Nasolacrimal Duct Obstruction and Epiphora Workup

Updated: Aug 17, 2018
  • Author: Sandra R Worak, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Workup

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

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 t 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]

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Other Tests

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.

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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]

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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