eMedicine Specialties > Ophthalmology > Lacrimal System

Nasolacrimal Duct, Obstruction: Differential Diagnoses & Workup

Author: Jorge G Camara, MD, Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine
Coauthor(s): Sandra R Worak, MD, Consulting Staff, Department of Orbit and Oculoplasty, Reconstructive and Lacrimal Surgery, East Avenue Medical Center; Alfonso U Bengzon, MD, MBA, Consulting Staff, Department of Ophthalmology, Makati Medical Center; Training Officer, Department of Ophthalmology Residency Training Program, Medical City General Hospital, Philippines
Contributor Information and Disclosures

Updated: Oct 22, 2008

Differential Diagnoses

Bell Palsy
Corneal Foreign Body
Blepharitis, Adult
Dacryocystitis
Cellulitis, Preseptal
Distichiasis
Cicatricial Pemphigoid
Dry Eye Syndrome
Conjunctivitis, Allergic
Ectropion
Conjunctivitis, Bacterial
Entropion
Conjunctivitis, Viral
Corneal Abrasion

Other Problems to Be Considered

Craniofacial abnormalities
Dacryoliths
Dacryocystocoeles
Inverted papilloma
Lacrimal sac abscess
Lacrimal sac tumors
Nasal allergies
Nasolacrimal sac mucocoeles
Nasolacrimal duct orifice cysts

Workup

Laboratory Studies

  • Send lacrimal discharge for the following studies (depending on suspected etiologies):
    • Gram stain/Giemsa stain
    • Cultures and sensitivities
    • KOH (suspected fungal infection)
    • Anticytoplasmic antibodies (Wegener granulomatosis) - Monitor disease activity

Imaging Studies

  • Dacryocystography
    • Visualization of anatomic details of the lacrimal drainage system using contrast material
    • Visual localization of the site of obstruction may help determine the surgical plan.
  • Dacryoscintigraphy
    • More sensitive and less invasive method of lacrimal system imaging
    • More sensitive for incomplete blocks of the upper drainage system
    • Functional lacrimal duct obstruction is easily diagnosed with dacryoscintigraphy. It may be classified by types of obstruction to predict postoperative results of silicone tube insertion.
      • Class I - Delayed secretion in the distal nasolacrimal duct
      • Class II – Delayed secretion in the proximal nasolacrimal duct
      • Class III - Delayed secretion from the prelacrimal sac to the lacrimal sac
    • Prelacrimal sac obstructions, in particular, may achieve better operative results with adjuvant treatments in addition to silicone tube insertion.
    • Does not provide as much detailed anatomic imaging as contrast DCG
  • Computed tomography scan
    • Use if suspecting traumatic, neoplastic, or mechanical causes of obstruction
    • Useful for diagnosis and preoperative surgical planning
  • Computed tomographic dacryocystography (CTDCG)
    • Axial plain computed tomography (CT) scan, followed by administration of water-soluble contrast in the conjunctival cul-de-sac or by cannulation of the lacrimal passages
    • Safe and useful for diagnosing lacrimal system blocks and medial canthal masses
    • Can evaluate dacryocystorhinostomy failures before re-operation
  • Nasal endoscopy - Used for postoperative evaluation of dacryocystorhinostomy and for dacryocystorhinostomy using the endonasal approach
  • Gadolinium-enhanced magnetic resonance dacryocystography
    • The overall sensitivity of magnetic resonance (MR) in detecting obstruction was 100%. MR helped to determine the canalicular and ductal obstruction in 100% of patients and the saccular obstruction in 80% of patients.
    • The authors of this study concluded that three-dimensional (3D) fast spoiled gradient-recalled (FSGR) technique for MR dacryocystography is a reliable and noninvasive method in the evaluation of the obstruction level in the lacrimal system in patients with epiphora.6

Other Tests

  • Tear production measurement to rule out tear deficiency or instability as the cause of possible reflex tearing
  • Schirmer test
    • Without topical anesthetic (stimulated tear production): Normal measurement is 10-30 mm wetting of Schirmer strip after 5 minutes.
    • With topical anesthesia (basic secretion): Normal measurement is greater than 5 mm of wetting of Schirmer strip paper after 5 minutes.
  • Tear break-up time test to rule out tear instability: Normal break-up time is 15-30 seconds. A time of 10 seconds or less is considered distinctly abnormal.
  • Fluorescein dye disappearance test
    • A positive result is indicated by +2 to +4 residual fluorescein 5 minutes after instillation.
    • Positive results indicate a partial or complete obstruction, or pump failure.
    • This test is simple and effective as a screening tool.
    • The shortcomings are inability to distinguish between physiologic and anatomic causes of drainage dysfunction, inability to distinguish between upper and lower abnormality, and false-positive results.
  • Lacrimal irrigation
    • Reflux of irrigating fluid in the opposite/upper punctum demonstrates patency of the canalicular system but suggests obstruction in the distal drainage system.
    • Lacrimal irrigation occasionally may be therapeutic by dislodging an obstructing stone or concretion or widening a partially stenosed passage.
    • Rarely, adult patients are completely relieved of symptoms after nasolacrimal probing and irrigation; others are only relieved temporarily or not at all.
  • Probing of canaliculi
    • When the irrigation test indicates obstruction, probing is used in an attempt to palpate or localize the site of obstruction.
    • The location of canalicular obstruction may be located, or the degree of stenosis may be estimated.
  • Jones dye tests
    • Jones I: Dye is instilled in the patient's eye, and the patient is asked to blow his or her nose after 5 minutes.
      • Presence of dye indicates a patent system and normal physiologic function.
      • Absence of dye indicates 3 possibilities: false-negative result, physiologic dysfunction, or anatomic obstruction.
    • Jones II: The patient’s lacrimal drainage system is irrigated after a negative Jones I, and the patient is asked to expel any drainage from his or her pharynx.
      • Presence of dye indicates a partial block at the lower sac or duct
      • Presence of saline indicates punctal or canalicular stenosis
      • Regurgitation indicates complete NLDO or complete common canaliculus block.
    • High level of false results from Jones test
  • Microreflux test
    • Screening test for PANDO
    • Positive test - Reflux of fluorescein-stained tears from the inferior punctum after counterclockwise lacrimal sac massage
    • Sensitivity of 97%
    • Specificity of 95%
  • Hornblass saccharine test
    • Instill saccharine drops in one eye and chloramphenicol eye drops in the other eye several minutes later.
    • The ability of the patient to detect the sweet taste of the saccharine and the bitter taste of the chloramphenicol denotes a patent lacrimal system.
    • False-negative results are possible.

Histologic Findings

A study published in Ophthalmic Plastic and Reconstructive Surgery in May 2003 presented clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy (DCR).7

Their data revealed the following, in decreasing order of frequency: nongranulomatous inflammation (85.1%); granulomatous inflammation consistent with sarcoidosis (2.1%); lymphoma (1.9%); papilloma (1.11%); lymphoplasmacytic infiltrate (1.1%); transitional cell carcinoma (0.5%); and single cases of adenocarcinoma, undifferentiated carcinoma, granular cell tumor, plasmacytoma, and leukemic infiltrate.7

They concluded that nongranulomatous inflammation consistent with chronic dacryocystitis is the most common diagnosis in lacrimal sac specimens obtained at DCR. Neoplasms resulting in chronic nasolacrimal duct obstruction occurred in 4.6% of cases and were unsuspected before surgery in 2.1% of patients.7

Staging

Diagnostic canalicular irrigation can determine the level of canalicular obstruction. 

  • Partial obstruction - Partial fluid flow into the nose, partial reflux 
  • Total common canalicular obstruction – Flow from the lower to the upper canaliculus with no flow into the nose 
  • Total functional occlusion – Partial obstruction under normal physiologic conditions
  • Complete nasolacrimal obstruction – Fluid flow into the nose with mucoid reflux

More on Nasolacrimal Duct, Obstruction

Overview: Nasolacrimal Duct, Obstruction
Differential Diagnoses & Workup: Nasolacrimal Duct, Obstruction
Treatment & Medication: Nasolacrimal Duct, Obstruction
Follow-up: Nasolacrimal Duct, Obstruction
Multimedia: Nasolacrimal Duct, Obstruction
References
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References

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Further Reading

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Keywords

nasolacrimal duct obstruction, nasolacrimal drainage obstruction, NLDO, tear-duct obstruction, tear duct obstruction, tear ducts, epiphora, tear drainage, lacrimal drainage system, tearing, tear production

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Contributor Information and Disclosures

Author

Jorge G Camara, MD, Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine
Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Sandra R Worak, MD, Consulting Staff, Department of Orbit and Oculoplasty, Reconstructive and Lacrimal Surgery, East Avenue Medical Center
Sandra R Worak, MD is a member of the following medical societies: Philippine Medical Association
Disclosure: Nothing to disclose.

Alfonso U Bengzon, MD, MBA, Consulting Staff, Department of Ophthalmology, Makati Medical Center; Training Officer, Department of Ophthalmology Residency Training Program, Medical City General Hospital, Philippines
Alfonso U Bengzon, MD, MBA is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Ron W Pelton, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, Utah Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Mark T Duffy, MD, PhD, Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic
Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience
Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting; Quest medical - lacrimal balloons Honoraria Speaking and teaching; Ortho-Neutrogenia Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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