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Year : 2018  |  Volume : 61  |  Issue : 2  |  Page : 296-297
Sunray appearance in lacrimal canaliculitis

1 Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication20-Apr-2018

How to cite this article:
Singh M, Wijesinghe H, Kakkar N. Sunray appearance in lacrimal canaliculitis. Indian J Pathol Microbiol 2018;61:296-7

How to cite this URL:
Singh M, Wijesinghe H, Kakkar N. Sunray appearance in lacrimal canaliculitis. Indian J Pathol Microbiol [serial online] 2018 [cited 2023 Jun 3];61:296-7. Available from:


Lacrimal canaliculitis is one of the most commonly misdiagnosed clinical entities among specialty trained ophthalmologists.[1]Actinomyces, Staphylococcus, and Streptococcus are among the leading causative microorganisms causing lacrimal canaliculitis.[2],[3] These patients suffer from long-standing ocular redness, watering, and discharge. The common misdiagnosis are chronic conjunctivitis, dacryocystitis, and chalazion.[1],[3] The management includes conservative and surgical modalities with lacrimal punctoplasty and canalicular curettage, showing better long-term outcomes.[4] The surgically evacuated “sulfur granule-like concretions” are subjected routinely to histopathology and microbiology examination.

The Actinomyces species are cast-forming, ubiquitous bacteria, found in human oral flora, and cause chronic granulomatous infections. Due to its anaerobic fastidious nature, the culture provides limited yield ranging from 11.1% to 71.4% in lacrimal canaliculitis.[3],[4] Hence, histopathology at many occasions provide the nature of causative organism (bacteria or fungi).

A 54-year-old Indian female complained of redness, watering, and discharge from the left eye for 2 years. The constant epiphora was associated with mucopurulent discharge. Three years ago, she underwent bilateral insertion of inferior punctal plugs for severe dry eyes. The ophthalmic examination revealed left medial lower eyelid edema with diffuse conjunctival congestion. On magnified slit-lamp biomicroscopy, the inferior lacrimal punctum was pouting and the canalicular region showed yellowish cystic dilatation [Figure 1]a. On localized pressure over the dilated canaliculus, expressible purulent discharge could be elicited. The left lacrimal sac region was normal and the sac regurgitation test was negative. These clinical features suggested left inferior lacrimal canaliculitis.
Figure 1: (a) Left inferior inflamed pouting punctum with discharge (yellow arrow). The canalicular region shows yellowish cystic dilatation (black arrow). (b) Yellow colored, gritty, sulfur granule-like inspissated concretions. (c) The classical “sunray appearance” of an actinomycetoma. (d) Higher magnification revealed multiple branching, filamentous, periodic acid–Schiff-positive bacilli suggestive of Actinomyces

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A 3-snip punctoplasty with canalicular curettage was performed. The evacuated material containing sulfur-like granules [Figure 1]b was sent for microbiological and histopathological analysis. The microbial cultures were sterile at the 2nd and 7th day. The pathological examination revealed predominant necrosis with multiple actinomycotic colonies [Figure 1]c entrapped with inflammatory cells. The polymorphs were the principal inflammatory cells. The classical sunray appearance of the actinomycetoma was elicited which on higher magnification revealed multiple branching, filamentous bacilli suggestive of Actinomyces [Figure 1]d. The colonies were stained brilliantly with periodic acid–Schiff stain. The final diagnosis of actinomycosis of lacrimal canaliculus was established. The other differential diagnosis for sunray or sunburst appearance can be osteosarcoma, severe periostitis, odontogenic myxoma, fibrous dysplasia, and plasmacytoma. Oral azithromycin (500 mg OD) for 2 weeks and topical fortified cephalosporin (2 h) for 1 month helped in complete recovery of the patient.

Grossly, typical actinomycotic sulfur granule-like concretions are yellow, cheesy, and have a gritty consistency.[2],[3],[4],[5] For microbiological examination, the inoculums placed on blood agar, chocolate agar, and Sabouraud Dextrose agar with anaerobic incubation have successfully identified Actinomyces israelii from canalicular concretions.[1],[3],[5] Efficient collection and transport methods have shown to improve microbial yields.[2],[3],[4]

The hematoxylin and eosin typically stain the aggregated filamentous branching bacteria such as Actinomyces. These features can sometimes overlap with those of Fusobacterium, Nocardiosis, Chromomycosis, and Botryomycosis.[3],[4],[5] Hence, the microbiological and histopathological identification of the causative organism of lacrimal canaliculitis has always remained a challenge. This diagnostic challenge has further implications on long-term management and overall recovery of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Singh M, Gautam N, Agarwal A, Kaur M. Primary lacrimal canaliculitis: A clinical entity often misdiagnosed. J Curr Ophthalmol 2018; 30: 87-90.  Back to cited text no. 1
Huang YY, Yu WK, Tsai CC, Kao SC, Kau HC, Liu CJ, et al. Clinical features, microbiological profiles and treatment outcome of lacrimal plug-related canaliculitis compared with those of primary canaliculitis. Br J Ophthalmol 2016; 100:1285-9.  Back to cited text no. 2
Freedman JR, Markert MS, Cohen AJ. Primary and secondary lacrimal canaliculitis: A review of literature. Surv Ophthalmol 2011;56:336-47.  Back to cited text no. 3
Zaldívar RA, Bradley EA. Primary canaliculitis. Ophthal Plast Reconstr Surg 2009;25:481-4.  Back to cited text no. 4
Kim UR, Wadwekar B, Prajna L. Primary canaliculitis: The incidence, clinical features, outcome and long-term epiphora after snip-punctoplasty and curettage. Saudi J Ophthalmol 2015;29:274-7.  Back to cited text no. 5

Correspondence Address:
Manpreet Singh
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_621_17

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