The ocular surface is continuously moistened with tears produced by specialized lacrimal glands. After nourishing the ocular surface, tears drain into the nose. The lacrimal glands are part of the secretory lacrimal system.
There are four key anatomic parts that form the excretory system:
Anomalies of any part of the excretory system can lead to an overflow of tears, a condition known as epiphora. Dacryostenosis, from the Greek word dákryon (tear) and stenósis (narrowing), generally refers to an obstruction that can affect any part of the excretory system. Dacryostenosis may be congenital or acquired.
Depending on the etiological factors, dacryostenosis can be classified into the following two broad categories:
The most common cause of congenital dacryostenosis is a mechanical obstruction located in the distal part of the nasolacrimal duct (NLD) at the level of the valve of Hasner, where this structure enters the nose. Persistence of an embryonal membrane or bone development abnormalities can cause difficulties in tear flow and eventually, mucopurulent discharge. For this reason, epiphora seems to be more common in premature infants compared to full-term babies. More rarely, the obstruction can be located near the nasolacrimal sac at the level of the valve of Rosenmueller: this more commonly causes a watery discharge.
When both the proximal and distal portions of the nasolacrimal system are obstructed, a dacryocystocele can occur. In this case, a bluish bulge below the medial canthus is seen. Congenital dacryocystoceles are less common but may be associated with potentially serious complications.
The etiology of acquired dacryostenosis is multifactorial and is not fully understood. Some cases may be related to trauma, neoplasm, systemic disease, radiotherapy, or chemotherapy. However, in most cases, the cause is "involutional" and classified as "idiopathic." Some authors have reported that the cause is secondary to anatomic changes in the diameter of the bony lacrimal canal, which occurs with aging. Women, in particular, have a smaller diameter of the lacrimal duct that tends to narrow with time. A congenital narrowness within the lacrimal drainage system is generally regarded as a disposition for lacrimal stenosis.
Some authors suggest that the cause may be from ascending inflammation from the region of the nose and sinus cavities. A descending infection from the conjunctiva has also been suggested as a cause of acquired dacryostenosis. Clinical studies indicate that nasal disease is sporadic in patients undergoing DCR.
Familial predisposition and osteoporotic changes have also been suggested as being predisposing factors.
Congenital dacryostenosis is quite common among newborns, with an incidence of between 1.2% and 20%. Congenital dacryostenosis is the most common cause of persistent tearing and ocular discharge in infants and young children. In one study, 20 percent of healthy infants were found to have problems in the lacrimal drainage at some point during the first year of life.
Acquired obstruction of the lacrimal drainage system causing epiphora, punctal discharge, and medial canthal swelling is a common ophthalmic complaint comprising approximately 3% of clinic visits in some series, with an annual incidence calculated as 37 cases per 100,000. The obstruction is more frequently situated at the level of the nasolacrimal duct or puncta, and less frequently at the level of the canaliculi. The incidence is higher among older people and in women.
Several factors may contribute to the chronic inflammation that arises in the epithelial layer of the nasolacrimal duct. Repeated episodes of dacryocystitis may lead to changes in the structural epithelial and subepithelial cells. In particular, loss of typical goblet and epithelial cells, which play a crucial role in tear outflow mechanism, has been described in pathological studies. Chronic inflammation may also cause fibrosis of the connective tissue fibers in the area of the lacrimal sac and nasolacrimal duct, with loss of blood vessels of the cavernous body that contribute to malfunctioning of the tear outflow mechanism and initiate a vicious circle.
In most instances of dacryostenosis, epiphora is the most common presenting symptom. However, other causes of epiphora should also be excluded.
Children with congenital dacryostenosis have a history of chronic or intermittent tearing and debris on the eyelashes. Usually, there is no conjunctival erythema, although some degree of irritation can result from overflow tearing and chronic rubbing of the eyes. Palpation of the lateral wall of the nose may cause watery reflux or mucopurulent discharge onto the eye. In adults, the most common complaint is epiphora (excessive tearing). Patients may also experience vision abnormalities. It has been demonstrated that these symptoms ultimately affect the quality of life.
In the case of bacterial infection of the content of the lacrimal sac, acute dacryocystitis can occur. Redness, pain, pulsation, epiphora, and tightness in the medial lid angle, along with a severe headache, will cause the patient to seek medical advice. If the obstruction does not resolve, mucous membrane inflammation may become chronic and acute episodes will recur.
The lumen of the duct may decrease continuously, sometimes even up to a complete closure that results in dilation of the lacrimal sac. Clinically, a bulge of the medial canthus due to the enlarged lacrimal sac is the typical sign of a chronic dacryostenosis. Mucous secretions are frequently visible coming out from the lacrimal puncta after slight pressure of the medial canthal swelling.
Diagnosis is typically made by history and physical examination.
Physical examination begins with an inspection of the eyelids, the lacrimal puncta, and the conjunctiva to rule out gross abnormalities. The lower eyelid may present with mild redness and an increase in the size of the tear film (tear meniscus). Massage of the lacrimal sac may provoke reflux of tears and/or mucous onto the eye through the puncta.
Additional Tests to Consider
The majority of congenital dacryostenosis cases resolve without the need for surgery. Treatment consists of performing lacrimal sac massages performed by the parents. Moderate pressure over the lacrimal sac should be applied in a downward direction two or three times per day. Antibacterial ointment application may be prescribed to avoid bacterial infection.
If the obstruction persists beyond the age of six months, lacrimal duct probing is advocated. This procedure is performed by an ophthalmologist, usually under general anesthesia. The procedure is performed by inserting a small blunt probe or irrigation cannula into the punctum and advancing it until it abuts the obstruction and reaches the nasal cavity. Irrigation with saline is often performed to ensure patency.
The combination of probing and irrigation is an easy, quick procedure with a high rate of success. Nasolacrimal intubation may be performed if there is significant stenosis of the bottom end of the nasolacrimal duct. The stent, which is made of silicone, is placed in the nasolacrimal system and removed in the office after two to six months. Success rates with this procedure are 90 to 96 percent in the case of primary treatment and 84 percent when performed after failed probing.
Additional procedures include balloon dacryocystoplasty, dacryocystorhinostomy, and conjunctivodacryocystorhinostomy. These interventions can be performed both in pediatric and adult patients. The balloon dacryocystoplasty is a simple and minimally invasive technique. It is usually advisable for the treatment of incomplete obstruction of the lacrimal drainage system and for cases who have failed a simple probing and irrigation procedure. Usually, a stent is left in place after the procedure.
Dacryocystorhinostomy (DCR) is a more complex procedure that requires the removal of a part of the lacrimal bone to create a window between the lacrimal sac and the nasal cavity. DCR preserves the active drainage mechanism. It can be done via external access or endoscopic nasal access. Usually, endoscopic access requires general anesthesia. Transcanalicular laser-assisted dacryocystorhinostomy is performed by inserting a small laser fiber into the canaliculi and may be done under local anesthesia. It involves less tissue removal compared to standard techniques, but the success is lower than standard DCR techniques.
When the obstruction is in the canaliculi, the procedures discussed above will not work. A conjunctivodacryocystorhinostomy may be indicated. This procedure involves a complete by-pass of the lacrimal drainage obtained, inserting a Pyrex glass tube (Jones tube). Periodic removal and cleaning of the Jones tube, followed by immediate replacement, may be needed. It has been shown that the device can be tolerated for at least four decades. Some authors suggest that the application of antimetabolites at the time of DCR increases the functional and anatomic success of DCR.
Opening of the obstructed nasolacrimal ducts in adults with an antegrade dilatation has been suggested, but sufficient studies proving the efficacy of this procedure have not been completed.
The most common presentation of dacryostenosis is epiphora. However, as mentioned above, in some instances, other signs and symptoms may be present. In the presence of eye redness and discomfort, conjunctivitis, foreign bodies, end corneal abrasion must be ruled out.
In children, spontaneous resolution is frequent and occurs by six months of age in approximately 90 percent of patients. If the obstruction persists more than the age of one year, spontaneous resolution is unlikely. In adults with acquired dacryostenosis, spontaneous resolution is rare. When surgery is needed, the prognosis depends on the technique and associated conditions.
Success rates of external and internal DCR are similar and reported to be more than 90% in most studies in the literature. The endoscopic approach may be preferred because it offers the advantage of allowing the surgeon to identify and correct intranasal abnormalities, which are the most common causes of DCR failure.
Dacryostenosis can evolve into an infection of the lacrimal sac (dacryocystitis), which, if left untreated, can cause complications such as endophthalmitis and orbital cellulitis. Signs and symptoms of acute dacryocystitis (erythema, swelling, warmth, tenderness of the lacrimal sac, and/or purulent discharge) must be identified. There is evidence that a relationship exists between congenital nasolacrimal duct obstruction and subsequent refractive error disorders in children. In particular, 10% of children with congenital nasolacrimal duct obstruction may develop anisometropia (with or without amblyopia).
When the obstruction is incomplete, the tearing can present only in a situation that stimulates higher production of tears (e.g., wind or cold) or when clearance of tears is reduced from edema of nasal mucosa during an upper respiratory infection. If symptoms occur frequently and become bothersome medical consultation should be sought. In the case of congenital obstruction, it is crucial to instruct caregivers to perform the Crigler local massage maneuver two to three times per day until symptoms resolve.
Dacryostensois can be diagnosed and managed by the primary care provider. It is essential to recognize this condition early timely diagnosis can avoid complete stenosis of the puncta or canaliculi. In case the diagnosis is uncertain, referral to an ophthalmologist is warranted so the appropriate intervention may be performed. If erythema, swelling, warmth, tenderness of the lacrimal sac, and/or purulent discharge are present, an acute infection may have developed, and ophthalmologic referral is suggested. Signs of anisometropia or amblyopia in the presence of nasolacrimal duct obstruction warrants referral to an ophthalmologist.
|||Maini R,MacEwen CJ,Young JD, The natural history of epiphora in childhood. Eye (London, England). 1998; [PubMed PMID: 9850262]|
|||Macewen CJ, Congenital nasolacrimal duct obstruction. Comprehensive ophthalmology update. 2006 Mar-Apr; [PubMed PMID: 16709344]|
|||Moscato EE,Kelly JP,Weiss A, Developmental anatomy of the nasolacrimal duct: implications for congenital obstruction. Ophthalmology. 2010 Dec; [PubMed PMID: 20656354]|
|||Lorena SH,Silva JA,Scarpi MJ, Congenital nasolacrimal duct obstruction in premature children. Journal of pediatric ophthalmology and strabismus. 2013 Jul-Aug; [PubMed PMID: 23614467]|
|||Olitsky SE, Update on congenital nasolacrimal duct obstruction. International ophthalmology clinics. 2014 Summer; [PubMed PMID: 24879099]|
|||Mansur C,Pfeiffer ML,Esmaeli B, Evaluation and Management of Chemotherapy-Induced Epiphora, Punctal and Canalicular Stenosis, and Nasolacrimal Duct Obstruction. Ophthalmic plastic and reconstructive surgery. 2017 Jan/Feb; [PubMed PMID: 27429222]|
|||Janssen AG,Mansour K,Bos JJ,Castelijns JA, Diameter of the bony lacrimal canal: normal values and values related to nasolacrimal duct obstruction: assessment with CT. AJNR. American journal of neuroradiology. 2001 May; [PubMed PMID: 11337326]|
|||Mauriello JA Jr,Palydowycz S,DeLuca J, Clinicopathologic study of lacrimal sac and nasal mucosa in 44 patients with complete acquired nasolacrimal duct obstruction. Ophthalmic plastic and reconstructive surgery. 1992; [PubMed PMID: 1554647]|
|||Paulsen FP,Thale AB,Maune S,Tillmann BN, New insights into the pathophysiology of primary acquired dacryostenosis. Ophthalmology. 2001 Dec [PubMed PMID: 11733281]|
|||Tahat AA, Dacryostenosis in newborns: probing, or syringing, or both? European journal of ophthalmology. 2000 Apr-Jun; [PubMed PMID: 10887923]|
|||MacEwen CJ,Young JD, Epiphora during the first year of life. Eye (London, England). 1991; [PubMed PMID: 1794426]|
|||Heindl LM,Junemann A,Holbach LM, A clinicopathologic study of nasal mucosa in 350 patients with external dacryocystorhinostomy. Orbit (Amsterdam, Netherlands). 2009; [PubMed PMID: 19229737]|
|||Woog JJ, The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota, 1976-2000 (an American Ophthalmological Society thesis). Transactions of the American Ophthalmological Society. 2007; [PubMed PMID: 18427633]|
|||Perez Y,Patel BC,Mendez MD, Nasolacrimal Duct Obstruction . 2020 Jan [PubMed PMID: 30422468]|
|||Juri Mandić J,Ivkić PK,Mandić K,Lešin D,Jukić T,Petrović Jurčević J, Quality of Life and Depression Level in Patients with Watery Eye. Psychiatria Danubina. 2018 Dec; [PubMed PMID: 30439808]|
|||Patel J,Levin A,Patel BC, Epiphora . 2020 Jan [PubMed PMID: 32491381]|
|||Steinkogler FJ, The postsaccal, idiopathic dacryostenosis--experimental and clinical aspects. Documenta ophthalmologica. Advances in ophthalmology. 1986 Sep 30; [PubMed PMID: 3780377]|
|||Papathanassiou S,Koch T,Suhling MC,Lenarz T,Durisin M,Stolle SRO,Raab P, Computed Tomography Versus Dacryocystography for the Evaluation of the Nasolacrimal Duct-A Study With 72 Patients. Laryngoscope investigative otolaryngology. 2019 Aug; [PubMed PMID: 31453347]|
|||Francis IC,Kappagoda MB,Cole IE,Bank L,Dunn GD, Computed tomography of the lacrimal drainage system: retrospective study of 107 cases of dacryostenosis. Ophthalmic plastic and reconstructive surgery. 1999 May; [PubMed PMID: 10355842]|
|||Kim S,Yang S,Park J,Lee H,Baek S, Correlation Between Lacrimal Syringing Test and Dacryoscintigraphy in Patients With Epiphora. The Journal of craniofacial surgery. 2020 Apr 10; [PubMed PMID: 32282674]|
|||[PubMed PMID: 32491356]|
|||Kushner BJ, Congenital nasolacrimal system obstruction. Archives of ophthalmology (Chicago, Ill. : 1960). 1982 Apr; [PubMed PMID: 6896140]|
|||Hu K,Patel J,Patel BC, Crigler Technique For Congenital Nasolacrimal Duct Obstruction . 2020 Jan [PubMed PMID: 32644693]|
|||Örge FH,Boente CS, The lacrimal system. Pediatric clinics of North America. 2014 Jun; [PubMed PMID: 24852150]|
|||Repka MX,Melia BM,Beck RW,Atkinson CS,Chandler DL,Holmes JM,Khammar A,Morrison D,Quinn GE,Silbert DI,Ticho BH,Wallace DK,Weakley DR Jr, Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 2008 Oct; [PubMed PMID: 18595756]|
|||Rosen N,Ashkenazi I,Rosner M, Patient dissatisfaction after functionally successful conjunctivodacryocystorhinostomy with Jones tube. American journal of ophthalmology. 1994 May 15; [PubMed PMID: 8172270]|
|||Ullrich K,Malhotra R,Patel BC, Dacryocystorhinostomy . 2020 Jan [PubMed PMID: 32496731]|
|||[PubMed PMID: 9224475]|
|||Scawn RL,Verity DH,Rose GE, Can Lester Jones tubes be tolerated for decades? Eye (London, England). 2018 Jan; [PubMed PMID: 28820185]|
|||Phelps PO,Abariga SA,Cowling BJ,Selva D,Marcet MM, Antimetabolites as an adjunct to dacryocystorhinostomy for nasolacrimal duct obstruction. The Cochrane database of systematic reviews. 2020 Apr 7; [PubMed PMID: 32259290]|
|||Patel BC, Management of acquired nasolacrimal duct obstruction: external and endonasal dacryocystorhinostomy. Is there a third way? The British journal of ophthalmology. 2009 Nov [PubMed PMID: 19854737]|
|||Lin GC,Brook CD,Hatton MP,Metson R, Causes of dacryocystorhinostomy failure: External versus endoscopic approach. American journal of rhinology [PubMed PMID: 28490404]|
|||Piotrowski JT,Diehl NN,Mohney BG, Neonatal dacryostenosis as a risk factor for anisometropia. Archives of ophthalmology (Chicago, Ill. : 1960). 2010 Sep; [PubMed PMID: 20837801]|