eMedicine Specialties > Ophthalmology > Lacrimal System

Nasolacrimal Duct, Obstruction

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

Introduction

Background

Epiphora is defined as the overflow of tears. The clinical spectrum of epiphora ranges from the occasionally bothersome trickle to the chronically irritating overflow. Epiphora is caused by a disruption in the balance between tear production and tear drainage. The lacrimal drainage system is a continuous and complex membranous channel whose function is dependent on the interaction of anatomy and physiology.

When faced with a patient who complains of tearing, the first step is to determine whether the epiphora is caused by an increase in lacrimation or a decrease in tear drainage. Trichiasis, superficial foreign bodies, eyelid malpositions, diseases of the eyelid margins, tear deficiency or instability, and cranial nerve V irritation may cause an abnormal increase in tear production. In the absence of these conditions, an abnormality in tear drainage is the most likely cause.

Abnormalities of tear drainage may be subdivided further into functional and anatomical. Functional failure is related to poor lacrimal pump function, which may be due to a displaced punctum, eyelid laxity, weak orbicularis, or cranial nerve VII palsy. Anatomical obstruction may occur at any point along the lacrimal drainage pathway and may be congenital or acquired. Congenital obstructions tend to produce symptoms during the neonatal period and are the subject of another article, Nasolacrimal Duct, Congenital Anomalies.

Classification of nasolacrimal drainage obstruction

The 2 types of acquired nasolacrimal drainage obstructions (NLDO) are primary and secondary. In 1986, Linberg and McCormick coined the term primary acquired nasolacrimal duct obstruction (PANDO) to describe an entity of nasolacrimal duct obstruction caused by inflammation or fibrosis without any precipitating cause.1 Bartley proposed an etiologic classification system for secondary acquired lacrimal drainage obstruction (SALDO) based on published cases.2,3,4

Pathophysiology

PANDO is more common in middle-aged and elderly females. Using CT scans, Groessl, Sires, and Lemke demonstrated that women have significantly smaller dimensions in the lower nasolacrimal fossa and middle nasolacrimal duct.5 They noted that changes in the anteroposterior dimensions of the bony nasolacrimal canal coincide with osteoporotic changes throughout the body. These quantitative measurements may help explain the higher incidence of PANDO in women. Others have suggested menstrual and hormonal fluctuations and a heightened immune status as factors that may contribute to the disease process. These may explain the prevalence in middle-aged and elderly females. Hormonal changes that bring about a generalized de-epithelialization in the body may cause the same within the lacrimal sac and duct. An already narrow lacrimal fossa in women predispose them to obstruction by the sloughed off debris.

The general categories of causes of SALDO include infectious, inflammatory, neoplastic, traumatic, and mechanical. Bacteria, viruses, fungi, and parasites have been implicated as causes of infectious lacrimal drainage obstruction. Bacteria, such as Actinomyces, Propionibacterium, Fusobacterium, Bacteroides, Mycobacterium, and Chlamydia species, have been associated with lacrimal drainage obstruction. Other bacteria include Nocardia, Enterobacter, Aeromonas, Treponema pallidum, and Staphylococcus aureus.

Viral causes of obstruction most commonly are seen with herpetic infection (eg, herpes simplex, herpes zoster, chickenpox, epidemic keratoconjunctivitis). The obstruction is due to the damage of the substantia propria of the canalicular elastic tissue and/or the adherence of the inflammatory membranes to the raw epithelial surface of the canaliculus.

Fungi may obstruct lacrimal passages by forming a stone (dacryolith) or cast. Species associated with obstruction are Aspergillus, Candida, Pityrosporum, and Trichophyton. Parasitic obstruction is rare but is reported in patients infected with Ascaris lumbricoides, which enters the lacrimal system through the valve of Hasner.

Inflammation may be endogenous or exogenous in origin. Wegener granulomatosis and sarcoidosis are 2 examples of conditions that lead to obstruction due to progressive inflammation within the nasal and lacrimal sac mucosa. Other endogenously arising inflammations associated with lacrimal obstruction are cicatricial pemphigoid, sinus histiocytosis, Kawasaki disease, and scleroderma.

Exogenous causes of cicatricial lacrimal drainage obstruction are eye drops, radiation, systemic chemotherapy, and bone marrow transplantation. Ophthalmic medications are the most common cause of iatrogenic punctal and canalicular scarring. Radiotherapy of the medial canthal area may cause a sufficiently severe inflammatory reaction to lead to punctal stenosis, although published reports vary on the amount of radiation causing the inflammation. Systemic chemotherapy with 5-fluorouracil (5-FU) has been known to occlude the puncta and canaliculi, although the incidence has declined since oncologic regimens today use much lower doses for shorter durations.

The use of I(131) for thyroid carcinoma is associated with a 3.4% incidence of documented NLDO and an overall 4.6% incidence of documented or suspected obstruction.

Canalicular and nasolacrimal duct obstruction is a common adverse effect of weekly docetaxel therapy used for metastatic breast cancer and non-small cell lung cancer.

Neoplasms may cause lacrimal obstruction by primary growth, secondary spread, or metastatic spread. Primary neoplasms may arise in the puncta, canaliculi, lacrimal sac, or nasolacrimal duct. Secondary spread from nearby tissues is more common than primary tumors. They are most commonly eyelid cancers (eg, basal cell carcinoma, squamous cell carcinoma), although spread from the maxillary antrum and the nasopharynx also have been reported. Studies have documented oncocytoma and cylindroma from direct extension. Metastatic spread, an extremely rare phenomenon, has been reported with primary sites from the breast and prostate.

Trauma may be iatrogenic in the case of scarring of the lacrimal passage after overly aggressive lacrimal probing. Iatrogenic causes of NLDO also may follow orbital decompression surgery, paranasal, nasal, and craniofacial procedures. Noniatrogenic traumatic causes are either blunt or sharp and most commonly involve the canaliculus, lacrimal sac, and nasolacrimal duct.

Posttraumatic dacryostenosis was found to have a frequent association with delayed treatment of facial fracture repair or bone loss in the lacrimal district.

Mechanical lacrimal drainage obstructions may be due to intraluminal foreign bodies, such as dacryoliths or casts. These may be caused by infection (eg, Actinomyces, Candida) as well as long-term administration of topical medications. Mechanical obstruction also may be caused by external compression from rhinoliths, nasal foreign bodies, or mucoceles.

Dentigerous cyst in the maxillary sinus has been reported to have caused nasolacrimal duct obstruction.

Frequency

United States

This condition is relatively common, but the exact frequency is not known.

International

The incidence rate worldwide is unknown.

Mortality/Morbidity

Epiphora can be a nuisance; if untreated, nasolacrimal duct obstruction can cause significant problems.

Race

No predilection to race has been established.

Sex

  • PANDO is more prevalent in women. Theories regarding this predilection in women are discussed in Pathophysiology. 
  • No gender predilection of SALDO exists.

Age

  • PANDO most commonly is diagnosed in middle-aged women. Previous studies have noted a high incidence of PANDO in individuals aged 50-70 years.

Clinical

History

  • Symptoms
    • Epiphora, mucoid, or purulent discharge
    • Recurrent dacryocystitis, recurrent conjunctivitis or ocular pemphigus
    • Painful, swelling medial canthus
    • Bloody tears
    • Epistaxis (nasal, sinus, or lacrimal sac tumor)
  • Past ocular history
    • Previous eye surgery (dacryocystorhinostomy)
    • Lid surgery
    • Glaucoma (antiglaucoma medications)
    • Use of other topical medications
  • Past medical history
    • Lymphoma, Wegener granulomatosis
    • Sarcoidosis
    • Ocular cicatricial pemphigoid
    • Kawasaki disease
    • Scleroderma
    • Sinus histiocytosis
    • Previous radiation treatment to medial canthal area systemic chemotherapy with 5-FU
    • Parasitic infection
    • Facial trauma
    • Previous nasal or sinus surgery

Physical

  • Gross observations include the following:
    • Overflow of tears
    • Fluctuant tender mass over lacrimal sac area or medial canthal area
    • Mucoid or purulent eye discharge - Significantly distended sac may not regurgitate with pressure due to the functional valve of Rosenmüller
    • Regurgitation test - Mucoid reflux with lacrimal massage indicative of lower system obstruction
  • Slit lamp findings include the following:
    • Tear meniscus height enhanced by fluorescein - Meniscus height greater than 2 mm
    • Punctal stenosis
    • Canaliculitis - Canalicular fullness and creamy pus when canaliculus is pressed
    • Expression of concretions from punctum
    • Pouting punctum with purulent material at opening

Causes

  • PANDO - Idiopathic inflammation and fibrosis of nasolacrimal duct, resulting in partial stenosis or complete obliteration of duct lumen
  • SALDO
    • Infectious
      • Bacteria
      • Viruses
      • Fungi
      • Parasites
    • Inflammatory
      • Exogenous
      • Endogenous
    • Neoplastic
      • Primary
      • Secondary
      • Metastatic
    • Traumatic
      • Idiopathic
      • Nonidiopathic
    • Mechanical
      • Intraluminal foreign body
      • External compression/occlusion

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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