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Ophthalmology > INFECTIOUS DISEASE
Actinomycosis
Article Last Updated: Mar 16, 2005
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO, is a member of the following medical societies: American Academy of Ophthalmic Executives, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Coauthor(s):
Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, EYE REPUBLIC Ophthalmology Clinic;
C Stephen Foster, MD, FACS, FACR, FAAO, Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution
Editors: Jorge G Camara, MD, Chairman, Department of Ophthalmology and Otorhinolaryngology, Director of Fellowship Training Program, St Francis Medical Center; Associate Professor, Department of Surgery, University of Hawaii School of Medicine; Donald S Fong, MD, MPH, Assistant Clinical Professor of Ophthalmology, Director, Clinical Trials Research, Department of Ophthalmology, Southern California Permanente Medical Group; Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal, and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
Actinomycetales, Actinomycetaceae, Actinomycetes, Actinomyces, Actinomyces israelii, A israelii, keratoactinomycosis, keratitis, canaliculitis, anaerobic bacillus
Background
The bacterial order Actinomycetales comprises 3 families: Actinomycetaceae, Mycobacteriaceae, and Streptomycetaceae. Genus Actinomyces, a member of the family Actinomycetaceae, grows as a fragile branching filament that tends to fragment into bacillary and coccoid forms producing chains of either conidia or arthrospores.
Actinomyces israelii species is a gram-positive, cast-forming, non–acid-fast, non–spore-forming anaerobic bacillus that is difficult to isolate and identify. Its filamentous growth and mycelialike colonies have a striking resemblance to fungi. They are soil organisms, often found in decaying organic matter (eg, wet hay, straw). It is primarily a commensal microbe found in normal oral cavities, in tonsillar crypts, in dental plaques, and in carious teeth.
Pathophysiology
Keratitis
Most reported cases of Actinomyces keratitis (keratoactinomycosis) are caused by A israelii. It is characterized by a dry ulceration with central necrosis, surrounded by a gutter of demarcation, usually accompanied by iritis and hypopyon. In severe cases, descemetocele and perforation may occur.
A primary corneal ulcer attributable to Actinomyces species is rare and usually follows corneal trauma. A rare case of keratoactinomycosis developing in the absence of any known ocular trauma was reported in Kuala Lumpur.
Canaliculitis
Primary chronic canaliculitis is an uncommon problem caused by A israelii (Streptothrix). McKellar presented a 10-year-old girl with a 6-month history of intermittent conjunctivitis and discharge from her pouted left lower punctum. Topical treatment with chloramphenicol/polymyxin sulphate failed despite a diagnosis of probable A israelii infection confirmed by microbiology. Surgical exploration revealed a canalicular diverticulum and 3 canaliculiths demonstrating solid casts of Actinomycetes on histologic examination. A therapeutic triad of punctoplasty, cast removal, and adjunctive topical cefazolin resulted in resolution.
Other ocular involvement
Actinomycetes have been described as causative organisms in conjunctivitis, blepharitis, dacryocystitis, postsurgical endophthalmitis, and infected porous orbital implant. Cervico-facial actinomycosis has also been reported.
Endophthalmitis, attributable to Actinomyces viscosus, developed in a 78-year-old man after cataract surgery. Postoperative endophthalmitis with this organism is a rare occurrence. Inflammation was characterized by anterior segment and vitreous cellular debris in cases of chronic postoperative endophthalmitis associated with Actinomyces species.
Frequency
United States
Primary chronic canaliculitis is an uncommon problem that can be overlooked; however, it may account for approximately 2% of all tearing problems. Actinomycosis may form in up to 2% of all lacrimal disease. Its occurrence is probably much less in other areas.
Race
No racial predilection exists.
Sex
No sexual predisposition exists.
Age
No age predisposition exists.
History
- Keratitis
- Symptoms
- Progressive visual haze
- Increasing ocular pain
- Photophobia
- Constant watering
- Redness
- Past ocular history
- Corneal trauma, especially when contaminated by vegetable matter
- Ongoing, nonresponsive treatment
- Personal history - Outdoor laborer
- Canaliculitis
- Symptoms
- Chronic or recurrent conjunctivitis
- Chronic mucopurulent discharge
- Epiphora
- Ocular surface irritation
- Medial eyelid and canthal pain
- Pouting punctum
- Failure to resolve despite topical treatment
- Past ocular and medical history similar to keratitis
Physical
- Keratitis
- Gross observations
- Some conjunctival congestion
- Gray-white corneal lesion
- Slit lamp findings
- A dry ulceration with central necrosis, surrounded by a gutter of demarcation, usually accompanied by iritis and hypopyon may be present.
- Gray-white satellite stromal infiltrates adjacent to advancing edges may be present.
- In severe cases, descemetocele and perforation may occur.
- Canaliculitis
- Gross observations
- Chronic discharge, swollen and pouted punctum
- A pouted punctum is clinically diagnostic, although it occurs in less than 50% of all patients who are affected.
- Typically, the discharge is particulate and contains concretions.
- The plica may be swollen and congested, and canalicular swelling and overlying lid erythema are often present.
- The lower lid is more commonly affected, and the lacrimal sac and the duct are usually not involved.
- Slit lamp findings
- Pouted punctum
- Plica may be swollen and congested.
- Particulate canalicular discharge with or without concretions
Causes
Blepharitis, Adult
Cellulitis, Preseptal
Chalazion
Conjunctivitis, Bacterial
Contact Lens Complications
Dacryocystitis
Endophthalmitis, Fungal
Endophthalmitis, Postoperative
Keratitis, Fungal
Nasolacrimal Duct, Obstruction
Ulcer, Corneal
Other Problems to be Considered
Propionibacterium propionicus canaliculitis
Candida species canaliculitis
Lab Studies
- Canalicular discharge and canaliculiths may be sent for the following studies:
- Gram stain/Giemsa stain
- Cultures and sensitivities (ie, blood agar, Sabouraud, anaerobic)
- Special stains (ie, calcofluor white)
Imaging Studies
- Distension dacryocystography: Contrast material is used to visualize the anatomic details of the lacrimal drainage system.
- Scanning electron microscopy
- 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.
Other Tests
- Probing may be performed with a lacrimal probe to check for a diverticulum and remaining casts.
Procedures
- Perform a 2-snip punctoplasty under anesthesia.
- Curettage may also be helpful in removing any adherent casts from the canaliculus.
- Subsequent lacrimal irrigation with 2 MU of penicillin in 20 mL of sterile water may be helpful.
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.
Medical Care
- Keratitis: Actinomycetes are usually susceptible to penicillins and cephalosporins. The treatment of keratoactinomycosis used to be excision of necrotic tissue, followed by cauterization. However, good results have been obtained by subconjunctival penicillin coadministered with systemic iodides. Alternatively, topical sulfacetamide or penicillin can be used.
- Canaliculitis: Actinomycetes are usually susceptible to penicillins and cephalosporins. Postoperatively, patients may be treated with topical cefazolin for 1 month. Adjunctive hyperbaric oxygen therapy for actinomycotic lacrimal canaliculitis has been reported.
Surgical Care
- Keratitis: All reported cases of keratoactinomycosis responded to therapy, which included intraocular, topical, and systemic antibiotics, as well as pars plana vitrectomy and partial iridectomy. Urgent keratoplasty for a corneal infection by Actinomyces species was reported in a 41-year-old man.
- Canaliculitis: Failure to resolve canaliculitis by using topical treatment requires surgical exploration of the canalicular system and removal of any casts. Extensive surgery is not always required. A 2-snip punctoplasty, cast removal, curettage, probing, and adjunctive antibiotic therapy usually result in resolution of the canaliculitis. Cultivation of the surgically obtained dacryoliths and secretion enables reliable proof of Actinomyces and allows for an appropriate therapy for canaliculitis. Even though Actinomyces is sensitive to penicillin, cure of canaliculitis does not occur until all the concretions and the granulations that are present in the canaliculus are meticulously removed.
Consultations
An oculoplastics consult may be required.
Actinomyces organisms are usually susceptible to penicillins and cephalosporins. Good results have been obtained by subconjunctival penicillin coadministered with systemic iodides. Alternatively, topical sulfacetamide or penicillin can be used.
Drug Category: Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
| Drug Name | Penicillin G (Pfizerpen) |
|---|
| Description | Exerts bactericidal action against penicillin-susceptible microorganisms during the stage of active multiplication. Acts by inhibiting biosynthesis of cell wall mucopeptide, rendering the cell wall osmotically unstable. Not active against penicillinase-producing bacteria, which include many strains of staphylococci |
|---|
| Adult Dose | Topical: 100,000-333,000 U/mL in topical
Subconjunctival: 0.5-1.0 million U/mL
Intravitreal: 2,000 U and probenecid 0.5 g PO qid (possible retinal toxicity)
Oral: 400,000 U PO qid (rarely used; poor stomach absorption)
IV: 2-6 million U IV q4h and probenecid 0.5 g PO qid
IM: Depends on formulation |
|---|
| Pediatric Dose | Topical: 10,000-20,000 U/mL
IV: 50,000 U/kg/d IV divided bid/tid |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid can increase effects; coadministration of tetracyclines can decrease effects |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Caution in impaired renal function |
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| Drug Name | Cefazolin (Ancef, Kefzol, Zolicef) |
|---|
| Description | First-generation cephalosporin with excellent activity against gram-positive cocci, including penicillinase-producing Staphylococcus aureus, penicillinase-producing Staphylococcus epidermidis, group A beta-hemolytic streptococci (Streptococcus pyogenes), group B streptococci (Streptococcus agalactiae), and Streptococcus pneumoniae. Ineffective against Bacteroides fragilis and only weak activity against gram-negative organisms. |
|---|
| Adult Dose | Topical: 133 mg/mL
Subconjunctival: 100 mg/mL
Intravitreal: 2.25 mg plus probenecid 0.5 g PO qid
IV/IM: 500-1,000 mg IV/IM q6h |
|---|
| Pediatric Dose | 25-100 mg/kg/d IV/IM divided q6-8h depending on severity of infection; not to exceed 6 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Prolonged use may result in overgrowth of nonsusceptible organisms; caution in GI disease, particularly colitis |
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Drug Category: Antiparasitic agents
Parasite biochemical pathways are sufficiently different from the human host to allow selective interference by chemotherapeutic agents in relatively small doses.
| Drug Name | Sulfacetamide sodium 10% (Sulamyd, Bleph-10) |
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| Description | N-acetyl-substituted derivative; at 30% solution, topical sulfacetamide has pH of 7.4 and has good tissue penetration. |
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| Adult Dose | Solution: Instill 1-3 gtt in affected eye q2-3h, while awake, with less frequent administration at night
Ointment: Apply 0.5-inch ribbon into the conjunctival sac 1-4 times/d |
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| Pediatric Dose | <2 months: Not established
>2 months: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Effects of sulfonylurea hypoglycemic agents, hydantoin anticonvulsants, and oral anticoagulants increase when administered concurrently with sulfacetamide sodium; PABA antagonizes effects of sulfonamides; PABA esters (eg, procaine) may inhibit antibacterial effect of these agents; trimethoprim enhances effects of sulfacetamide |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | Caution in severely dry eye; ointment may retard corneal epithelial healing; if inflammation or pain persists >48 h or becomes aggravated, reevaluate therapy; adverse effects include local irritation, brow ache, blurred vision, transient burning and stinging, and sensitivity reactions (rare cases of Stevens-Johnson syndrome and exfoliative dermatitis have been reported); GI upset and bone marrow depression have been described |
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Further Outpatient Care
- Patients should receive follow-up care as needed.
In/Out Patient Meds
- Postoperatively, patients may be treated with topical cefazolin for 1 month.
Prognosis
- Prognosis is excellent once the organism is positively identified and appropriately treated.
Patient Education
- Patients should be advised to wear protective eye gear when working with vegetable matter.
Medical/Legal Pitfalls
- Failure to properly identify the organism with subsequent appropriate medical and surgical management may lead to a persistent epiphora; intermittent, mucopurulent discharge; and a localized, tumorlike swelling on the involved site.
Special Concerns
- While performing this work, the author was a Fellow and affiliated with the Ocular Immunology and Uveitis Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School.
| Media file 1:
Canaliculitis of the left lower lid. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School. |
 |  View Full Size Image | |
Media type: Photo
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| Media file 2:
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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Media type: Photo
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| Media file 3:
A pediatric patient with canaliculitis. Courtesy of Peter Rubin, MD, Director, Eye Plastics Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School. |
 | View Full Size Image | |
Media type: Photo
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| Media file 4:
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. |
 | View Full Size Image | |
Media type: Photo
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| Media file 5:
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. |
 | View Full Size Image | |
Media type: Photo
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| Media file 6:
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. |
 | View Full Size Image | |
Media type: Image
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- Barnard D, Davies J, Figdor D. Susceptibility of Actinomyces israelii to antibiotics, sodium hypochlorite and calcium hydroxide. Int Endod J. Sep 1996;29(5):320-6. [Medline].
- Briscoe D, Edelstein E, Zacharopoulos I. Actinomyces canaliculitis: diagnosis of a masquerading disease. Graefes Arch Clin Exp Ophthalmol. Aug 2004;242(8):682-6. [Medline].
- Demant E, Hurwitz JJ. Canaliculitis: review of 12 cases. Can J Ophthalmol. Apr 1980;15(2):73-5. [Medline].
- Dhaliwal U, Arora VK, Singh N. Clinical and cytopathologic correlation in chronic inflammations of the orbit and ocular adnexa: a review of 55 cases. Orbit. Dec 2004;23(4):219-25. [Medline].
- Eloy P, Brandt H, Nollevaux MC. Solid cast-forming actinomycotic canaliculitis: case report. Rhinology. Jun 2004;42(2):103-6. [Medline].
- Figdor D, Davies J. Cell surface structures of Actinomyces israelii. Aust Dent J. Apr 1997;42(2):125-8. [Medline].
- Fulmer NL, Neal JG, Bussard GM, Edlich RF. Lacrimal canaliculitis. Am J Emerg Med. Jul 1999;17(4):385-6. [Medline].
- Georg LK, Coleman RM, Brown JM. Evaluation of an agar precipitin test for the serodiagnosis of actinomycosis. J Immunol. Jun 1968;100(6):1288-92. [Medline].
- Holmberg K, Nord CE, Wadstrom T. Serological studies of Actinomyces israelii by crossed immunoelectrophoresis: taxonomic and diagnostic applications. Infect Immun. Aug 1975;12(2):398-403. [Medline].
- Hussain I, Bonshek RE, Loudon K, et al. Canalicular infection caused by Actinomyces. Eye. 1993;7 ( Pt 4):542-4. [Medline].
- Khan A, Lightman S. The eye in gastrointestinal disease. Hosp Med. Sep 2003;64(9):548-51. [Medline].
- Lambert FW Jr, Brown JM, Georg LK. Identification of Actinomyces israelii and Actinomyces naeslundii by fluorescent-antibody and agar-gel diffusion techniques. J Bacteriol. Nov 1967;94(5):1287-95. [Medline].
- Lee AG. Ocular whipple''s disease. Ophthalmology. Nov 2002;109(11):1952-3; author reply 1953. [Medline].
- Leigh RJ, Good EF, Rudy RP. Ophthalmoplegia due to actinomycosis. J Clin Neuroophthalmol. Sep 1986;6(3):157-9. [Medline].
- Marthin JK, Lindegaard J, Prause JU. Lesions of the lacrimal drainage system: a clinicopathological study of 643 biopsy specimens of the lacrimal drainage system in Denmark 1910-1999. Acta Ophthalmol Scand. Feb 2005;83(1):94-9. [Medline].
- Martin MV. The use of oral amoxycillin for the treatment of actinomycosis. A clinical and in vitro study. Br Dent J. Apr 7 1984;156(7):252-4. [Medline].
- McKellar MJ, Aburn NS. Cast-forming Actinomyces israelii canaliculitis. Aust N Z J Ophthalmol. Nov 1997;25(4):301-3. [Medline].
- Medical Economics. Physicians' Desk Reference. NJ:. Medical Economics Press;1999.
- Mohr JA, Rhoades ER, Muchmore HG. Actinomycosis treated with lincomycin. JAMA. Jun 29 1970;212(13):2260-2. [Medline].
- Richards WW. Actinomycotic lacrimal canaliculitis. Am J Ophthalmol. Jan 1973;75(1):155-7. [Medline].
- Robboy SJ, Vickery AL Jr. Tinctorial and morphologic properties distinguishing actinomycosis and nocardiosis. N Engl J Med. Mar 12 1970;282(11):593-6. [Medline].
- Scarano FJ, Ruddat MS, Robinson A. Actinomyces viscosus postoperative endophthalmitis. Diagn Microbiol Infect Dis. Jun 1999;34(2):115-7. [Medline].
- Shah JK. Actinomycosis: a ten year review. East Afr Med J. Sep 1971;48(9):496-501. [Medline].
- Shauly Y, Nachum Z, Gdal-On M, et al. Adjunctive hyperbaric oxygen therapy for actinomycotic lacrimal canaliculitis. Graefes Arch Clin Exp Ophthalmol. Jul 1993;231(7):429-31. [Medline].
- Smith RL, Henderson PN. Actinomycotic canaliculitis. Aust J Ophthalmol. Feb 1980;8(1):75-9. [Medline].
- Stupp T, Pavlidis M, Busse H. Presurgical and postsurgical ultrasound assessment of lacrimal drainage dysfunction. Am J Ophthalmol. Nov 2004;138(5):764-71. [Medline].
- Sullivan TJ, Aylward GW, Wright JE. Actinomycosis of the orbit. Br J Ophthalmol. Aug 1992;76(8):505-6. [Medline].
- Sullivan TJ, Hakin KN, Sathananthan N, et al. Chronic canaliculitis. Aust N Z J Ophthalmol. Nov 1993;21(4):273-4. [Medline].
- Takemura M, Yokoi N, Nakamura Y. Canaliculitis caused by Actinomyces in a case of dry eye with punctal plug occlusion. Nippon Ganka Gakkai Zasshi. Jul 2002;106(7):416-9. [Medline].
- Tost F, Bruder R, Ostendorf M. High-frequency ultrasonography applied to disorders of the lacrimal canaliculi (Part 2). J Fr Ophtalmol. Dec 2003;26(10):1035-8. [Medline].
- Tost F, Bruder R, Clemens S. 20-MHz ultrasound of pre-saccular lacrimal ducts. Ophthalmologe. Jan 2002;99(1):25-8. [Medline].
- Tost F, Bruder R, Clemens S. Clinical diagnosis of chronic canaliculitis by 20-MHz ultrasound. Ophthalmologica. 2000;214(6):433-6. [Medline].
- Vecsei VP, Huber-Spitzy V, Arocker-Mettinger E, Steinkogler FJ. Canaliculitis: difficulties in diagnosis, differential diagnosis and comparison between conservative and surgical treatment. Ophthalmologica. 1994;208(6):314-7. [Medline].
- Weinberg RJ, Sartoris MJ, Buerger GF Jr, Novak JF. Fusobacterium in presumed Actinomyces canaliculitis. Am J Ophthalmol. Sep 1977;84(3):371-4. [Medline].
- Zimmerman TJ, et al, eds. Textbook of Ocular Pharmacology. Philadelphia: Lippincott-Raven;1997.
Actinomycosis excerpt Article Last Updated: Mar 16, 2005
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