Lacrimal System

Overview, Signs and Symptoms of an Obstruction

The lacrimal gland produces tears which enter into the "duct" that drain the tears from the eye into the nose. The most common symptoms are If one has a plugged up "tear duct," not only will tears spill over the eyelids and run down the face, but the stagnant tears within the system can become infected.
      (1) excess tearing (tears may run down the face) and
      (2) mucous discharge

This may lead to recurrent red eyes and infections.
The excessive tearing can also produce secondary skin changes on the lower eyelids.

Congenital Nasolacrimal Duct Obstruction

The nasolacrimal duct is a duct that connects the lacrimal glands in the eye to the nasal cavity. In this article, we shall briefly review the epidemiology, clinical presentation and the common causes of this condition.


Clinical research has shown that nasolacrimal duct obstruction occurs in 2 to 4 out of 100 newborn babies. However, this number dramatically increases in children who have Down syndrome with statistics suggesting about 22% to 36% developing this condition.

There are a number of different reasons why nasolacrimal duct obstruction occurs. The epidemiological statistics have shown that of all the cases, 35% of them actually due to obstruction, 15% occur due to the improper formation of the opening of the lacrimal duct (punctual agenesis), 10% have some form of abnormal connection i.e. congenital fistula and 5% have defects in the structure of the head and face.

As such, congenital nasolacrimal duct obstruction does not differentiate between race and sex. It is typically seen in newborns.

Congenital nasolacrimal duct obstruction can result in numerous clinical presentations. These conditions bring with them a varying degree of morbidity and mortality.

The first condition that may occur is amniotocoele. Here, there is distension of the tear producing gland i.e. the lacrimal gland. Amniotic fluid enters the lacrimal sac and gets trapped within it. This can result in swelling of the lacrimal sac. Treating this can be done through inserting a small probe through the nasolacrimal duct.

Dacrocystitis is another condition that may develop where there is inflammation and distension of the lacrimal sac. It occurs in the neonatal period which is just after the baby has been born. In these patients as well, probing the lacrimal sac through the nasolacrimal duct is the treatment.

Finally, in newborns who have narrowing of the nasolacrimal duct, accumulation of pus or pus within the lacrimal sac may take place. This can manifest as constant watering of the eye or expulsion of pus from the eye. The treatment usually involves antibiotics, compression and massage of the lacrimal sac. If left untreated, newborns may have matted eyes every morning and excessive tearing of the eyes.

Clinical presentation

  • History forms an important part of making a diagnosis. There may be a family history of nasolacrimal duct problems and other abnormalities such as glaucoma. A detailed examination of the eye is useful in determining whether the patient has congenital nasolacrimal duct disease.
  • A special test known as the dye disappearance test is useful in determining whether there is any obstruction. In addition, tests to ascertain whether the patient has glaucoma need to be conducted.


Nasolacrimal duct obstruction is not very common but does have some recognised causes. The top three causes include :

  • genetic causes i.e. having a family history of nasolacrimal duct obstruction
  • premature birth
  • drug use by the mother during pregnancy

It is commonly accompanied by other eye abnormalities.


  • 9 out of 10 cases resolve within the first year of life. If required, massage therapy over the lacrimal gland may be helpful.
  • In patients in whom this does not work, using a probe can cure up to 95% of cases. Other procedures include the insertion of a tube into the nasolacrimal gland or the insertion of a balloon catheter.
  • Special surgical procedures include a dacrocystorhinostomy - a procedure that helps restore normal tear flow.

Acquired (ADULT-ONSET) Nasolacrimal Duct Obstruction

Epiphora is the overflow of tears which is caused by an imbalance in tear production and tear drainage. Other than conditions that cause an abnormal increase in tear production, an abnormality in tear drainage is the most likely cause of epiphora. It may be either functional due to a displaced punctum, eyelid laxity, weak orbicularis, or facial nerve palsy or an anatomical obstruction may block the drainage of tears. Anatomical obstruction of the nasolacrimal duct may be congenital which occurs during the neonatal period or acquired which manifests during adulthood.

Classification of Acquired Nasolacrimal Drainage Obstruction (NLDO)

Acquired nasolacrimal drainage obstruction may be primary or secondary.

  • Primary acquired nasolacrimal drainage obstruction (PANDO) is caused by inflammation or fibrosis without any precipitating cause. The name was given by Linberg and McCormick in 1986.
  • Secondary acquired lacrimal drainage obstruction (SALDO) is further classified further based on aetiology as infectious, inflammatory, neoplastic, traumatic and mechanical. This classification was proposed by Bartley.


Although quite common, the frequency of nasolacrimal drainage obstruction is unknown. It has no racial predilection.
PANDO is more commonly seen in middle-aged and elderly females. This is due to the significantly smaller dimensions in the lower nasolacrimal fossa and middle nasolacrimal duct among women. Middle-aged women exhibit alterations in the dimensions of the bony nasolacrimal canal that coincides with osteoporotic changes elsewhere in the body, which supports the higher incidence of PANDO in women. Some suggest that sudden hormonal changes incite generalized de-epithelialization predisposing a narrow duct to be blocked by sloughed off debris.
SALDO is aetiologically classified as infectious, inflammatory, neoplastic, traumatic, and mechanical.
Infectious lacrimal drainage obstruction: Bacteria, viruses, fungi, and parasites that have all been implicated are as follows:

  • Bacterial Causes – Most common causes are Actinomyces, Propionibacterium, Fusobacterium, Bacteroides, Mycobacterium, and Chlamydia.
  • Viral Causes – Most commonly Herpes virus. Due to canalicular obstruction and damage.
  • Fungal Causes - Aspergillus, Candida, Pityrosporum, and Trichophyton. Usually cause obstruction due to dacryolith/stone or cast formation.
  • Parasitic Causes – Rare but can be caused by Ascaris lumbricoides entering through the valve of Hasner.

Inflammatory lacrimal drainage obstruction: May be endogenous or exogenous in origin.

  • Endogenous Causes – Most commonly due to Wegener granulomatosis and sarcoidosis. Other causes include cicatricial pemphigoid, sinus histiocytosis, Kawasaki disease, and scleroderma.
  • Exogenous Causes – Eye drops, radiation, systemic chemotherapy, and bone marrow transplantation all cause punctal and canalicular scarring, stenosis and occlusion in varying degrees.

Neoplastic lacrimal drainage obstruction: Neoplasms cause obstruction by primary growth, secondary spread, or metastatic spread.

Traumatic lacrimal drainage obstruction: May be iatrogenic or non-iatrogenic.

  • atrogenic Causes - Trauma and subsequent scarring due to overenthusiastic lacrimal probing, orbital decompression surgery, paranasal, nasal, and craniofacial surgery all cause obstruction.
  • Non-iatrogenic Causes - Either blunt or sharp injury to the canaliculus, lacrimal sac, and nasolacrimal duct results in post-traumatic dacryostenosis.

Mechanical lacrimal drainage obstruction

  • Intraluminal foreign bodies – Dacryoliths or casts due to infection or long-term use of topical medications.
  • External compression – Due to rhinoliths, nasal foreign bodies, or mucoceles. Dentigerous cyst in the maxillary sinus is also thought of as a culprit.


  • Patients with NLDO most commonly present with epiphora, mucoid or purulent discharge with a painful, swollen medical canthus. They frequently have features of recurrent dacryocystitis, recurrent conjunctivitis, or ocular pemphigus. Some cases present with bloody tears and even epistaxis as in nasal, sinus or lacrimal sac tumours.
  • A thorough past ocular and medical history is in order to evaluate the cause of the disease. Always ask for previous eye surgery, lid surgery, use of antiglaucoma medications, or any other topical medications. Past medical history should all causes cited in the previous section.

On examination, the following findings may be present.

  • Gross observation shows overflowing tears, fluctuant tender mass over medial canthus, mucoid or purulent eye discharge. Regurgitation test results in mucoid reflux with lacrimal massage indicating lower system obstruction.
  • Slit lamp examination shows enhancement of tear meniscus height by fluorescein greater than 2 mm, punctal stenosis, canaliculitis, concretions expressed from the punctum


  • Imaging studies may include dacryocystography, dacryoscintigraphy, CT scan, CT dacryocystography (CTDCG), nasal endoscopy, or Gadolinium-enhanced magnetic resonance dacryocystography.
  • Other tests include Schirmer test, Fluorescein dye disappearance test, lacrimal irrigation, probing of the canaliculi, Jones dye tests, microreflux test, Hornblass saccharine test
  • Diagnostic canalicular irrigation determines the level of canalicular obstruction staging it as partial obstruction, total common canalicular obstruction, total functional occlusion and complete nasolacrimal obstruction.


Medical Care

  • Topical antibiotics in early infections
  • Systemic antibiotics in chronic or severe infections

Surgical Care

  • External dacryocystorhinostomy
  • Endoscopic mechanical/nonlaser dacryocystorhinostomy
  • Endoscopic laser dacryocystorhinostomy
  • Endoscopic laser-assisted dacryocystorhinostomy
  • Conjunctivodacryocystorhinostomy (CDCR)
  • Balloon catheter dilatation
  • Inferior meatus surgery

Evaluation of Tearing

History of symptoms

unilateral vs. bilateral

  • nasal/sinus/facial fracture or surgery
  • bloody tears/pain w/o inflammation: rule out tumor
  • nasal polyps, sinusitis
  • hay fever
  • external ocular irritation
  • Bells palsy
  • epinephrine
  • phospholine iodide

Etiologies of Epiphora

  • surface irritation/reactive hypersecretion
  • outflow obstrutionn
  • Idiopathic hypersecretion
  • Inadequate Drainage
  • 5th nerve stimulation: external/corneal disease pseudoepiphora
    • dry eye syndrome
    • conjunctivitis
    • blepharitis
    • uveitis
    • entropion
    • trichiasis
    • thyroid eye disease
    • sinusitis
    • hay fever
    • dental problems
      • VII nerve aberrant regeneration
      • post-Bell’s palsy; crocodile tears
  • central nervous system
  • Inadequate Drainage
    • Stiff Lid
    • from burn, scar tissue, scleroderma
    • lacrimal pump dysfunction, punctal displacement
    • Punctal Problems
      • Agenesis
        • probe membranes, if none seen, do cut down (over probe)
        • can inject methylene blue inferior to medial canthal tendon
      • Stenosis
        • treat with dilation, ampullotomy (one-snip), may need silicone intubation
        • Eversion / Malpositions
        • rx with internal vertical shortening, may need horizontal lid shortening for laxity
        • transconjunctival cautery inferior to puncta in bedridden pt
    • Conjunctivochalasis
      • can occlude punctum
      • Rx: vasoconstrictor (Visine, etc) course then PF may be helpful
    • Canalicular Problems
      • Common Canaliculus Occlusion
      • trauma
      • meds: 5-FU, IDU, PI, eserine
      • viral infection
      • autoimmune (pemphigoid, Stevens-Johnson)
    • Canaliculitis
      • mostly actinomyces israelii, gm filamentous rod, yellow concretions (sulfur), other bact & fungi
      • Rx: compresses, antibiotics, curretage, canaliculotomy to remove concretions
    • Functional Occlusion
      • may be total occlusion if poor pump function
      • repeat probings
      • NLD Obstruction
    • Congenital

Examination of the Lacrimal System

  • check puncta for stenosis, position
  • conjunctivochalasis - is excess conjunctiva obstructing puncta opening
  • conjunctival injection
  • trichiasis
  • entropion
  • pseudoepiphora: tear evalaution (meniscus, tear break up time)
  • keratopathy
  • lid stiffness
  • lid laxity
  • pump function Lagophthalmos
  • check VII nerve
  • look up nose
  • Schirmer 1
  • push on sac, look for discharge
  • Basic Tear Secretion (BST)
    • tear strips after anesthesia

  • Dye Disappearance Test (DDT)
    • Fluorescein to both fornices, look with blue light for asymmetry after 5 min.
  • Primary Dye Test
    • Fluorescein to eyes, blow nose, dye present or absent
  • Irrigation (JONES I)
  • estimate flow through system
  • topical anesthesia
  • lower punctal dilation and irrigation, noting stenosis
  • drawing amount of flow 0-100%:
  • reflux around canula or out superior punctum without lacrimal sac distension = common canaliculus block, if same lacrimal sac distension likely complete nasolacrimal duct obstruction
  • if no reflux but w/pain lacrimal sac distention = nasolacrimal duct obstruction w with patent valve of Rosenmuller
  • if reflux and drainage to nose = partial nasolacrimal duct obstruction

  • Secondary Dye Test = Informal Jones II
    • irrigate, dye present in nose = functional nasolacrimal duct obstruction, patent canalicular system, functional pump; or absent
  • Probing
    • diagnostic probing of adult upper system (puncta, canaliculi, lac sac) ok to find level of obstruction, not to probe NLD
  • Dacryocystogram (DCG)
    • good for anatomy, not physiology evaluation
  • CT

Lacrimal System Infections


Symptoms include pain, tenderness and swelling of the lateral aspect of the eyelid
May occur with systemic diseases such as Sjogren's, sarcoidosis, syphilis, TB, lymphoma, and benign lymphoid hyperplasia
May occur in patients with mums, EBV, zoster


Canaliculitis is a clinical condition that is characterized by infection of the canaliculi in the eye. It commonly affects individuals over the age of 50 years. It is caused due to obstruction within the canaliculus, the presence of a foreign body or the presence of diverticulum which harbours bacteria within it.

History and examination

Patients often complain of a long-standing history of one eye being red and inflamed. The inner aspect of the eye constantly displays a thick discharge which can be clear or rather discoloured.
On examination, the lacrimal punctum is swollen and inflamed. The swelling is due to accumulation of fluid and is called oedema. The area is tender to touch. When gently compressed, the cloudy, purulent discharge is expressed through the punctum.


Diagnosis is through clinical history and examination in most cases. If a probe is passed through the lacrimal punctum, a grating sensation is experienced due to the presence of sulphur stones (concretions) within it.

Laboratory investigations are conducted on the discharge. Tests are conducted to ascertain the type of infection that is affecting the canaliculus. Staining may be performed with a different stains and microscopic assessment may reveal the presence of organisms such as Actinomyces or aspergillus.


The treatment of canaliculitis is fairly straightforward and involves the application of warm compressions, massage of the local area and antibiotic creams and ointments applied locally. These treatments may or may not help the patient. In the event of this being the case, patients may require to undergo a surgical procedure to help clear the infection. This is usually offered when irrigation with a sterile solution and broad-spectrum antibiotics is ineffective. Procedures can include deployment of the canaliculus through a procedure called canaliculotomy.

The procedure is fairly straightforward and is performed by making a tiny incision on the conjunctival aspect of the canaliculus. The sulphur concretions are then removed and antibiotics are used to clear any residual infection.


Canaliculitis is a rare condition that affects individuals over the age of 50 years. It is characterised by bacterial or fungal infections within the canaliculi and the formation of concretions that are rich in sulphur. Treatments can include topical antibiotics and drainage, though in some cases surgical treatment may be required.

Symptoms include pain, swelling, tenderness of the INNER canthus of the eye

Etiology is usually actinomycetes


Symptoms: acute onset, tearing (from nasolacrimal duct obstruction), redness, purulent discharge, tender swollen lacrimal sac

An infection within the "tear duct" causes a painful swelling in the inner corner of the eyelids.

If the tearing causes severe symptoms, surgery can be performed to create a new tear duct. This operation is called "dacryocystorhinostomy." (see below). Small silicone tubes my be placed in the tear system to keep the new tear duct open while healing occurs. Surgical elimination of the obstruction by creating a new tear duct is necessary to eliminate the tearing and infection that can result from such a blockage

Acute Dacryocystitis

many etiologies, all cause nasolacrimal duct obstruction with obstruction of drainage from lacrimal sac to nose

  • chronic tear stasis causes 2o infxn
  • edema, erythema below medial canthal tendon w/lac sac distention
  • +/- pain
  • rule out ethmoidal sinusitis, don't probe


  • warm compresses
  • oral/IV abx (Keflex, Augmentin), topical only limited value
  • Incision Drainage localized abscess


  • mucocele, chronic conjunctivitis, orbital cellulitis
  • most need DCR after acute infection subsides

Chronic Dacryocystitis

  • distended lac sac with minimal inflammation suppurative discharge from punctum c/w nasolacrimal duct obstruction
  • probe/irrigate upper system only
  • dacryoliths from Actinomyces, Candida, topical meds, can cause lacrimal colic if impacted in NLD
  • Treatment usually needs DCR for resolution

Treatment of Obstruction

Traditional Surgical Treatments

Since its introduction in the early years of this century, Incisional dacryocystorhinostomy (DCR) has been the "traditional" procedure most often relied upon for relief of epiphora (chronic tearing) and nasolacrimal duct obstruction in adults. However, the high success rate (> 90%) for incisional DCR is balanced by a number of potential drawbacks:

  • Recovery time is significant
  • An incisional scar may develop due to invasive procedure
  • Potential for excess bleeding
  • May not be necessary for partial obstructions

Dacryocystorhinostomy (DCR)

  • goal: anastomosis between lacrimal sac and nasal cavity (middle meatus)
  • decreased success with prior nasal fractures, children, nasal mucosal disease, broad flat nasal bridge, and re-operation
  • Anesthesia Incision
    • General
          because of pt anxiety during bony excision
    • MAC with Local
          with 2% lidocaine/epinephrine with deep infiltration to bone
          pack middle turbinate of nose with nasal neosynephrine/Afrin/Cocaine mixture
  • avoid angular vessels, prevent bowstring contractures causing epicanthal folds
  • dissect skin from muscle with Tenzel periosteal elevators
  • spread orbicularis off periosteum with Steven’s or elevators just lateral to medial canthal tendon (push to bone, then spread)
  • vertically incise periosteum 2 mm medial to ant lacrimal crest, dissect away posteriorly, lacrimal sac reflected (supero)temporally
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