Nasolacrimal Duct Obstruction and Epiphora Clinical Presentation

Updated: Aug 17, 2018
  • Author: Sandra R Worak, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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A patient may present with a simple case of tearing or watery eyes. This should be distinguished from true epiphora.

Symptoms of nasolacrimal duct obstruction may include the following:

  • 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 may include the following:

  • Previous eye surgery (dacryocystorhinostomy)
  • Lid surgery
  • Glaucoma (antiglaucoma medications) [6, 7]
  • Use of topical medications
  • Trauma

Past medical history may include the following:

  • Lymphoma, [8] 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
  • Previous nasal or sinus surgery


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



Primary acquired nasolacrimal duct obstruction

Partial stenosis or complete obliteration of duct lumen may result from idiopathic inflammation and fibrosis of nasolacrimal duct.

Secondary acquired nasolacrimal duct obstruction


Infectious causes include the following:

  • Bacterial - Staphylococcus aureus, Actinomyces, Pseudomonas, Propionibacterium, Fusobacterium, Bacteroides, Mycobacterium, Chlamydia, Nocardia, Aeromonas, Enterobacter, Treponema pallidum
  • Viral - Herpes simplex, herpes zoster, varicella zoster (chickenpox), adenoviruses (epidemic keratoconjunctivitis)
  • Fungal - Aspergillus, Candida, Pityrosporum, Trichophyton
  • Parasitic - Ascaris species



Drug-induced causes may include the following:

  • Antineoplastic therapy [9, 10]
  • Topical antiglaucoma therapy [11]
  • Intranasal cocaine [12]

Ophthalmic medications are the most common cause of iatrogenic punctal and canalicular scarring. Radiotherapy of the medial canthal area may cause a severe inflammatory reaction that leads 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.


Endogenous causes include the following:

  • Wegener granulomatosis
  • Sarcoidosis
  • Cicatricial pemphigoid
  • Sinus histiocytosis
  • Kawasaki disease
  • Scleroderma


Neoplastic causes can be primary, secondary, or metastatic.

Inverted papilloma is the most common benign neoplasm, and lymphoma is the most common malignant neoplasm arising from the nasolacrimal duct. [13]


Mechanical causes include the following:

  • Intraluminal foreign body
  • External compression/occlusion
  • Traumatic


Potential complications include the following:

  • Dacryocystitis
  • Chronic conjunctivitis
  • Preseptal cellulitis