canaliculitis is a common encounter in ophthalmic practice but supernumerary puncta and canaliculi ( spc ) are rare congenital disorders . in a large series
a 59-year - old gentleman presented with painful swelling of the left lower lid for a week , which was associated with epiphora .
the swelling was confined to the nasal aspect of the left lower lid ( 0.50.5 mm ) with inflamed overlying skin ( figure 1a ) .
eversion of the lower eyelid revealed two puncta , 0.5 mm apart ( figure 1b ) .
the outer punctum was situated at the normal anatomical position ; whereas the inner punctum in the caruncle . gentle pressure did not result in any regurgitation from the both puncta .
the patient was treated with oral cloxacillin 500 mg , 6 hourly for 5 days .
the outer punctum had a soft stop with regurgitation of fluid from the same punctum .
the outer punctum - canaliculus system was a cul - de - sac ( figure 1c ) .
c ) dacryocystography showed pooling of dye in the cul - de - sac ( white arrow ) .
c ) dacryocystography showed pooling of dye in the cul - de - sac ( white arrow ) .
most spcs ( 78% ) present with epiphora . among the 23 patients reported by satchi et al . , none presented with canaliculitis .
sequestration of tear and debris in the cul - de - sac served as nidus for infection . the resultant canaliculitis with its surrounding edema caused obstruction of the lacrimal drainage ; hence epiphora .
epiphora however , may develop despite patent lacrimal drainage system . the 2-compartment model for lacrimal canalicular drainage of kakizaki et al .
, suggested that the muscle of duverney - horner may deviate normal flow within the accessory canaliculus and thence transport tears back to the lacrimal tear lake , leading to epiphora .
a solid epithelial cord forms in the region of the medial lower eyelid ( figure 2a ) and sends projections to form the canaliculi and the nasolacrimal duct ( figure 2b ) .
spc is due to extra out - budding of the solid epithelial cord ( figure 2c ) .
canalization begins at 4 months of gestation with disintegration of the central ectodermal core , forming lacrimal drainage outflow system . in this case , the extra inner canalicular epithelial bud ( nearer to the main epithelial cord ) underwent complete canalization and remained connected to the main epithelial cord .
the outer canalicular epithelial bud , although its punctum is located at the normal anatomical position , was separated from the main epithelial cord ; forming a cul - de - sac ( figure 2d ) . 

c ) extra out - budding of the solid epithelial cord in supernumerary puncta and canaliculi .
d ) the outer canalicular epithelial cord was separated from the main epithelial cord , forming a cul - de - sac .
c ) extra out - budding of the solid epithelial cord in supernumerary puncta and canaliculi .
d ) the outer canalicular epithelial cord was separated from the main epithelial cord , forming a cul - de - sac .
 we report the first case of supernumerary puncta and canaliculi presented with canaliculitis . 
 a-59 year - old gentleman presented with painful swelling of the left lower lid for a week , which was associated with epiphora . 
 the swelling was confined to the nasal aspect of the left lower lid ( 0.50.5 mm ) with inflamed overlying skin . 
 two puncta ( 0.5 mm apart ) were noted . 
 the outer punctum at the normal anatomical position was a cul - de - sac while the inner punctum it the caruncle was patent . 
 we described the embryology leading to supernumerary puncta and canaliculi to explain the paradoxical patency of the abnormally located punctum as well as the pathomechanism leading to canaliculitis . 
 the patient was treated with oral cloxacillin 500 mg , 6 hourly for 5 days ; the cellulitis subsided after three days . 
Introduction
Case Report
Discussion