Laboratory Studies
The following laboratory studies may be usefl:
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Canalicular discharge and canaliculiths
Gram stain/Giemsa stain
Cultures and sensitivities (ie, blood agar, Sabouraud, anaerobic)
Special stains (ie, calcofluor white)
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Smears and corneal scrapings
Ziehl-Neelsen stain
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Anterior chamber (aqueous fluid) aspirate
Gram stain/Giemsa stain
Cultures and sensitivities (ie, blood agar, Sabouraud, anaerobic)
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Vitreous samples
Gram stain/Giemsa stain
Cultures and sensitivities (ie, blood agar, Sabouraud, anaerobic)
Polymerase chain reaction
rRNA sequence analysis
Imaging Studies
The following imaging studies may be useful:
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Distension dacryocystography: Contrast material is used to visualize the anatomic details of the lacrimal drainage system.
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Scanning electron microscopy
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High-resolution ultrasound (transducer frequency of 20 MHz): The 20-MHz scanner images may reveal pathological findings that are invisible during a slit lamp examination. Ultrasonic images of chronic canaliculitis show ectasia of the canaliculus and sulfur grains measuring 1-2 mm in diameter. [35, 36, 37, 38]
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Brain and orbital CT scan may be of use in cases of painful ophthalmoplegia.
Other Tests
Probing may be performed with a lacrimal probe to check for a diverticulum and remaining casts.
Procedures
Canaliculitis
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A 2-snip punctoplasty may be performed under anesthesia.
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Curettage may also be helpful in removing any adherent casts from the canaliculus.
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Subsequent lacrimal irrigation with 2 MU of penicillin in 20 mL of sterile water may be helpful.
Endophthalmitis
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A diagnostic and therapeutic, 3-port, pars plana vitrectomy may be performed in cases where a diagnosis has not been achieved.
Histologic Findings
Histologic examination of the canaliculiths demonstrated that they consisted of solid casts of Actinomycetes with typical branching and filamentous structures. The organisms were found by using a Gram stain on the histopathologic preparations and by using a scanning electron microscopy.
Electron microscopic results of an actinomycosis of the lacrimal canaliculus were presented in 1980. The interior of the actinomycotic conglomerate showed no evidence of a cellular defense reaction, but, in the loosely woven outer network of hyphae, a massive granulocytic reaction was observed to be present. After phagocytosis, the structure of the actinomycotic microorganisms within the granulocytes was not significantly damaged. Within the tissue of the lacrimal canaliculus, adjacent to the actinomycotic conglomerate, an increased number of plasma cells were observed to be present; however, no organisms were present.
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Canaliculitis of the left lower lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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Canaliculitis of the right upper lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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A pediatric patient with canaliculitis. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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A patient presenting with pseudocanaliculitis secondary to a chalazion. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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A patient presenting with pseudocanaliculitis secondary to a chalazion. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
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Actinomyces israelii (non–spore-forming, gram-positive bacilli). Courtesy of Medical Education Information Center, Department of Pathology and Laboratory Medicine, The University of Texas-Houston Medical School.
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Actinomyces israelii. (The image is labeled.)
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Actinomycosis.
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Clinical slit-lamp photographs of Actinomyces infectious crystalline keratopathy (A) upon initial presentation, (B) immediately following first repeat penetrating keratoplasty, and (C and D) low and high magnification of recurrent corneal opacities 6 months later. White arrows highlight temporal opacity within host cornea.
