DIAGNOSIS OF EPIPHORA AND
MANAGEMENT OF ACQUIRED NASOLACRIMAL DUCT OBSTRUCTION
M. VARDE, B. MUKHERJEE
ANATOMY OF THE LACRIMAL DRAINAGE SYSTEM:
a) Puncta One punctum is present at the medial end of both the superior and inferior lids. They are situated on slight elevations called the lacrimal papillae and face posteriorly so it is necessary to evert the medial lids to inspect them. Malposition or stenosis (narrowing) of the puncta may cause epiphora. b) Vertical canaliculus This is about 2mm long and joins the horizontal canaliculus at a right angle called the ampulla. c) Horizontal canaliculus This is about mm long and usually joins its fellow to form the common canaliculus which immediately enters the lacrimal sac through the !a !alve lve of "osenmuller (flap of mucosa to prevent reflu#).
d) Lacrimal sac This is about $%mm long and funnels into the nasolacrimal duct. e) Nasolacrimal duct This is about l2mm long and opens into the inferior nasal meatus& lateral to the inferior turbinate (concha). The !alve of 'asner closes the opening. f) Valves bout seven other valves have been described within the nasolacrimal duct besides those of "osenmuller and 'asner but they have no valvular function and are usually ignored.
PHYSIOLOGY OF THE
LACRIMAL DRAINAGE SYSTEM:
ETIOLOGY OF EPIPHORA:
hen a patient complains of tearing& the first step is to determine whether it is caused by an increase in tear production (lacrimation) or a decrease in tear drainage (epiphora). Ocular surface irritation due to trichiatric lashes& foreign bodies& eyelid malpositions& blepharitis or meibomitis& tear film instability may cause an abnormal increase in tear production. *n the absence of these conditions& an abnormality in tear drainage is the most li+ely cause. ,eficiencies of tear drainage may be functional or anatomical. -unctional failure is related to eyelid malposition (entro or ectropion& centurion syndrome)
and/or poor lacrimal pump function due to lid la#ity or orbicularis wea+ness (e.g. agerelated or !**th cranial nerve palsy). natomical obstruction can develop at any site along the lacrimal drainage pathway. 0ro#imal bloc+s maybe seen in congenital agenesis or ac1uired stenosis of puncta or punctual plugs/ cauterization for treatment for dry eyes. c1uired nasolacrimal duct obstructions (3,O) can be differentiated into primary and secondary. 0rimary 3,O (0,O) occurs predominantly in middleaged females. The reason for this is probably the narrower built of the 3,O in females and hormonal changes associated with menopause. 4econdary 3,O (4,O) can be due to infectious& inflammatory& neoplastic& traumatic&
and
mechanical
causes.
5acteria&
such
as
ctinomyces&
0ropionibacterium& -usobacterium& 5acteroides& Mycobacterium& ocardia& 6nterobacter& Treponema pallidum& 4taphylococcus aureus and 7hlamydia species& have been associated with lacrimal drainage obstruction. !iral causes are
'erpes
simple#&
'erpes
zoster&
chic+enpo#
and
adenovirus
+eratoconjunctivitis. -ungal causes of 3,O are spergillus and 7andida. They cause obstruction due to formation of casts or dacryoliths. 0arasitic obstruction is rare but is reported in patients infected with scaris lumbricoides& which enters the lacrimal system through the valve of 'asner. *nflammatory diseases such as egener granulomatosis and sarcoidosis& also cicatricial pemphigoid& histiocytosis and scleroderma can cause 3,O secondary to chronic inflammation and scarring of the duct mucosa. 7hronic use of eyedrops (as in glaucoma)& systemic chemotherapy& radiation and bone marrow transplantation are e#ogenous causes of secondary inflammatory 3,O. eoplasms may cause 3,O by primary growth if arising from the nasolacrimal drainage system mucosa. 4econdary obstruction can be due to
neoplasms e#tending into the nasolacrimal duct arising from the lids (basal cell& sebaceous or s1uamous carcinoma)& the ma#illary antrum and the nasopharyn#. Trauma may be iatrogenic in the case of scarring of the lacrimal passage after overly aggressive lacrimal probing or following orbital& craniofacial or nasopharyngeal procedures. oniatrogenic traumatic causes are either blunt or sharp and may be associated with midfacial fractures involving the bones of the nasolacrimal duct. asoorbitoethmoidal fractures are an important cause of traumatic 3,O with telecanthus. Mechanical lacrimal drainage obstructions may be due to intraluminal foreign bodies& such as dacryoliths or casts& or may be caused by e#ternal compression from rhinoliths& nasal foreign bodies& or mucoceles. "are causes are rhinosporidiosis and lacrimal sac tumors. asolacrimal duct obstruction can be a cause for persistent watering& chronic dacryocystitis with mucous discharge and acute dacryocystitis. ccurate diagnosis is the prere1uisite for ade1uate management of these cases.
EVALUATION OF EPIPHOA! Histor" The patient8s main symptoms will be epiphora& mucoid or purulent discharge and/or a (recurrent) painful red swelling in the area of the medial canthus or a persistent nontender swelling in case of a mucocele. 0ast ocular history to be elicited includes previous lacrimal surgery (dacryocystorhinostomy or dacryocystectomy)& lid surgery& use of chronic antiglaucoma or other topical medications& previous acute dacryocystitis& as well as previous conjunctivitis.
0ast medical history might yield lymphoma& egener granulomatosis& sarcoidosis& ocular cicatricial pemphigoid& scleroderma& trauma to midface& systemic chemo or local radiotherapy as well as previous nasal or sinus surgery.
#linical E$amination 9eneral inspection: 6#amination of the adne#a should include tearfilm height& matting of lashes& lid position and (occult) lid la#ity (snapbac+ test& pinch test& lateral and medial canthal tendon la#ity). The medial canthal region is to be e#amined for scars from previous surgeries or trauma as well as any present swellings. 0osition of the swelling with respect to the medial canthal tendon& overlying s+in and signs of inflammation& presence of a fistula and tenderness should be noted. 4litlamp e#amination: "ule out functional causes for epiphora li+e blepharitis/meibomitis& lidglobe malapposition (as in 7enturion 4yndrome) foreign bodies& conjunctivochalasis& acute conjunctivitis or intraocular inflammation. *nspect the punctal position and configuration; pouting of the puncta suggests canaliculitis. 3oo+ for forniceal scarring or shortening which might give a diagnostic clue for previous adenoviral conjunctivitis or ocular pemphigoid and evaluate the lid margin (+eratinisation& trichiatric lashes& entro/ectropion). 4chirmer8s test for stimulated and basal tear secretion as well as tearfilm brea+up time is done to rule out pathologies of tear secretion and composition which may lead to epiphora. regurgitation of mucoid or mucopurulent fluid on pressure over the lacrimal sac area (regurgitation test or
ROPLAS )
is indicative of an obstruction in the
lower lacrimal drainage system& e.g. the nasolacrimal duct with accumulation of mucous in the lacrimal sac. 4yringing findings suggestive of an 3,O are delayed regurgitation through the opposite punctum (superior& if syringing is done from the inferior one) which may be total or partial and may have stands or fla+es of mucoid or mucopurulent fluid. 0ressure over the sac area as well as syringing should be avoided in cases of acute dacryocystitis. This is because of the pain and discomfort to the patient as well as spread of the infection and limited diagnostic value. The inflamed and oedematous tissues may give a false positive finding on syringing. 7lassically& 3,O with chronic dacryocystitis will give positive results for the "O034 test as well as for the syringing. The finding of a positive regurgitation on pressure over the lacrimal sac in combination with a patent nasolacrimal duct (3,) on syringing is consistent with the diagnosis of an atonic sac or sump syndrome following dacryocystorhinostomy. 4yringing findings suggestive of a complete 3, bloc+ in combination with a negative regurgitation sign is seen in cases of shrun+en sac& encysted mucoceles with intact "osenm
The Jones dye tests are to se1uentially diagnose an obstruction in the nasolacrimal drainage system. -or >ones *& fluorescein dye is instilled in the patient?s eye& and the patient is as+ed to blow his nose after = minutes.
0resence of dye indicates a patent system and normal physiologic function.
bsence of dye can have @ reasons: falsenegative result& physiologic dysfunction& or anatomic obstruction. To ascertain the level of the obstruction& the >ones ** test is performed. The patient8s lacrimal drainage system is irrigated after a negative >ones *& and the patient is as+ed to e#pel any drainage from his or her pharyn#. 0resence of dye indicates a partial bloc+ at the lower sac or duct. bsence of dye in combination with the syringing findings is suggestive of a complete 3,O.
*n the Hornblass saccharine test & saccharine drops are instilled in one eye and chloramphenicol eye drops in the other eye several minutes later. The ability of the patient to detect the sweet taste of the saccharine and the bitter taste of the chloramphenicol denotes a patent lacrimal system.
Laborator" investi%ations The discharge can be sent for further investigations depending on the suspected aetiology& such as 9ram& 9iemsa or AO' staining (for suspected bacterial or fungal infections) and bacterial or fungal culture with antibiotic sensitivity.
Ima%in% &tudies Bray of the orbit and paranasal sinuses can be useful in the setting of posttraumatic 3,O. 7onventional dacryocystography (,79) is performed by injecting
a
radiographic contrast material into the
lacrimal drainage
passageways with a cannula. There are oilbased and waterbased contrast materials. The former will give better contrast and accuracy of imaging& care has to be ta+en though to avoid e#travasation which will lead to severe and prolonged inflammation. The patency of the passage can be judged. 7ircumscribed filling defects can indicate dacryoliths or tumours. More detailed information can be obtained from a computed tomography (7T) of the orbit and paranasal sinuses& if needed with dacryocystography (7T,79). *ndications for 7T imaging in the setting of an ac1uired 3,O are posttraumatic cases as well as suspected secondary 3,O due to mass lesions& such as neoplasms. The role for magnetic resonance imaging (M"*) is limited because of the lac+
of depiction of bony structures& but can be useful in the further differentiation of soft tissue masses.
'edical 'ana%ement *n acute dacryocystitis& the first line of treatment is the administration of oral or& in severe cases& intravenous antibiotics in order to prevent orbital cellulitis and/or septicemia. The antibiotic regimen should cover 9rampositive as well as 9ramnegative organisms. The underlying cause& the 3,O& has to be surgically treated once the acute infection has been managed. 6ndonasal endoscopic dacryocystorhinostomy can be considered in cases of acute dacryocystitis. 6#ternal dacryocystorhinotomy is to be avoided in the acute phase due to the high probability of later wound healing problems and fistula formation. ny lacrimal abscess can be incised as an out patient procedure. 3,O due to fungal infection will need surgical debul+ing as well as systemic antifungal treatment.
&ur%ical 'ana%ement The principle of surgical management of a nasolacrimal duct obstruction is to create a passage from the lacrimal sac into the nasal cavity& thereby bypassing the obstruction situated most commonly in the middle and lower nasolacrimal duct. This procedure is termed dacryocystorhinotomy (,7"). There are several approaches to ,7". The e#ternal ,7" is the CgoldD standard& in comparison to which the other developments are evaluated. Through a s+in incision over the medial canthal region the lacrimal fossa is identified and a bony ostium created& through which the lacrimal sac and the nasal mucosa are anstomosed. *n endonasal ,7"& the area of the sac is
identified by nasal endoscopy& a bony ostium is again created and the medial wall of the lacrimal sac e#cised. This approach has the advantages of leaving the medial canthal anatomy and the lacrimal pump function undisturbed as well as avoiding a sin incision with subse1uent scar. The incidence of intraoperative bleeding is lower than in the e#ternal approach. 7oncomitant nasal pathology can be dealt with in the same sitting (e.g. septoplasty& poly removal& turbinectomy) and this approach is suitable for acute infections. On the other hand it needs specialised instrumentation and training and the success rate is reported slightly lower than in e#ternal ,7"& depending on the e#perience of the surgeon. ewer developments are the transcanalicular ,7" and the assistance of endonasal and transcanalicular approaches with radiofre1uency devices or lasers and the use of antimetabolites in e#ternal and endonasal ,7".
E$ternal (#! 3ocal anaesthesia is given to the nasal mucosa with 3ignocaine spray and subse1uent pac+ing with ribbon gauze soa+ed in 2ml of %.$E (%.%=E in paediatric cases) Bylometazoline (OtrivinF) with 2E 3ignocaine (BylocaineF). This will serve analgesia as well as haemostasis of the nasal mucosa. The surgery can be performed in general or local anaesthesia. *n adults& local anaesthesia with sedation is preferred since during e#tubation positive pressure can lead to haemmorrhage. regional nerve bloc+ with 2E 3ignocaine with $:2%%&%%% 6pinephrine G %.=E 5upivacaine (MarcaineF) is given to the infraorbital as well as the supratrochlear nerve and local infiltration is administered to the incision site above the medial canthal region& again mainly for haemostasis. The incision is made through s+in in a slightly curved line @ mm medial to the medial canthus starting from the level of the medial canthal tendon inferomedially and avoiding the angular vessles. 5lunt dissection of the orbicularis fibres is done and the medial canthal tendon (M7T) and anterior lacrimal crest are e#posed. The overlying periosteum is
incised and reflected laterally along with the lacrimal sac to e#pose the lacrimal fossa. The osteotomy is initiated at the junction of the ma#illary and the lacrimal bones in the depth of the fossa and enlarged with bone punches to a size of about 2 # $.= cm. The nasal mucosa is infiltrated with 2E 3ignocaine with $:2%%&%%% 6pinephrine. The puncta are dilatated and a probe is placed into one or both canaliculi to tent the lacrimal sac. n 'shaped incision is made into the sac along the entire length to achieve an anterior and a posterior flap. The posterior flap may be e#cised at this stage or retained for anastomosis. nastomosis of the posterior flaps is done prior to any silicone intubation& followed by the suturing of the anterior flaps with an absorbable suture. The s+in can be closed with nonabsorbable (H% nylon/prolene) sutures.
Endonasal (#! 6ndoscopically guided endonasal ,7" can be one under local or general anaesthesia. -ollowing nasal pac+ing with ribbon gauze soa+ed in 2ml of %.$E (%.%=E in paediatric cases) Bylometazoline (OtrivinF) with 2E 3ignocaine (BylocaineF)& nasal endoscopy is done and the ostium site viewed (anterior to the middle turbinate. thin& fle#ible light source (such as used in vitrectomies) can be passed though the punctum and canaliculus into the lacrimal sac. The glow can be viewed during endoscopy and act as guideline where to initiate the ostium. ny associated nasal pathology can be corrected before starting the actual procedure& e.g. septoplasty or turbinectomy. The ostium site is infiltrated with 2E 3ignocaine with $:2%%&%%% 6pinephrine. The mucosa is incised and removed to e#poe the underlying bone of the lacrimal fossa and the osteotomy is made. The lateral wall of the lacrimal sac can be visualised by applying pressure from e#ternally. The sac is then incised and the lateral wall e#cised. silicone intubation can be done if indicated. t the end of the surgery a nasal pac+ is inserted. "egular followup with nasal endoscopy and irrigation is mandatory in the followup period.
Modifications The success rate of standard e#ternal ,7" is appro#imately % I JKE; that of conventional endoscopic ,7" is K= I J=E. There are several modifications through which the success rate (patency of the anastomosis) can be increased. The use of antimetabolites is one of these measures. The drugs used are Mitomycin 7 (%.%= I %.Lmg/ml; 2 I =min topical intraoperative application onto nasal mucosa) and =-luoruracil (2.= I =.%mg/ml; =min intraoperative topical application onto nasal mucosa or as 2.= I =.%mg (%.=ml) injection into nasal mucosa). 4everal studies have demonstrated the increase in success rate (J=.= JK.E) as well as a larger ostium size following e#ternal ,7" with MM7. "adiofre1uency devices that reduce the bleeding from the nasal mucosa during incision can assist endonasal ,7". The *ncision into mucosa and sac are made with the device. -or laserassisted endonasal (and transcanalicular) ,7" there are several lasers available. The AT0 (potassiumtitanylphosphate)laser is characterized by its high energy& which ma+es it suitable for osteotomy. ,ue to the high energy there is a high incidence of scarring due to thermal injury. The AT0 laser has only been used in few studies. The ,iode laser has enough energy for performing or aiding in the osteotomy and produces minimal thermal injury. Other lasers used in ,7" are the 6rbium& eodym and 'olmium:9lasers. Their energy is not sufficient for osteotomy. 4urgery can be done with minimal scarring. The lasers are mainly used for opening of stenoses in failed ,7"s as well as in canalicular stenoses.
Neer develo*ments Transcanalicular surgery and microendoscopic lacrimal surgery and are the current developments. Transcanalicular ,7" can be performed with or without endoscopy. The diameter of canaliculi in adults is appro#imately $mm. 4oft tissue stenoses following failed ,7" can be opened by microdrills or lasers& introduced via a fle#ible probe. -or creating the osteotomy in ,7"& the microdrills are not powerful enough& hence AT0 or ,iode lasers can be used. The success rate has been reported as I J=E. ,iagnostic microendoscopy can be performed with a fle#ible canalicular endoscope (%.= %.Kmm)& inserted into a modified >
(acr"oc"stectom" +(#T) ,7T involves the removal of the lacrimal sac as well as nasolacrimal duct. 3imited ,7T is the removal of the sac only. The main indication for performing a ,7T is suspected lacrimal sac malignancy. 5ut also chronic infections as in rhinosporidiosis& tuberculosis and actinomycosis and chronic inflammatory conditions such as egener8s granulomatosis are reasons for performing a ,7T instead of a ,7" in the setting of a nasolacrimal duct bloc+. *n these cases& the chance of reactivation of the disease through the surgery is high. ,7T can also be indicated in cases of 3,O with dry eyes as in ocular pemphigoid in which the chances of postoperative epiphora are minimal. ,7T ta+es less time than a ,7" and chances of haemmorrhage are much less. *t
can be performed under local anaesthesia without sedation since no osteotomy is performed. This ma+es the procedure suitable in elderly& frail individuals who have a high ris+ for local anaesthesia with sedation due to their medical conditions& especially if the main complaint is chronic or recurrent dacryocystitis rather than epiphora. *n elderly patients& the basal tear production is reduced so that the patient may have minimal or no epiphora following surgery. The procedure is begun as the standard ,7". The medial canthal tendon is visualized and cut to e#pose the fundus of the sac. ny adhesions are dissected and the sac freed. *f malignancy is suspected& a biopsy can be ta+en for frozen section from the sac or the surrounding tissue. The sac is then bluntly dissected inferiorly up to the nasolacrimal duct and cut at the level of the common canaliculus. *n case of malignancy the bony canal can be removed. The sac is grasped and twisted until it is freed completely and sent for
histopathological
analysis.
The
wound
is
closed
after
ensuring
haemostasis.
&ummar" c1uired nasolacrimal duct obstruction is a common cause for epiphora and can be the underlying condition for acute and chronic dacryocystitis. There are numerous causes including degenerative& infective and malignant conditions. Thorough history and investigation is mandatory for planning of the appropriate management. There are various clinical tests to confirm the diagnosis of an 3,O and imaging has a role in certain conditions. 4urgical management is essentially dacryocystorhinostomy. 6#ternal or endonasal ,7" are the standard procedures& transcanalicular and microendoscopic as well as laserassisted ,7" belong to the newer developments. 4uspected malignancy is a contraindication for ,7" surgery& dacryocystectomy should be performed in these cases.
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et al.
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et
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*
et
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and
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r#a
9
et
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