Epiphora is defined as the overflow of tears. 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 anatomy and physiology.
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 the most likely cause.
Abnormalities of tear drainage may be subdivided further into functional and anatomical. 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 lacrimal drainage pathway and may be congenital or acquired. Congenital obstructions tend to produce symptoms during the neonatal period and are the subject of another article, Nasolacrimal Duct, Congenital Anomalies.
Classification of nasolacrimal drainage obstruction
The 2 types of acquired nasolacrimal drainage obstructions (NLDO) are primary and secondary. In 1986, Linberg and McCormick coined the term primary acquired nasolacrimal duct obstruction (PANDO) to describe an entity of nasolacrimal duct obstruction caused by inflammation or fibrosis without any precipitating cause.[1] Bartley proposed an etiologic classification system for secondary acquired lacrimal drainage obstruction (SALDO) based on published cases.[2, 3, 4]
PANDO is more common in middle-aged and elderly females. Using CT scans, Groessl and colleagues demonstrated that women have significantly smaller dimensions in the lower nasolacrimal fossa and middle nasolacrimal duct.[5] They noted that changes in the anteroposterior dimensions of the bony nasolacrimal canal coincide with osteoporotic changes throughout the body. These quantitative measurements may help explain the higher incidence of PANDO in women. Others have suggested menstrual and hormonal fluctuations and a heightened immune status as factors that may contribute to the disease process. These may explain the prevalence in middle-aged and elderly females. Hormonal changes that bring about a generalized de-epithelialization in the body may cause the same within the lacrimal sac and duct. An already narrow lacrimal fossa in women predispose them to obstruction by the sloughed off debris.
The general categories of causes of SALDO include infectious, inflammatory, neoplastic, traumatic, and mechanical. Bacteria, viruses, fungi, and parasites have been implicated as causes of infectious lacrimal drainage obstruction.
Viral causes of obstruction most commonly are seen with herpetic infection. The obstruction is due to the damage of the substantia propria of the canalicular elastic tissue and/or the adherence of the inflammatory membranes to the raw epithelial surface of the canaliculus.
Fungi may obstruct lacrimal passages by forming a stone (dacryolith) or cast. Parasitic obstruction is rare but is reported in patients infected with Ascaris lumbricoides, which enters the lacrimal system through the valve of Hasner.
Inflammation may be endogenous or exogenous in origin. Wegener granulomatosis and sarcoidosis are 2 examples of conditions that lead to obstruction due to progressive inflammation within the nasal and lacrimal sac mucosa. Other endogenously arising inflammations associated with lacrimal obstruction are cicatricial pemphigoid, sinus histiocytosis, Kawasaki disease, and scleroderma.
Exogenous causes of cicatricial lacrimal drainage obstruction are eye drops, radiation, systemic chemotherapy, and bone marrow transplantation.
The use of 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.
Canalicular and nasolacrimal duct obstruction is a common adverse effect of weekly docetaxel therapy used for metastatic breast cancer and non-small cell lung cancer.
Neoplasms 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. Secondary spread from nearby tissues is more common than primary tumors. They are most commonly eyelid cancers (eg, basal cell carcinoma, squamous cell carcinoma), although spread from the maxillary antrum and the nasopharynx also have been reported. Studies have documented oncocytoma and cylindroma from direct extension. Metastatic spread, an extremely rare phenomenon, has been reported with primary sites from the breast and prostate.
Trauma may be iatrogenic in the case of scarring of the lacrimal passage after overly aggressive lacrimal probing. Iatrogenic causes of NLDO also may follow orbital decompression surgery, paranasal, nasal, and craniofacial procedures. Noniatrogenic traumatic causes are either blunt or sharp and most commonly involve the canaliculus, lacrimal sac, and nasolacrimal duct. Posttraumatic dacryostenosis was found to have a frequent association with delayed treatment of facial fracture repair or bone loss in the lacrimal district.
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
Obstruction of lacrimal drainage passageway
Possible diagnostic tests that may be necessary to evaluate the condition and their possible results
Treatment protocols 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.[13]
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 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[15]
Criterion standard in the morphological study of the lacrimal passages and quantification of stenosis[16]
Nasal endoscopy - 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 three-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.[17]
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
A positive result is indicated by +2 to +4 residual fluorescein 5 minutes after instillation.
Positive results indicate a partial or complete obstruction, or pump failure.
This test is simple and effective as a screening tool.
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/upper punctum demonstrates patency of the canalicular system but suggests obstruction in the distal drainage system.
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 the degree of stenosis may be estimated.
Jones dye tests
Jones I: Dye is instilled in the patient's eye, and the patient is asked to blow his or her 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
Microreflux test
Screening test for PANDO
Positive test - Reflux of fluorescein-stained tears from the inferior punctum after counterclockwise lacrimal sac massage
Sensitivity of 97%
Specificity of 95%
Hornblass saccharine test
Instill saccharine drops in one eye and chloramphenicol eye drops in the other eye several minutes later.
The ability of the patient to detect the sweet taste of the saccharine and the bitter taste of the chloramphenicol denotes a patent lacrimal system.
A study presented clinicopathologic findings from lacrimal sac biopsy specimens obtained during dacryocystorhinostomy (DCR).[18]
Their data revealed the following, 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.[18]
They concluded that nongranulomatous inflammation consistent with chronic dacryocystitis is the most common diagnosis in lacrimal sac specimens obtained at DCR.[18] Neoplasms resulting in chronic nasolacrimal duct obstruction occurred in 4.6% of cases and were unsuspected before surgery in 2.1% of patients.[18]
A case of necrotizing sialometaplasia of the lacrimal sac mimicking squamous cell carcinoma was reported in 2016.[19]
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.
Highly successful in older children who failed previous probing
Success in children older than 24 months is 82.9%. Success in children younger than 24 months is 65.4%.
Balloon catheter dilatation is more effective than simple probing for older children with nasolacrimal duct obstruction because of stenosis that extends along the distal nasolacrimal duct.
No significant advantage exists over simple nasolacrimal duct probing in patients with typical membranous obstruction at the Hasner valve.
Endoscopically assisted balloon dacryoplasty has been shown as a treatment for incomplete NLDOs to provide substantial improvement or even complete relief.
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[20]
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.[21]
Hydrogel stents[22]
See the list below:
Late success rate of 78.3%
Well-tolerated for acquired nasolacrimal duct obstruction; decreases incidence of nasal adhesions
Polypropylene sutures 3/0[23]
See the list below:
Left in the lacrimal sac for 3 weeks
Good results
Otologic T-tubes[24, 25]
See the list below:
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
Adjunctive use of mitomycin-C
Adjunctive use of mitomycin-C during dacryocystorhinostomy procedures significantly increases the success rate without adverse effects.[26, 27, 28, 29, 30] See the list below:
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.
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 2-3 weeks.
Sandra R Worak, MD, Consulting 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
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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