Author Block: Larissa Gouvea , Michael Mimouni, Sara Alshaker, Nizar Din, Dan Deangelis, Nancy Tucker, Harmeet Gill, Allan Slomovic, Clara Chan.  University of Toronto.

Author Disclosure Block: L. Gouvea:  None.  M. Mimouni:   None.  S. Alshaker:  None.   N. Din:  None.  D. Deangelis:   None.  N. Tucker:  None.   H. Gill:  None.  A. Slomovic:   None.  C. Chan:  None., Larissa Gouvea: Not Current  Michael Mimouni: Not Current  Sara Alshaker: Not Current  Nizar Din: Not Current  Dan Deangelis: Not Current  Nancy Tucker: Not Current  Harmeet Gill: Not Current  Allan Slomovic: Not Current  Clara Chan: Not Current

Abstract Title: Clinical features and management of keratoconjunctivitis associated with inadequate tear drainage

Abstract Body: Purpose:  To describe clinical features and management of toxic keratoconjunctivitis associated with punctal and/or canaliculus stenosis (toxic soup syndrome).    Study Design:  Retrospective observational case series  Methods:   Electronic medical record database search for the key words “toxic soup syndrome” and retrospective chart review was performed. 35 eyes of 25 patients seen at a tertiary cornea clinic between January 2017 and December 2021. Gender, age, distance corrected visual acuity (DCVA), topical medications, symptoms, clinical signs, and outcomes after medical and surgical interventions were analyzed. Main outcome measured was improvement in ocular surface signs and symptoms after interventions.   Results:  Overall, 35 eyes of 25 patients with a mean age of 66.47 ± 12.57 years of which 72% were of female gender were included. Primary complaint was hyperemia and epiphora in all patients. Rosacea or meibomian gland disease was present in all patients, 7 (28%) had glaucoma, and 7 (28%) developed limbal stem cell deficiency (LSCD). Twenty-two patients (88%) were using topical medications on presentation. All eyes had either punctal plugs, cauterized puncta, or punctal and/or canaliculus stenosis. Management of all patients comprised of suspension of all preserved topical medications and institution of some type of anti-inflammatory therapy. Nineteen patients (76%) improved after improvement of lacrimal drainage. One patient with severe resistance in the canaliculus required ongoing preservative free topical steroids.  Conclusions:  Chronic drug induced or pooled inflammatory mediators causing toxic conjunctivitis may be aggravated by punctal and/or canaliculus stenosis leading to “toxic soup syndrome”. Obstruction removal leads to improvement in most patients.