CLINICAL MANAGEMENT GUIDELINES

Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)

Aetiology

Predisposing factors
Symptoms

Signs

Differential diagnosis

Congenital
Some babies have a persistent membranous obstruction at opening of
nasolacrimal duct into nose; unilateral or bilateral
Acquired
Usually idiopathic (ie no established cause)
Usually involutional (ie age-related) stenosis (ie abnormal narrowing) of
nasolacrimal passages
Punctal or canalicular stenosis/occlusion
post-infective (chlamydia, herpes simplex/zoster, staphylococcal)
post-cicatricial disease (ocular pemphigoid, Stevens-Johnson)
post-conjunctivitis medicamentosa (see Clinical Management
Guideline on Conjunctivitis medicamentosa)
iatrogenic (eg repeated probing, eyelid surgery)
secondary to ectropion or punctal eversion
Mechanical (trauma, tumours, obstruction by lashes or foreign matter eg
dacryoliths [calcium stones], punctal/canalicular plugs)
Infection of canaliculi (canaliculitis)
rarely, due to Actinomyces (Streptothrix sp.) a Gram-positive
bacillus
such cases usually unilateral
pouting punctum typical
Local infection (chronic sinusitis, dacryocystitis)
Age: congenital in babies, acquired in later life
Other factors: see above
Epiphora
Irritation
Blurred vision due to excessive tear meniscus, especially on downgaze,
eg when reading
Congenital
Epiphora and sticky discharge
Pressure over lacrimal sac may cause reflux of purulent material from
puncta
Acquired
Check puncta for
size (normally 0.2 to 0.3 mm diameter)
apposition to the globe and marginal tear strip
contact with opposite lid on eye closure
Congenital
Congenital glaucoma (acute)
Punctal atresia (congenital absence or abnormal narrowing of puncta)
Acquired
Rule out inflammation or infection (pain, discharge, swelling, redness,
mucus reflux on syringing in adults, history of sinusitis)
canaliculitis (chronic mucopurulent conjunctivitis, punctum
expresses chalky concretions, redness & tenderness over
canaliculi)
dacryocystitis (distended tender lacrimal sac)
Tumour of lacrimal sac or canaliculi (rare)
can produce lacrimal obstruction
swelling at or below inner canthus ( blood in tears)
Bells palsy (lacrimal pump failure due to orbicularis weakness)

Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)

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CLINICAL MANAGEMENT GUIDELINES

Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)

Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Congenital
Diagnostic test
Fluorescein disappearance test
a drop of 1% fluorescein should disappear from the tear
meniscus in 5-10 minutes (cobalt blue light, room lights off); any
longer suggests partial or complete obstruction
Therapy
Do not syringe or probe
Instruct parent in massage. Gentle pressure with finger over common
canaliculus, stroking downwards firmly to raise pressure in lacrimal sac
and encourage opening of valve. Suggest ten strokes, twice daily
Regular cleaning of discharge from lids
Refer for probing if condition fails to resolve by 12 months
Acquired
Diagnostic tests
Lacrimal syringing (NB not in congenital cases)
instil a drop of topical anaesthetic
gently dilate punctum with punctal dilator
syringe with normal saline via lacrimal cannula
if saline passes into nose (patient swallows and tastes salt)
nasolacrimal system is patent
if there is resistance to the passage of the cannula and reflux
from opposed canaliculus - common canaliculus is stenosed
if no saline passes into nose - complete lacrimal duct obstruction
Jones fluorescein dye test
significant amount of fluorescein remaining in tear meniscus two
minutes or more after instillation indicates restricted drainage
check for appearance of fluorescein in the nose (examine tissue
after nose blow; if fluorescein present, lacrimal system is patent)
place anaesthetic-soaked cotton bud in nose under inferior
turbinate (if bud stained with fluorescein after 5 min, lacrimal
system is patent)
Therapy
Lacrimal lavage (saline syringing) may be effective in some cases:
local (discrete) obstruction
subacute inflammation or infection
It is less likely to be effective:
in stenosis in the elderly
where there is an underlying disease (inflammation, tumour)
Pharmacological
Congenital
Topical broad spectrum antibiotic eg chloramphenicol drops (only if
clinical evidence of infection)
Acquired
Topical broad spectrum antibiotic eg chloramphenicol drops (only if
clinical evidence of infection)
For Actinomyces infection, ofloxacin drops (generally in conjunction with
curettage of sulphur granules)
Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
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Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)

Management Category

Congenital
B2: alleviation or palliation; normally no referral (due to high rate of
spontaneous resolution during the first 12 months of life)
Acquired
B1: Initial management (including drugs) followed by routine referral
Possible management by Ophthalmologist
Lacrimal syringing
Probing (through puncta, canaliculi, sac, to nasolacrimal duct)
Congenital: not until 12 months of age to allow for spontaneous
canalisation
in resistant acquired cases has limited success and carries risk of
aggravation of underlying disease and of tissue trauma
Canalicular curettage
for Actinomyces infection
Punctal dilatation where there is stenosis
Surgical removal of posterior wall of vertical limb of canaliculus
considered when repeated punctal dilatation ineffective
X-ray imaging of radiopaque liquid injected into the lacrimal drainage
system (dacryocystogram, DCG)
pinpoints any obstructions and guides surgery
Surgery in canalicular or nasolacrimal duct obstruction includes
dacryocystorhinostomy, DCR (surgical or endolaser)
if other measures have failed, insertion of a Lester-Jones tube
Evidence base
Anijeet D, Dolan L, MacEwen CJ. Endonasal versus external
dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane
Database of Systematic Reviews 2011, Issue 1. Art. No.: CD007097.
DOI: 10.1002/14651858.CD007097.pub2
Authors' conclusions:
The only trial included in the review provides evidence that endonasal
DCR has statistically higher risk of failure compared to external DCR.
However, this conclusion is limited by paucity of RCTs, small number of
participants and lack of clarity of the methodological process. Well
conducted RCTs with sufficient power are required to answer the
research question.
(The Oxford 2011 Levels of Evidence = 2)

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