Laboratory Studies
Send lacrimal discharge for the following studies (depending on suspected etiologies):
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Gram stain/Giemsa stain
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Cultures and sensitivities
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KOH (suspected fungal infection)
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Anticytoplasmic antibodies (Wegener granulomatosis) - Monitor disease activity
Imaging Studies
See the list below:
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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.
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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
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Computed tomography scan
Use if suspecting traumatic, neoplastic, or mechanical causes of obstruction
Useful for diagnosis and preoperative surgical planning
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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]
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Nasal endoscopy - Used for postoperative evaluation of dacryocystorhinostomy and for dacryocystorhinostomy using the endonasal approach
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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]
Other Tests
See the list below:
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Tear production measurement to rule out tear deficiency or instability as the cause of possible reflex tearing
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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.
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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.
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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.
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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.
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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.
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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
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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%
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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.
Histologic Findings
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]
Staging
Diagnostic canalicular irrigation can determine the level of canalicular obstruction.
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Partial obstruction - Partial fluid flow into the nose, partial reflux
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Total common canalicular obstruction – Flow from the lower to the upper canaliculus with no flow into the nose
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Total functional occlusion – Partial obstruction under normal physiologic conditions
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Complete nasolacrimal obstruction – Fluid flow into the nose with mucoid reflux
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Dacryocystitis of the left nasolacrimal system.
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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.
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Endoscopic laser-assisted dacryocystorhinostomy. Courtesy of Jorge G Camara, MD, University of Hawaii John A Burns School of Medicine.
