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Version 4 (03.12.08)
Name:
CONDITION
Aetiology
Nasolacrimal duct obstruction (Nasolacrimal drainage
dysfunction) (Disorders of the lacrimal drainage system)
Congenital
- some 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 (i.e. abnormal
narrowing) of nasolacrimal passages
- punctal or canalicular stenosis/occlusion
- post-infective (chlamydia, herpes simplex/zoster,
staphylococcal)
- post-cicatricial disease (ocular pemphigoid, StevensJohnson)
- post-conjunctivitis medicamentosa (see Clinical Management
Guideline)
- iatrogenic (eg repeated probing, eyelid surgery)
- secondary to ectropion or punctal eversion
- mechanical (trauma, tumours, obstruction by foreign matter
e.g. lashes, 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)
COMMENTS
Version 4 (03.12.08)
Name:
CONDITION
Nasolacrimal duct obstruction (Nasolacrimal drainage
dysfunction) (Disorders of the lacrimal drainage system)
Predisposing
factors
Age: congenital in babies, acquired in later life
Other factors: see above
Symptoms
Epiphora
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 purulent
material from puncta
Acquired
Check puncta for
- size (normally 0.5 to 2.0 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, pouting
punctum expresses chalky concretions, redness &
tenderness over canaliculi
COMMENTS
Version 4 (03.12.08)
Name:
CONDITION
Nasolacrimal duct obstruction (Nasolacrimal drainage
dysfunction) (Disorders of the lacrimal drainage system)
- 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)
Bell’s palsy (lacrimal pump failure due to orbicularis weakness)
Management by Optometrist
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
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
- refer for probing if condition fails to resolve by 12 months
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) -
COMMENTS
Version 4 (03.12.08)
Name:
CONDITION
Nasolacrimal duct obstruction (Nasolacrimal drainage
dysfunction) (Disorders of the lacrimal drainage system)
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 under inferior
turbinate (if bud stained with fluorescein after 5 min, lacrimal
system is patent)
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)
Pharmacological
Congenital
Topical broad spectrum antibiotic e.g. chloramphenicol drops
(only if clinical evidence of infection)
Acquired
Topical broad spectrum antibiotic e.g. chloramphenicol drops
COMMENTS
Version 4 (03.12.08)
Name:
CONDITION
Nasolacrimal duct obstruction (Nasolacrimal drainage
dysfunction) (Disorders of the lacrimal drainage system)
(only if clinical evidence of infection)
For Actinomyces infection, ofloxacin drops (generally in
conjunction with curettage of ‘sulphur granules’)
Referral
(Category)
Congenital
B2: alleviation or palliation; normlly no referral (due to high rate
of spontaneous resolution during the first 12 months of life)
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
COMMENTS
Version 4 (03.12.08)
Name:
CONDITION
Nasolacrimal duct obstruction (Nasolacrimal drainage
dysfunction) (Disorders of the lacrimal drainage system)
- dacryocystorhinostomy, DCR (surgical or endolaser)
if other measures have failed, insertion of a Lester-Jones tube
Evidence base
Congenital:
Primary treatment of nasolacrimal duct obstruction with probing
in children younger than 4 years. Paediatric Eye Disease
investigator group. Ophthalmology 2008; 115: 577-84
(Centre for Evidence-based Medicine Level of Evidence = 2b)
COMMENTS