Acquired Nasolacrimal Duct Obstruction

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Symptoms

  • Unilateral or bilateral tearing, often indoors and outdoors
  • Crusty eyelids in the morning

Classification

Causes

  • Idiopathic, inflammations, medications especially cytostatics, radiation, trauma, mechanical, tumors, etc.

Work-up

  • Dry eye is as an important differential diagnosis (more outdoors than indoors, superficial punctate keratitis, reduced tear breakup time/Schirmer test
  • Lid architecture
    • Ectropion? Increased lid laxity / lower lid sagging / temporally lower?
  • Lacrimal puncta:
    • Open? Apposed? Covered by conjunctival folds (chalasis) or prominent caruncle?
  • Pressure on the lacrimal sac: discharge of secretion?
  • Fluorescein retention test: Instill fluorescein 2% into both eyes and compare the tear meniscus after 5 minutes
    • Normally, only a small amount of fluorescein should be present
  • Probing and irrigation of the lacrimal system
    • Soft-stop (pre-saccal stenosis) or hard-stop (post-saccal stenosis)?
    • Patency (does fluid reach the nose/throat)?
    • Little or much resistance? (possibly partial stenosis)
    • Reflux (clear fluid, mucus/pus?)
    • location of stenosis in case of reflux + soft-stop:
      • From the other lacrimal punctum: Stenosis in the common canaliculus
      • From the same lacrimal punctum: Stenosis in the canaliculus
    • Note: Anatomical variations exist in about 10% of patients.
  • Dacryozystography + Dacryo-CT: Recommended before any dacryocystorhinostomy (DCR)

Treatment

  • Closed lacrimal punctum: Punctoplasty (3-snip or with Kelly punch)
  • Problematic lid architecture: Consider lateral canthopexy
  • Pre-saccal stenosis
    • Partial: Consider probing / canalicular surgery
    • Complete: Usually conjunctivo-DCR with Lester Jones tube
  • Post-saccal stenosis: Dacryocystorhinostomy (DCR) externally (Toti) or endonasally (+ ENT).
    • Partial: Consider probing and temporary insertion of a stent (e.g. Masterka)

Sources

  • Kanski‚Äôs Clinical Ophthalmology: A Systematic Approach; John E Salmon MD; Elsevier; 9th Edition (2019)
  • Review of Ophthalmology: Neil J. Friedman; Peter K. Kaiser; William B. Trattler; Elsevier, 3rd Edition (2018)