• Idiopathic (80%)
• Trauma/midface fractures
• Iatrogenic
1. Irradiation
2. Radioactive iodine treatment (RAI)
3. Extensive maxillary antrostomy
4. Nasal osteotomy in rhinoplasty
Neoplasm
• Inverting papilloma
• Lacrimal sac tumor
Systemic
• Granulomatosis with polyangiitis (GPA)
• Sarcoidosis
• Sicca/Sjögren’s syndromes
Anatomic
• Eyelid laxity/malposition
• Facial palsy/paralysis
• Scarring/mass obstruction
• Entropion
• Ectropion
Diagnostic Evaluation of Epiphora
Ophthalmologic Testing
• Fluorescein dye test
1. Fluorescein solution of 2% instilled in conjunctival cul-de-sac
2. Persistence/asymmetric clearance at 5 minutes indicates decreased outflow
• Jones Test
1. Jones 1: performed following fluorescein dye test
– Dye placed in inferior conjunctival cul-de-sac
– Duration of 5 to 10 minutes: attempt to recover from inferior meatus
2. Jones 2: performed following Jones 1 testing
– Saline irrigation through lacrimal system
– Irrigant in nose indicates low grade obstruction
– Dye in irrigant indicates low sac or duct obstruction and patent canalicular system
3. Lacrimal Probing
– Performed after negative Jones 2 test
– Measure distance at which obstruction encountered
Imaging
• Computed Tomography (CT)
1. Allows identification of associated sinus disease, septal deviation, anatomic abnormality, or tumor
2. Good for evaluation of bony anatomy
3. Useful for intraoperative image guidance
• Magnetic Resonance Imaging (MRI)
1. Rarely utilized
2. Good for soft tissue anatomy
• Ultrasound
1. Simple, noninvasive evaluation of nasolacrimal system
2. Cannot evaluate canalicular or physiologic obstruction
3. Able to identify dilated sac, neoplasm, or dacryolith
• Dacryoscintigraphy (DS)
1. Radionuclide solution instilled in eye and physiologic flow assessed while images obtained
2. Poor resolution limits usefulness
• Dacryocystography (DCG)
1. Gold standard of nasolacrimal system imaging
2. Radiopaque contrast solution instilled into canaliculus
3. DCG-CT allows for greater bony detail
4. DCG-MRI allows for fine soft tissue detail and can differentiate mucous, blood, and neoplasm
5. Percutaneous-contrasted DCG allows bypass of common canalicular obstruction and evaluation of lacrimal sac
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