Obstruction Nasolacrimal Duct Treatment & Management

  • Author: Jorge G Camara, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 9, 2012
 

Medical Care

  • The type of antibiotic depends on the suspected infecting agent or the results of cultures and sensitivities.
  • Topical antibiotics with lacrimal massage may be adequate for early infections.
  • Systemic antibiotics may be necessary for more chronic or severe infections, such as those causing dacryocystitis, canaliculitis, or preseptal cellulitis (may progress to orbital abscesses).
  • Although sensitive to penicillin, Actinomyces organisms usually require complete removal of the canalicular stones for complete treatment.
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Surgical Care

  • External dacryocystorhinostomy
    • Criterion standard of lacrimal bypass surgeries
    • Success rates up to 95%
    • Facilitates identification and removal of dacryoliths and lacrimal sac tumors; also allows for biopsy of every lacrimal sac
    • Requires skin incision
    • Creates a communication between the lacrimal sac and nasal cavity, bypassing the obstructed nasolacrimal duct
  • Endoscopic mechanical/nonlaser dacryocystorhinostomy
    • Involves the creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps
    • Difficult to make definite evidence-based determinations about the relative efficacy of endonasal and external dacryocystorhinostomy because of the deficiencies in the reported literature
    • Available data suggest that endonasal dacryocystorhinostomy may be a viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients.
    • May be indicated on a primary basis or as revisional surgery following failed external or endonasal dacryocystorhinostomy
    • Some studies comparing endonasal dacryocystorhinostomy with external dacryocystorhinostomy suggested lower success rates in the endonasal group. Other studies yielded success rates comparable with or exceeding those of external surgery.
    • Complications of endonasal dacryocystorhinostomy do not generally appear to be greater in frequency or magnitude than those associated with external dacryocystorhinostomy.
    • Disadvantages of endonasal dacryocystorhinostomy include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure.
    • Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal dacryocystorhinostomy than external dacryocystorhinostomy. In one study, the success rate of 93.5% compares favorably with that of standard external dacryocystorhinostomy (95.8%).
    • Anatomical success rate (91%) compares favorably with the success rate of other techniques for endonasal dacryocystorhinostomy and is also similar to the success of external dacryocystorhinostomy.
    • Experience in endoscopic nasal surgery is important, as other ancillary procedures may be required within the nose at the time of surgery.
  • Endoscopic laser dacryocystorhinostomy
    • The KTP laser or the holmium:YAG laser is used.
    • In one study, the success rate in the endonasal group improved from 50% in the first 38 cases to 79% in the last 38 cases, thereby demonstrating a learning curve.
  • Endoscopic laser-assisted dacryocystorhinostomy
    • Advantages
      • No skin incision
      • Less bleeding
      • Faster recovery
    • Approaches
      • Endocanalicular
      • Trans-conjunctival
      • Endoscopic nasal
    • Endoscopic laser-assisted dacryocystorhinostomy is shown in this video.
      Endoscopic laser-assisted dacryocystorhinostomy.
  • Conjunctivodacryocystorhinostomy
    • Conjunctivodacryocystorhinostomy (CDCR) is performed in cases of flaccid canaliculi, paralysis of lacrimal pump, absence or obliteration of canaliculi, when site of obstruction is proximal (punctum, canaliculi, lacrimal sac), congenital malformations, cicatricial conjunctival disease, chemical burns, irradiation, and tumors of the lacrimal sac.
    • The procedure uses a Pyrex Jones tube, which serves as a conduit between the medial conjunctival cul-de-sac and the nasal cavity.
  • Balloon catheter dilatation
    • The use of balloon catheter dilation for the treatment of adults with partial nasolacrimal duct obstruction and for children with congenital nasolacrimal duct obstruction has been described with good results in patients without active infection.
    • This treatment is effective for congenital nasolacrimal duct obstruction.
    • This treatment is highly successful in older children who failed previous probing.
    • Success in children older than 24 months is 82.9%. Success in children younger than 24 months is 65.4%.
    • Balloon catheter dilatation is more effective than simple probing for older children with nasolacrimal duct obstruction because of stenosis that extends along the distal nasolacrimal duct.
    • No significant advantage exists over simple nasolacrimal duct probing in patients with typical membranous obstruction at the Hasner valve.
    • Endoscopically assisted balloon dacryoplasty has been shown as a treatment for incomplete NLDOs to provide substantial improvement or even complete relief.
  • Stents may be used as a first-line treatment for epiphora.
    • Polyurethane stents
      • Low success rate for the treatment of PANDO
      • May induce inflammation and fibrous tissue formation
      • May cause further difficulties in subsequent lacrimal surgeries
      • Does not appear to be an efficacious therapeutic option for treating epiphora caused by postsaccal obstruction
    • Silicone: Double bicanalicular silicone intubation with the placement of 2 loops of silicone tubing through the nasolacrimal duct for the treatment of persistent nasolacrimal duct obstruction in children is an effective alternative to dacryocystorhinostomy in selected children who have failed conventional therapies.
    • For treatment of epiphora in adults with presumed functional nasolacrimal duct obstruction, silicone intubation has good long-term success, according to a study by Moscato et al.[14]
    • Hydrogel stents[15]
      • Newly designed stent with a late success rate of 78.3%
      • Well-tolerated; useful for acquired nasolacrimal duct obstruction, maintaining apposition of mucosal edge and decreasing incidence of nasal adhesions
    • Otologic T-tubes[16, 17]
      • Cheap and easy self-retaining stent to ensure a patent rhinostomy
      • Success rate of 73-82%
      • Inserted without passing through the punctum but directly through the medial wall sac
  • Adjunctive use of mitomycin-C during dacryocystorhinostomy procedures significantly increases the success rate without adverse effects.[18, 19, 20, 21, 22]
    • Success rate of 87.5-95%
    • Mitomycin-C, 0.2 mg/mL, may be used intraoperatively and postoperatively after external, endoscopic, and endolaser-assisted dacryocystorhinostomy and after balloon dacryoplasty.
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Consultations

This condition can be co-managed by the following specialists:

  • Otolaryngologist
  • Radiologist
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Diet

Normal

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Activity

As tolerated

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Proceed to Medication
 
 
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 Academy of Ophthalmology and Philippine Medical Association

Disclosure: Nothing to disclose.

Alfonso U Bengzon, MD, MBA  Consulting Staff, Department of Ophthalmology; Section Head, Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, The Medical City General Hospital, Philippines; Consultant Head, The Medical City Diagnostic and Laser Eye Center

Alfonso U Bengzon, MD, MBA is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Specialty Editor Board

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 College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, AO Foundation, and Colorado Medical Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

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.

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 Honoraria Speaking and teaching

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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Dacryocystitis of the left nasolacrimal system.
Dacryocystogram. A patent nasolacrimal system on the right side of a patient and a blocked system on the contralateral side at the level of the nasolacrimal duct.
Endoscopic laser-assisted dacryocystorhinostomy.
 
 
 
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