Nasolacrimal Duct Obstruction and Epiphora

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]

PANDO is more common in middle-aged and elderly females. Using CT scans, Groessl and colleagues 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.

Viral causes of obstruction most commonly are seen with herpetic infection. 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. 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.

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

Nasolacrimal drainage obstruction 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. SALDO has no sexual predilection.

Age

Previous studies have noted a high incidence of PANDO in individuals aged 50-70 years.

Surgical treatment provides resolution of primary acquired nasolacrimal duct obstruction in 85%-99% of cases.

Both external dacryocystorhinostomy and endoscopic laser dacryocystorhinostomy have success rates higher than 90%; external dacryocystorhinostomy is slightly more successful.

Patients should be aware that epiphora caused by nasolacrimal duct obstruction is surgically treatable. Early recognition of secondary causes may provide the patient with more conservative treatment options.

Explain the following to the patient:

• Normal lacrimal drainage process

• Obstruction of lacrimal drainage passageway

• Possible diagnostic tests that may be necessary to evaluate the condition and their possible results

• Treatment protocols and options

• If surgery is necessary, discuss the prognosis and possible intraoperative and postoperative complications.

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

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

Potential complications include the following:

• Dacryocystitis
• Chronic conjunctivitis
• Preseptal cellulitis

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

See the list below:

• 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 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)[14]

  • 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[15]

  • Criterion standard in the morphological study of the lacrimal passages and quantification of stenosis[16]

• 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.[17]

See the list below:

• 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.

A study presented clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy (DCR).[18]

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.[18]

They concluded that nongranulomatous inflammation consistent with chronic dacryocystitis is the most common diagnosis in lacrimal sac specimens obtained at DCR.[18] Neoplasms resulting in chronic nasolacrimal duct obstruction occurred in 4.6% of cases and were unsuspected before surgery in 2.1% of patients.[18]

A case of necrotizing sialometaplasia of the lacrimal sac mimicking squamous cell carcinoma was reported in 2016.[19]

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

For treatment of nasolacrimal duct obstruction, 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.

External dacryocystorhinostomy

See the list below:

• 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

See the list below:

• Involves the creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps
• 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
• 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.

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 are as follows:

• No skin incision
• Less bleeding
• Faster recovery

Approaches are as follows:​

• Endocanalicular
• Trans-conjunctival
• Endoscopic nasal

Endoscopic laser-assisted dacryocystorhinostomy is shown in the video below.

 

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.

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.

Inferior meatus surgery

An endoscopic surgery for distal nasolacrimal duct obstruction at or near the Hasner valve

Confers 92.8% short-term success rate; 90% long-term success rate with a mean follow-up of 6.2 years[20]

Stents

Stents may be used as a first-line treatment for epiphora.

Polyurethane stents

See the list below:

• Low success rate for the treatment of PANDO
• May induce inflammation and fibrous tissue formation

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.[21]

Hydrogel stents[22]

See the list below:

• Late success rate of 78.3%
• Well-tolerated for acquired nasolacrimal duct obstruction; decreases incidence of nasal adhesions

Polypropylene sutures 3/0[23]

See the list below:

• Left in the lacrimal sac for 3 weeks
• Good results

Otologic T-tubes[24, 25]

See the list below:

• 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

Adjunctive use of mitomycin-C during dacryocystorhinostomy procedures significantly increases the success rate without adverse effects.[26, 27, 28, 29, 30]  See the list below:

• 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.

Nasolacrimal duct obstruction can be co-managed by the following specialists:

• Otolaryngologist
• Radiologist

Normal

As tolerated

See the list below:

• Excessive bleeding (epistaxis)

• Poor/delayed wound healing

• Wound infection

• Accidental removal of tube/stent by the patient

• Restrictive strabismus[31]

• Lacrimal sump syndrome[32]

Early consultation when symptoms of tearing appear would be beneficial.

Appropriate antibiotics with lacrimal massage are the initial remedies for mild cases of obstruction.

After the dacryocystorhinostomy, patients are given antibiotic eye drops and a nasal decongestant spray.

The silicone stent tube is removed after ≥3 months. In some situations (ie, Wegener granulomatosis), the stents may need to be retained indefinitely.

Dacryocystorhinostomy may be performed as an outpatient procedure, especially if performed with a laser; there is less bleeding and faster recovery.

Antibiotic/steroid eye drops, such as tobramycin/dexamethasone combination eye drops, are prescribed postoperatively for use 2-3 times per day for 2-3 weeks as prophylaxis to infection and to decrease postoperative inflammation.

Nasal decongestant sprays are prescribed postoperatively for use 2-3 times per day for 2-3 weeks.

The definitive treatment of nasolacrimal duct obstruction is mainly surgical.

Medical therapy with systemic oral antibiotics is necessary in cases of canaliculitis, cellulitis, or dacryocystitis secondary to the obstruction.

See Dacryocystitis and Cellulitis, Preseptal regarding medical treatment.