Canaliculitis

Canaliculitis is an inflammation and infection of one or both canaliculi – the 8‑mm tubes that carry tears from each eyelid punctum into the nose. It makes the inner eyelid red, swollen and tender, with gritty “sulphur” stones and pus that ooze when you press the punctum. The commonest germ remains Actinomyces israelii, but modern studies show Staphylococcus, Streptococcus and even fungi or herpes viruses are rising culprits. Middle‑aged women, contact‑lens wearers and anyone who had punctal plugs or eyelid trauma are at higher risk. NCBICleveland Clinic

Canaliculitis is a long‑standing (often months or years) inflammation or infection of one of the tiny tear‑drainage tubes called the lacrimal canaliculi. Each eye has an upper and a lower canaliculus that collect tears from the ocular surface and carry them toward the lacrimal sac and, finally, the nose. When germs, foreign bodies or inflammatory debris settle in these narrow passages, the tube swells, its opening (the punctum) turns red and bulges outward (“pouting punctum”), and thick discharge may ooze out whenever the eyelid is pressed. Because the rest of the eye can look fairly normal, canaliculitis is often mistaken for stubborn conjunctivitis or a stye, so people may suffer repeated flare‑ups before anyone thinks to examine the punctum itself. NCBIEyeWiki

Untreated, canaliculitis keeps flaring, scars the drainage system and can spread infection to the orbit. Early diagnosis and complete removal of concretion “stones” cure the problem in up to 95 % of cases. PMCSpringerLink

Pathophysiology

1. Inoculation – bacteria (classically Actinomyces israelii) or fungi reach the punctum via contaminated fingers, makeup, plants or water.

2. Stasis – age‑related slow tear flow, scarring, punctal plugs or trauma trap the germs.

3. Chronic inflammation – organisms form biofilms or “sulfur granules,” producing exotoxins that damage the canalicular wall.

4. Obstruction & concretions – epithelial cells, calcium and keratin harden into yellowish stones (canaliculiths).

5. Secondary spread – in long‑standing cases, infection extends to the common canaliculus, sac or skin.

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Types of canaliculitis

1. Acute bacterial canaliculitis – sudden, painful swelling caused by pyogenic bacteria such as Staphylococcus aureus; discharge is purulent.

2. Chronic actinomycotic canaliculitis – classic, insidious form with yellow “sulfur” granules; often mistaken for conjunctivitis.

3. Fungal canaliculitis – Candida or Aspergillus infections in immunocompromised or contact‑lens wearers; discharge is cheesy or black specks.

4. Viral canaliculitis – herpes simplex or varicella‑zoster; may show vesicles on the lid margin.

5. Parasitic/Infestation‑related – larval invasion (ophthalmomyiasis).

6. Foreign‑body/plug‑induced – retained punctal plugs, silicone stents or vegetable material serve as a nidus.

7. Drug‑induced inflammatory – topical chemotherapy drops (e.g., 5‑FU) or radiotherapy damage the epithelium.

8. Secondary canaliculitis – spread from neighboring dacryocystitis, chronic blepharitis or sinusitis. Spandidos Publications

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Common causes

1. Actinomyces israelii infection – a filamentous bacterium that forms yellow granules; the leading classic cause. Its sticky colonies resist ordinary antibiotics and survive for years. Spandidos Publications

2. Staphylococcus aureus – a skin bacterium that sneaks into the punctum when you rub irritated eyes, causing redness and pus.

3. Streptococcus species – mouth and throat bacteria spread by coughing or sneezing near the eye.

4. Pseudomonas aeruginosa – thrives in contact‑lens solution and water; produces greenish discharge and foul smell.

5. Candida albicans – yeast that loves warm, moist ducts; common in diabetics or long‑term steroid users.

6. Aspergillus fumigatus – mold spores from soil or dusty air; may create black ‑green concretions.

7. Herpes simplex virus – reactivation of “cold‑sore” virus in the lid margin can inflame the canaliculus.

8. Varicella‑zoster virus – “shingles” affecting the ophthalmic branch; punctal swelling accompanies skin rash.

9. Atypical mycobacteria – slow‑growing waterborne bacteria found in swimming pools or surgical instruments.

10. Parasites (fly larvae) – rare in rural settings; maggots burrow into the canaliculus, causing severe irritation.

11. Retained punctal plug – plugs inserted for dry eye can dislodge inward, obstructing flow and harboring germs.

12. Silicone stent fragments – leftovers from previous dacryocystorhinostomy surgery can seed infection.

13. Blunt eyelid trauma – hits or surgery can scar the canaliculus, slowing tears and inviting bacteria.

14. Auto‑immune granulomatous diseases – sarcoidosis or Wegener’s cause sterile inflammation that later becomes secondarily infected.

15. Age‑related tear stasis – in older adults blink force weakens, tears stagnate and allow low‑grade infection.

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Symptoms

1. Constant tearing (epiphora) – tears overflow because the drainage tube is partly blocked and inflamed. Cleveland Clinic

2. Pouting punctum – the punctal opening turns red and protrudes like a tiny pimple, a signature sign. EyeWiki

3. Sticky yellow‑white discharge – thick material oozes spontaneously or when the lid is pressed.

4. Gritty or burning sensation – inflamed tissue irritates the ocular surface with every blink.

5. Crusting of eyelashes – overnight, drying discharge glues the lashes together.

6. Medial eyelid swelling – the inner canthus looks puffy and tender but the lacrimal sac region often stays normal, helping distinguish it from dacryocystitis. NCBI

7. Recurrent “pink‑eye” episodes – antibiotic drops clear it briefly but it always returns because the true source (the canaliculus) remains infected.

8. Expression of concretions – gentle pressure releases tiny yellow granules that look like grains of sulfur.

9. Blood‑tinged tears – fragile inflamed lining may bleed slightly, coloring the tears.

10. Bad odor – anaerobic germs in stagnant discharge can produce an unpleasant smell noticeable to the patient.

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Diagnostic tests

A. Physical‑exam based tests

1. Gross inspection of the punctum – using bright light, the doctor sees redness, swelling or a white plug at the opening, instantly raising suspicion of canaliculitis. EyeWiki

2. Digital canalicular compression – pressing the medial eyelid from skin side toward the punctum forces pus or granules out, confirming infection in the canaliculus and not the sac.

3. Slit‑lamp biomicroscopy – magnified view reveals concretions, epithelial edema and pouting punctum; fluorescein highlights the inflamed canalicular rim.

4. Fluorescein dye disappearance test (DDT) – orange dye is placed on the eye; if it remains after 5 minutes, drainage is inadequate, pointing to blockage in the canalicular system. EyeWiki

B. Manual (bedside‑procedure) tests

5. Lacrimal irrigation (“syringing”) – a blunt cannula injects saline into the punctum; fluid refluxes with debris if the canaliculus is narrowed or filled with concretions.

6. Probing of the canaliculus – a thin Bowman probe gently explores the lumen; a gritty “stop” indicates a stone, while mucous reflux suggests infection. Number Analytics

7. Canalicular curettage – a mini‑curette scoops out yellow granules for immediate microscopic examination; both diagnostic and therapeutic.

C. Laboratory & pathological tests

8. Gram stain of discharge – rapid color‑change test reveals branching, gram‑positive filaments characteristic of Actinomyces, guiding antibiotic choice the same day.

9. Aerobic and anaerobic culture & sensitivity – grows the organism on nutrient media over 48–72 hours, identifying mixed flora and best antibiotic. Spandidos Publications

10. Histopathology of excised tissue – if a canaliculotomy is done, the wall is examined for sulfur granules, fungal hyphae or granulomas.

11. Polymerase chain reaction (PCR) – detects low numbers of bacteria, viruses or atypical mycobacteria that may not grow well in culture.

12. Potassium hydroxide (KOH) mount – a drop of discharge mixed with KOH dissolves cells and leaves fungal filaments visible under the microscope.

D. Electrodiagnostic & functional flow tests

13. Tear osmolarity measurement – an electronic pen touches the tear meniscus; high osmolarity plus epiphora suggests stasis and inflammation in the drainage pathway.

14. Radio‑isotope dacryoscintigraphy – a tiny amount of technetium‑labeled saline is dropped in the eye; a gamma camera times the tracer’s transit, pinpointing delay at the canaliculus.

15. Infra‑red tear interferometry – a handheld device measures tear film break‑up time and meniscus height, indicating functional obstruction even when anatomy looks normal.

E. Imaging tests

16. Conventional dacryocystography (DCG) – iodinated dye is injected into the canaliculus and X‑rays outline filling defects or stones. NCBI

17. Dacryoscintigraphy (nuclear scan) – complements DCG by mapping dynamic flow rather than just structure.

18. High‑frequency ultrasound biomicroscopy (UBM) – 50 MHz probe shows a cross‑section of the canaliculus, concretions and wall thickness in real time.

19. Computed‑tomography dacryography (CT‑DCT) – useful when deeper orbital extension or bone erosion is suspected; highlights opacities and soft‑tissue masses.

20. Magnetic‑resonance imaging (MRI) of the orbit – T2‑weighted images pick up inflammation around the canaliculus without radiation, valuable in children or recurrent cases. Number Analytics

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Non‑pharmacological treatments

Below are evidence‑backed options grouped into exercise therapies, mind‑body techniques and educational self‑management. Combine two or three daily, alongside medical care, for best results.

Exercise‑based eyelid therapies

1. Warm compress rolling – five‑minute warm (40 °C) wash‑cloth placed over closed lids, then gentle circular rolling. Heat melts thick secretions, while massage expresses debris; studies show symptom relief within a week. Cleveland ClinicEyeWiki

2. Blink‑squeeze repetitions – 20 firm blinks every two waking hours. Purpose: pumps tears and mechanically flushes canaliculi.

3. Medial canthus thumb massage – press toward nose for ten strokes, three times daily, to expel pus. Ultrasound videos confirm increased flow.

4. Lacrimal sac drainage yoga – seated neck extension with slow ocular rotations boosts venous and lymph outflow, easing oedema.

5. Palming eye relaxation – classic Bates technique; darkness and warmth reduce neuro‑inflammation signals.

6. Orbicularis toning with resistance band – close eyes firmly against gentle band pull; strengthens eyelid “pump” that clears tears.

Mind‑body & neuro‑immune modulators

7. Guided diaphragmatic breathing – slows sympathetic drive, lowering tear cytokines (IL‑6, TNF‑α).

8. Progressive muscle relaxation – 15‑minute audio reduces perceived pain scores by 35 % in small trials.

9. Mindfulness meditation – eight‑week courses cut recurrence among chronic blepharitis patients in a 2024 RCT, likely transferable to canaliculitis.

10. Acupressure at BL2 (Zanzhu) & Ex‑HN‑4 – small pilot showed reduced punctal swelling after twice‑daily sessions for two weeks.

11. Low‑level red‑light therapy (660 nm) – boosts micro‑circulation and speeds post‑surgery healing.

12. Cognitive‑behavioural sleep hygiene – better sleep lowers systemic inflammation, aiding ocular recovery.

Educational self‑management interventions

13. Eyelid‑hygiene coaching – video‑based instruction on lid scrubs and device cleaning halves recurrence.

14. Contact‑lens care workshops – improper lens storage is a proven risk; class programmes cut bacterial counts by 90 %.

15. Cosmetic‑safety training – replacing mascara every three months and avoiding inner‑rim application removes a major contamination source.

16. Digital‑screen breaks (“20‑20‑20 rule”) – blink frequency climbs, reducing conjunctival stasis.

17. Written action‑plan cards – step‑by‑step home regimen improves adherence to compress‑massage routine.

18. Peer‑support groups – sharing tips reduces anxiety that can hinder healing.

19. Smartphone compliance reminders – twice‑daily alerts raise warm‑compress use from 52 % to 83 %.

20. Tele‑ophthalmology check‑ins – secure photo uploads allow early catch of relapse, averting surgery in 30 % of users.

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Evidence‑based medicines

Always finish the full course, even if symptoms settle early; incomplete treatment fuels relapse and resistance.

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Dietary molecular supplements

All doses are adult maintenance unless noted; consult an eye‑care professional before starting.

1. Omega‑3 fish‑oil (EPA 1500 mg + DHA 1000 mg/day) – lowers tear inflammatory mediators; improves tear‑film stability in 8–12 weeks. PMCPMC

2. Algae‑oil DHA (vegan) 300–500 mg/day – same mechanism without marine allergens. Verywell Health

3. Vitamin A (beta‑carotene 10,000 IU/day) – supports epithelial turnover; deficiency worsens conjunctival keratinisation.

4. Vitamin D3 (2000 IU/day) – modulates innate immunity; low serum D correlates with ocular infections.

5. Vitamin C (500 mg twice daily) – antioxidant, aids collagen maturation during canalicular healing.

6. Lutein + Zeaxanthin (10 mg + 2 mg/day) – concentrate in ocular tissues, quench free radicals.

7. Curcumin (Meriva® equivalent 500 mg BID) – NF‑κB inhibitor; pre‑clinical data show anti‑microbial synergy. PMCPubMed

8. Resveratrol (250 mg/day) – down‑regulates IL‑1β and MMP‑9, easing chronic inflammation.

9. Quercetin (250 mg TID) – natural flavonoid with anti‑biofilm action.

10. Multi‑strain oral probiotics (≥10 billion CFU/day) – gut–eye axis studies reveal reduced systemic inflammation and fewer ocular flares.

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Regenerative & stem‑cell–based eye‑drop therapies

Most remain off‑label or in clinical trials; access via specialist centres only.

1. 20 % Autologous Serum Eye Drops (ASED) – 1 drop QID for 3 months; supplies growth factors (EGF, TGF‑β) that speed epithelial repair after surgery. PMC

2. Platelet‑Rich Plasma (PRP) drops 20 % – 1 drop QID × 8 weeks; higher PDGF levels than ASED, proven to promote corneal wound healing. tropocells.com

3. Umbilical Cord Serum Drops 20 % – used when autologous blood is unsuitable; richer in nerve growth factor. BioMed Central

4. MSC‑derived Exosome Nano‑drops – experimental dose BID; carry micro‑RNAs that switch off ocular surface inflammation. PubMedPMC

5. Amniotic Membrane Extract Drops – anti‑scarring peptides reduce post‑curettage fibrosis.

6. Gene‑activated PRP (G‑PRP) drops – PRP enriched with VEGF‑siRNA for anti‑angiogenesis; phase‑I safety study underway.

Surgical procedures

1. Canaliculotomy with curettage – local anaesthetic incision along canaliculus, scoop out dacryoliths, irrigate antibiotic; 92–97 % anatomical success, low relapse. ResearchGate

2. Punctoplasty and silicone intubation – punctum widened, tube left 3 months; preserves drainage, prevents scarring.

3. CO₂ laser‑assisted punctoplasty – ultra‑precise; less bleeding, faster recovery and >85 % cure in small series. SpringerLink

4. Mini‑invasive snip‑and‑squeeze technique – punctum sparing; suited to soft, superficial stones.

5. Combined dacryocystorhinostomy (DCR) with canalicular stents – for recurrent disease extending into lacrimal sac; restores complete tear flow.

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Ways to prevent canaliculitis

1. Keep eyelid margins clean (lid‑scrub once nightly).

2. Replace eye cosmetics every 3 months.

3. Wash hands before touching eyes or lenses.

4. Disinfect contact lenses daily; never sleep in lenses.

5. Avoid sharing towels, pillows or makeup.

6. Control blepharitis and meibomian gland dysfunction promptly.

7. Manage chronic sinus or nasal polyps – they raise reflux infection risk. PMC

8. Take full antibiotic courses for eye infections to prevent smouldering bacteria.

9. Maintain adequate vitamin D and omega‑3 intake (immune support).

10. Schedule yearly eye exams after age 40 or if you had punctal plugs.

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When should you see an eye‑doctor urgently?

• Sudden inner‑eyelid swelling, redness and pain

• Yellow or gritty discharge when pressing the punctum

• Hard “stones” felt at lid margin

• Watering that does not clear with artificial tears

• Eye becomes sensitive to light or vision blurs

• Fever, facial cellulitis or spreading redness
  These signs suggest active canaliculitis or complications; prompt specialist care prevents scarring. Cleveland Clinic

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Practical do’s & don’ts at home

Do:

1. Apply warm compresses morning and night.

2. Massage the inner lid gently after every compress.

3. Finish all eyedrops and oral medications exactly as prescribed.

4. Keep follow‑up appointments.

5. Stay hydrated to help antibiotic levels.

Don’t:

1. Pick or squeeze the punctum forcefully – it drives bacteria deeper.

2. Share eye products or towels.

3. Use contact lenses while discharge persists.

4. Rub eyes with unwashed hands.

5. Skip doses when symptoms improve; relapse risk soars.

Frequently asked questions

1. Is canaliculitis contagious?
   No. It is an internal canal infection; discharge itself is infectious but standard hygiene prevents spread. Cleveland Clinic

2. Does it damage vision?
   Rarely. Vision blur is usually temporary from watering or ointments.

3. Why was my problem misdiagnosed as conjunctivitis?
   Because early signs mimic pink‑eye; key clue is “pouting punctum” and gritty stones. NCBI

4. How long will antibiotic drops take to work?
   Pain and redness ease in 3–5 days; complete cure needs 2–4 weeks and often surgery.

5. Is surgery painful?
   Most procedures use local anaesthetic; mild soreness for 24 hours.

6. What is the success rate?
   Modern canaliculotomy cures >90 % first time. PMC

7. Will the silicone stent bother me?
   You’ll feel a soft tube at the inner corner but most patients adapt within a day.

8. Can hot compresses alone cure it?
   They relieve symptoms but rarely eradicate bacteria sheltered in stones. reviewofoptometry.com

9. Do dietary supplements replace antibiotics?
   No. Supplements support healing but cannot kill entrenched bacteria.

10. Is laser surgery safer than classic blade surgery?
    CO₂ laser makes a neater cut and heals quicker, but long‑term cure rates are similar. SpringerLink

11. Can I wear makeup after surgery?
    Wait at least two weeks and use fresh products to avoid reinfection.

12. What if I’m allergic to penicillin?
    Fluoroquinolone or azithromycin drops plus doxycycline orally are effective alternatives.

13. Could canaliculitis come back?
    Yes, if any stones remain or hygiene lapses; meticulous curettage and lid‑care cut risk.

14. Are stem‑cell drops covered by insurance?
    Currently experimental; most insurers do not cover them outside trials.

15. How do I protect my other eye?
    Follow prevention steps, treat blepharitis aggressively and maintain good nutrition.

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Last Updated: July 15, 2025.