Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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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

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

Signs

Congenital

  • Epiphora and sticky discharge
  • Pressure over lacrimal sac may cause reflux of mucopurulent material from puncta

Acquired

  • Check puncta for
    • size (normally 0.2 to 0.3 mm diameter)
    • apposition to the globe and marginal tear strip
    • contact with opposite lid on eye closure

Differential diagnosis

Congenital

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

Acquired

Rule out inflammation or infection (pain, discharge, swelling, redness, mucus reflux on syringing in adults, history of sinusitis):

  • canaliculitis (chronic mucopurulent conjunctivitis, punctum expresses chalky concretions, redness & tenderness over canaliculi)
  • dacryocystitis (distended tender lacrimal sac) 

Tumour of lacrimal sac or canaliculi (rare):

  • can produce lacrimal obstruction
  • swelling at or below inner canthus (± blood in tears)

Facial nerve palsy (lacrimal pump failure due to orbicularis weakness)

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

Non pharmacological

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 (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)

Pharmacological

Congenital

Topical broad spectrum antibiotic e.g. chloramphenicol drops (only if clinical evidence of infection)

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

Acquired

Topical broad spectrum antibiotic e.g. chloramphenicol drops (only if clinical evidence of infection)
For Actinomyces infection, ofloxacin drops (generally in conjunction with curettage of ‘sulphur granules’

(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: initial management (including drugs) followed by routine referral

Possible management by ophthalmologist

  • Lacrimal syringing
  • 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

Evidence base

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

Sources of evidence

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

Lay summary

The narrow tube that collects tears from the inner corner of the each eye and drains them to the inside of the nose is called the nasolacrimal duct. Normally it functions well but it may sometimes become blocked, causing the eye to water. This may happen as the result of infection, inflammation or the effects of medications or surgery. Occasionally babies are born with the duct(s) not fully open, but most of these go on to open without treatment before the age of 12 months.

In adults, the blockage can be confirmed by attempting to pass a little saline solution through the nasolacrimal duct, using a small syringe. Fluorescein dye can also be used to test whether the duct is free. However, syringing by itself rarely cures the blockage. If infection is the cause, antibiotic drops may be needed.

If the optometrist’s management of the condition is not successful, the patient should be referred to the ophthalmologist, who may carry out further tests including special X-rays. If surgery is needed, a new passage can be created between the tear sac (at the inner corner of the eye) and the inside of the nose; this can be done either using conventional surgical instruments or with the aid of a laser.

Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
Version 6
Date of search 17.11.17
Date of revision 29.03.18
Date of publication 09.05.18
Date for review 16.11.19
© College of Optometrists

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