Sections

Nasolacrimal Duct Obstruction and Epiphora

Sections Nasolacrimal Duct Obstruction and Epiphora
Overview
Presentation
- History
- Physical
- Causes
- Complications
- Show All
DDx
Workup
Treatment
Medication
Media Gallery
References

Presentation

History

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

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

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

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

Inflammatory

Exogenous

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

Endogenous causes include the following:

Wegener granulomatosis
Sarcoidosis
Cicatricial pemphigoid
Sinus histiocytosis
Kawasaki disease
Scleroderma

Neoplastic

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

Mechanical causes include the following:

Intraluminal foreign body
External compression/occlusion
Traumatic

Complications

Potential complications include the following:

Dacryocystitis
Chronic conjunctivitis
Preseptal cellulitis

Differential Diagnoses

Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction. A clinicopathologic report and biopsy technique. Ophthalmology. 1986 Aug. 93(8):1055-63. [QxMD MEDLINE Link].
Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 1. Ophthal Plast Reconstr Surg. 1992. 8(4):237-42. [QxMD MEDLINE Link].
Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 2. Ophthal Plast Reconstr Surg. 1992. 8(4):243-9. [QxMD MEDLINE Link].
Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification system, case reports, and a review of the literature. Part 3. Ophthal Plast Reconstr Surg. 1993. 9(1):11-26. [QxMD MEDLINE Link].
Groessl SA, Sires BS, Lemke BN. An anatomical basis for primary acquired nasolacrimal duct obstruction. Arch Ophthalmol. 1997 Jan. 115(1):71-4. [QxMD MEDLINE Link].
Kashkonli MB, Rezaee R, Nilforonshan N, et al. Topical antiglaucoma medications and lacrimal drainage system obstruction. Ophthal Plast Reconstr Surg. 2008 May-Jun. 24(3):175-6.
Seider N, Miller B, Beiran I. Topical glaucoma therapy as a risk factor for nasolacrimal duct obstruction. Am J Ophthalmol. 2008 Jan. 145(1):120-123. [QxMD MEDLINE Link].
Berry-Brincat A, Tomlins P, Hall A, Quinlan M, Cheung D. Primary extrasac orbital lymphoma presenting as nasolacrimal obstruction. Orbit. 2008. 27(3):175-7. [QxMD MEDLINE Link].
Yamagishi T, Ochi N, Yamane H, Hasebe S, Takigawa N. Epiphora in lung cancer patients receiving docetaxel: a case series. BMC Res Notes. 2014 May 30. 7:322. [QxMD MEDLINE Link]. [Full Text].
Esmaeli B, Hidaji L, Adinin RB, Faustina M, Coats C, Arbuckle R, et al. Blockage of the lacrimal drainage apparatus as a side effect of docetaxel therapy. Cancer. 2003 Aug 1. 98(3):504-7. [QxMD MEDLINE Link].
Kashkouli MB, Pakdel F, Hashemi M, Ghaempanah MJ, Rezaee R, Kaghaz-Kanani R, et al. Comparing anatomical pattern of topical anti-glaucoma medications associated lacrimal obstruction with a control group. Orbit. 2010 Apr. 29(2):65-9. [QxMD MEDLINE Link].
Alexandrakis G, Tse DT, Rosa RH, Johnson TE. Nasolacrimal duct obstruction associated with chronic intranasal cocaine abuse. Arch Ophthalmic. 1999 Dec. 117(12):1617-22. [QxMD MEDLINE Link].
Tanweer F, Mahkamova K, Harkness P. Nasolacrimal duct tumours in the era of endoscopic dacryocystorhinostomy: literature review. J Laryngol Otol. 2013 Jul. 127 (7):670-5. [QxMD MEDLINE Link].
Udhay P, Noronha OV, Mohan RE. Helical computed tomographic dacryocystography and its role in the diagnosis and management of lacrimal drainage system blocks and medial canthal masses. Indian J Ophthalmol. 2008 Jan-Feb. 56(1):31-7. [QxMD MEDLINE Link]. [Full Text].
Gökçek A, Argin MA, Altintas AK. Comparison of failed and successful dacryocystorhinostomy by using computed tomographic dacryocystography findings. Eur J Ophthalmol. 2005 Sep-Oct. 15(5):523-9. [QxMD MEDLINE Link].
Taupin T, Taief Boudrigua Aicha L, Baggio E, Gensburger M, Pialat JB. [Comparison of 3T dacryo-MRI by instillation with dacryo-CT scan for evaluation of epiphora.]. J Fr Ophtalmol. 2014 Jun 24. [QxMD MEDLINE Link].
Karagülle T, Erden A, Erden I, Zilelioglu G. Nasolacrimal system: evaluation with gadolinium-enhanced MR dacryocystography with a three-dimensional fast spoiled gradient-recalled technique. Eur Radiol. 2002 Sep. 12(9):2343-8. [QxMD MEDLINE Link].
Anderson NG, Wojno TH, Grossniklaus HE. Clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2003 May. 19(3):173-6. [QxMD MEDLINE Link].
Gomez A, Gladstone G. Necrotizing sialometaplasia of the lacrimal sac mimicking squamous cell carcinoma: Necrotizing dacyocystometaplasia. Orbit. 2016 Feb. 35 (1):48-50. [QxMD MEDLINE Link].
Daraei P, DelGaudio JM. Inferior Meatus Surgery for Distal Nasolacrimal Duct Obstructions: Long-term Outcomes and Treatment Paradigm. JAMA Otolaryngol Head Neck Surg. 2014 Jun 26. [QxMD MEDLINE Link].
Moscato EE, Dolmetsch AM, Silkiss RZ, Seiff SR. Silicone intubation for the treatment of epiphora in adults with presumed functional nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2012 Jan. 28(1):35-9. [QxMD MEDLINE Link].
Goldberg RA, Samimi DB, Tsirbas A, Douglas RS. The hydrogel lacrimal stent for dacryocystorhinostomy: preliminary experience. Ophthal Plast Reconstr Surg. 2008 Mar-Apr. 24(2):85-9. [QxMD MEDLINE Link].
Baruch B, Sarwagi M, Sahu P, Dubey KP, Gupta A, Kumar A. Polypropylene in Endoscopic Dacryocystorhinostomy: A Novel Stent. Indian J Otolaryngol Head Neck Surg. 2018 June. 70(2):240-243. [QxMD MEDLINE Link].
Erkan AN, Yilmazer C, Altan-Yaycioglu R. Otologic T-tube in endonasal dacryocystorhinostomy: a new approach. Acta Otolaryngol. 2007 Dec. 127(12):1316-20. [QxMD MEDLINE Link].
Oghan F, Ozcura F. A novel stenting technique in endoscopic dacryocystorhinostomy. Eur Arch Otorhinolaryngol. 2008 Aug. 265(8):911-5. [QxMD MEDLINE Link].
Kim KR, Song HY, Shin JH, Kim JH, Choi EK, Lee YJ. Efficacy of mitomycin C irrigation after removal of an occluded nasolacrimal stent. J Vasc Interv Radiol. 2007 Apr. 18(4):519-25. [QxMD MEDLINE Link].
Kim KR, Song HY, Shin JH, et al. Eficacy of Mitomycin-C irrigation after balloon dacryoplasty. J Vasc Interv Radiol. 2007 Jun. 18(6):757-62.
Nemet AY, Wilcsek G, Francis IC. Endoscopic dacryocystorhinostomy with adjunctive mitomycin C for canalicular obstruction. Orbit. 2007 Jun. 26(2):97-100. [QxMD MEDLINE Link].
Tabatabaie SZ, Heirati A, Rajabi MT, Kasaee A. Silicone intubation with intraoperative mitomycin C for nasolacrimal duct obstruction in adults: a prospective, randomized, double-masked study. Ophthal Plast Reconstr Surg. 2007 Nov-Dec. 23(6):455-8. [QxMD MEDLINE Link].
Yildirim C, Yaylali V, Esme A, Ozden S. Long-term results of adjunctive use of mitomycin C in external dacryocystorhinostomy. Int Ophthalmol. 2007 Feb. 27(1):31-5. [QxMD MEDLINE Link].
Ashenhurst ME, Hill VE, Keyhani K. Restrictive strabismus following Jones tube insertion: a case series of 8 patients. Can J Ophthalmol. 2007 Aug. 42(4):613-6. [QxMD MEDLINE Link].
Migliori ME. Endoscopic evaluation and management of the lacrimal sump syndrome. Ophthal Plast Reconstr Surg. 1997 Dec. 13(4):281-4. [QxMD MEDLINE Link].
Golub JS, Parikh SL, Budnick SD, Bernardino CR, DelGaudio JM. Inverted papilloma of the nasolacrimal system invading the orbit. Ophthal Plast Reconstr Surg. 2007 Mar-Apr. 23(2):151-3. [QxMD MEDLINE Link].
Bajaj MS, Mahindrakar A, Pushker N. Dentigerous cyst in the maxillary sinus: a rare cause of nasolacrimal obstruction. Orbit. 2003 Dec. 22(4):289-92. [QxMD MEDLINE Link].
Becelli R, Renzi G, Mannino G, Cerulli G, Iannetti G. Posttraumatic obstruction of lacrimal pathways: a retrospective analysis of 58 consecutive naso-orbitoethmoid fractures. J Craniofac Surg. 2004 Jan. 15(1):29-33. [QxMD MEDLINE Link].
Burns JA, Morgenstern KE, Cahill KV, Foster JA, Jhiang SM, Kloos RT. Nasolacrimal obstruction secondary to I(131) therapy. Ophthal Plast Reconstr Surg. 2004 Mar. 20(2):126-9. [QxMD MEDLINE Link].
Camara JG, Bengzon AU, Henson RD. The safety and efficacy of mitomycin C in endonasal endoscopic laser-assisted dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2000 Mar. 16(2):114-8. [QxMD MEDLINE Link].
Camara JG, Santiago MD. Success rate of endoscopic laser-assisted dacryocystorhinostomy. Ophthalmology. 1999 Mar. 106(3):441-2. [QxMD MEDLINE Link].
Camara JG, Santiago MD, Rodriguez RE, Medalle RA, Young DA, Atebara NH. The Micro-Reflux Test: a new test to evaluate nasolacrimal duct obstruction. Ophthalmology. 1999 Dec. 106(12):2319-21. [QxMD MEDLINE Link].
Couch SM, White WL. Endoscopically assisted balloon dacryoplasty treatment of incomplete nasolacrimal duct obstruction. Ophthalmology. 2004 Mar. 111(3):585-9. [QxMD MEDLINE Link].
de Bree R, Scheeren RA, Kummer A, Tiwari RM. Nasolacrimal duct obstruction caused by an oncocytoma. Rhinology. 2002 Sep. 40(3):165-7. [QxMD MEDLINE Link].
Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology. 2003 Jan. 110(1):78-84. [QxMD MEDLINE Link].
Esmaeli B, Hidaji L, Adinin RB, et al. Blockage of the lacrimal drainage apparatus as a side effect of docetaxel therapy. Cancer. 2003 Aug 1. 98(3):504-7. [QxMD MEDLINE Link].
Esmer O, Karadag R, Soylu E, Oner AF, Burakgazi-Dalkilic E. Nasolacrimal system obstruction, ptosis and esotropia due to chemotherapy in acute lymphoblastic leukemia. Cutan Ocul Toxicol. 2013 Oct. 32(4):330-2. [QxMD MEDLINE Link].
Katowitz JA, Low JE. Lacrimal surgery. Duane's Ophthalmology. [book on CD-ROM]; 1998. Vol 5: Chapter 79.
Kim N, Park C, Park DJ, Kim HH, Kim S, Kim YJ, et al. Lacrimal drainage obstruction in gastric cancer patients receiving S-1 chemotherapy. Ann Oncol. 2012 Aug. 23(8):2065-71. [QxMD MEDLINE Link].
Kloos RT, Duvuuri V, Jhiang SM, Cahill KV, Foster JA, Burns JA. Nasolacrimal drainage system obstruction from radioactive iodine therapy for thyroid carcinoma. J Clin Endocrinol Metab. 2002 Dec. 87(12):5817-20. [QxMD MEDLINE Link].
Lueder GT. Balloon catheter dilation for treatment of older children with nasolacrimal duct obstruction. Arch Ophthalmol. 2002 Dec. 120(12):1685-8. [QxMD MEDLINE Link].
Lueder GT. Endoscopic treatment of intranasal abnormalities associated with nasolacrimal duct obstruction. J AAPOS. 2004 Apr. 8(2):128-32. [QxMD MEDLINE Link].
Mauffray RO, Hassan AS, Elner VM. Double silicone intubation as treatment for persistent congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2004 Jan. 20(1):44-9. [QxMD MEDLINE Link].
Mirza S, Al-Barmani A, Douglas SA, Bearn MA, Robson AK. A retrospective comparison of endonasal KTP laser dacryocystorhinostomy versus external dacryocystorhinostomy. Clin Otolaryngol Allied Sci. 2002 Oct. 27(5):347-51. [QxMD MEDLINE Link].
Nguyen LK, Linberg JV. Evaluation of the lacrimal system. In: Surgery of the eyelid, orbit, and lacrimal system. American Academy of Ophthalmology. 1995. 3:254-69.
Oztürk S, Konuk O, Ilgit ET, Unal M, Erdem O. Outcome of patients with nasolacrimal polyurethane stent implantation: do they keep tearing?. Ophthal Plast Reconstr Surg. 2004 Mar. 20(2):130-5. [QxMD MEDLINE Link].
Paul L, Pinto I, Vicente JM. Treatment of complete obstruction of the nasolacrimal system by temporary placement of nasolacrimal polyurethane stents: preliminary results. Clin Radiol. 2003 Nov. 58(11):876-82. [QxMD MEDLINE Link].
Rogers GA, DelGaudio JM. Inferior meatus dacryolith: an easily managed cause of epiphora. Arch Otolaryngol Head Neck Surg. 2008 Oct. 134(10):1110-1. [QxMD MEDLINE Link].
Seider N, Miller B, Beiran I. Topical glaucoma therapy as a risk factor for nasolacrimal duct obstruction. Am J Ophthalmol. 2008 Jan. 145(1):120-123. [QxMD MEDLINE Link].
Shepler TR, Sherman SI, Faustina MM, Busaidy NL, Ahmadi MA, Esmaeli B. Nasolacrimal duct obstruction associated with radioactive iodine therapy for thyroid carcinoma. Ophthal Plast Reconstr Surg. 2003 Nov. 19(6):479-81. [QxMD MEDLINE Link].
Tao S, Meyer DR, Simon JW, Zobal-Ratner J. Success of balloon catheter dilatation as a primary or secondary procedure for congenital nasolacrimal duct obstruction. Ophthalmology. 2002 Nov. 109(11):2108-11. [QxMD MEDLINE Link].
Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2004 Jan. 20(1):50-6. [QxMD MEDLINE Link].
Tsirbas A, Wormald PJ. Endonasal dacryocystorhinostomy with mucosal flaps. Am J Ophthalmol. 2003 Jan. 135(1):76-83. [QxMD MEDLINE Link].
Wobig JL, Dailey RA. Surgery of the Lacrimal System. In: Surgery of the eyelid, orbit, and lacrimal system. American Academy of Ophthalmology. 1995. 3:270-87.
Woog JJ, Kennedy RH, Custer PL, Kaltreider SA, Meyer DR, Camara JG. Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology. 2001 Dec. 108(12):2369-77. [QxMD MEDLINE Link].

Media Gallery

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. Courtesy of Jorge G Camara, MD, University of Hawaii John A Burns School of Medicine.

of 3

Author

Sandra R Worak, MD Consulting Staff, Department of Orbit and Oculoplasty, Reconstructive and Lacrimal Surgery, East Avenue Medical Center and St Luke's Medical Center

Sandra R Worak, MD is a member of the following medical societies: Philippine Academy of Ophthalmology, Philippine Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

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

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department 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, Association for Research in Vision and Ophthalmology, American Glaucoma Society

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

Acknowledgements

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

Disclosure: Nothing to disclose.