Evaluation and Management of Acquired Lacrimal Obstruction

Fig. 5.1 Treatment pathway: history and examination steps. Summary of evaluation of acquired nasolacrimal obstruction. Essential steps in history and the sequential examination steps proceeding from left to right beginning with tear volume and ending with inferior meatus.

Treatment pathway: examination and treatment. Summary of examination and treatment of acquired nasolacrimal obstruction. No reflux: fluid is forced into the nose with no reflux into the upper lid. Par

Fig. 5.2 Treatment pathway: examination and treatment. Summary of examination and treatment of acquired nasolacrimal obstruction. No reflux: fluid is forced into the nose with no reflux into the upper lid. Partial reflux: saline fluid is forced out the fellow ipsilateral canaliculus with some fluid in the nose. Full reflux: all the normal saline refluxes out of the ipsilateral companion punctum with no fluid forced into the nose.

5.2 Evaluation of Patients with Epiphora: History

The critical goal is to establish if a patient has overproduction or underdrainage of tears. This process can be simplified by a series of sequential steps on history and examination as shown in ▶ Fig. 5.1.

5.2.1 Does the Patient Have Ocular Irritation or Not? If So, Are Tears the Cause or the Result of the Ocular Irritation?

The afferent arm of the tearing reflex originates as trigeminal nerve endings within the cornea. 5 Hence, anything that causes corneal irritation and therefore pain stimulates tear production. Conversely, reduced drainage of tears from the conjunctival sac with resultant stasis of tears on the cornea will irritate the cornea and cause a foreign body sensation and irritation. It is therefore critical to delineate on history whether the patient feels that the irritation precedes (causes) the epiphora and is likely to be due to irritation of the cornea.

In this case, the corneal irritation is due to either dry patches developing on the cornea in dry eye or ocular exposure, or a physical irritation such as lash-to-cornea touch.

If, however, the patient feels that the ocular irritative symptoms are secondary to (occur after) the epiphora, then the foreign body sensation is more likely due to stasis of tears on the cornea secondary to reduced lacrimal drainage.

The tear film is a complex trilamellar structure of mucus, aqueous, and lipid layers that should be produced in an adequate volume and function. An important function of tears is to adhere to the cornea for the period between blinks when the corneal tear film is again replenished. As such, dry eye can be divided into sicca, which is a reduction in volume of tears within the tear film, and quality issues that are often due to abnormalities of the lipid layer, associated with meibomian gland dysfunction (MGD).

 For the Dry Eye: Is the Tear Volume Inadequate or Is Tear Quality Reduced?

Tear Volume

Causes of reduced tear volume include sicca. The dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. Sjögren’s syndrome should also be considered in the differential of the dry eye.

When there are symptoms with tearing secondary to dry eye, these patients will have irritation or stinging causing the tearing or preceding the tearing. They tend to get more issues toward the end of the day and complain of the eyes feeling heavy and tired. It is worse when exposed to a dry environment or performing visual tasks, such as driving or reading, as the blink rate is reduced undertaking these tasks.

Tear Quality

Blepharitis is often associated with dysfunction of the meibomian glands. The meibomian glands produce the lipid layer of tears. Blepharitis is a common condition and a cause of poor tear quality. These patients tend to note crusting of the eyelids on waking associated with discharge and often describe a burning sensation associated with red eyelid rims. They also tend to get the progression of symptoms throughout the day, especially when undertaking visual tasks when the blink rate reduces. On further questioning, they have a history of rosacea, acne type symptoms, and facial flushing, which can be associated with alcohol consumption.

If ocular irritation is not due to a dry eye, the focus of our attention becomes the following.

5.2.2 Is the Cause of the Tearing due to Ocular Irritation? If So, Is It Related to Physical Trauma or Air Exposure?

The other cohort of patients that will have irritation causing the tearing. They are further divided into either physical or air exposure groups.

 For Ocular Irritation, Is the Ocular Irritation Secondary to Physical Irritation or Air Exposure?


Physical causes of stimulation/irritation of the cornea include trichiasis (follicles in a normal position but lashes misdirected toward the cornea), distichiasis (lash follicles originate in an abnormally posterior position at the lid margin emerging from the meibomian glands) and entropion (the entire lid turns in causing normal lashes and skin to irritate the cornea). These conditions stimulate the corneal nerve endings causing pain and stimulating lacrimation. Patients with trichiasis and distichiasis tend to have a history of epilation by an eye care physician. Entropion or spastic entropion tends to be episodic; during episodes of spastic entropion, there is a lot of irritation and tearing. This will settle for hours to days, only to recur. Over time, this will progressively get worse until it becomes constant.

Air Exposure

The normal palpebral aperture (distance between the upper and lower eyelid) is 7 to 10 mm; thus, lower lid retraction or ectropion causing only a 1-mm lowering of the lid margin will increase ocular exposure by a minimum of 10%. Other less common causes of ocular exposure include upper lid retraction (most commonly thyroid orbitopathy), proptosis, and facial nerve palsy.

Patients with lower lid retraction and ectropion tend to have similar symptoms to the sicca and dry eye patients, except the former present red eye and inflamed tarsal conjunctiva of ectropion and associated mucus discharge in the mornings and throughout the day. The mucus produced overnight by the irritated tarsal conjunctiva dries during sleep as the aqueous solution of the tear film reduces overnight and the eyelids are glued together on waking.

 Now Consider the Following: Is Ocular Irritation Caused by Tearing?

If the patient notes that their epiphora is not preceded by ocular irritation but rather follows or is caused by the tearing, “underdrainage” is considered. Tears are a dilute protein solution made up of lysozymes, lactoferrin, secretory immunoglobulin A, serum albumin, lipocalin and lipophilin, and electrolytes. A study comparing the composition of normal tears to those with acquired lacrimal duct obstruction found patients with acquired lacrimal duct obstruction had more alkaline tears, higher calcium concentration, and unstable proportion of tear proteins compared with normal persons. 6 Irritation results from stasis of tears.

The lacrimal drainage apparatus is divided into the proximal and distal sections. The proximal section includes the punctum, canaliculus, and the common canaliculus. The distal lacrimal section consists of the lacrimal sac and the nasolacrimal duct that opens into inferior meatus of the nose.

Once underdrainage is presumed, our approach is to classify ocular irritation caused by tearing into four key groups. It is worth noting that the four key groups are also to be considered for epiphora with absence of ocular irritation ( ▶ Fig. 5.1):

  • Prepunctal.

  • Pump dysfunction.

  • Punctal to canaliculus.

  • Common canaliculus to inferior meatus.


Any condition that blocks access to the punctum is considered prepunctal. This includes conjunctivochalasis, redundant plica, and lateralized or enlarged caruncle abutting the puncta. Conjunctivochalasis is redundant, loose, nonedematous bulbar conjunctival folds over the lid margin that affect the flow of tears along the lower lid tear meniscus. Similarly redundancy of the plica semilunaris overlying the lower lid punctum can abut and occlude the punctum. Punctal apposition syndrome occurs when laxity of the lateral canthal tendon allows medialization of the lower punctum (normally sits medial to the upper punctum) such that it lines up with the upper punctum. With blinking, the upper and lower puncta “kiss” occluding each other during the active phase of the blink.

History is usually noncontributory in diagnosing prepunctal issues, and they are much better diagnosed on examination. Patients with conjunctivochalasis may comment on a foreign body sensation in the eye.

Pump Dysfunction

During active phase of blinking, tears are actively driven via the upper and lower canaliculi into the sac. The orbicularis, along with its attachment around the lacrimal sac and bony attachment at the medial and lateral canthal tendons, plays a crucial role in a dynamic pump mechanism. If these muscles or tendons are compromised in any way, such as facial nerve palsy, underdrainage can occur. 7

Medical history will entail a facial nerve injury or operations involving the facial nerve, parotid surgery, or Bell’s palsy. It is in examination as described below that pump dysfunction is most effectively diagnosed.

Punctal to Canaliculus

Stenosis of the punctum can be defined as inability to pass a 26-gauge lacrimal cannula. 8 Chronic blepharitis is widely associated with punctal stenosis secondary to the development of fibrotic change within the ostium. Topical and systemic medications and numerous systemic diseases have also been implicated. Eyelid malposition, due to either localized inflammation or underuse, may also cause punctal stenosis. Canalicular obstruction can be anatomically classified as proximal with involvement of the proximal 2 to 3 mm, mid-canalicular obstructions 3 to 8 mm from the punctum, and distal obstructions as defined by a membrane at the opening of the common canaliculus to the lacrimal sac. 9

A history of chronic use of preserved eye drops, certain chemotherapeutics (e.g., docetaxel), and significant episode of conjunctivitis preceding the tearing should raise a suspicion of canalicular stenosis. History of any surgery to punctum, punctal snips or canaliculi or any trauma should be elicited.

Common Canaliculus to the Inferior Meatus

Stricture formation or obstruction secondary to trauma, infections, prior surgery, postradiation, chronic sinus disease, or neoplasms can affect and obstruct any portion of the nasolacrimal system.

For common canaliculus to inferior meatus, you might ask for a history of use of punctal plugs, as these can migrate and cause a stricture.

5.3 Evaluation of Patient with Epiphora: Examination

The flow diagram in ▶ Fig. 5.2 allows for a systematic approach to examination and subsequent treatment, which is outlined in the following section.

5.3.1 Dye Disappearance Test

On examination, the fluorescein dye disappearance test (DDT) is the most important functional test in deciding whether epiphora is likely secondary to overproduction or underdrainage. At the start of the consultation, two drops of either 1 or 2% fluorescein solution is instilled into each conjunctival sac. After 5 minutes of history taking, a fluorescein stain tear meniscus that remains high is considered delayed DDT and would be due to outflow obstruction ( ▶ Fig. 5.3). A normal or negative DDT (DDT–) is defined as having fluorescein cleared from the meniscus over a 5-minute period. 10

Dye disappearance test. A positive dye disappearance test in the right eye. Note the fluorescein stain tear meniscus remains high compared to the left eye.

Fig. 5.3 Dye disappearance test. A positive dye disappearance test in the right eye. Note the fluorescein stain tear meniscus remains high compared to the left eye.

A DDT– indicates that the epiphora is likely due to dry eye with reflex dumping of tears or ocular irritation as per ▶ Fig. 5.2.

5.3.2 The Jones 1 and 2 Tests

In a patient with a delayed DDT (positive DDT), a Jones test under nasal endoscopic control is the next important functional test. Two sprays of Co-Phenylcaine intranasally at the start of the consultation will decongest the nose and allow a more efficient endoscopic examination. A Jones test is aimed at detecting any fluorescein egress at the distal end of the nasolacrimal duct within the inferior meatus. Jones initially described this by placing a cotton tip within the inferior meatus. 11 It is much more effectively done using an endoscope ( ▶ Fig. 5.4a). A Jones 2 test is performed when the Jones test is repeated after flushing the lacrimal system with normal saline via the upper or lower canaliculus ( ▶ Fig. 5.4b).

(a) The Jones 1 test. A positive Jones 1 test with visible fluorescein seen in the right inferior meatus. (b) The Jones 2 test. The Jones test is repeated after flushing the lacrimal system with norma

Fig. 5.4 (a) The Jones 1 test. A positive Jones 1 test with visible fluorescein seen in the right inferior meatus. (b) The Jones 2 test. The Jones test is repeated after flushing the lacrimal system with normal saline via the upper or lower canaliculus.

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Feb 25, 2020 | Posted by in OTOLARYNGOLOGY | Comments Off on Evaluation and Management of Acquired Lacrimal Obstruction

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