H04.551-553 Acquired Stenosis Of Nasolacrimal Duct

Corneal edema is a clinical sign of corneal disease.  The condition is characterized by an increase in corneal thickness secondary to an abnormal accumulation of fluid.  The excess fluid produces a swelling of the corneal tisssue and can result in a loss of stromal transparency that produces blurred vision or visual impairment. 

A congenital nasolacrimal duct obstruction results from a membrane in the duct that did not spontaneously perforate as expected at birth.  Acquired nasolacrimal duct obstructions can be non-specific (idiopathic) or specific in nature.  Non-specific obstructions are thought to originate from an inflammation of the lacrimal sac, while specific obstructions are linked to inflammatory diseases.

Other causes of acquired specific obstructions include the following:

• Infection
• Trauma
• Surgical injury
• Neoplasm

Structural Damage to the Eye 

• If an infection is present, a palpable mass may appear at the inner canthus
• Palpebral conjunctiva may have papillae as a result of the body’s response Staphylococcus aureus 
• Physical examination of eyelids can show signs of edema, hyperemia and tender to touch
• Extent of signs and symptoms found depends on the cause of obstruction 

Functional Damage to the Eye

• Distorted, decreased or obstructed vision secondary to excessive tears or excessive blinking

The main goal of the diagnostic evaluation in a patient with nasolacrimal obstruction is to accomplish the following:

• Determine the etiology of the obstruction and determine whether it is congenital or acquired
• Alleviate the symptoms
• Determine a treatment program

Patient History

Patients with nasolacrimal obstruction will present with the following abnormal clinical signs and symptoms:

• Excessive tearing
• Pain around the inner corners of the eye
• Discharge around the inner corners of the eye  

External Ocular Examination with Biomicroscopy

		Clinical Appearance of the Eyelid Eyelid edema, hyperemia or tender to touch Palpebral conjunctiva may present with papillae Mucous discharge from the punctum Excessive tearing
Clinical Appearance of theTear Film If the obstruction is non-specific in nature, other clinical diagnostic test such as Jones fluorescein dye test can help determine if the lacrimal drainage system is fully patent or partly obstructed as well as determine the location of the obstruction The upper system pertains to the eyelids, puncta, canaliculi and the common canaliculus The lower system involves the lacrimal sac, the duct and the nose Certain types of diagnostic imaging, such as dacryocystography (DCG), computed tomography (CT-DCG), ultrasound and endocscopy can further locate the obstruction If fluorescein dye does not stain a facial tissue when the patient blows their nose – the upper drainage system is not patent

DIAGNOSTIC TESTS

External Ocular Photography

• To document the progress or lack of progress of a condition

Congenital Obstruction

• Congenital nasolacrimal obstructions are a result of an imperforated membrane that usually spontaneously opens at the time of birth.  Sometimes the membrane can persist and extend into adulthood.  By the first year of age, if the membrane has not spontaneously perforated, then the probing of the membrane is a successful treatment option.  After the age of six, the success rate of probing declines significantaly and a surgical treatment called dacryocystorhinostomy (DCR) is preferred.

Acquired Obstruction 

• Acquired Obstructions are often classified into non-specific (idiopathic) and specific acquired obstructions.
• Non-specific acquired obstructions are thought to originate from an inflammation of the lacrimal sac. These early inflammatory conditions encourage the nose and the respiratory-like mucus membranes in the nasolacrimal canal to release more inflammatory mediators resulting in obstruction of the structure.
• Specific causes of nasolacrimal obstructions are caused by inflammatory conditions like sarcoidosis and Wegener’s granulomatosis as well as infections, trauma, surgical injury, foreign bodies, or neoplasm of the lacrimal sac and duct.
• Dacryocystitis is an infection of the lacrimal sac and can be classified as acute, subacute or chronic.  It may be localized or extend to other orbital tissue and lead to pericystitis or orbital cellulites.  If it is localized to the lacrimal sac, a palpable mass can be found at the inner canthus of the involved eye.  As the infection develops, the nasolacrimal sac pushes on the canaliculus and prevents the sac from being reducible.  As a result, the chronic stasis and build up of material leads to an infection.  Staphylococcus aureus is the common bacteria causing the infection

Punctal Stenosis

• The punctum has become blocked by some means, while the lacrimal canaliculi and nasolacrimal duct are patent

Patients with epiphora of unknown etiology should undergo a thorough lacrimal evaluation that includes at least the following:

• Consideration by history and physical examination (including slit lamp), of likely pre-punctal and/or non-obstructive causes for epiphora such as disturbances of ocular surface tear flow by eyelid malposition, allergy, dry eye, and blepharitis
• Non-invasive testing to diagnose punctal or post-punctal obstruction and to identify the site and degree of obstruction, such as by using dye disappearance testing when appropriate
• Initiation of appropriate treatment

Dilation of the Lacrimal Punctum without Irrigation Useful treatment when mechanical, inflammatory, or infectious processes cause or contribute to obstruction of normal tear drainage resulting in epiphora (excess tearing) or persistent infection Obstruction most commonly occurs in the lacrimal punctum or nasolacrimal duct and sac Local anesthetic is instilled, and then the lacrimal punctum is gradually dilated using probes of increasing size
		Dilation of the Lacrimal Punctum with Irrigation If simple dilation fails to establish patency, lacrimal irrigation may be performed by inserting an irrigating cannula into the lower punctum Saline is discharged through the cannula into the nasolacrimal drainage system
Nasolacrimal Obstruction If a nasolacrimal drainage system obstruction is present distal to the lacrimal punctum, irrigation will produce a regurgitation of saline out of the punctal orifice  For patients in whom nasolacrimal irrigation or probing fails to establish patency, further surgical treatment is available

Intraocular Surgery

• Dacryocystorhinostomy (DCR) is a surgical procedure where the lacrimal sac is drained into the nose

1.  Camara J.  Obstruction Nasolacrimal Duct.  Medscape/EMedicine. http://emedicine.medscape.com/article/1210141-overview#showall.  Last accessed August 13, 2014.
2.  Dacryostenosis.  The Merck Manual.  Oct 2013. http://www.merckmanuals.com/professional/eye_disorders/eyelid_and_lacrimal_disorders/dacryostenosis.html.  Last accessed August 13, 2014.