Aetiology

Obstruction or stenosis of the nasolacrimal duct, causing excess tearing (epiphora); congenital or acquired aetiology

Congenital
Between 5% and 20% of newborn babies have incomplete canalisation due to persistent membranous obstruction at opening of nasolacrimal duct into nose (valve of Hasner); can be unilateral or bilateral

Acquired
Usually idiopathic (i.e. no established cause)
Usually involutional (i.e. age-related) stenosis (abnormal narrowing) of nasolacrimal passages
Punctal or canalicular stenosis/occlusion  

• post-infective (chlamydia, herpes simplex/zoster, staphylococcus)
• post-cicatricial disease (ocular pemphigoid, Stevens-Johnson)
• post-conjunctivitis medicamentosa (see Clinical Management Guideline on Conjunctivitis medicamentosa)
• iatrogenic (e.g. repeated probing, eyelid surgery)
• secondary to ectropion or punctal eversion

Mechanical (trauma, tumours, obstruction by lashes or foreign matter, e.g. 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)

Predisposing factors

Female gender
Frequent eye infections
Cranio-facial defects (e.g. Goldenhar syndrome)
Neoplasia

Symptoms of nasolacrimal duct obstruction

Excessive watering
Irritation
Blurred vision due to excessive tear meniscus, especially on downgaze, e.g. when reading

Differential diagnosis

Congenital
Congenital glaucoma (tearing is a common sign)
Punctal atresia (congenital absence or abnormal narrowing of puncta)

Acquired
Malposition of the eyelids e.g. ectropion, entropion. Lacrimal pump failure following facial nerve palsy. See appropriate Clinical Management Guidelines 

Proximal lacrimal obstruction, e.g. 

• canaliculitis (chronic mucopurulent conjunctivitis, punctum expresses chalky concretions, redness & tenderness over canaliculi)
• dacryocystitis (distended tender lacrimal sac): see Clinical Management Guidelines on Acute and Chronic Dacryocystitis
• tumour of lacrimal sac or canaliculi (rare, can produce lacrimal obstruction swelling at or below inner canthus (± blood in tears)

Management by optometrist

Practitioners should work within their scope of practice, and where necessary seek further advice or refer the patient elsewhere

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

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

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Therapy
Do not syringe or probe
Instruct parent in Crigler technique (lacrimal sac massage). Gentle pressure with index finger over lacrimal sac and massage downwards. Suggest ten strokes, twice daily. RCT evidence has shown effectiveness of the technique in infants under 6 months of age.
Regular cleaning of discharge from lids
(GRADE*: Level of evidence=low, Strength of recommendation=strong)

High rate of spontaneous resolution during the first 12 months of life (>50% resolve within 6 months, over 70% by 12 months). Children with unilateral obstruction or where symptoms persist beyond 12 months may benefit from probing.
(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

Acquired
Diagnostic tests
Lacrimal syringing (irrigation test) (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 (if bud stained with fluorescein after 5 min, lacrimal system is patent)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

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)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

Congenital
Topical broad spectrum topical antibiotic e.g. chloramphenicol drops: only if clinical evidence of infection
(GRADE*: Level of evidence=low, Strength of recommendation=weak)

Acquired
Topical broad spectrum topical antibiotic e.g. chloramphenicol drops: only if clinical evidence of infection
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
 

Management category

Congenital 
B2: alleviation or palliation; normally no referral (due to high rate of spontaneous resolution during the first 12 months of life; children with unilateral obstruction or persistent symptoms over 12 months may benefit from probing)
Acquired 
B1 (modified): initial management (including drugs) followed by routine referral for possible surgical management if fails to resolve

Possible management in secondary care or local primary/community pathways where available

Additional guidance may be available

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

Stent intubation

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 (a Pyrex tube leading from the inner canthus to the nasal space which needs regular maintenance, i.e. cleaning, by the patient)

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
 

Sources of evidence

Asano M, Takeuchi M, Ohno T, Nakamura J, Mizuki N, Matsumura N. Lacrimal sac massage for congenital nasolacrimal duct obstruction: a multicentre randomised controlled trial. Br J Ophthalmol. 2024 Jan 19:bjo-2023-324595. doi: 10.1136/bjo-2023-324595. Online ahead of print.

Avdagic E, Phelps PO Nasolacrimal duct obstruction as an important cause of epiphora. Dis Mon. 2020;66(10):101043

Jawaheer L, MacEwen CJ, Anijeet D. Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2017;2:CD007097

Lin AE, Chang YC, Lin MY, Tam KW, Shen YD. Comparison of treatment for congenital nasolacrimal duct obstruction: a systematic review and meta-analysis. Can J Ophthalmol. 2016;51(1):34-40

Marcet MM, Kuk AK, Phelps PO. Evidence-based review of surgical practices in endoscopic endonasal dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction and other new indications. Curr Opin Ophthalmol. 2014;25(5):443-8

Ohtomo K, Ueta T, Toyama T, Nagahara M. Predisposing factors for primary acquired nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol. 2013;251(7):1835-9

Petris C, Liu D. Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2017;7:CD011109

Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
Version 9
Date of search 16.04.24
Date of revision 30.05.24
Date of publication 02.07.24
Date for review 15.04.26
© College of Optometrists