Canaliculitis is a polyethological disease manifested by inflammation of the lacrimal tubules. Common symptoms for all forms of canaliculitis are hyperemia, swelling and soreness in the affected area. Diagnostics is based on physical examination data, microscopic and cultural examination of secretions, diaphanoscopy and radiographic techniques. Conservative treatment includes tubule washing, instillation with antiseptics, corticosteroids and etiotropic drugs, depending on the form of the disease. If necessary, surgical intervention is indicated – probing or dissection of the tubules.
Canaliculitis is an acute or chronic inflammation of the lacrimal tubules. This pathology often occurs against the background of other diseases of bacterial, viral or fungal nature. The disease is more common among middle-aged and elderly people. At the initial visit to an ophthalmologist, 2.4% of patients are diagnosed with mycotic canaliculitis. The first description of a fungal lesion of the lacrimal tubules was presented in 1854 by Gref. Women are more likely to suffer from this form. Canaliculitis occurs in 70% of patients with trachoma. In 1934, Rupert described the phenomenon of the fusion of two cystic cavities in trachomatous etiology. The defeat of the lacrimal tubules of syphilitic and tuberculous nature is extremely rare today.
Canaliculitis can be of bacterial, fungal or viral etiology. Often, the disease occurs against the background of conjunctivitis or blepharitis, which makes it difficult to diagnose. Infectious agents can enter the lacrimal canal from the surrounding structures of the organ of vision (conjunctiva, eyelids) or retrograde (through the lacrimal sac and nasolacrimal duct). The most common pathogens are pyogenic staphylococci, streptococci, Pseudomonas aeruginosa or E. coli. Viral canaliculitis is observed in individuals with herpetic or adenoviral conjunctivitis. The herpes simplex virus leads to the destruction of the surface layers of the lacrimal tubule, which contributes to the formation of scars and strictures. Prolonged persistence of the virus in the human body can cause complete obliteration.
Mycotic canaliculitis is provoked by Wolf-Israel actinomycetes, less often by sporotrichiella and aspergillus. If the disease is caused by actinomycetes, it is considered as pseudomycosis, since the pathogens belong to prokaryotes. Fungi of the genus Candida lead to candidiasis of the lacrimal tubules, pathogens most often penetrate from the oral cavity. Syphilitic canaliculitis develops when infected with pale treponema, tuberculosis – with Koch’s wand. Mycobacteria enter the lacrimal tubules from the lower nasal concha during sneezing. A common cause of canaliculitis is chlamydia infection (trachoma). The addition of vulgar flora leads to an indistinct clinical picture and often mimics the symptoms of purulent canaliculitis.
The cause of inflammation of the lacrimal tubules may be a mechanical barrier to the outflow of tears when obstructed by eyelashes or foreign bodies. Less often, total blockage is observed during the formation of concretions as a result of calcification of fungal colonies. An unfavorable course of canaliculitis is noted with toxic epidermal necrolysis or malignant exudative erythema.
From a clinical point of view, acute and chronic canaliculitis are distinguished. In acute course, hyperemia and swelling of the skin along the course of the tubule are detected. Patients complain of pain when touching and pronounced discomfort. An early symptom of the disease is increased lacrimation. The progression of the inflammatory process leads to redness and swelling of the mouths of tear points, which is manifested by the elevation of the papilla above the surrounding tissues. When pressed in the projection area of the tubule, mucus is released, which is subsequently replaced by purulent exudate.
Due to the wide choice of drugs for the treatment of acute canaliculitis, the chronic form is quite rare. Tuberculosis, syphilitic, mycotic and trachomatous chronic canaliculitis are isolated. Inflammation of the lacrimal tubules of a tuberculous nature is characterized by pronounced compaction of the edema zone, hyperemia and intense pain syndrome. Purulent contents appear only when the tuberculous tubercle disintegrates. In some cases, destruction leads to the formation of an erosive defect that does not heal for a long time, bleeds, can be covered with granulations or perforate. Canaliculitis of syphilitic nature is diagnosed only with tertiary syphilis. The chronic course leads to the formation of gum with the formation of multiple ulcers.
The primary symptom of mycotic canaliculitis is minor lacrimation, which is caused by irritation of the conjunctiva. Over time, hyperemia of the medial parts of the eyeball develops. Then the hyperemia spreads to the semilunar fold, the area of the lacrimal muscle and tubules. Patients complain of accumulation of dry crusts in the inner corner of the eyes after waking up, itching and burning. These phenomena are caused by the release of viscous exudate. Intense hyperemia, accompanied by edema, appears on average 3-4 weeks after the onset of the first signs of the disease. Due to the swelling of the eyelids, the tear point turns outwards, increases in volume and takes the form of a depression. Eversion of the lacrimal point leads to increased lacrimation. Over time, the viscous exudate is replaced by pus and mushy fungal masses. Mycotic canaliculitis is characterized by a unilateral lesion, which is accompanied by discomfort without a pronounced pain syndrome.
Clinically, chlamydial canaliculitis differs from other forms of the disease by the formation of persistent strictures and obliteration of lacrimal tubules. The adhesive-catarrhal form develops at 1-2 stages of trachoma. Pathology is manifested by hyperemia and thickening of the medial parts of the eyelids. Impurities of mucus or purulent masses are detected in the lacrimal fluid. Pus makes it difficult to drain the contents. Stagnation leads to stretching of the walls of the tubule, followed by the formation of a cystic cavity. Often such cysts are multiple and affect 2-3 strokes at the same time.
Diagnosis of acute canaliculitis is based on the results of palpation, a tubular test and diagnostic washing of the tear tubules. With palpatory examination, the tubule is dense, painful. Pressure is accompanied by the release of mucopurulent exudate. The result of the tubular test is ambiguous. It can be either negative or weakly positive. The liquid during diagnostic washing freely passes into the nasal cavity.
With tuberculous canaliculitis in the anamnesis, tuberculosis is detected in most patients. The diagnosis can be confirmed using microscopic and cultural methods of research. In a smear under microscopy, Koch sticks are detected. The culture method makes it possible to detect colonies of mycobacteria. It is possible to verify syphilitic canaliculitis in patients with tertiary syphilis only with the help of serological diagnostics (ELISA).
In mycotic canaliculitis, palpation is usually painless and is accompanied by the release of fungal colonies with purulent masses. For a more detailed study, it is necessary to conduct a glass wand from the inside of the eyelid from the nose to the tear point. Externally, the colonies of the fungus can have a different color (gray, greenish, brown) and consistency (mushy, hard). In the later stages, washing cannot be performed due to the obturation of the tubules by calcification products.
During diaphanoscopy of the eye, foci of darkening corresponding to fungal masses are observed. Dacryolites, which are products of colony calcination, are most clearly visible. Microscopic examination reveals the filaments of mycelium in the smear. Sowing on nutrient media allows you to confirm the growth of the crop. For differential diagnosis with papillomatosis, radiography using a contrast preparation is recommended. With mycotic canaliculitis, an uneven expansion of the tubule is detected, and with papillomatosis, a filling defect is detected.
In the early stages of chlamydial canaliculitis, when rinsed, the liquid is released in frequent drops or a jet. With a prolonged course, obstruction of the tubules is observed. Using diaphanoscopy or radiography, it is possible to visualize cystic cavities.
A common therapeutic measure for all forms of canaliculitis is the mechanical removal of pathological masses by pressing along the course of the tubule. After removal, the conjunctiva and the tubular cavity are washed with antiseptic agents. To relieve inflammation, instillation of corticosteroids is recommended. Hormonal ointments in small quantities can be injected into the tubule cavity using a special cannula. Antibacterial therapy is indicated for acute canaliculitis. It is carried out by instillation of gentamicin or levomycetin into the conjunctival cavity.
With trachomatous, syphilitic, tuberculous and mycotic canaliculitis, the primary task is to treat the underlying pathology. Conservative therapy of trachomatous canaliculitis involves oral administration of antimicrobials from groups of macrolides and sulfonamides together with instillations. In case of stenosis or obturation, the tubule should be probed. Mycotic canaliculitis requires dissection of the tubule with the removal of fungal masses, the next step is the instillation of antiseptics and antifungal drugs. Treatment of tuberculous canaliculitis includes topical use of isoniazid and rifampicin. In case of tertiary syphilis, penicillin antibiotics are included in the complex of therapeutic measures.
Prognosis and prevention
Specific measures for the prevention of canaliculitis in ophthalmology have not been developed. For early screening, it is necessary to inspect and palpate the projection area of the lacrimal tubules in viral or bacterial diseases of the conjunctiva and eyelids. Patients are advised to observe eye hygiene, carry out timely treatment of candidiasis, syphilis, trachoma and tuberculosis, which can cause the development of chronic canaliculitis.
The prognosis for life and working capacity in acute canaliculitis is favorable. Chronic forms of the disease are difficult to treat, accompanied by dysfunction of the tubules, lead to the formation of scars and strictures and are considered less favorable from the point of view of prognosis.