May 2015 Online Photo Diagnosis
By William Townsend, OD, FAAO
Dacryoliths Associated with Canaliculitis
This 86-year-old male presented for continuing care of primary open angle glaucoma and recurrent uveitis. His current ocular medications included timolol maleate ophthalmic solution q12h. OD and OS and loteprednol q.h.s. OD and OS. Biomicroscopy revealed moderate nuclear sclerosis OD and OS. In the left eye, we also noted epiphoria, injection, and a mucopurulent discharge apparently emanating from the lower punctum. Our initial diagnosis was epiphoria secondary to canaliculitis.
After topically instilling proparacaine into the lower cul-de-sac and syringing the lower canaliculus with proparacaine, we dilated and irrigated the canaliculus. This procedure flushed copious amounts of mucopurulent material and many dacryoliths from the punctum. We used alternating expression and irrigation to deliver numerous dacryoliths onto the lid surface, and we eventually produced patency between the canaliculus and lacricmal duct. We prescribed topical moxifloxacin to reduce bacterial load and increased the dosing of loteprednol in the left eye q12h to reduce inflammation.
Canaliculitis refers to inflammation of the canaliculi from infectious or mechanical trauma.1 Typical presentation may include conjunctival injection, epiphoria, purulent discharge, a swollen punctum, and dacryoliths or canaliculiths.1 Infectious agents associated with canaliculitis include Actinomyces israelii as well as staphylococcus and streptococcus species. Dacryoliths are concretions of debris and protein that calcify in the lacrimal drainage passages.2 Although they have the potential to block lacrimal outflow, they do not necessarily do so; patency may exist, even in the presence of dacryoliths or canaliculiths.2
Recent analysis of a dacryolith using polarized X-ray fluorescence spectrometry revealed that the bulk of the constituents were non-organic and included calcium, potassium, iron, titanium, and manganese as well as the oxidized forms of these elements.3
1. Zaveri J, Cohen AJ. Lacrimal canaliculitis. Saudi J Ophthalmol. 2014 Jan;28:3-5.
2. Dhillon N, Kreis AJ, Madge SN. Dacryolith-Induced Acute Dacryocystitis: A Reversible Cause of Nasolacrimal Duct Obstruction. Orbit. 2014 Jun;33:199-201.
3. Ozer S, Ozer PA, Ortarik Z, Tuncer SC, Gullu B. Kadioglu YK. Analysis of inorganic elements in a dacryolith using polarized X-ray fluorescence spectrometry: a case report. Eye (Lond). 2012 Jun;26:887.