Obstruction Nasolacrimal Duct Workup

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

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
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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.Dacryocystogram. A patent nasolacrimal system on tDacryocystogram. 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.
  • 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)[10]
    • 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[11]
  • 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.[12]
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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.
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Histologic Findings

A study presented clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy (DCR).[13]

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.[13]

They concluded that nongranulomatous inflammation consistent with chronic dacryocystitis is the most common diagnosis in lacrimal sac specimens obtained at DCR.[13] Neoplasms resulting in chronic nasolacrimal duct obstruction occurred in 4.6% of cases and were unsuspected before surgery in 2.1% of patients.[13]

Dacryocystitis of the left nasolacrimal system. Dacryocystitis of the left nasolacrimal system.
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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
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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 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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