A Lacrimal Gland Duct Stones Misdiagnosed as Refractory Conjunctivitis: A Case Report

A Lacrimal Gland Duct Stones Misdiagnosed as Refractory Conjunctivitis: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Lacrimal Gland Duct Stones Misdiagnosed as Refractory Conjunctivitis: A Case Report Shang Li, Yuyan Huang, Yang Zhang, Xu zhang, Ying Jie This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6232103/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Aug, 2025 Read the published version in BMC Ophthalmology → Version 1 posted 12 You are reading this latest preprint version Abstract Purpose: Stones located in the temporal canthus were relatively rare. We presented a case of giant lacrimal duct stone associated with Haemophiles influenzae and described the clinical features. Case presentation: A female patient presented persistent secretion in the lateral canthal region of the right eye. Surgical exploration was performed, and bacterial culture, tissue pathology analysis and magnetic resonance imaging (MRI) examination were completed. A huge stone was found in the temporal canthus, which was composed of amorphous acidic substances. The bacterial culture results showed infection with Haemophilus influenzae, and the postoperative MRI results showed no signs of inflammation around the lacrimal gland. The patient's symptoms disappeared immediately after the operation. Conclusion: Lacrimal duct stone was a very rare diagnosis but worth considering when a patient presented a unilateral lateral refractory conjunctivitis. Lacrimal gland duct Stone Haemophilus influenzae Refractory conjunctivitis Temporal canthus Figures Figure 1 Background Conjunctival redness with secretion is usually diagnosed as conjunctivitis. If symptoms are combined with eyelid mass, it is usually diagnosed as a chalazion. However, above symptoms can also be caused by stones in the lacrimal system. Compared to nasolacrimal duct, stones in the lacrimal duct are very rare. Stones in the lacrimal system are usually accompanied by obvious changes in the lacrimal glands [ 1 , 2 ] , but the diagnosis of cases without obvious changes in the lacrimal glands is more complicated. Previously, there have been reports of cases where chalazions were misdiagnosed as conjunctivitis 3 , but there are no reports of lacrimal stones without obvious masses. Here we described a case of lacrimal duct stone and reviewed the possible mechanisms of lacrimal duct stone formation, intending to provide new diagnostic strategy for refractory conjunctivitis. Case presentation A 34-year-old female presented conjunctival redness and increased secretion for 3 months. Before coming to our hospital, the patient had been treated with topical antibiotic eye drops, which did not work. The only abnormal in the health condition was the high-density lipoprotein cholesterol of the patient was 2.0 mmoL/L. Besides, the patient underwent double eyelids operation on both eyes 4 years previously, and the right eyelid chalazion excision 3 years previously. Ophthalmological examination showed purulent discharge and temporal blepharoplasty at the right eye, but no mass was touchable (Fig. 1 A). There were no other obvious abnormalities in the anterior segment and fundus of both eyes, and the visual acuity and intraocular pressure of both eyes were within normal range. The results of lacrimal passage irrigation showed that both eyes were unobstructed with no secretions. We performed an exploratory operation from the secretion opening under local anesthesia. A huge yellow stone was found and removed (Fig. 1 B). Pathological results showed eosinophilic amorphous material, which was considered to be calculous pathological change. (Fig. 1 C) Gram-negative (G − ) coccobacilli was observed in the stone (Fig. 1 D). No fungal growth was observed, but the bacterial culture results of the stone showed Haemophilus influenzae growth. After the operation, we gave the prescription of antibiotics such as Gemifloxacin and levofloxacin. The conjunctival redness and ocular secretions subsided after surgery (Fig. 1 E), and an orbital magnetic resonance imaging (MRI) 10 days after surgery showed no abnormal signals were found in the lacrimal gland area and the eyelids (Fig. 1 F). There was no recurrence during the 7-month follow-up period. Discussion This case reported a giant stone located in the lateral canthus with no specific symptoms except for purulent ocular discharge, with was misdiagnosed as conjunctivitis, and the stone was associated with Haemophilus influenzae infection. Reports on stones in the lacrimal duct system were mostly reported in the nasolacrimal duct and lacrimal gland currently, but there were few reports on stones located in a special location: lateral canthus. Othman et al. [ 1 ] reported a case of lacrimal duct stone accompanied by obvious lacrimal gland enlargement. Kim et al. [ 3 ] reported 3 cases of lacrimal duct stones that were misdiagnosed as chalazions. And Zhao et al. [ 2 ] reported a case of lacrimal duct stone resented with lacrimal gland prolapse. Unfortunately, the preoperative MRI examination in this case could not be completed due to the patient's personal reason. But the postoperative MRI examination showed no obvious abnormal MRI signals or inflammatory edema reactions in the lacrimal gland or lacrimal duct system. Therefore, we inferred that the location of the stone was far away from the lacrimal gland and was most likely located at the opening of the lacrimal duct. The pathogenesis of lacrimal duct stone was still unclear. Abnormal tear dynamics, protein-encapsulated accumulation of various components, and infection were possible causes. Stasis in tear dynamics was important factor in the formation of lacrimal stones. We speculated that epithelial debris or cosmetics blocking the lacrimal duct opening in the lacrimal duct may be the initiating factors for stone formation. Besides, the core of a lacrimal duct stone may be developed from various components. Previous studies have reported ingredients such as eyelashes, [ 4 ] cilium or rabbit fur [ 2 ] and other components. It has been well established that protein is the main component of lacrimal gland stones were mainly composed of protein, [ 5 ] and calcium. [ 6 ] Histological examination all reported eosinophilic amorphous material with calcification changes, [ 1 ] with was consistent with our results. However, no obvious core material was found in this case. Regarded with the patient's previous eye surgery history and her own high-density lipoprotein cholesterol level, we speculated that the patient's ocular surface homeostasis was unstable, accompanied by extensive lipid secretion. The stone may have developed from the detached and dissolved epithelial tissue and lipid deposits. Microbial growth may further promote stone formation. Most previous studies reported that the lacrimal system was infected with Gram-negative (G + ) bacteria. The bacterial culture conducted by Kim et al. [ 3 ] showed Pseudomonas aeruginosa around the stone. In this case, we found Haemophilus influenzae in the culture of the stone, but we were not sure whether this was the causes of the disease. Baker et al. [ 7 ] reported a case of a stone in the palpebral lobe of the lacrimal gland and was cultured positive for Haemophilus influenzae. Halborg et al. [ 5 ] reported three cases of stones confined to the lacrimal ductile, in which G + bacteria were all observed. Haemophilus influenzae was commonly found in the respiratory infections, but was also the most common bacterium in neonatal dacryocystitis. [ 8 ] Along with Streptococcus pneumoniae and Staphylococcus aureus, it was a common pathogen of lacrimal gland inflammation. [ 9 ] When there was an infection of G + bacteria in the lacrimal system, it may cause tissue damage and inflammation, further creating a favorable environment for the G − bacteria colonization and spread, which may lead to the prolongation of the course of the disease. [ 10 ] Therefore, for unilateral persistent refractory conjunctivitis, clinicians should pay attention to the patient's potential lacrimal duct infection. During treatment, the use of combined antibiotics should be considered to cover G + and G − bacteria to improve the effects of treatment. Conclusion Lacrimal duct stones may have no obvious signs. Common symptoms included unilateral eye redness, secretions, tearing, pain, and palpable masses, which were similar to symptoms of conjunctivitis or chalazion. Therefore, for patients with persistent unilateral canthal conjunctivitis and poor antibiotic treatment effects, lacrimal duct stones should be considered. Declarations Ethics approval and consent to participate This study was conducted in accordance with the declaration of Helsinki, and the patient signed an informed consent for the use of human materials and data mentioned in this report for scientific research. Consent for publication Written informed consent for publication was obtained from the patient. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding No funding was obtained for this study. Authors' contributions SL collected and interpreted the data and critically reviewed the literature. YH drafted this manuscript. YZ and XZ collected the data. YJ critically reviewed the final version of the manuscript. All authors have read and approved the final manuscript. Acknowledgements Not applicable References Othman OB, Takahashi Y, Valencia MRP, Kakizaki H. A stone in the lacrimal gland: a case report and literature review. Orbit . 2020;39(1):48-52. Zhao J, Xu Z, Han A, Zeng L, Hao G, Chen B. A huge lacrimal gland ductule dacryolith with a hairy nucleus: a case report. BMC ophthalmol . 2018;18:1-2. Kim SC, Lee K, Lee SU. Lacrimal gland duct stones: misdiagnosed as chalazion in 3 cases. Can J Ophthalmol . 2014;49 (1):102-05. Baratz KH, Bartley GB, Campbell RJ, Garrity JA. An eyelash nidus for dacryoliths of the lacrimal excretory and secretory systems. Am J Ophthalmol . 1991;111(5):624-27. Halborg J, Prause JU, Toft PB, Skjødt K, Tommerup NR, Nielsen OF, et al. Stones in the lacrimal gland: a rare condition. Acta Ophthalmol . 2009;87(6):672-75. Chandravanshi SL. Spontaneous expulsion of lacrimal gland ductule stones by eyelid squeezing: a rare event. Orbit . 2014; 33(3): 223-25. doi: 10.3109/01676830.2014.894538. Baker RH, Bartley GB. Lacrimal gland ductule stones. Ophthalmology . 1990;97(4):531-34. doi: 10.1016/S0161-6420(90)32553-8 Bekmez S, Eriş E, Altan EV, Dursun V. The role of bacterial etiology in the tear duct infections secondary to congenital nasolacrimal duct obstructions. J Craniofac Surg. 2019;30(7):2214-16. Wai KM, Locascio JJ, Wolkow N. Bacterial dacryoadenitis: clinical features, microbiology, and management of 45 cases, with a recent uptick in incidence. Orbit . 2022;41(5):563-71. Ruhal R, Kataria R. Biofilm patterns in gram-positive and gram-negative bacteria. Microbiol Res . 2021;251:126829. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Aug, 2025 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 16 Jun, 2025 Reviews received at journal 05 Jun, 2025 Reviewers agreed at journal 05 Jun, 2025 Reviews received at journal 03 Jun, 2025 Reviewers agreed at journal 12 May, 2025 Reviews received at journal 09 May, 2025 Reviewers agreed at journal 26 Mar, 2025 Reviewers invited by journal 26 Mar, 2025 Editor assigned by journal 26 Mar, 2025 Editor invited by journal 24 Mar, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 24 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6232103","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":440462568,"identity":"7535462e-0021-4337-bcf2-fdc61f216f36","order_by":0,"name":"Shang Li","email":"","orcid":"","institution":"Beijing Tongren Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shang","middleName":"","lastName":"Li","suffix":""},{"id":440462569,"identity":"cd1b43b6-8198-4228-aa23-19af0be09570","order_by":1,"name":"Yuyan Huang","email":"","orcid":"","institution":"Beijing Tongren Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuyan","middleName":"","lastName":"Huang","suffix":""},{"id":440462570,"identity":"a32dbef3-cbf6-41cc-8cc4-ef773793e603","order_by":2,"name":"Yang Zhang","email":"","orcid":"","institution":"Beijing Tongren Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Zhang","suffix":""},{"id":440462571,"identity":"36af6cd0-dc71-48b7-b671-17f1e48c6270","order_by":3,"name":"Xu zhang","email":"","orcid":"","institution":"Beijing Tongren Hospital, Capital Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"zhang","suffix":""},{"id":440462572,"identity":"884d3630-45a7-4a0a-b059-51248d08deff","order_by":4,"name":"Ying Jie","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYBACxmYQaQAimA8wPDAgTQtbAkMCMVqQAI8BQwIx6pjbmQ8w8xTcseuf3fPxQ0LB4cTtDMwPH93A6zC2BGYeg2fJM+6c3SyRYHA4cWcDm7FxDl4tPAZALYeTDSRyN4C1bDjAwyaNXwv/B6iWnMc/iNTCwwDSYgfUwkasLWwGjHMMDidI3Egzs0gwSDfecJiAXwz7Dz9gePPnsD3/jOTHNz78sZbdcLz54WO8WhoY2H/xMDAkNkD4wJhlxqMcBORBjvvBwGAP5dcRUD8KRsEoGAUjEQAAMfdMJjX8c18AAAAASUVORK5CYII=","orcid":"","institution":"Beijing Tongren Hospital, Capital Medical University","correspondingAuthor":true,"prefix":"","firstName":"Ying","middleName":"","lastName":"Jie","suffix":""}],"badges":[],"createdAt":"2025-03-15 10:08:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6232103/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6232103/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-025-04287-2","type":"published","date":"2025-08-07T15:58:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80581776,"identity":"9db6e376-ae37-412b-a9b3-138d3d02dd7c","added_by":"auto","created_at":"2025-04-14 23:23:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":5197242,"visible":true,"origin":"","legend":"\u003cp\u003eA) Slit lamp photography of the patient's right eye before surgery. There was some secretion at the temporal canthus. B) The large complete yellow stone (8 mm × 4 mm × 3 mm) was removed by the operation. C) Pathological image of the yellow stone (×200), scale bar = 100 μm. D) Gram staining image of the conjunctival tissue of the temporal canthus: G\u003csup\u003e+\u003c/sup\u003e bacteria were observed (×1000). The G\u003csup\u003e+\u003c/sup\u003e bacteria was indicated by arrows. Scale bar = 50 μm. E) Slit lamp photography of the patient's right eye 10 days after surgery. F) Orbital MRI scan of the patient 10 days after surgery.\u0026nbsp;\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6232103/v1/f4e96589e88d3d63888c288c.png"},{"id":88814209,"identity":"476f6ce8-d3e7-4e4f-9313-bcfb077ac6ff","added_by":"auto","created_at":"2025-08-11 16:08:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5093126,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6232103/v1/bc9f9090-d322-4f03-b8b9-44cfc72c51c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Lacrimal Gland Duct Stones Misdiagnosed as Refractory Conjunctivitis: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eConjunctival redness with secretion is usually diagnosed as conjunctivitis. If symptoms are combined with eyelid mass, it is usually diagnosed as a chalazion. However, above symptoms can also be caused by stones in the lacrimal system. Compared to nasolacrimal duct, stones in the lacrimal duct are very rare. Stones in the lacrimal system are usually accompanied by obvious changes in the lacrimal glands\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, but the diagnosis of cases without obvious changes in the lacrimal glands is more complicated. Previously, there have been reports of cases where chalazions were misdiagnosed as conjunctivitis\u003csup\u003e3\u003c/sup\u003e, but there are no reports of lacrimal stones without obvious masses. Here we described a case of lacrimal duct stone and reviewed the possible mechanisms of lacrimal duct stone formation, intending to provide new diagnostic strategy for refractory conjunctivitis.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 34-year-old female presented conjunctival redness and increased secretion for 3 months. Before coming to our hospital, the patient had been treated with topical antibiotic eye drops, which did not work. The only abnormal in the health condition was the high-density lipoprotein cholesterol of the patient was 2.0 mmoL/L. Besides, the patient underwent double eyelids operation on both eyes 4 years previously, and the right eyelid chalazion excision 3 years previously. Ophthalmological examination showed purulent discharge and temporal blepharoplasty at the right eye, but no mass was touchable (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). There were no other obvious abnormalities in the anterior segment and fundus of both eyes, and the visual acuity and intraocular pressure of both eyes were within normal range. The results of lacrimal passage irrigation showed that both eyes were unobstructed with no secretions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWe performed an exploratory operation from the secretion opening under local anesthesia. A huge yellow stone was found and removed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Pathological results showed eosinophilic amorphous material, which was considered to be calculous pathological change. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC) Gram-negative (G\u003csup\u003e\u0026minus;\u003c/sup\u003e) coccobacilli was observed in the stone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). No fungal growth was observed, but the bacterial culture results of the stone showed Haemophilus influenzae growth. After the operation, we gave the prescription of antibiotics such as Gemifloxacin and levofloxacin. The conjunctival redness and ocular secretions subsided after surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE), and an orbital magnetic resonance imaging (MRI) 10 days after surgery showed no abnormal signals were found in the lacrimal gland area and the eyelids (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF). There was no recurrence during the 7-month follow-up period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case reported a giant stone located in the lateral canthus with no specific symptoms except for purulent ocular discharge, with was misdiagnosed as conjunctivitis, and the stone was associated with Haemophilus influenzae infection. Reports on stones in the lacrimal duct system were mostly reported in the nasolacrimal duct and lacrimal gland currently, but there were few reports on stones located in a special location: lateral canthus. Othman et al.\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e reported a case of lacrimal duct stone accompanied by obvious lacrimal gland enlargement. Kim et al.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e reported 3 cases of lacrimal duct stones that were misdiagnosed as chalazions. And Zhao et al.\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e reported a case of lacrimal duct stone resented with lacrimal gland prolapse. Unfortunately, the preoperative MRI examination in this case could not be completed due to the patient's personal reason. But the postoperative MRI examination showed no obvious abnormal MRI signals or inflammatory edema reactions in the lacrimal gland or lacrimal duct system. Therefore, we inferred that the location of the stone was far away from the lacrimal gland and was most likely located at the opening of the lacrimal duct.\u003c/p\u003e \u003cp\u003eThe pathogenesis of lacrimal duct stone was still unclear. Abnormal tear dynamics, protein-encapsulated accumulation of various components, and infection were possible causes. Stasis in tear dynamics was important factor in the formation of lacrimal stones. We speculated that epithelial debris or cosmetics blocking the lacrimal duct opening in the lacrimal duct may be the initiating factors for stone formation. Besides, the core of a lacrimal duct stone may be developed from various components. Previous studies have reported ingredients such as eyelashes,\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e cilium or rabbit fur\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e and other components. It has been well established that protein is the main component of lacrimal gland stones were mainly composed of protein,\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e and calcium.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e Histological examination all reported eosinophilic amorphous material with calcification changes,\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e with was consistent with our results. However, no obvious core material was found in this case. Regarded with the patient's previous eye surgery history and her own high-density lipoprotein cholesterol level, we speculated that the patient's ocular surface homeostasis was unstable, accompanied by extensive lipid secretion. The stone may have developed from the detached and dissolved epithelial tissue and lipid deposits.\u003c/p\u003e \u003cp\u003eMicrobial growth may further promote stone formation. Most previous studies reported that the lacrimal system was infected with Gram-negative (G\u003csup\u003e+\u003c/sup\u003e) bacteria. The bacterial culture conducted by Kim et al.\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e showed Pseudomonas aeruginosa around the stone. In this case, we found Haemophilus influenzae in the culture of the stone, but we were not sure whether this was the causes of the disease. Baker et al.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e reported a case of a stone in the palpebral lobe of the lacrimal gland and was cultured positive for Haemophilus influenzae. Halborg et al.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e reported three cases of stones confined to the lacrimal ductile, in which G\u003csup\u003e+\u003c/sup\u003e bacteria were all observed. Haemophilus influenzae was commonly found in the respiratory infections, but was also the most common bacterium in neonatal dacryocystitis.\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e Along with Streptococcus pneumoniae and Staphylococcus aureus, it was a common pathogen of lacrimal gland inflammation.\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e When there was an infection of G\u003csup\u003e+\u003c/sup\u003e bacteria in the lacrimal system, it may cause tissue damage and inflammation, further creating a favorable environment for the G\u003csup\u003e\u0026minus;\u003c/sup\u003e bacteria colonization and spread, which may lead to the prolongation of the course of the disease.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e Therefore, for unilateral persistent refractory conjunctivitis, clinicians should pay attention to the patient's potential lacrimal duct infection. During treatment, the use of combined antibiotics should be considered to cover G\u003csup\u003e+\u003c/sup\u003e and G\u003csup\u003e\u0026minus;\u003c/sup\u003e bacteria to improve the effects of treatment.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLacrimal duct stones may have no obvious signs. Common symptoms included unilateral eye redness, secretions, tearing, pain, and palpable masses, which were similar to symptoms of conjunctivitis or chalazion. Therefore, for patients with persistent unilateral canthal conjunctivitis and poor antibiotic treatment effects, lacrimal duct stones should be considered.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the declaration of Helsinki, and the patient signed an informed consent for the use of human materials and data mentioned in this report for scientific research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSL collected and interpreted the data and critically reviewed the literature. YH drafted this manuscript. YZ and XZ collected the data. YJ critically reviewed the final version of the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOthman OB, Takahashi Y, Valencia MRP, Kakizaki H. A stone in the lacrimal gland: a case report and literature review. \u003cem\u003eOrbit\u003c/em\u003e. 2020;39(1):48-52. \u003c/li\u003e\n\u003cli\u003eZhao J, Xu Z, Han A, Zeng L, Hao G, Chen B. A huge lacrimal gland ductule dacryolith with a hairy nucleus: a case report. \u003cem\u003eBMC ophthalmol\u003c/em\u003e. 2018;18:1-2.\u003c/li\u003e\n\u003cli\u003eKim SC, Lee K, Lee SU. Lacrimal gland duct stones: misdiagnosed as chalazion in 3 cases. \u003cem\u003eCan J Ophthalmol\u003c/em\u003e. 2014;49 (1):102-05. \u003c/li\u003e\n\u003cli\u003eBaratz KH, Bartley GB, Campbell RJ, Garrity JA. An eyelash nidus for dacryoliths of the lacrimal excretory and secretory systems. \u003cem\u003eAm J Ophthalmol\u003c/em\u003e. 1991;111(5):624-27. \u003c/li\u003e\n\u003cli\u003eHalborg J, Prause JU, Toft PB, Skj\u0026oslash;dt K, Tommerup NR, Nielsen OF, et al. Stones in the lacrimal gland: a rare condition. \u003cem\u003eActa Ophthalmol\u003c/em\u003e. 2009;87(6):672-75. \u003c/li\u003e\n\u003cli\u003eChandravanshi SL. Spontaneous expulsion of lacrimal gland ductule stones by eyelid squeezing: a rare event. \u003cem\u003eOrbit\u003c/em\u003e. 2014; 33(3): 223-25. doi: 10.3109/01676830.2014.894538.\u003c/li\u003e\n\u003cli\u003eBaker RH, Bartley GB. Lacrimal gland ductule stones. \u003cem\u003eOphthalmology\u003c/em\u003e. 1990;97(4):531-34. doi: 10.1016/S0161-6420(90)32553-8\u003c/li\u003e\n\u003cli\u003eBekmez S, Eriş E, Altan EV, Dursun V. The role of bacterial etiology in the tear duct infections secondary to congenital nasolacrimal duct obstructions.\u003cem\u003e J Craniofac Surg. \u003c/em\u003e2019;30(7):2214-16. \u003c/li\u003e\n\u003cli\u003eWai KM, Locascio JJ, Wolkow N. Bacterial dacryoadenitis: clinical features, microbiology, and management of 45 cases, with a recent uptick in incidence. \u003cem\u003eOrbit\u003c/em\u003e. 2022;41(5):563-71.\u003c/li\u003e\n\u003cli\u003eRuhal R, Kataria R. Biofilm patterns in gram-positive and gram-negative bacteria. \u003cem\u003eMicrobiol Res\u003c/em\u003e. 2021;251:126829. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lacrimal gland duct, Stone, Haemophilus influenzae, Refractory conjunctivitis, Temporal canthus","lastPublishedDoi":"10.21203/rs.3.rs-6232103/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6232103/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose: Stones located in the temporal canthus were relatively rare. We presented a case of giant lacrimal duct stone associated with Haemophiles influenzae and described the clinical features.\u003c/p\u003e\n\u003cp\u003eCase presentation: A female patient presented persistent secretion in the lateral canthal region of the right eye. Surgical exploration was performed, and bacterial culture, tissue pathology analysis and magnetic resonance imaging (MRI) examination were completed. A huge stone was found in the temporal canthus, which was composed of amorphous acidic substances. The bacterial culture results showed infection with Haemophilus influenzae, and the postoperative MRI results showed no signs of inflammation around the lacrimal gland. The patient's symptoms disappeared immediately after the operation.\u003c/p\u003e\n\u003cp\u003eConclusion: Lacrimal duct stone was a very rare diagnosis but worth considering when a patient presented a unilateral lateral refractory conjunctivitis.\u003c/p\u003e","manuscriptTitle":"A Lacrimal Gland Duct Stones Misdiagnosed as Refractory Conjunctivitis: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-14 23:23:06","doi":"10.21203/rs.3.rs-6232103/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-16T09:40:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-05T04:13:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164555970425367207350217599568758892370","date":"2025-06-05T04:09:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-03T16:27:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184437205963003591358301522028347687656","date":"2025-05-12T04:34:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-09T19:32:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5205372600080599425854335352849466021","date":"2025-03-26T11:30:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-26T08:21:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T08:18:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-24T11:11:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T09:08:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-03-24T09:06:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a760da7a-c1e9-41f1-8cd3-60c835d7499a","owner":[],"postedDate":"April 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T16:04:07+00:00","versionOfRecord":{"articleIdentity":"rs-6232103","link":"https://doi.org/10.1186/s12886-025-04287-2","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2025-08-07 15:58:04","publishedOnDateReadable":"August 7th, 2025"},"versionCreatedAt":"2025-04-14 23:23:06","video":"","vorDoi":"10.1186/s12886-025-04287-2","vorDoiUrl":"https://doi.org/10.1186/s12886-025-04287-2","workflowStages":[]},"version":"v1","identity":"rs-6232103","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6232103","identity":"rs-6232103","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}