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Upper and Lower Canaliculitis With Nasolacrimal Duct Obstruction in a Child

Grossman, Jennifer L. B.A.*; Djenderedjian, Levon M.D.*; Xia, Rong M.D. Ph.D.; Shinder, Roman M.D., F.A.C.S.*

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Ophthalmic Plastic and Reconstructive Surgery: March/April 2020 - Volume 36 - Issue 2 - p e57
doi: 10.1097/IOP.0000000000001419
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A 5-year-old male presented with 3 weeks of right eye tearing and medial canthus crusting. He was otherwise healthy with no recent fever, history of similar episodes, history of childhood tearing, sick contacts, upper respiratory infection, or trauma. On exam, there was nontender edema of the right medial upper and lower eyelid in the area of the canaliculi and pouting puncta that displayed mucopurulent discharge on gentle pressure (Fig. A). Upper and lower canaliculitis was suspected and canaliculotomy was recommended, but the parents elected to first try topical antibiotics that failed to show clinical improvement over a two-week period. The child was subsequently brought to the operating room where a punctal-sparing superior and inferior canaliculotomy was carried out and multiple yellow concretions were retrieved (Fig. B). Intraoperative lacrimal irrigation also proved the child to have a complete nasolacrimal duct obstruction for which probing and bicanalicular stenting was performed. Histopathologic assessment of the concretions after Gram staining revealed a branching network of Gram-positive filamentous rods consistent with actinomyces (Fig. C). The clinical and histologic findings confirmed a diagnosis of upper and lower canaliculitis with simultaneous nasolacrimal duct obstruction. The patient’s symptoms resolved within 1 week of surgery and the stent was removed after 8 weeks. The child remains asymptomatic after 3 months of follow-up. Canaliculitis in children is rare and typically involves a single canaliculus. Involvement of both the superior and inferior canaliculus in a child, in this case with simultaneous nasolacrimal duct obstruction, is an exceedingly rare constellation of lacrimal outflow pathologies. The authors theorize that the infectious canaliculitis and resultant inflammation tracked to the lower portion of the outflow system and led to a secondary nasolacrimal duct obstruction in this case which has been previously described.

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Canaliculitis. A, Clinical photograph displaying purulent discharge from the right inferior punctum during gentle pressure. B, Intraoperative photograph showing concretion retrieved from canaliculus. C, Histology revealed a dense population of gram positive rods (Gram Stain, 20X).
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