Epiphora is defined as the involuntary overflow of tears down the cheek. The clinical spectrum of epiphora ranges from the occasionally bothersome trickle to the chronically irritating overflow. Epiphora is caused by a disruption in the balance between tear production and tear drainage. The lacrimal drainage system is a continuous and complex membranous channel whose function is dependent on the interaction of its anatomy, position of the eyelids, and the physiology of tear drainage.
When faced with a patient who complains of tearing, the first step is to determine whether the epiphora is caused by an increase in lacrimation or a decrease in tear drainage. Trichiasis, superficial foreign bodies, eyelid malpositions, diseases of the eyelid margins, tear deficiency or instability, and cranial nerve V irritation may cause an abnormal increase in tear production. In the absence of these conditions, an abnormality in tear drainage is considered.
Abnormalities of tear drainage may be subdivided further into functional and anatomical disorders. Functional failure is related to poor lacrimal pump function, which may be due to a displaced punctum, eyelid laxity, weak orbicularis, or cranial nerve VII palsy. Anatomical obstruction may occur at any point along the upper and lower lacrimal drainage pathway. Congenital lacrimal obstructions are observed not long after birth, on the 1st to 3rd month of life and are the subject of another article, Nasolacrimal Duct, Congenital Anomalies.
Classification of nasolacrimal drainage obstruction
Acquired nasolacrimal duct obstructions (NLDO) are classified as primary and secondary. In 1986, Linberg and McCormick coined the term primary acquired nasolacrimal duct obstruction (PANDO) to describe an entity of lacrimal drainage disorders caused by inflammation or fibrosis without any precipitating cause.[1] Bartley proposed an etiologic classification system for secondary acquired lacrimal duct obstruction (SALDO) based on published cases.[2, 3, 4]
PANDO mainly is caused by inflammation, fibrosis, mucosal edema, vascular congestion, and stasis.[5] A systematic review by Ali and Paulsen focused on vascular theories where recurrent malfunction leads to structural epithelial and subepithelial changes that affect the behavior of perilacrimal cavernous bodies. Middle-aged and elderly females who are the most affected population, were noted to have smaller dimensions in the lower nasolacrimal fossa and middle nasolacrimal duct.[6] Some studies suggest menstrual hormonal changes bring about a generalized de-epithelialization as well within the lacrimal sac and nasolacrimal duct.
Causes of SALDO include infectious, inflammatory, neoplastic, traumatic, and mechanical disorders.
The microbiology of acquired nasolacrimal duct obstruction were reported to be more frequented with gram-positive organisms, followed by gram-negative bacteria, anaerobic bacteria and fungi. Gram-negative organisms were reported to be present in NLDO secondary to chronic dacryocystitis.(ref 64) Fungal causes have been documented, and are suspected when the patient is unresponsive to antimicrobial antibiotics. This may be secondary to chronic sinus and nasal infections.[7] Parasitic obstruction is rare but is reported in patients infected with Ascaris lumbricoides, which enters the lacrimal system through the valve of Hasner. Viral tests have isolated coronaviruses, RSV, adenovirus and SARS-CoV-2, and HSV1.[8, 9]
Inflammation may be endogenous or exogenous in origin. Wegener granulomatosis and sarcoidosis are conditions that lead to obstruction due to progressive inflammation within the nasal and lacrimal sac mucosa. Other endogenously arising inflammations reported are cicatricial pemphigoid, sinus histiocytosis, Kawasaki disease, and scleroderma. Exogenous causes of lacrimal drainage obstruction are chronic use of some anti-glaucoma drops, radiation, systemic chemotherapy, and bone marrow transplantation. The use of Iodine-131 I(131) for thyroid carcinoma is associated with a 3.4% incidence of documented NLDO and an overall 4.6% incidence of documented or suspected obstruction. Weekly use of docetaxel therapy used for metastatic breast cancer and non-small cell lung cancer has been reported to be associated with canalicular and nasolacrimal duct obstruction.
Neoplasms resulting in chronic nasolacrimal duct obstruction occur in 4.6% of cases and were unsuspected before surgery in 2.1% of patients.[10] These may cause lacrimal obstruction by primary growth, secondary spread, or metastatic spread. Primary neoplasms may arise in the puncta, canaliculi, lacrimal sac, or nasolacrimal duct. Lacrimal sac biopsies in acquired NLDO revealed adenoid cystic carcinoma, eccrine spiradenoma and small B-cell lymphoma.[11] Secondary spread from nearby tissues is more common than primary tumors. They are most commonly eyelid carcinomas, maxillary antrum tumors, and the nasopharynx tumors. Rare cases of a nasal oncocytoma, medial canthal cylindroma, and necrotizing sialometaplasia of the lacrimal sac[12] have caused nasolacrimal duct obstruction from direct extension. Metastatic spread, an extremely rare phenomenon, has been reported with primary sites from the breast and prostate.
Naso-orbitethmoidal fractures are the most common etiology for traumatic nasolacrimal duct obstruction.[13, 14] HIgh-velocity blunt injuries from motor vehicle accidents commonly involve the whole lacrimal drainage system. Delayed treatment of postraumatic facial fractures also may cause stenosis or bone loss in the lacrimal district. Scarring of the lacrimal passage after frequent overly aggressive lacrimal probing may be an iatrogenic cause of trauma. Iatrogenic NLDO also may follow orbital decompression surgery, paranasal, nasal, and craniofacial procedures.
Mechanical lacrimal drainage obstructions may be due to intraluminal foreign bodies, such as dacryoliths or casts. These may be caused by infection (eg, Actinomyces, Candida) as well as long-term administration of topical medications. Mechanical obstruction also may be caused by external compression from rhinoliths, nasal foreign bodies, or mucoceles. Dentigerous cyst in the maxillary sinus has been reported to have caused nasolacrimal duct obstruction.
Surgical treatment provides resolution of primary acquired nasolacrimal duct obstruction in 85-99% of cases.
Both external dacryocystorhinostomy and endoscopic laser dacryocystorhinostomy have success rates higher than 90%; external dacryocystorhinostomy is slightly more successful.
Patients should be aware that epiphora caused by nasolacrimal duct obstruction is surgically treatable. Early recognition of secondary causes may provide the patient with more conservative treatment options.
Explain the following to the patient:
Normal lacrimal drainage process
Level of obstruction of lacrimal drainage passageway
Possible diagnostic tests that may be necessary to evaluate the condition and their possible results
Treatment guidelines and options
If surgery is necessary, discuss the prognosis and possible intraoperative and postoperative complications.
Ophthalmic medications are the most common cause of iatrogenic punctal and canalicular scarring. Radiotherapy of the medial canthal area may cause a severe inflammatory reaction that leads to punctal stenosis, although published reports vary on the amount of radiation causing the inflammation. Systemic chemotherapy with 5-fluorouracil (5-FU) has been known to occlude the puncta and canaliculi, although the incidence has declined since oncologic regimens today use much lower doses for shorter durations.
Endogenous
Endogenous causes include the following:
Wegener granulomatosis
Sarcoidosis
Cicatricial pemphigoid
Sinus histiocytosis
Kawasaki disease
Scleroderma
Neoplastic
Neoplastic causes can be primary, secondary, or metastatic.
Inverted papilloma is the most common benign neoplasm, and lymphoma is the most common malignant neoplasm arising from the nasolacrimal duct.[22]
Visualization of anatomic details of the lacrimal drainage system using contrast material
Visual localization of the site of obstruction may help determine the surgical plan.
View Image
Dacryocystogram. A patent nasolacrimal system on the right side of a patient and a blocked system on the contralateral side at the level of the nasola....
Dacryoscintigraphy
More sensitive and less invasive method of lacrimal system imaging
More sensitive for incomplete blocks of the upper drainage system
Functional lacrimal duct obstruction is easily diagnosed with dacryoscintigraphy. It may be classified by types of obstruction to predict postoperative results of silicone tube insertion.
Class I - Delayed secretion in the distal nasolacrimal duct
Class II – Delayed secretion in the proximal nasolacrimal duct
Class III - Delayed secretion from the prelacrimal sac to the lacrimal sac
Prelacrimal sac obstructions, in particular, may achieve better operative results with adjuvant treatments in addition to silicone tube insertion.
Does not provide as much detailed anatomic imaging as contrast DCG
Computed tomography (CT) scan
Use if suspecting traumatic, neoplastic, or mechanical causes of obstruction
Useful for diagnosis and preoperative surgical planning
Axial plain computed tomography (CT) scan, followed by administration of water-soluble contrast in the conjunctival cul-de-sac or by cannulation of the lacrimal passages
Safe and useful for diagnosing lacrimal system blocks and medial canthal masses
Can evaluate dacryocystorhinostomy failures before re-operation[24]
Criterion standard in the morphological study of the lacrimal passages and quantification of stenosis[25]
Nasal endoscopy
Pre-operative evaluation to rule out nasal pathologies
Used for postoperative evaluation of dacryocystorhinostomy and for dacryocystorhinostomy using the endonasal approach
Gadolinium-enhanced magnetic resonance dacryocystography
The overall sensitivity of magnetic resonance (MR) in detecting obstruction was 100%. MR helped to determine the canalicular and ductal obstruction in 100% of patients and the saccular obstruction in 80% of patients.
The authors of this study concluded that 3-dimensional (3D) fast spoiled gradient-recalled (FSGR) technique for MR dacryocystography is a reliable and noninvasive method in the evaluation of the obstruction level in the lacrimal system in patients with epiphora.[26]
Tear production measurement to rule out tear deficiency or instability as the cause of possible reflex tearing
Schirmer test
Without topical anesthetic (stimulated tear production): Normal measurement is 10-30 mm wetting of Schirmer strip after 5 minutes.
With topical anesthesia (basic secretion): Normal measurement is greater than 5 mm of wetting of Schirmer strip paper after 5 minutes.
Tear break-up time test to rule out tear instability: Normal break-up time is 15-30 seconds. A time of 10 seconds or less is considered distinctly abnormal.
Fluorescein dye disappearance test
Stained tears that are retained 5 minutes after instillation indicate a partial or complete obstruction or pump failure
This test is simple and effective as a screening tool, especially for uncooperative pediatric patients.
The shortcomings are inability to distinguish between physiologic and anatomic causes of drainage dysfunction, inability to distinguish between upper and lower abnormality, and false-positive results.
Lacrimal irrigation
Reflux of irrigating fluid in the opposite punctum demonstrates patency of the canalicular system but suggests obstruction in the distal drainage system.
Reflux of irrigating fluid out the same punctum implicates either a canalicular or common canalicular obstruction
Mucoid reflux confirms a nasolacrimal duct obstruction
Lacrimal irrigation occasionally may be therapeutic by dislodging an obstructing stone or concretion or widening a partially stenosed passage.
Rarely, adult patients are completely relieved of symptoms after nasolacrimal probing and irrigation; others are only relieved temporarily or not at all.
Probing of canaliculi
When the irrigation test indicates obstruction, probing is used in an attempt to palpate or localize the site of obstruction.
The location of canalicular obstruction may be located, or estimated and then measured using a Bowman lacrimal probe.
Jones dye tests
Jones I: Dye is instilled in the patient's eye, and the patient is asked to blow their nose after 5 minutes.
Presence of dye indicates a patent system and normal physiologic function.
Absence of dye indicates 3 possibilities: false-negative result, physiologic dysfunction, or anatomic obstruction.
Jones II: The patient’s lacrimal drainage system is irrigated after a negative Jones I, and the patient is asked to expel any drainage from his or her pharynx.
Presence of dye indicates a partial block at the lower sac or duct
Presence of saline indicates punctal or canalicular stenosis
Regurgitation indicates complete NLDO or complete common canaliculus block.
High level of false results from Jones test
Digital pressure over lacrimal sac
Regurgitation on pressure over lacrimal sac - ROPLAS ( R Thomas et al, 1997)[14]
Specificity 99.3%
Sensitivity 93.2%
Positive test - mucoid discharge comes out of punctum after pressure on the area above the inferior orbital rim towards the medial canthus
Screening test for PANDO; obstruction may be located at or beyond the lacrimal sac
Microreflux test (JG Camara et al, 1999) (ref 69)
Specificity of 95%
Sensitivity of 97%
Functional laxity of the valve of Rosenmuller allows reflux of tears in a patient with PANDO
Positive test - Reflux of fluorescein-stained tears out the punctum after moderate digital pressure over the lacrimal sac
Screening test for PANDO done under slit lamp examination with the use of fluorescein dye drops
Lacrimal sac biopsy during dacryocystorhinostomy revealed the following histologic findings, in decreasing order of frequency: nongranulomatous inflammation (85.1%); granulomatous inflammation consistent with sarcoidosis (2.1%); lymphoma (1.9%); papilloma (1.11%); lymphoplasmacytic infiltrate (1.1%); transitional cell carcinoma (0.5%); and single cases of adenocarcinoma, undifferentiated carcinoma, granular cell tumor, plasmacytoma, and leukemic infiltrate.[10]
More recent studies shwoed histopathologic findings of inflammatory inflitrates, fibrosis, capillary proliferation and chronic inflammatory signs.[27]
Nongranulomatous inflammation consistent with chronic dacryocystitis is the most common diagnosis in lacrimal sac specimens obtained at DCR.[10, 27]
Diagnostic lacrimal apparatus irrigation can determine the level of lacrimal drainage obstruction. Patency of the lacrimal drainage is determined with nasal passage of fluid
Upper drainage system blocks:
Canalicular obstruction - cannula reaches a soft stop with reflux of tears in the same punctum
For treatment of nasolacrimal duct obstruction, the type of antibiotic depends on the suspected infecting agent or the results of cultures and sensitivities.
Topical antibiotics with lacrimal massage may be adequate for early infections.
Systemic antibiotics may be necessary for more chronic or severe infections, such as those causing dacryocystitis, canaliculitis, or preseptal cellulitis (may progress to orbital abscesses).
Although sensitive to penicillin, Actinomyces organisms usually require complete removal of the canalicular stones for complete treatment.
Involves the creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps
A viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients
May be indicated on a primary basis or as revisional surgery
Some studies comparing endonasal dacryocystorhinostomy with external dacryocystorhinostomy suggested lower success rates in the endonasal group. Other studies yielded success rates comparable with or exceeding those of external surgery.
Complications of endonasal dacryocystorhinostomy do not generally appear to be greater in frequency or magnitude than those associated with external dacryocystorhinostomy.
Disadvantages of endonasal dacryocystorhinostomy include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure.
Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal dacryocystorhinostomy than external dacryocystorhinostomy. In one study, the success rate of 93.5% compares favorably with that of standard external dacryocystorhinostomy (95.8%).
Anatomical success rate (91%) compares favorably with the success rate of other techniques for endonasal dacryocystorhinostomy and is also similar to the success of external dacryocystorhinostomy.
Endoscopic laser dacryocystorhinostomy
The KTP laser or the holmium:YAG laser is used.
In one study, the success rate in the endonasal group improved from 50% in the first 38 cases to 79% in the last 38 cases, thereby demonstrating a learning curve.
Endoscopic laser-assisted dacryocystorhinostomy
Advantages are as follows:
No skin incision
Less bleeding
Faster recovery
Approaches are as follows:
Endocanalicular
Trans-conjunctival
Endoscopic nasal
Endoscopic laser-assisted dacryocystorhinostomy is shown in the video below.
View Video
Endoscopic laser-assisted dacryocystorhinostomy. Courtesy of Jorge G Camara, MD, University of Hawaii John A Burns School of Medicine.
Conjunctivodacryocystorhinostomy
Conjunctivodacryocystorhinostomy (CDCR) is performed in cases of flaccid canaliculi, paralysis of lacrimal pump, absence or obliteration of canaliculi, when site of obstruction is proximal (punctum, canaliculi, lacrimal sac), congenital malformations, cicatricial conjunctival disease, chemical burns, irradiation, and tumors of the lacrimal sac.
The procedure uses a Pyrex Jones tube, which serves as a conduit between the medial conjunctival cul-de-sac and the nasal cavity.
Balloon catheter dilatation
The use of balloon catheter dilation for the treatment of adults with partial nasolacrimal duct obstruction and for children with congenital nasolacrimal duct obstruction has been described with good results in patients without active infection.
This treatment is effective for congenital nasolacrimal duct obstruction. See Congenital Anomalies of the Nasolacrimal Duct
Inferior meatus surgery
An endoscopic surgery for distal nasolacrimal duct obstruction at or near the Hasner valve
Confers 92.8% short-term success rate; 90% long-term success rate with a mean follow-up of 6.2 years[28]
Stents
Stents may be used as a first-line treatment for epiphora.
Polyurethane stents
See the list below:
Low success rate for the treatment of PANDO
May induce inflammation and fibrous tissue formation
Silicone
Double bicanalicular silicone intubation with the placement of 2 loops of silicone tubing through the nasolacrimal duct for the treatment of persistent nasolacrimal duct obstruction in children is an effective alternative to dacryocystorhinostomy in selected children who have failed conventional therapies.
For treatment of epiphora in adults with presumed functional nasolacrimal duct obstruction, silicone intubation has good long-term success, according to a study by Moscato et al.[29]
Hydrogel stents[30]
Considerations include the following:
Late success rate of 78.3%
Well-tolerated for acquired nasolacrimal duct obstruction; decreases incidence of nasal adhesions
Polypropylene sutures 3/0[31]
Considerations include the following:
Left in the lacrimal sac for 3 weeks
Good results
Otologic T-tubes[32, 33]
Considerations include the following:
Cheap and easy self-retaining stent to ensure a patent rhinostomy
Success rate of 73-82%
Inserted without passing through the punctum but directly through the medial wall sac
Timing of removal of stents have been variably published. Timing of removal ranges from 1-6 months. However, it was discovered that some lacrimal stents harbor bacterial biofilms and physical deposits, favoring earlier removal.[74, 75]
Adjunctive use of mitomycin-C
Adjunctive use of mitomycin-C during dacryocystorhinostomy procedures significantly increases the success rate without adverse effects.[34, 35, 36, 37, 38]
Success rate of 87.5-95%
Mitomycin-C, 0.2 mg/mL, may be used intraoperatively and postoperatively after external, endoscopic, and endolaser-assisted dacryocystorhinostomy and after balloon dacryoplasty.
After the dacryocystorhinostomy, patients are given antibiotic eye drops and a nasal decongestant spray in the immediate post-operative period. All medications are discontinued after long-term follow up after a successsful surgery.
The silicone stent tube at least after 1 month. In some situations (ie, Wegener granulomatosis), the stents may need to be retained indefinitely.
Antibiotic/steroid eye drops, such as tobramycin/dexamethasone combination eye drops, are prescribed postoperatively for use 2-3 times per day for 2-3 weeks as prophylaxis to infection and to decrease postoperative inflammation.
Nasal decongestant sprays are prescribed postoperatively for use 2-3 times per day for 1-2 weeks.
The definitive treatment of nasolacrimal duct obstruction is mainly surgical.
Medical therapy with systemic oral antibiotics is necessary in cases of canaliculitis, cellulitis, or acute dacryocystitis secondary to the obstruction.
See Dacryocystitis and Cellulitis, Preseptal regarding medical treatment.
Sandra R Worak, MD, Consultant Staff, Department of Orbit and Oculoplasty, Reconstructive and Lacrimal Surgery, East Avenue Medical Center and St Luke's Medical Center
Disclosure: Nothing to disclose.
Coauthor(s)
Alfonso U Bengzon, MD, MBA, Consulting Staff, Department of Ophthalmology; Section Head, Section of Oculoplastic and Orbit Surgery, Department of Ophthalmology, The Medical City General Hospital, Philippines; Consultant Head, The Medical City Diagnostic and Laser Eye Center
Disclosure: Nothing to disclose.
Specialty Editors
Simon K Law, MD, PharmD, Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine
Disclosure: Nothing to disclose.
Chief Editor
Hampton Roy, Sr, MD, † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Disclosure: Nothing to disclose.
Additional Contributors
Ron W Pelton, MD, PhD, Private Practice, Colorado Springs, Colorado
Disclosure: Nothing to disclose.
Acknowledgements
Jorge G Camara, MD Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine
Ali, Mohammed Javed F.R.C.S.,PhD; Paulsen, Friedrich Hon F.A.S. Etiopathogenesis of Primary Acquired Nasolacrimal Duct Obstruction: What We Know and What We Need to Know. Ophthalmic Plastic and Reconstructive Surgery. Oct 2019. 35:426-433.
Nguyen LK, Linberg JV. Evaluation of the lacrimal system. In: Surgery of the eyelid, orbit, and lacrimal system. American Academy of Ophthalmology. 1995. 3:254-69.
Wobig JL, Dailey RA. Surgery of the Lacrimal System. In: Surgery of the eyelid, orbit, and lacrimal system. American Academy of Ophthalmology. 1995. 3:270-87.
Dacryocystogram. A patent nasolacrimal system on the right side of a patient and a blocked system on the contralateral side at the level of the nasolacrimal duct.
Dacryocystitis of the left nasolacrimal system.
Endoscopic laser-assisted dacryocystorhinostomy. Courtesy of Jorge G Camara, MD, University of Hawaii John A Burns School of Medicine.
Dacryocystitis of the left nasolacrimal system.
Dacryocystogram. A patent nasolacrimal system on the right side of a patient and a blocked system on the contralateral side at the level of the nasolacrimal duct.
Endoscopic laser-assisted dacryocystorhinostomy. Courtesy of Jorge G Camara, MD, University of Hawaii John A Burns School of Medicine.
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