BLOG: Unilateral conjunctivitis not always related to lacrimal duct obstruction

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It has always been the teaching that recurrent unilateral conjunctivitis must be evaluated for partial or complete nasal lacrimal duct obstruction. This may be congenital or acquired. In the adult population, women are more commonly involved than men, with an average age range of 50 to 70 years. This may be caused by a narrower nasal lacrimal duct system than in men or postmenopausal hormonal changes on the mucosa. The diagnosis is made by observing discharge or epiphora, pressing on the lacrimal sac fossa to see if the lacrimal sac is enlarged or painful. If discharge on pressure emanates from either punctum, the diagnosis is made of nasal lacrimal duct obstruction, with the blockage distal to the lacrimal sac. Otherwise, it is necessary to gently irrigate the lacrimal system, looking for reflux from the lower system to the upper system, with little to no irrigant going down the nasal lacrimal duct. A DCR is highly successful in resolving the problem.

A second cause is canaliculitis. Canaliculitis is more common than is written about. It is diagnosed in 2% of the patients presenting with epiphora or low-grade conjunctivitis. The average age is in the 50s, women more commonly affected than men.

Figure 1. Canaliculitis.

The lower canaliculus is more commonly involved than the upper, but it can occur in both. Discharge may be seen coming from either punctum on pressure. The punctum is pouting with dilatation. There is thickening of the punctum canaliculus with or without tenderness on palpation or erythema (Figure 1).

The etiology is bacterial (Actinomyces israelii), fungal (Aspergillus, Candida), viral (herpes simplex, zoster, etc.), drug-induced (antivirals, 5-fluorouracil, etc.), intracanalicular plugs or idiopathic.

The most common infectious agent Actinomyces israelii. This is a gram-positive anaerobic rod branched or filamentous. It is characterized by yellow clusters called sulfur granules that represents clumped masses of filamentous organisms. Concretions may coalesce and dilate the lumen and form diverticula, which may fistulize. On physical examination, probing gives a grating sensation.

In general, purulent material should have a gram stain, Giemsa stain, anaerobic cultures and fungal cultures. Practically speaking, however, surgical treatment and debridement are most effective without doing the stains and cultures unless there is a recurrence. Systemic and topical antibiotics, however, are ineffective alone. Under local anesthetic infiltration, a one-snip punctoplasty vertically is performed, followed by a horizontal canaliculostomy with multiple curettings of debris with a chalazion curette. The curetting needs to be complete to avoid recurrence. Irrigation to demonstrate patency is unpredictable distally due to edema from the infectious process. In general, I do not culture the first time around and have been fortunate to have little or no recurrence. After debridement, the use of penicillin 100,000 U/mL in artificial tears or a 1% tincture of iodine four times a day for 7 to 10 days is effective for Actinomyces. Practically speaking, I found, however, an antibiotic steroid drop plus the surgical debridement seems to work extremely well. In the case of a fungal etiology, topical nystatin 20,000 U/mL or amphotericin B 1 mg/mL to 5 mg/mL is effective. Follow-up exam after resolution of infection may find patency or a blind pouch obstruction distally.

If the infection is gone and there is still epiphora, the choices are excising the scar tissue with end-to-end repair with silicone intubation of the upper and lower system or a DCR with a Jones tube. Practically speaking, however, the latter two rarely need to be performed.

The third entity, which was first described by Geoffrey Rose, MD, in 2004, is giant fornix syndrome. This occurs in the older population, between 77 and 93 years of age. Both men and women are equally affected, and the syndrome is unilateral. It presents as a chronic, relapsing, copious, purulent conjunctivitis within the upper and/or lower fornices, with a coagulum seen in either location. This is composed of a large amount of bacteria on a protein coagulum, which is lodged in the deep forniceal spaces. Cultures may be positive for Staphylococcus aureus. Untreated, the patient may develop punctate keratopathy, corneal vascularization, corneal thinning and perforation.

Diagnosis is made by observing copious discharge, deep fornices, deep superior sulcus with or without ptosis, and keratopathy.

Treatment consists of topical and systemic antibiotics with povidone-iodine 5% irrigations. This may result in short-term success, but relapses are common. This may necessitate a conjunctival Müller’s muscle resection if there is a ptosis present or a conjunctival shortening procedure of one or both fornices, with an attempt of normalization of the forniceal anatomy to limit bacterial overgrowth. Short-term results appear encouraging.

In summary, these three entities must be considered in unilateral conjunctivitis.