Canaliculitis

Canaliculitis is an uncommon inflammatory condition affecting the canaliculi, which are tiny ducts located in the eyelids responsible for draining tears from the eye surface into the lacrimal sac and ultimately into the nasal cavity. Although rare, canaliculitis is an important consideration in patients presenting with chronic, unexplained ocular discomfort or discharge.

Anatomy and Function of the Canaliculi

The human eye contains a delicate lacrimal drainage system, facilitating the outflow of tears produced by the lacrimal glands. Tears serve to lubricate, nourish, and protect the ocular surface, and excess fluid is drained through a system comprising the puncta, canaliculi, lacrimal sac, and nasolacrimal duct. Each eyelid has a small opening, called a punctum, near its inner corner. From these puncta, the superior and inferior canaliculi extend medially and join to form a common canaliculus before opening into the lacrimal sac.

What is Canaliculitis?

Canaliculitis refers to infection or inflammation of one or more canaliculi. This condition is frequently misdiagnosed or overlooked, often mistaken for chronic conjunctivitis or dacryocystitis due to overlapping symptoms like persistent eye discharge and redness. However, accurate identification is essential for proper management and relief of symptoms.

Causes and Risk Factors

Canaliculitis is most commonly caused by infectious agents, though non-infectious etiologies are possible. The most frequent culprit is the bacterium Actinomyces israelii, a Gram-positive, filamentous bacterium that thrives in low-oxygen environments. Other bacterial pathogens include Streptococcus and Staphylococcus species. Less commonly, fungal organisms (Aspergillus, Candida) or viruses may be involved. Non-infectious canaliculitis can be linked to foreign bodies or trauma.

Risk factors include:

• Increasing age (most cases occur in middle-aged or older adults)
• Female sex (though all genders can be affected)
• Previous history of eye surgeries or procedures involving the lacrimal system
• Presence of punctal plugs for dry eye management
• Chronic conjunctivitis or blepharitis

Clinical Presentation

Canaliculitis often presents with chronic, unilateral symptoms. Hallmark signs and symptoms include:

• Chronic mucopurulent (pus-like) discharge from the inner corner of the eye
• Redness and mild swelling near the medial canthus (nose-side eyelid)
• Tenderness over the canaliculus
• Pouting or eversion of the punctum
• Expression of concretions (yellowish, gritty granules) or pus on pressure over the canaliculus
• Epiphora (excessive tearing)
• Sometimes, a palpable or visible canalicular mass

Symptoms usually progress slowly and can persist for weeks or months before diagnosis.

Differential Diagnosis

Because of its non-specific symptoms, canaliculitis can be mistaken for:

• Chronic conjunctivitis
• Dacryocystitis (infection of the lacrimal sac)
• Blepharitis (eyelid inflammation)
• Nasolacrimal duct obstruction
• Lacrimal sac tumors

A careful history and detailed examination are crucial for distinguishing canaliculitis from these more common disorders.

Diagnosis

Diagnosis of canaliculitis is based on clinical suspicion and examination findings. Key steps include:

• Observation of localized swelling, tenderness, and redness at the medial canthus
• Gentle pressure over the canaliculus causing discharge of pus or concretions
• Microscopic examination and culture of expressed material to identify causative organisms
• Imaging studies (dacryocystography or ultrasound) are rarely necessary but can be helpful in atypical or recurrent cases

A classic sign is the presence of “sulfur granules”—yellowish, gritty concretions expressed from the canaliculus, often associated with Actinomyces infection.

Management and Treatment

Successful management of canaliculitis typically involves removing the infectious material and treating the underlying infection.

Conservative (Non-surgical) Management

In early or mild cases, non-surgical therapy may be attempted:

• Irrigation of the canaliculus with antibiotic solutions (e.g., penicillin, cephalosporins, or fluoroquinolones)
• Topical or systemic antibiotics based on culture results
• Warm compresses and eyelid hygiene

However, conservative treatment alone is often insufficient, particularly in chronic cases where concretions are present.

Surgical Management

Surgical intervention is frequently required for definitive cure and may include:

• Curettage: Dilation of the punctum and removal (curettage) of concretions and granulation tissue from the canaliculus
• Canaliculotomy: A small incision is made along the canaliculus to access and clear the infected material, followed by irrigation and closure

After surgical cleaning, antibiotics are prescribed to prevent recurrence and eradicate residual organisms.

Management of Underlying Causes and Recurrence

Addressing predisposing factors is key—this may involve removing punctal plugs, treating chronic blepharitis, or managing dry eye conditions. Recurrences are possible if all infectious material is not cleared or if underlying issues like foreign bodies persist.

Prognosis

With timely and appropriate treatment, prognosis for canaliculitis is excellent. Most patients achieve complete relief from symptoms, though scarring or stenosis of the canaliculus can occasionally occur, potentially impacting tear drainage and requiring further intervention.

Complications

If left untreated, canaliculitis can lead to chronic discomfort, persistent discharge, and secondary infections spreading to the lacrimal sac or ocular surface. Rarely, chronic inflammation can cause scarring, canalicular obstruction, or fistula formation.

Prevention and Patient Education

Because canaliculitis is uncommon and may arise spontaneously, there are no guaranteed preventive measures. However, patients can reduce risk by:

• Maintaining good eyelid hygiene, especially with a history of blepharitis or conjunctivitis
• Seeking prompt evaluation for persistent eye discharge or tearing
• Following postoperative instructions after any lacrimal surgery or procedure

Educating patients and healthcare providers about the signs and importance of canaliculitis can help reduce misdiagnosis and ensure timely care.

Nursing Care of Patients with Canaliculitis

Nursing care plays a vital role in the effective treatment, comfort, and recovery of patients with canaliculitis. This document provides an in-depth overview of canaliculitis, its clinical features, and the comprehensive nursing care required to optimize patient outcomes.

Nursing Assessment

A thorough nursing assessment is critical to tailor interventions appropriately.

• Obtain a detailed patient history, including onset, duration, and progression of symptoms.
• Assess for risk factors such as previous ocular surgeries, insertion of punctal plugs, or chronic eye diseases.
• Evaluate the affected eye for the characteristic signs of canaliculitis: swelling, redness, discharge, visible concretions, and punctal changes.
• Monitor for systemic symptoms, though these are rare in canaliculitis.

Nursing Interventions

1. Symptom Relief and Comfort Measures

• Apply warm compresses to the affected eye several times daily to promote drainage and comfort. Instruct patient on the proper technique: use clean, warm (not hot) water and gentle pressure.
• Cleanse the eyelid margins with sterile saline or prescribed solutions to remove crusting and discharge, using a gentle wiping motion from the inner to outer canthus.
• Encourage the use of prescribed lubricating eye drops to alleviate irritation and dryness.
• Monitor the patient’s pain level, and administer prescribed analgesics if necessary.
• Encourage the patient to avoid rubbing the eyes or touching them with unwashed hands.

2. Infection Control

• Emphasize the importance of hand hygiene before and after touching the affected area or administering eye medications.
• Use gloves when cleaning the eye, handling dressings, or collecting specimens.
• Dispose of used swabs, tissues, and other materials in appropriate biohazard containers.
• Educate the patient and family members about infection prevention, including not sharing towels, linens, or eye cosmetics.

3. Medication Administration

• Administer prescribed topical or systemic antibiotics as ordered. Actinomyces infections may respond better to penicillin-based antibiotics; bacterial and fungal canaliculitis may require different agents.
• Instruct the patient on proper instillation techniques for eye drops and ointments: tilt the head backward, pull the lower eyelid gently to form a pocket, instill the drop without touching the eye, and close the eye gently for 1-2 minutes.
• Monitor for signs of medication side effects or allergic reactions, such as increased redness, swelling, or itching.
• Record and report the patient’s response to therapy and any changes in discharge or discomfort.

4. Pre- and Post-Procedure Care

Canaliculitis may require minor surgical procedures, such as canaliculotomy (incision of the canaliculus), curettage of concretions, or irrigation with antibiotic solutions. Nurses should:

• Prepare the patient emotionally and physically for the procedure by explaining the steps, expected sensations, and recovery.
• Ensure informed consent is obtained and correct patient identification prior to the procedure.
• Monitor vital signs before, during, and after the procedure as appropriate.
• Assist the physician during the procedure by providing sterile equipment and supporting patient comfort.
• Post-procedure, observe for complications such as bleeding, increased pain, or signs of spread of infection.
• Reinforce post-procedure instructions, including wound care, use of prescribed medications, and signs to report immediately (e.g., fever, severe pain, sudden vision changes).

5. Patient and Family Education

• Explain the nature of canaliculitis, expected course of treatment, and prognosis.
• Discuss the importance of completing the full course of prescribed medications, even if symptoms improve.
• Review signs of complications or recurrence and when to seek medical attention.
• Provide instructions for at-home care, such as warm compresses and eyelid hygiene.
• Advise on preventive measures, such as avoiding contaminated water, removing eye makeup thoroughly, and not using expired eye products.
• Encourage follow-up appointments to monitor healing and identify any issues early.

6. Emotional Support

• Acknowledge the patient’s discomfort, anxiety, or concerns regarding vision and appearance.
• Offer reassurance about the treatability of canaliculitis and support patients through their recovery.
• Connect the patient with additional resources, such as support groups or counseling, if needed.

Monitoring and Evaluation

Ongoing monitoring is essential to ensure effective management of canaliculitis:

• Assess the eye regularly for reduction of swelling, discharge, and redness.
• Monitor for any progression or complications, such as abscess formation or involvement of adjacent structures.
• Evaluate patient’s adherence to treatment and at-home care.
• Document all interventions, patient responses, and any communication with the healthcare team.

Prevention of Recurrence

Recurrence of canaliculitis is possible if predisposing factors persist or if the infection is not fully eradicated. Nursing strategies for prevention include:

• Ensuring removal of all canalicular concretions during procedures
• Educating patients on the risks of reusing contaminated eye products
• Advising routine eyelid hygiene, especially in patients with a history of ocular infections
• Encouraging prompt reporting of new symptoms

Special Considerations

Certain populations, such as older adults or immunocompromised patients, may be at higher risk for complications or atypical presentations. Nurses must adapt care to address these factors, including closer monitoring and individualized patient education.

Collaboration with Multidisciplinary Team

Effective nursing care for canaliculitis relies on collaboration with ophthalmologists, primary care physicians, pharmacists, and, when necessary, infectious disease specialists. Timely communication and coordination ensure comprehensive and patient-centered care.

REFERENCES

1. American Academy of Ophthalmology. EyeWiki®. Canaliculitis. https://eyewiki.aao.org/Canaliculitis.
2. American Academy of Ophthalmology. EyeWiki®. Canalicular Laceration. https://eyewiki.aao.org/Canalicular_Laceration_(Trauma%29).
3. Wang Q, Sun S, Lu S, Hu R, Sun H, Gu Y, Zhang Z. Clinical diagnosis, treatment and microbiological profiles of primary canaliculitis. Exp Ther Med. 2023 Feb 20;25(4):157. doi: 10.3892/etm.2023.11856. PMID: 36911369; PMCID: PMC9996171.
4. Feroze KB, Patel BC. Canaliculitis. https://www.ncbi.nlm.nih.gov/books/NBK441922/. [Updated 2022 May 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. 
5. Su, Y., Zhang, L., Li, L. et al. Surgical procedure of canaliculoplasty in the treatment of primary canaliculitis associated with canalicular dilatation. BMC Ophthalmol 20, 245 (2020). https://doi.org/10.1186/s12886-020-01503-z
6. Merck Manual Consumer Version. Canaliculitis. https://www.merckmanuals.com/home/eye-disorders/eyelid-and-tearing-disorders/canaliculitis. 
7. Zaveri J, Cohen AJ. Lacrimal canaliculitis. https://pubmed.ncbi.nlm.nih.gov/24526851/. Saudi J Ophthalmol. 2014 Jan;28(1):3-5. Epub 2013 Nov 13.

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

Connect with “Nurses Lab Editorial Team”

I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.