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Symptoms

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

Classification

• Congenital nasolacrimal duct obstruction (see separate article).
• Acquired pre-saccal / post-saccal nasolacrimal duct obstruction

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’s 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)