 89:759-763.  Back to cited text no. 13
    
14.
Sathananthan N, Sullivan TJ, Rose GE, Moseley IF. Intubation dacryocystography in patients with a clinical diagnosis of chronic canaliculitis (streptothrix). Br J Radiol 1993; 66:389-393.  Back to cited text no. 14
    
15.
Briscoe D, Edelstein E, Zacharopoulos I, Keness Y, Kilman A, Zur F, Assia EI. Actinomyces canaliculitis: diagnosis of a masquerading disease. Graefes Arch Clin Exp Ophthalmol 2004; 242:682-686.  Back to cited text no. 15
    
16.
Yuksel D, Hazirolan D, Sungur G, Duman S Actinomyces canaliculitis and its surgical treatment. Int Ophthalmol 2012; 32:183-186.  Back to cited text no. 16
    
17.
Vecsei VP, Huber-Spitzy V, Arocker-Mettinger E, Steinkogler FJ Canaliculitis: difficulties in diagnosis, differential diagnosis and comparison between conservative and surgical treatment. Ophthalmologica 1994; 208:314-317.  Back to cited text no. 17
    
18.
Fowler AM, Dutton JJ, Fowler WC, Gilligan P Mycobacterium chelonae canaliculitis associated with SmartPlug use. Ophthal Plast Reconstr Surg 2008; 24:241-243.  Back to cited text no. 18
    
19.
Mohan ER, Kabra S, Udhay P, Madhavan HN Intracanalicular antibiotics may obviate the need for surgical management of chronic suppurative canaliculitis. Indian J Ophthalmol 2008; 56:338-340.  Back to cited text no. 19
    
20.
Pavilack MA, Frueh BR. Through curettage in the treatment of chronic canaliculitis. Arch Ophthalmol 1992;110:200-202.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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