this study was a retrospective analysis of all patients of 
 lacrimal canaliculitis managed at sankara nethralaya , chennai ; 
 during the period of january 1988 to may 2002 . only those 
 patients with microbiologically proven chronic canaliculitis 
 of more than three months duration and a minimum of three 
 weeks post - treatment follow - up . 
 expressed material from the canaliculus was collected with 
 the help of cotton - tipped applicator in all the patients under 
 aseptic precautions after instilling one drop of sterile 0.5% 
 proparacaine hydrochloride ( paracaine 0.5% , sunways ) or 
 4% lignocaine hydrochloride ( lidocaine , xylocaine 4%,astra 
 idl ) eye drop as a local anesthetic agent . all patients were treated with canalicular expression of 
 pus and topical antibiotic drops ( fortified cefazolin 50 mg / ml + 
 ciprofloxacin 0.3% ) eight to ten times a day either alone or in 
 combination with canalicular irrigation with two milliliters of 
 fortified cefazolin solution ( 50 mg / ml).the line of treatment was 
 decided by the clinical judgment of severity of the condition . fortified cefazolin solution ( 50 mg / ml ) was prepared by 
 injecting 10 ml of water for injection into the commercially 
 available vial of cefazolin , containing 500 mg of the drug 
 in powder form . lower canaliculus 
 ( eight out of 12 ) was more commonly involved than the upper 
 canaliculus ( four out of 12 ) . epiphora , discharge , irritation and 
 recurrent or chronic conjunctivitis were the common symptoms . all patients had symptoms for more than three months duration 
 ( range : 3 to 24 months , mean:13.25 months ) . all patients had a 
 pouting punctum and erythema as well as thickening of medial 
 eyelid [ fig . 1 ] . eight patients had punctal regurgitation , which 
 could be induced by pressure over the involved canaliculus 
 [ fig . 2 ] . syringing was done in all patients through the involved 
 canaliculus and was patent in all of them . in vitro resistance to ciprofloxacin canalicular expression of pus and topical antibiotic drops 
 alone was the initial treatment in five patients ( patient nos . 4 , 
 7 , 9 , 10 , 11 ) while canalicular expression , topical antibiotic 
 drops and antibiotic irrigation was performed in the remaining 
 seven patients . of the five patients treated with topical antibiotics alone , good clinical improvement was seen in three patients while in 
 two patients ( patient nos . 4 and 9 ) , the condition was persistent 
 at the end of three weeks . canalicular irrigation with fortified 
 cefazolin was performed subsequently in these two patients 
 with good response . all patients who initially received canalicular antibiotic 
 irrigation in addition to topical antibiotics showed good 
 response to treatment . the average number of irrigations 
 required per patient was 4.5 ( range 1 - 8 ) . all patients were symptom - free with complete resolution 
 and none needed canalicular curettage or canaliculotomy . canaliculitis should be suspected in any patient with 
 unexplained epiphora , recurrent conjunctivitis , eyelid swelling 
 and pain . pouting punctum , peripunctal erythema , thickening 
 of medial eyelid and punctal regurgitation are the important 
 signs of canaliculitis . usually , it is localized to a single punctum , 
 as in all the cases in our series . in our study , polymicrobial infection was common in 
 contrast to earlier studies , where actinomyces or nocardia was 
 found to be the commonest organism.8,9 since all the 
 organisms isolated were sensitive to either cefazolin or ciprofloxacin or 
 both , our patients were treated with canalicular expression and 
 topical antibiotic ( ciprofloxacin 0.3% and fortified cefazolin 
 50 mg / ml ) with or without canalicular irrigation with fortified 
 cefazolin solution . these patients were subsequently treated 
 successfully with antibiotic irrigation . increased bioavailability 
 of the drug at the site of infection may have been responsible 
 for the excellent therapeutic response in this cross - over 
 group . none of the patients treated with canalicular irrigation 
 with antibiotic solution had any recurrence or persistence of 
 the disease . in our series , canalicular expression followed by topical 
 antibiotic drops and canalicular irrigation with antibiotic 
 solution according to the sensitivity pattern of the microorganism was found to be effective in all cases . based on our study , we 
 recommend use of fortified cefazolin , both in the form of 
 topical eye drops and for syringing the affected canaliculus 
 along with topical ciprofloxacin eye drops . this treatment has 
 the advantage of eliminating the risk of iatrogenic canalicular 
 scarring with preservation of lacrimal pump function . in the 
 present age , due to availability of potent , bactericidal , broad- 
 spectrum antibiotics like ciprofloxacin and cefazolin , invasive 
 procedures like canalicular curettage and canaliculotomy however , we feel a prospective study 
 comparing these modalities of treatment will be needed to 
 reassess the role of canalicular curettage and canaliculotomy 
 in the management of suppurative lacrimal canaliculitis .
chronic suppurative lacrimal canaliculitis is an important cause 
 of ocular surface discomfort . 
 treatment with topical antibiotics 
 is often inadequate and surgical treatment by canaliculotomy 
 and canalicular curettage has been the mainstay of treatment 
 in the past . 
 the role of canalicular antibiotic irrigation has 
 been inadequately studied . 
 we report the clinical features , 
 microbiological profile and treatment outcome in a series of 
 12 patients with suppurative lacrimal canaliculitis . 
 two patients 
 had actinomyces infection , five had nocardia infection and 
 seven patients had polymicrobial infection . 
 three patients had 
 resolution of canaliculitis on combination broad - spectrum topical 
 antibiotic therapy using ciprofloxacin and fortified cefazolin . 
 in nine patients , 
 topical antibiotic therapy was combined with 
 canalicular irrigation using fortified cefazolin . 
 all patients had 
 excellent resolution of canaliculitis without the need for surgical 
 treatment . 
 availability of broad - spectrum antibiotics and 
 canalicular irrigation may offer an alternative to surgery in the 
 management of suppurative lacrimal canaliculitis .