A 70-year-old female patient presented with complaint of “whitish gritty discharge” from her left eye of 6 months’ duration. The patient provided written informed consent for publication of the research details and clinical images.

Slit-lamp examination revealed swelling and erythema on the medial aspect of her left lower lid. On lid eversion, a pouting punctum was seen. Another accessory punctum was noticed, 2 mm lateral to the punctum. Both the puncta had whitish gritty secretions plugging them. On palpation, the lower canaliculus was found to be tender and thickened. Rest of the anterior segment and posterior segment examination was unremarkable. Based on case history and clinical examination, a provisional diagnosis of chronic canaliculitis caused by Actinomyces species was made. Double puncta in left eye and right eye punctum were dilated and granules plugging both the orifices left eye were expressed out in a minor operating room under sterile conditions with the help of a cotton tip applicator. Syringing with antibiotic solution both eyes was done which was painless and patent. Patient was advised ocular hygiene, warm compression, and local massage. Topical antibiotic neomycin was given four times a day for 1 week only for left eye. Microbiological examination of these secretions revealed anaerobic Gram-positive filamentous bacilli confirming the presence of A. israelii, and the whitish granules were found to be its aggregations, commonly known as “sulfur granules” (Fig. 1A). On 1 week follow-up the canaliculitis had resolved. Syringing was normal in both eyes. Topical antibiotics were continued for another week and patient kept on monthly follow-up. On every follow- up, patient was symptom free and both canaliculi were normal in appearance.

The close proximity of the two puncta, along with the pouting nature of these orifices (as a result of chronic inflammation) resembled the appearance of a “pig snout,” thus prompting us to call this appearance as “pig snout” canaliculus (Fig. 1B). Double puncta are associated with more complications and poorer prognosis hence early and prompt treatment is required. It is more prone to cause ocular surface dryness, periorbital cellulitis, orbital pyogenic infections compared to single punctum. Most studies have found canaliculotomy to be safe and effective [1]. In our case, the concretions were plugging the opening of canaliculus hence gently pressure with cotton tip easily removed the concretions and there was no need of snip or curettage. To the best of our knowledge, double punctum associated with actinomycetes canaliculitis has not been reported in literature so far and with this case, we share a rare presentation of this condition.