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Purpose: To report a case of lacrimal drainage pathway disease-associated keratopathy (LDAK) with endophthalmitis. Observations: An 80-year-old man with diabetic retinopathy and nephropathy was referred to our hospital with endophthalmitis of the left eye. Slit-lamp examination revealed slight eye discharge, peripheral corneal ulcers, diffuse hyperemia of the conjunctiva, iris synechia, and a large amount of fibrin in the anterior chamber of the left eye. No puncta of the left eye were observed. The patient had undergone trabeculectomy for primary open-angle glaucoma 5 years previously. B-mode echo examination confirmed vitreous opacity in the left eye. We suspected endophthalmitis and performed a par-plana vitrectomy, bacterial culture, and polymerase chain reaction examination for eye discharge, aqueous humor, and vitreous humor. However, no bacteria or viruses were detected. The eye discharge and corneal peripheral ulcers did not improve following surgery. A lacrimal syringe test was performed two weeks after surgery, and bacterial concretion and discharge were observed. We detected Actinomyces in the bacterial concretions and performed dacryocystorhinostomy. After surgery, the corneal ulcer improved, and eye discharge disappeared. Conclusions and importance: LDAK causes corneal perforation and endophthalmitis. In cases of intraocular inflammation with corneal ulcers, a lacrimal syringing test should be performed, even in the absence of lacrimal findings on slit-lamp examination.

Purpose: To report a case with corneal perforation, presumably due to ocular cicatricial pemphigoid (OCP) and bacterial concretion derived from lacrimal canaliculitis. Observations: A patient with OCP demonstrated adherence of concretion to the cornea of her right eye. She also demonstrated canaliculitis in this eye. We removed a whitish precipitate from the bottom of the corneal ulcer. When we flushed her lacrimal pathway, a marked amount of bacterial concretion and dense mucosa were refluxed from both puncta on the right side. On the next day, corneal perforation was visible from the area where concretion was removed. We performed punctoplasty and removed the bacterial concretion from the lacrimal canaliculus and sac. After the operation, her symptoms improved and corneal perforation recovered. Conclusions and Importance: Both lacrimal canaliculitis and OCP can cause corneal perforation, and adherence of bacterial concretion onto the cornea is very rare. However, once it occurs, corneal perforation can rapidly follow. OCP sometimes causes corneal epithelial damage, which may influence adherence to concretion. Canaliculitis in patients with OCP should be managed carefully.

Purpose: To report a case with lacrimal fistula presumably associated with Sjögren's syndrome. Observations: A patient with Sjögren's syndrome was referred to our hospital for fistula from the inferior lacrimal canaliculus to the palpebral conjunctiva of her left lower eyelid. She also revealed severe dry eye in both eyes. She had no history of trauma or congenital lacrimal fistula. She was administering 0.3% purified sodium hyaluronate and 3% diquafosol sodium solution 6 times a day for dry eye. The Schirmer-1 test indicated that tear secretion was 0 mm for 5 min for both eyes. She was diagnosed with Sjögren's syndrome based on increased levels of blood Sjögren's-syndrome-related antigen A and Sjögren's-syndrome-related antigen B antibodies, decreased saliva volume, and lip biopsy. We performed silicone tube intubation and patched the fistula with conjunctiva. We observed the lacrimal sac and nasolacrimal duct under lacrimal micro-endoscopy; there was no bacterial concretion, obstruction, and inflammation of lacrimal mucosa. After the operation, her symptoms improved and lacrimal perforation healed after the removal of the silicone tube. Conclusions and importance: Sjögren's syndrome can cause not only corneal perforation but also mucosal perforation, which may lead to a lacrimal fistula. Sjögren's syndrome patients with severe dry eye should be managed carefully. Keywords: Lacrimal fistula, Sjögren's syndrome, dry eye