A Major Review of Fungal Lacrimal Drainage Infections

Purpose: Lacrimal system infections, such as canaliculitis and dacryocystitis, are usually of bacterial etiology. We present a review of fungal lacrimal drainage infections. Methods: A literature review was conducted using Medline and Embase databases following PRISMA guidelines. Twenty-seven studies met the inclusion criteria and were synthesized narratively. Data obtained include demographics, clinical presentation, types of fungal infection, location of the infection, investigations, medical and surgical treatment (acute and delayed), and symptom resolution. Results: A total of 118 cases of fungal lacrimal infections have been reported so far. The most commonly reported species were Candida (27.1%) and Aspergillus (23.7%). The majority [74.6% (88/118)] involved the lacrimal sac and the nasolacrimal duct. Of these, 42.0% (37/88) had concurrent casts or dacryoliths. A total of 14.4% (17/118) involved only the canaliculus. Where specified, nearly all patients reported local symptoms of epiphora (77.4%, 24/31). A total of 66.7% (12/18) of patients had risk factors, including immunosuppression, trauma, concurrent fungal infection elsewhere, and lacrimal sac diverticulum. Where specified, all cases (56/56) showed improvement or resolution of symptoms. Of these, 66.1% (37/56) required only medical or conservative management. Conclusion: Fungal lacrimal infections are uncommon but should be suspected in patients presenting with new epiphora in the context of dacryocystitis, especially in the presence of casts or dacryoliths, while a smaller proportion causes canaliculitis. Diagnosis is challenging, requiring a combination of clinical suspicion, risk factor assessment (eg, immunosuppression), and laboratory confirmation. Treatment approaches range from conservative medical management to surgical interventions. Further research is needed to better understand their pathogenesis, especially regarding their relationship with dacryolith formation.