من طرف Clinical case history - Q&A
A 54-year old woman presented with a five-month history of a
lump in her right upper lid. This had varied in size but, overall,
didn’t seem to be improving. The eye had not been sticky or
watery and there had been no disturbance to vision. She had had
no ocular problems in the past and neither had anyone in her
family. She was in good health.
VAs were:
Right 6/6
Left 6/4
On examination, the appearance was as shown in Figure 1. There
was an approximately 1cm lump at the medial end of the right
upper eyelid. If pressed firmly, this was tender, but no discharge
was forthcoming. The overlying skin was slightly red.
Figure 1 The appearance before treatment
Questions
1. What structure within the lid is affected
and abnormal in this case?
2. What is the diagnosis?
3. How might the absence of epiphora and
discharge be explained?
4. How might the problem be solved
(treated)?
Answers
1. The disturbed structure is the upper
canaliculus. The lateral 5/6th of lid
margin is curved and delineated by
the lashes.
The medial 1/6th is more straight and
lash free. The lacrimal punctum is
located at the junction of the change
in contour. From the punctum, the
lacrimal canaliculus runs medially
within the lid margin. The upper and
lower canaliculi then join to form the
common canaliculus which, in turn,
drains tears into the lacrimal sac
located deep to the medial canthus.
2. The diagnosis is ’right upper
canaliculitis’. The lining (mucosa) of
the canaliculus and the surrounding
soft tissues are inflamed and swollen.
This is probably due to chronic
infection. There is retention of
mucopus within the canaliculus
producing the lump. Sometimes, this
material can solidify into a stone
known as a ‘dacryolith’.
The appearance is similar to a
chalazion (meibomian gland cyst), but
the position is wrong for this. The
meibomian glands are located within
the tarsal plate and restricted to the
lash bearing lateral 5/6th of the lid.
They open onto the lid margin just
behind the lashes.
3. In this case, both ends of the upper
canaliculus appeared to have become
blocked off by swelling and fibrosis.
The upper punctum could not be
entered with a punctal dilator. The
material within the canaliculus was,
therefore, trapped and could not be
expressed either through the upper
punctum or via the common
canaliculus, to the lower punctum or
lacrimal sac. The lower and common
canaliculi were unaffected and,
therefore, tears could drain preventing
the development of a watery eye.
4. The only sure way to settle this
problem was to surgically open the
upper canaliculus and release the
retained material. Under local
anaesthetic, the lid margin from the
punctum to the canthus was incised
and the canaliculus was de-roofed and
converted to an open gutter to
prevent re-accumulation. There was no
dacryolith, but mucopus was drained
and sent for culture.
Canaliculitis is sometimes caused by,
or associated with, unusual
organisms, e.g. Actinomyces, but on
this occasion, the relatively common
gram negative bacterium,
Haemophilus influenzae was isolated.
A short course of topical antibiotic
was given and the problem resolved.
Figure 2 shows the same eye
six weeks later.
Expand your clinical knowledge with our series of cases from
the files of consultant ophthalmic surgeon, Chris Heaven.
Case number FIVE
Photographs by
courtesy of the
Department of
Medical Illustration,
Wigan and Leigh
NHS Trust. Figure 2 The appearance six weeks after treatment
About the author
Chris Heaven is consultant ophthalmic
surgeon at the Royal Albert Edward
Infirmary in Wigan, Lancashire.
lump in her right upper lid. This had varied in size but, overall,
didn’t seem to be improving. The eye had not been sticky or
watery and there had been no disturbance to vision. She had had
no ocular problems in the past and neither had anyone in her
family. She was in good health.
VAs were:
Right 6/6
Left 6/4
On examination, the appearance was as shown in Figure 1. There
was an approximately 1cm lump at the medial end of the right
upper eyelid. If pressed firmly, this was tender, but no discharge
was forthcoming. The overlying skin was slightly red.
Figure 1 The appearance before treatment
Questions
1. What structure within the lid is affected
and abnormal in this case?
2. What is the diagnosis?
3. How might the absence of epiphora and
discharge be explained?
4. How might the problem be solved
(treated)?
Answers
1. The disturbed structure is the upper
canaliculus. The lateral 5/6th of lid
margin is curved and delineated by
the lashes.
The medial 1/6th is more straight and
lash free. The lacrimal punctum is
located at the junction of the change
in contour. From the punctum, the
lacrimal canaliculus runs medially
within the lid margin. The upper and
lower canaliculi then join to form the
common canaliculus which, in turn,
drains tears into the lacrimal sac
located deep to the medial canthus.
2. The diagnosis is ’right upper
canaliculitis’. The lining (mucosa) of
the canaliculus and the surrounding
soft tissues are inflamed and swollen.
This is probably due to chronic
infection. There is retention of
mucopus within the canaliculus
producing the lump. Sometimes, this
material can solidify into a stone
known as a ‘dacryolith’.
The appearance is similar to a
chalazion (meibomian gland cyst), but
the position is wrong for this. The
meibomian glands are located within
the tarsal plate and restricted to the
lash bearing lateral 5/6th of the lid.
They open onto the lid margin just
behind the lashes.
3. In this case, both ends of the upper
canaliculus appeared to have become
blocked off by swelling and fibrosis.
The upper punctum could not be
entered with a punctal dilator. The
material within the canaliculus was,
therefore, trapped and could not be
expressed either through the upper
punctum or via the common
canaliculus, to the lower punctum or
lacrimal sac. The lower and common
canaliculi were unaffected and,
therefore, tears could drain preventing
the development of a watery eye.
4. The only sure way to settle this
problem was to surgically open the
upper canaliculus and release the
retained material. Under local
anaesthetic, the lid margin from the
punctum to the canthus was incised
and the canaliculus was de-roofed and
converted to an open gutter to
prevent re-accumulation. There was no
dacryolith, but mucopus was drained
and sent for culture.
Canaliculitis is sometimes caused by,
or associated with, unusual
organisms, e.g. Actinomyces, but on
this occasion, the relatively common
gram negative bacterium,
Haemophilus influenzae was isolated.
A short course of topical antibiotic
was given and the problem resolved.
Figure 2 shows the same eye
six weeks later.
Expand your clinical knowledge with our series of cases from
the files of consultant ophthalmic surgeon, Chris Heaven.
Case number FIVE
Photographs by
courtesy of the
Department of
Medical Illustration,
Wigan and Leigh
NHS Trust. Figure 2 The appearance six weeks after treatment
About the author
Chris Heaven is consultant ophthalmic
surgeon at the Royal Albert Edward
Infirmary in Wigan, Lancashire.