Aetiology

Obstruction or stenosis of the nasolacrimal duct, causing excess tearing (epiphora); congenital or acquired aetiology

Congenital
Between 5% and 20% of babies have a persistent membranous obstruction at opening of nasolacrimal duct into nose; unilateral or bilateral

Acquired
Usually idiopathic (i.e. no established cause)
Usually involutional (i.e. age-related) stenosis (abnormal narrowing) of nasolacrimal passages
Punctal or canalicular stenosis/occlusion  

• post-infective (chlamydia, herpes simplex/zoster, staphylococcus)
• post-cicatricial disease (ocular pemphigoid, Stevens-Johnson)
• post-conjunctivitis medicamentosa (see Clinical Management Guideline on Conjunctivitis medicamentosa)
• iatrogenic (e.g. repeated probing, eyelid surgery)
• secondary to ectropion or punctal eversion

Mechanical (trauma, tumours, obstruction by lashes or foreign matter, e.g. dacryoliths [calcium stones], punctal/canalicular plugs)
Infection of canaliculi (canaliculitis)

• rarely, due to Actinomyces (Streptothrix sp.) – a Gram-positive bacillus
• such cases usually unilateral
• pouting’ punctum typical

Local infection (chronic sinusitis, dacryocystitis)

Predisposing factors

Age: congenital in babies, acquired in later life
Female gender
One case series identifed a history of infective conjunctivitis and regular swimming in chlorinated water as predisposing factors
Other factors: see above

Symptoms of nasolacrimal duct obstruction

Epiphora  and mucous discharge
Irritation
Blurred vision due to excessive tear meniscus, especially on downgaze, e.g. when reading

Differential diagnosis

Congenital
Congenital glaucoma (acute)
Punctal atresia (congenital absence or abnormal narrowing of puncta)

Acquired
Malposition of the eyelids e.g. ectropion, entropion. Lacrimal pump failure following facial nerve palsy. See appropriate Clinical Management Guidelines 

Proximal lacrimal obstruction, e.g. 

• canaliculitis (chronic mucopurulent conjunctivitis, punctum expresses chalky concretions, redness & tenderness over canaliculi)
• dacryocystitis (distended tender lacrimal sac): see Clinical Management Guidelines on Acute and Chronic Dacryocystitis
• tumour of lacrimal sac or canaliculi (rare, can produce lacrimal obstruction swelling at or below inner canthus (± blood in tears)

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Congenital
Diagnostic test
Fluorescein disappearance test

• a drop of 1% fluorescein should disappear from the tear meniscus in 5-10 minutes (cobalt blue light, room lights off); any longer suggests partial or complete obstruction

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Therapy
Do not syringe or probe
Instruct parent in massage. Gentle pressure with finger over common canaliculus, stroking downwards firmly to raise pressure in lacrimal sac and encourage opening of valve. Suggest ten strokes, twice daily
Regular cleaning of discharge from lids

High rate of spontaneous resolution during the first 12 months of life (>50% resolve within 6 months, 70% by 12 months). Children with unilateral obstruction may benefit from early probing by ophthalmologist
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

Acquired
Diagnostic tests
Lacrimal syringing (irrigation test) (NB not in congenital cases)

• instil a drop of topical anaesthetic
• gently dilate punctum with punctal dilator
• syringe with normal saline via lacrimal cannula
• if saline passes into nose (patient swallows and tastes salt) – nasolacrimal system is patent
• if there is resistance to the passage of the cannula and reflux from opposed canaliculus – common canaliculus is stenosed
• if no saline passes into nose – complete lacrimal duct obstruction

Jones fluorescein dye test

• significant amount of fluorescein remaining in tear meniscus two minutes or more after instillation indicates restricted drainage
• check for appearance of fluorescein in the nose (examine tissue after nose blow; if fluorescein present, lacrimal system is patent)
• place anaesthetic-soaked cotton bud in nose (if bud stained with fluorescein after 5 min, lacrimal system is patent)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Therapy
Lacrimal lavage (saline syringing) may be effective in some cases:

• local (discrete) obstruction
• subacute inflammation or infection

It is less likely to be effective:

• in stenosis in the elderly
• where there is an underlying disease (inflammation, tumour)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Congenital
Topical broad spectrum topical antibiotic e.g. chloramphenicol drops (only if clinical evidence of infection)
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Acquired
Topical broad spectrum topical antibiotic e.g. chloramphenicol drops (only if clinical evidence of infection)
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
 

Management category

Congenital 
B2: alleviation or palliation; normally no referral (due to high rate of spontaneous resolution during the first 12 months of life; children with unilateral obstruction may benefit from early probing by ophthalmologist)
Acquired 
B1 (modified): initial management (including drugs) followed by routine referral for possible surgical management if fails to resolve

Possible management by ophthalmologist

Probing (through puncta, canaliculi, sac, to nasolacrimal duct)

• Congenital: not until 12 months of age to allow for spontaneous canalisation
• in resistant acquired cases has limited success and carries risk of aggravation of underlying disease and of tissue trauma

Canalicular curettage

• for Actinomyces infection

Punctal dilatation where there is stenosis
Surgical removal of posterior wall of vertical limb of canaliculus

• considered when repeated punctal dilatation ineffective

X-ray imaging of radiopaque liquid injected into the lacrimal drainage system (dacryocystogram, DCG)

• pinpoints any obstructions and guides surgery

Surgery in canalicular or nasolacrimal duct obstruction includes

• dacryocystorhinostomy, DCR (surgical or endolaser)
• if other measures have failed, insertion of a Lester-Jones tube (a Pyrex tube leading from the inner canthus to the nasal space which needs regular maintenance, i.e. cleaning, by the patient)

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Avdagic E, Phelps PO Nasolacrimal duct obstruction as an important cause of epiphora. Dis Mon. 2020;66(10):101043

Jawaheer L, MacEwen CJ, Anijeet D. Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2017;2:CD007097

Lin AE, Chang YC, Lin MY, Tam KW, Shen YD. Comparison of treatment for congenital nasolacrimal duct obstruction: a systematic review and meta-analysis. Can J Ophthalmol. 2016;51(1):34-40

Marcet MM, Kuk AK, Phelps PO. Evidence-based review of surgical practices in endoscopic endonasal dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction and other new indications. Curr Opin Ophthalmol. 2014;25(5):443-8

Ohtomo K, Ueta T, Toyama T, Nagahara M. Predisposing factors for primary acquired nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol. 2013;251(7):1835-9

Petris C, Liu D. Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2017;7:CD011109

Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
Version 8
Date of search 24.01.22
Date of revision 28.01.22
Date of publication 22.11.22
Date for review 23.01.24
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