assessment and management of proximal and incomplete symptomatic obstruction of the lacrimal drainage system

Key words: Canalicular stenosis, Epiphora, Functional lacrimal obstruction, Nasolacrimal duct, Stenosis, Punctal stenosis Assessment and Management of Proximal and Incomplete Symptomat

Eye Research Center, Rassoul Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran

Corresponding Author: Dr Mohsen Bahmani Kashkouli, Eye Plastic Unit, Rassoul Akram Hospital, Sattarkhan-Niayesh St., Tehran 14455-364, Iran E-mail: bahmanik@eyeplasticsurgeries.com

Access this article online Website:

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DOI:

10.4103/0974-9233.92117

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INTRODUCTION

Anatomy

The lacrimal drainage apparatus is divided into the proximal

and distal sections The proximal section includes

the punctum, canaliculus, and the common canaliculus,

successively.1-3 The distal lacrimal drainage system consists of

the lacrimal sac and the nasolacrimal duct that finally open

into the lateral nasal wall, below the inferior meatus.1 The

lacrimal drainage system begins at the superior and inferior

puncta The external lacrimal punctum is approximately 0.3

mm in diameter.4 The papilla is the elevated tissue surrounded

internally by a ring of connective tissue.4 The lacrimal puncta are

components of tarsal plates in both the upper and lower lids.5

The upper punctum is 6.0 mm from the medial canthus and the

lower 6.5 mm.2 Both the superior and inferior puncta should

sit in apposition to the globe in the tear lake.4 The puncta allow

entrance into the ampulla, which is directed perpendicularly to

the lid margin for 2 mm and after a 90-degree bend continues

as the canaliculi.1 The upper and lower canaliculi course along

the lid margins and measure 8 – 10 mm in length and 0.5 –

1.0 mm in diameter.3 In approximately 90% of the individuals,

the distal section of the canaliculi joins to form the common canaliculus before entering the lacrimal sac.3 At the entrance

of the lacrimal sac, the common canaliculus may dilate slightly, forming the sinus of Maier.3 The canaliculi are lined with stratified, squamous, non-keratinized, non-mucin-producing epithelium surrounded by elastic tissue, which permits dilation

up to two-to-three times the normal diameter.3 The valve of Rosenmuller is a functional one-way valve that is presumably formed by the mucosal folds and the manner in which it enters the sac.1-3 The common canaliculus bends behind the medial canthal tendon before entering the lacrimal sac at an acute angle The oblique entrance prevents a tear reflux from the sac back into the canaliculi.1,2 The lacrimal sac lies in the lacrimal sac fossa, behind the medial canthal tendon.1,2 The lacrimal fossa

is bordered by the anterior and posterior lacrimal crests, to which the medial canthal tendon attaches.2 Its medial aspect is tightly adherent to the periosteal lining of the fossa The medial canthal tendon is a complex structure, composed of anterior and posterior crura.1,2 The superficial head attaches to the anterior lacrimal crest, and the deep head (Horner’s muscle), to the posterior lacrimal crest.1,2 The medial wall of the fossa (lamina papyracea) is composed of the lacrimal bone posteriorly and

ABSTRACT

Epiphora is a common complaint of patients who present to an Ophthalmology Clinic In

many cases, epiphora is due to an obstruction in the lacrimal drainage system However, a

subgroup of symptomatic patients with epiphora has a patent lacrimal drainage system Such

cases are usually termed ‘functional obstruction’ and / or ‘stenosis of the lacrimal drainage

system’ Various etiologies and diagnostic and therapeutic approaches have been described

in literature, which implies the lack of a standardized approach This article will review

the evolving diagnostic and therapeutic approaches in literature, and in the end, propose a

paradigm in approaching this group of patients.

Key words: Canalicular stenosis, Epiphora, Functional lacrimal obstruction, Nasolacrimal

duct, Stenosis, Punctal stenosis

Assessment and Management of Proximal and

Incomplete Symptomatic Obstruction of the Lacrimal Drainage System

Mohsen Bahmani Kashkouli, Farzad Pakdel, Victoria Kiavash

the frontal process of the maxillary bone anteriorly.1 The total

sac measures a length of 12–15 mm vertically and 4–8 mm

anteroposteriorly.1 The fundus of the sac extends above the

tendon for 3 to 5 mm The sac rests in the lacrimal sac fossa,

with its medial aspect tightly adherent to the periosteal lining of

the fossa The nasolacrimal duct travels inferolaterally and slightly

posteriorly, in its bony course, to the inferior turbinate for an

intraosseous course of 12–13 mm and extends another 2–3

mm into the inferior meatus.1 The opening of the nasolacrimal

duct is located 25–30 mm posterior to the lateral margin of the

anterior nares.1 The lacrimal pump actively drains the tears into

the puncta, propelling them forward.2 The pump action is due

to blinking, which results in a contraction of the deep heads of

pretarsal and preseptal orbicularis.1 A classic disorder of this

functional component is seen in facial nerve palsy — the power

of the blink reflex (orbicularis muscle) is decreased, and tearing

occurs without obvious anatomical obstruction

PUNCTAL STENOSIS

Punctal stenosis is a common cause of epiphora.6,7 It might be

congenital or arise from acquired causes.8 Punctal stenosis can

be an isolated disorder or associated with canalicular stenosis,

eyelid laxity or malposition.8-12 An associated nasolacrimal duct

obstruction can be found in 8.5% of the cases.6 Kashkouli et al.6

suggest that associated upper tear drainage stenosis (canaliculi

and common canalicular) is present in almost 50% of the patients

with acquired external punctal stenosis (AEPS) Association of

AEPS with canalicular and common canalicular stenosis has

been reported with trachoma,13 systemic chemotherapy,8,10,11,14

cicatrizing diseases of the conjunctiva,15,16 and medial ectropion.17

Fezza et al.,18 have evaluated the sequelae of systemic 5-FU and

have found varying degrees of punctal and canalicular stenosis,

severe enough to warrant surgical intervention McNab19 has

reported about 14 patients on topical ocular medications (six

on topical anti-glaucoma therapy) from three weeks to 20 years,

who developed lacrimal punctal and canalicular stenosis

Etiology

The common causes of acquired punctual stenosis include

infectious and inflammatory eyelid disorders, ocular surface

diseases, systemic and topical medications, such as, antiviral,

anti-glaucoma and anti-neoplastic medications, eyelid tumors,

and trauma.6,8-10,13,14,19-22 Chronic punctal eversion may also

result in stenosis.17 Paclitaxel used for the treatment of head and

neck angiosarcoma can cause severe punctual and canalicular

stenosis.23 Kashkouli et al.6 reported punctal stenosis after one

year of topical latanoprost therapy They6 reported chronic

blepharitis (infectious ulcerative, seborrheic, or rosacea) as a

cause of external punctual stenosis in 45% of their patients,

unknown etiology in 27%, and medial ectropion in 23%.6

Edelstein and Reiss24 found that cicatricial changes from

chronic blepharitis caused recurrent punctal stenosis after

wedge punctoplasty.Stenosis of the punctum and proximal

canaliculus are reported to be frequent after spontaneous loss of punctal plugs, by accumulation of debris, including inflammatory reactions resulting in scar formation or the act of probing itself, prior to plug insertion.25-32 Boldin et al.,33 hypothesized that mechanical stress on the mucosa might lead to mild chronic inflammation, causing stenosis of the punctum The histological findings associated with topical anti-glaucoma medications include conjunctival metaplasia, decrease in goblet cells and increased number of sub-conjunctival fibroblasts, macrophages, and other inflammatory cells, which may account for punctal-canalicular stenosis in this group of patients.16,34-41 Tissue atrophy and involutional changes cause the dense fibrotic structures of the punctum to be less resilient and the surrounding orbicularis fibers to become atonic, resulting in punctal stenosis.15

Diagnosis

A detailed history of any systemic or topical medication, surgery, trauma or scarring, and infection is warranted It is valuable to grade the severity of epiphora using a uniform grading system such as the Munk scale [Table 1].42 Slit lamp examination starts with recognizing the papilla, presence of a membrane or fibrosis over the punctum, punctum size, tear meniscus height, eyelid margin, conjunctiva around the punctum, eyelid malposition, position of the punctum in the tear lake, and any sign of previous surgery The Schirmer test,43 tear break up time,44 ocular surface staining, and tear meniscus height will highlight any associated ocular surface abnormalities Abnormal dye disappearance test shows an abnormal tear drainage system and is especially helpful

in pediatric patients.44 Examination of eyelid laxity [Figure 1] by

means of the eyelid distraction test45 will assist in determining the health of the lacrimal pump

Recognizing the relative degrees of punctal stenosis is

a fundamental parameter for assessment of the severity of the underlying fibrosis and inflammation, and directs the practitioner to the best treatment option Hence, recording the punctal size will make management easier The benefits of grading are to standardize the terms describing the external lacrimal punctum, which would make comparison of the outcomes of various studies easier.46 A lacrimal punctal grading

system (grades 0 – 5) has been introduced by Kashkouli et al.,6

in 2003 [Figure 2] The reliability and good inter-observer correlation of this grading system were confirmed in 2008.46

Kashkouli et al.’s6 grading system is based on punctual shape and size on slit lamp examination as well as the ease of introducing

a punctal dilator [Table 2] Although very good agreement

Table 1: Munk scale for epiphora grading 42 Grade Munk Scale

0 No epiphora

1 Epiphora requiring dabbing less than twice a day

2 Epiphora requiring dabbing 2–4 times a day

3 Epiphora requiring dabbing 5–10 times a day

4 Epiphora requiring dabbing more than 10 times a day

5 Constant epiphora

Table 2: Grading of External Lacrimal Puncum 46

Grade Clinical finding on slit lamp examination; Insertion

method for a #00 Bowman probe

0 No papilla and punctum (punctal atresia); surgery to create

a papilla

1 Papilla is covered by a membrane; a #25 needle, followed

by a punctal finder Exudative or true membrane or fibrosis,

difficult to recognize with standard punctum dilator

2 Less than normal size, but recognizable; a punctal finder and

then a standard punctum dilator required

3 Normal; regular punctum dilator required

4 Small slit (< 2 mm); no intervention required

5 Large slit (≥ 2 mm); no intervention required

was found between the observers, less experienced observers

tended to overestimate the punctal grading.46 Any other lacrimal

drainage stenosis could be defined by performing diagnostic

irrigation and probing Following punctal dilation, a #00

Bowman probe was passed through the punctum and ampulla

into the canaliculus A hard stop signifies a patent canaliculus

Usually a gritty sensation or mild resistance while passing the

probe implies canalicular stenosis Soft resistance to the probe

that cannot be overcome may signify obstruction Location of

the canalicular stenosis and obstruction can be measured by

grasping the punctal end of the probe and withdrawing it from

the canaliculus [Figure 3] Irrigation of the lacrimal system

can provide valuable information about the anatomic patency

of the lacrimal drainage system, especially the inferior section

[Figure 3] Irrigation is performed with a 2-ml syringe filled

with normal saline and a 26-G lacrimal cannula Return from

the same punctum with some passage of fluid to the nose could

imply canalicular stenosis Common canalicular stenosis typically

results in the return of clear fluid from the opposite punctum,

with some nasal passage Complete nasolacrimal duct (NLD)

obstruction results in the regurgitation of saline and some

mucous through the other punctum Patients with stenotic NLD

show passage of fluid to the nose and minimum reflux from the

other canaliculus

TREATMENT

The basic principles in the treatment of punctal stenosis include

creating an adequate opening, while maintaining the position

of the punctum against the lacrimal lake, and preserving the

lacrimal pump function.47,48 The reported success rate ranges

between 76 and 96% for the treatment of acquired external

punctal stenosis, with better results in cases of the lower

eyelid position and normal diagnostic probing and irrigation

test.8,24,48-54

Repeated dilation of the stenotic punctum is a simple procedure

that may provide temporary improvement of the symptoms,

but recurrences of stenosis are common unless additional

procedures are performed.48

Different methods of punctoplasty have been used to augment

punctal size, including 1, 2, and 3-snip punctoplasty,55-58 punctum pucker procedure,51 posterior punctectomy with intraoperative mitomycin-C (MMC),47 one-snip punctoplasty, with mini Monoka tube insertion,52 microsurgical punctoplasty,53 punch (wedge) punctoplasty,24 laser punctoplasty, and electrocautery.49

Two-snip57 and three-snip58 punctoplasties have been advocated after failure of one-snip punctoplasty Bodian59 introduced unroofing the proximal canaliculus and noted recurrent scarring in two of the seven eyes Offut and Cowen53 reported

a microsurgical technique in which they externalized the vertical canaliculus using an operating microscope for meticulous dissection of tissues around the punctum

Mathew et al.7 described a simple technique of inserting the mini Monoka using a Nettleship dilator without a snip procedure

Kashkouli et al.,52 suggested a horizontal one-snip procedure

to facilitate punctal canalicular insertion Kashkouli et al.52

performed punctoplasty and monocanalicular stenting in order

to address the associated canalicular and common canalicular stenosis and concluded that while less stenotic puncta (grade 2) responded well to simpler procedures such as a snip procedure

or punctal dilation, more stenotic puncta (grade 1 or 0) were needed to maintain patency.52 Complete functional success in 77.4% and anatomical success in 96.2%, after a mean

follow-up of 18.5 months, was reported.52 In patients with AEPS and NLD stenosis, punctoplasty with bicanalicular stent insertion was performed

Fein49 reported early success in 28 of 35 eyes after cautery to treat AEPS, with recurrence of epiphora in nine cases of 24 eyes after a one-year follow-up Kristan and Branch15 inserted

a temporary punctal plug after a one-snip punctoplasty and achieved symptomatic improvement in all 25 AEPS Microsurgical punctoplasty had 96% functional and 100% anatomic success rates in 28 AEPS cases.53 Posterior punctectomy with the use of

MMC was performed by Ma’luf et al.,47 with a functional success rate of 96% and an anatomical success rate of 100% at a one-year follow-up MMC was also used with one-snip punctoplasty to open the stenotic punctum after two unsuccessful attempts.54

Chak60 reported a conservative method of rectangular three-snip punctoplasty (two vertical cuts on either side of the vertical canaliculus and one cut at the base)

CANALICULAR STENOSIS

The frequency of canalicular obstruction has been reported

to be between 16 and 25% in patients with epiphora.61 The most common symptom is intermittent or constant tearing Canalicular obstructions could be anatomically classified as:

proximal with involvement of the proximal 2–3 mm, mid-canalicular obstructions 3–8 mm from the punctum, and distal

obstructions as defined by a membrane at the opening of the common canaliculus to the lacrimal sac.62

A plethora of factors have been reported to be associated with

canalicular obstructions [Table 3] In congenital anophthalmos

or severe microphthalmos the lacrimal system is affected in up

to 78% of the cases, mostly due to canalicular stenosis (58%),

and less commonly, common canalicular stenosis (7.3%).62,63

Topical anti-glaucoma medications have repeatedly been

associated with lacrimal drainage stenosis.19,37-40,64,65 Kashkouli

et al.,64,65 reported a significantly higher frequency of both upper

(76.92%) and lower (50%) lacrimal drainage system obstruction

in patients receiving topical anti-glaucoma medications,

including pilocarpine, timolol, and dorzolamide, as a single or

combination therapy Additionally, the risk of lacrimal drainage

obstruction was increased by the use of combination therapy

and the risk of obstruction was almost twice that of the general

population and significantly higher in the upper lacrimal drainage

system.64,65 Docetaxel has been reported to cause epiphora due

to canalicular stenosis.66 The mechanisms of drug-induced

lacrimal drainage obstruction may be related to the medications

themselves, preservatives or duration of topical treatment.64

This condition has been proposed to be either dose-related

or idiosyncratic.19 There are some reports of upper lacrimal

drainage system obstruction associated with topical MMC, used

in glaucoma filtering surgery and ocular surface neoplasia.12

However, Kashkouli et al.,67 conducted a comparative study and

concluded that there was no significant effect of topical MMC,

used during filtration surgery, on lacrimal system obstruction

Canalicular obstruction could also occur after photodynamic

therapy with verteporfin, used for treating choroidal neovascular

membranes.68

Diagnosis

History of any concurrent ocular or systemic disease, topical

and systemic medications, surgeries, allergy, trauma, previous

ocular interventions, including those for dry eye disease, need

to be recorded A comprehensive ophthalmic examination

should be performed, including staining of the ocular surface,

to detect any tear film abnormality, examination of lid, especially

the medial aspect, for malpositions (entropion, ectropion),

punctual grading, and assessment of conjunctival and caruncular

apposition to the punctum The medial canthal region should be

palpated and compressed, looking for any regurgitation through

the puncta (regurgitation test) Mucopurulent regurgitation

signifies NLD obstruction

Dye disappearance test (DDT) is useful to differentiate

hyperlacrimation from lacrimal drainage obstruction (whether

functional or anatomical) In this test, one drop of fluorescein

2% or a fluorescein strip wetted by artificial tears is gently placed

or briefly inserted in the inferior fornix of each eye The tear

meniscus height is evaluated with cobalt blue light after five

minutes for the clearance of fluorescein and symmetry of dye

in both eyes Anatomic patency of the lacrimal drainage system can further be assessed by lacrimal irrigation and in-office probing [Figure 3]

Dacryocystography is of little diagnostic value in canalicular disorders, especially canalicular stenosis.69 Lacrimal scintigraphy could be useful in those patients with presumed functional epiphora.70 Canalicular endoscopy can directly reveal the site and nature of the obstructing lesion.71 However, the price and availability hinder its use on a routine basis in most clinics

Treatment

Goals of treatment for canalicular stenosis include: relieving the patients’ symptoms; maintenance of anatomic patency of the canaliculi; preventing progression to complete obstruction, and maintaining the function of the opposite canaliculus Timely diagnosis and appropriate management of a canalicular stricture can prevent more complicated surgeries such as conjunctivodacryocystorhinostomy (CJDCR) The underlying causes of canalicular obstruction must be determined and addressed [Table 3] The site and extent of stenosis must be determined

One-snip punctoplasty and canalicular intubation (mini Monoka) is a simple and effective method of treating punctal canalicular stenosis.52 Balloon canaliculoplasty is an alternative treatment option in patients with canalicular stenosis Following graded dilation of canaliculus with Bowman’s probes, a 2-mm balloon dilator is introduced into the canaliculus and advanced approximately 10 mm to the lacrimal sac, until a hard stop is felt The balloon is then inflated to a pressure of four bars for

90 seconds and then deflated Subsequently it is inflated to four bars for 60 seconds and then deflated The procedure

is concluded with a silicone intubation.71 Zoumalan et al.,72

performed this method on 41 canaliculi and achieved 76.2% partial or complete success

Caversaccio et al.,73 studied the results of double bicanalicular silicone tubes placed after endoscopic DCR in 44 patients with canalicular stenosis They73 found that 32 (63%) of the patients

Table 3: Etiologies of Punctal-Canalicular Obstruction

Congenital Acquired

A Inflammatory: Blepharitis, Canaliculitis, Infections (viral, bacterial, fungal), Ocular Cicatricial Pemphigoid, Steven Jonson Syndrome, Trachoma, ectropion

B Trauma: Laceration, Chemical Burn; Thermal Burn, Radiotherapy

C Drug-induced: Docetaxel, paclitaxel, Pilocarpine; Timolol, Dorzolamide; Idoxuridine; trifluridine; Fluorouracil, echothiophate iodide, Dipivefrin, Betaxolol, Mitomycin, Isotretinoin, Verteporfin

D Systemic disease: Neoplasm, Lichen Planus, Inflammatory Bowel Disease,

E Iatrogenic: Punctum plugs, Cauterization, Surgical, Longstanding intubation, Radiotherapy.

Involutional

became symptom-free.73 Hwang et al.,74 compared double versus

single intubation of canaliculi during dacryocystorhinostomy

(DCR) for canalicular stenosis and found higher anatomical

success rates (96.5%) in the double intubation group and the

same functional success rate in both groups A fine membranous

obstruction of the common canaliculus can be easily visualized

by passing a lacrimal probe and can be removed during DCR.75

Endocanalicular approaches for severe stenosis and complete

obstruction of canaliculi have recently gained popularity.71

Endocanalicular lacrimal probes are fine metal tubes within

which instruments such as laser, drill or trephine may be used

to investigate or treat the lacrimal drainage system.76

Non-endoscopic canalicular trephination for obstruction yielded

variable results, depending on the affected segment Eyes

with distal bicanalicular, common canalicular, and proximal

bicanalicular obstruction achieved 66, 59, and 55% success,

respectively.76 Nemet et al.,77 found this approach effective in

four of five (80%) cases with common canalicular and distal

canalicular obstructions Both microtrephination and balloon

canaliculoplasty have also been used in canalicular strictures.78

Laser canaliculoplasty71,79 has also been used in focal stenosis

(approximately 2 mm or less) within the canaliculi The success

rate varies between 43 and 84%.62,71,79

PARTIAL AND FUNCTIONAL

NASOLACRIMAL DUCT OBSTRUCTION

Functional NLD obstruction, by definition, is epiphora without

detectable lacrimal drainage system obstruction The term

‘functional obstruction’ is confusing, as it implies anatomically

patent lacrimal passages with a physiological dysfunction.80

Different reasons have been cited in the literature, including

partial obstruction of NLD, which is patent upon

positive-pressure irrigation through the canaliculus,81-83 lacrimal pump

failure due to eyelid laxity,84 conjunctivochalasis85 and

megalo-caruncle [Figure 4]86 occluding the punta, punctal apposition

[Figure 5],87 and subtle medial ectropion [Figure 6] preventing

punctual apposition to the lacrimal lake.17 Tearing without

mucopurulent discharge is the most common presenting

symptom

The caruncle may increase in size in older patients, probably

as a result of senile hypertrophic changes, and in Graves’

ophthalmopathy.86 This enlarged caruncle may prevent nasal

sliding of the lower punctum during eyelid closure and push the

medial lower eyelid off the globe Similarly, conjunctivochalasis

may cause epiphora due to blockage of the punctum by redundant

bulbar conjunctiva protruding over the lower eyelid margin and

blocking the entrance to the punctum.85

Diagnosis

Diagnosis of functional lacrimal system obstruction is based on

a history of epiphora, positive dye disappearance test, and free passage of fluid on irrigation test The diagnosis of partial NLD obstruction is the same, except for some cases that might have both passage of fluid into the nose as well as minimum reflux from the other canaliculus.88,89 Some90 define the functional obstruction as (a) a negative Jones I and positive Jones II dye test, or (b) a freely patent nasolacrimal system to irrigation with minimum or no reflux from the upper canaliculus or punctum At times, a technetium scan or dacryocystography assist in establishing the diagnosis and classification of NLD stenosis.70,90,91 Based on lacrimal scintigraphy, a pre-sac delay is diagnosed if the tracer fails to reach the sac by the end of the dynamic phase A post-sac delay is diagnosed if there is early filling of the sac, but it continues to remain full of contrast at the end of the study.90 Appropriate examination of the eyelid and conjunctiva reveals laxity of the eyelid, facial nerve palsy, conjunctivochalasis, megalo-caruncle, and punctal apposition,

if they are taken into consideration at the time of examination

Rosenstock et al.,80 have shown that physiological dysfunctions are almost always located in the upper system Others90 believe that partial NLD obstruction, whether pre-sac or post-sac, are also in this category In fact, most of the time there are multiples causes of functional obstruction of the lacrimal drainage system Hence, all entities other than complete obstruction

of the lacrimal system might be included in the category of functional obstruction Recognizing each etiology and treating

it appropriately may obviate more invasive procedures

Treatment

Management of partial NLD obstr uction includes dacryocystorhinostomy, balloon catheter dilatation, with and without silicone intubation, silicone intubation (monocanalicular, bicanalicular, double bicanalicular), and probing.70,90-107

External DCR is a widely used standard procedure with success rates ranging from 70 to 95%, but may be complicated by nasal bleeding, infection, cerebrospinal fluid leak, punctal eversion, and a skin scar.90,93,94 Delaney90 reviewed the success rate of external DCR for adult patients with partial LD obstruction and found subjective success rates of 84% at four months of follow-up and 70% at three years of follow-up Endonasal DCR success rates vary from 63 to 94% and may be complicated by nasal bleeding, nasal mucosal scarring, granuloma, osteotomy-nasal septal adhesion, and damage to the orbital contents.96,97

Wormald and Tsirbas70 assessed the results of endonasal DCR

in adult patients with partial LD obstruction at a minimum of

12 months’ follow-up, and reported an 84% success rate In

another study, standard endonasal DCR was compared with laser endonasal DCR in adult patients with partial LD obstruction, with a success rate of 82% in the former and 71.5% in the latter.98 Better success of DCR for post-sac stenosis (80%) rather than pre-sac stenosis (46%), with three years of follow-up has been reported.90

Figure 6: Subtle punctal ectropion Figure 5: Punctal apposition in primary gaze (a) and up-gaze (b)

a

b

Figure 4: Megalo-caruncle obstructing the punctum before (a) and after (b) lower

eyelid pull

a

b

Figure 1: Digital subtraction test of lower eyelid laxity Figure 2: External lacrimal punctal grading: Grade 0 (a), 1 (b), 2 (c), 3 (d), 4 (e),

and 5 (f)

a

c

e

b

d

f

Figure 3: Diagnostic probing and irrigation of the lacrimal drainage system: punctal

dilation (a), advancement of probe (b), measuring the soft stop in the canaliculus,

up to the tip of the probe (c), and nasolacrimal irrigation (d)

a

c

b

d

Balloon catheter dilatation with and without intubation has been

used for NLD stenosis and yielded success rates between 53 and 68%.

82,91,99,100 Perry et al.,101 reported an objective success rate

of 73% at six months and a subjective success rate of 60% at

six months in adult patients Couch and White82 reported lower

success rates, with complete resolution of tearing in 56% of the

patients and reduced tearing in 34%, after a mean follow-up of

seven months However, Kashkouli and associates102 compared

endoscopically assisted balloon dacryocystoplasty and silicone

intubation with silicone intubation alone in adults, and found no

difference in the outcome between the two treatment methods

(61 vs 54%)

Bicanalicular or monocanalicular silicone intubation have been

used with success rates of 53 to 60%.92,95,103,104 Kashkouli and

associates89 compared monocanalicular versus bicanalicular

intubation for NLD stenosis in adults and found no difference

in the success rates (61.5 vs 59%, respectively) Double

bicanalicular silicone intubation was used in 18 patients with

NLD stenosis and resulted in complete resolution of symptoms

in 79% of the patients.81 Fayet et al.,105 found that the success rate

did not seem to correlate with the duration of intubation after

one month, but the complication rate did Frueh106 mentioned

that most complications from silicone tubing occurred in

the interval of two to four months after placement of the

tubing In general, a shorter time of intubation is now being

considered.89,102

Probing was shown to have limited success in approximately 50% of the adult patients with NLD stenosis.107

One important point in comparing different results is the duration of the follow-up In general, longer follow-up is associated with lower success rates regardless of the type of treatment

Eyelid and conjunctival causes of functional lacrimal drainage obstruction should also be addressed appropriately One of the major causes in this category is the eyelid laxity in which lacrimal pump failure occurs and results in a matted eye.45 Lateral canthal tightening is the mainstay of treatment in this regard.84,108,109

Liu and Stasior108 suggested a cause and effect relation between longer flaccid eyelids and tearing

Caruncle and bulbar conjunctiva can mechanically occlude the entrance to the lacrimal drainage system Some patients with Epiphora, classified as functional lacrimal drainage obstruction

at presentation, have presented with enlarged caruncles.86

Carunculectomy has been reported to alleviate epiphora in 77% of these patients.86 Bulbar conjunctivochalasis occluding the lower punctum must be treated.85

Proposed Treatment paradigm for Epiphora without complete obstruction of lacrimal drainage system

Lacrimal DS` obstruction

Conjunctivo

chalasis caruncleMegalo- appositionPunctal Lower Eylidlaxity stenosispunctal canalicularstenosis stenosisNLD

Excision Carunculectomy Lower eyelid

Balloon dilation

± intubation

Intubation Or Balloon dilation

± intubation Or Endocanalicular

± intubation

Blopharoptosis repair and/or Lower eyelid tightening

Grade I Grade II

Punctoplasty + Intubation Punctoplasty

Failure

Re-evaluation of other causes

Dacryocystorhinostomy Treat as above

+

-Subtle punctal ectropion

Ectropion repair

Figure 7: Proposed paradigm for treatment of epiphora without complete obstruction of the lacrimal drainage system

In conclusion, there are different etiologies to be evaluated

and addressed in patients with epiphora without complete

obstruction of the lacrimal drainage system, a condition referred

to as functional obstruction We propose a paradigm for

treatment of such patients, taking into consideration that in

some cases there may be more than one cause of epiphora

requiring simultaneous treatment [Figure 7]

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Cite this article as: Kashkouli MB, Pakdel F, Kiavash V Assessment and

management of proximal and incomplete symptomatic obstruction of the lacrimal drainage system Middle East Afr J Ophthalmol 2012;19:60-9.

Source of Support: Tehran University Eye Research Center, Tehran, Iran, Conflict of Interest: None declared.