What is the treatment for inflammation of the lacrimal punctum?

Treatment of Lacrimal Punctum Inflammation

For inflammation of the lacrimal punctum (canaliculitis), the primary treatment is surgical canaliculotomy with curettage to remove concretions, followed by topical broad-spectrum antibiotics for 1-2 weeks. 1

Clinical Recognition and Diagnosis

Lacrimal canaliculitis presents with characteristic features that are frequently misdiagnosed:

• Classic presentation includes: mild to severe swelling of the canaliculus, mucopurulent discharge from the punctum, red pouting punctum, epiphora, and medial canthal swelling 2, 3
• Common misdiagnoses include conjunctivitis, blepharitis, dacryocystitis, hordeolum, and chalazion 1, 3
• Most common causative organisms are Actinomyces (producing sulfur granules/concretions), Staphylococcus, and Streptococcus 1, 3

Treatment Algorithm

Primary Surgical Management (Preferred for Most Cases)

Surgical intervention is employed in approximately 74% of cases and represents the definitive treatment: 3

1. Incise the lacrimal punctum to gain access 1
2. Perform canaliculotomy to expose the affected canaliculus 1, 2
3. Curettage of the canaliculus to remove actinomyces granules, concretions, or dacryoliths 4, 1
4. Consider silicone intubation of the lacrimal system for prophylaxis of post-surgical stenosis 1
5. Postoperative topical broad-spectrum antibiotic for 1-2 weeks 1

Medical Management (Limited Role)

Medical management alone is used in only approximately 21% of cases and has higher failure rates: 3

• Topical or systemic antibiotics may be attempted in early or mild cases 2
• However, medical therapy alone is notorious for recurrences and treatment failures 3

Important Caveats and Complications

Punctal Plug-Related Canaliculitis

A critical pitfall is secondary canaliculitis caused by punctal plugs, which must be recognized and managed differently: 5

• Thermal labile polymer plugs placed intracanalicularly have been specifically associated with canaliculitis, dacryocystitis, and keratitis 5
• Silicone plugs can also cause irritation and secondary infection if displaced into the lacrimal system 5
• Management requires plug removal before treating the underlying infection 6
• For thermosensitive acrylic plugs causing complications (granuloma formation, canaliculitis, chronic inflammation), a specialized removal technique using a small lid clamp with or without microforceps expansion of the punctum is effective 6

Chronic Infection Considerations

The vicious cycle of lacrimal infection must be addressed: 4

• Infection leads to inflammation → post-inflammatory sequelae → occlusion and stagnation → further infection 4
• Histological sampling is imperative during surgery on chronically infected mucosa, as changes can range from inflammatory infiltrates to metaplasia, dysplasia, and even squamous cell carcinoma 4
• Dacryoliths (larger concretions in the lacrimal sac) may require dacryocystorhinostomy rather than simple canaliculotomy 4

When to Use Antibiotics Sparingly

Antibiotic prophylaxis for lacrimal surgery is recommended only in specific circumstances: 4

• Associated rhinosinusitis
• Active inflammation of the lacrimal sac
• History of infected mucocele or dacryocystitis
• Otherwise, antibiotics should be used sparingly in chronic infection 4

Follow-Up Considerations

• Recurrence is common with this condition 3
• Monitor for signs of persistent inflammation or re-accumulation of concretions
• Address any underlying predisposing factors (punctal plugs, chronic dry eye, immunosuppression)