Royal College of Ophthalmologists Guidelines (Focus)

Management of Epiphora

A watery eye can be the product of excess tear production (hyper-lacrimation), disturbed ocular surface tear flow (lid malposition) or disturbed outflow (epiphora). Occasionally all three mechanisms can be involved. Epiphora is due to some form of compromised  drainage which may be caused by: a) punctal Plimosis, b) canalicular stenosis and obstruction or c) naso-lacrimal duct blockage. Obstruction of the naso-lacrimal duct may be congenital, in which case it is most usually due to delayed canalization of the valve of Hasner, or it may be acquired.

In adults the commonest cause of epiphora is primary acquired nasolacrimal duct obstruction (NLDO) which is associated with inflammation of the nasolacrimal duct.

Epiphora in the presence of a patent lacrimal system to syringing and in the absence of excess tear production or lid malposition is defined as functional NLDO. 

Management of less common causes of epiphora such as congenital facial abnormalities and secondary acquired obstructions am not discussed in this article.

EPIPHORA IN CHILDREN

Symptomatic NLDO occurs in approximately 5-6% of infants. A sticky, watery eye with positive regurgitation on pressure over the lacrimal sac confirms the diagnosis. Other diagnostic measures such as probing or dacryoscytography (DCG) may be combined with treatment under general anaesthesia.

As there is a high spontaneous rate of remission (60-90%) in the first year of life, probing should be delayed until 10-12 months of age.1, 2 Parents can be instructed to undertake lacrimal sac massage during the intervening period. Earlier probing is only justified if their is severe recurrent infection.

Probing of the naso-lacrimal duct is the first line of treatments However probe failure increases with age and is known to double every 6 months.1 For this reason and in cases of persistent epiphora, a second probing two to four months later is advocated. In failed cases with persistent epiphora and recurrent infection, it may be necessary to perform a dacryocystorhinostomy (DCR). Alternatively bicanalicular silicone incubation with Crawford, Juneman or Ritleng tubes can be carried out with a claimed success rate of 88-95%.4,5

EPIPHORA IN ADULTS

Causes of disturbed ocular surface tear flow such as lid malposition (euryblepharon, punctal ectropion, punctal phimosis) or ocular surface irritation (dry eye, blepharitis) should be excluded first.

Identification of the site of the obstruction causing epiphora is most important, This information has been shown to dramatically increase the chance of successful tmatrnent.6

INVESTIGATIONS

Identification of the site of blockage requires one or more of the following tests:

Dye tests

Two or three drops of sodium fluorescein are instilled into the lateral fornix. Dye may drain completely (dye disappearance) and be collected by a swab at the inferior meatus (Jones I), when the drainage system is patent. No more tests are necessary at this stage. With compromised drainage, dye usually overflows medially onto the cheek. In the presence of lid malpositions it overflows medially, centrally or laterally, according to the lid position. 

The ocular surface is examined simultaneously. Conjunctival and corneal staining should be noted to rule out ocular surface disease. On the whole dye tests are objective and not reliable.

Syringing and probing

The lower puncti are gently dilated under topical anaesthesia. Next, one or two mls of local anaesthesia are injected using a lacrimal canula. If there is regurgitation, the largest lacrimal probe which can be inserted without damaging the annulus is used. If it enters the sac without my resistance, the site of blockage is most probably NLD. If a site of resistance is noted, the probe is grasped with forceps at the punctum and withdrawn. The exposed end is measured to identify accurately the site of the blockage. A smaller sized probe is then inserted. Resistance at the same site reveals a complete canalicular obstruction. In the case of stenosis the smaller probe can be passed through and into the sac. Syringing of the NLD then follows. The same examination is repeated for the upper puncti. An experienced examiner can gather enough information at this stage to plan treatment.

Macro dacryocystography (MDCG) and scintigraphy

These further investigations may be used to confirm the diagnosis. MDCG is particularly useful to reveal details of lacrimal sac anatomy and the site of nasolacrimal duct obstruction.8 MDCG with a delayed erect film 5 minutes after injection of contrast medium can detect functional NLDO by showing delayed clearance of the lacrimal sac.9 Scintigraphy is mainly used to confirm a diagnosis of functional blockage when there is delayed or no out- flow of radioactive media in the presence of a normal DCG.

Canalicular Endoscopy

More recent investigative tools are available such as the microcanalicular endoscope, which can demonstrate the site and type of blockage. However, experienced lacrimal surgeons can usually gather sufficient information by simply probing the canaliculi.

TREATMENT

Nasolacrimal duct blockage

External DCR is still the most popular choice for NLDO and dacryocystitis and has a success rate of 80-95%. If there is canalicular damage or a narrow upper nasal cavity it may be necessary to insert a silicone tube. Day-case external DCR under local anaesthesia is gaining popularity.

Endonasal DCR is acknowledged to have a lower success rate.10,11 Power tool and laser assisted DCR's can be performed as day case procedures and can be less time consuming.12

Balloon dilatation dacryoplasty his also been shown to be effective in partial nasolacrimal duct obstruction with a claimed success rate of 60%.12

Canalicular obstruction

a) Canalicular blockage
More complex surgical procedures are necessary if intubation is not successful. The micro-surgical repair of canaliculi has been proposed with a canaliculo-DCR being reserved for distal canalicular blockage. Retrograde intubation of the canaliculi combined with DCR is used for proximal canalicular obstruction and punctal agenesis, with a success rate of 60-70%.13 During a standard DCR the inner opening of the common canaliculus is identified and probed towards the blocked canaliculi. On reaching the site of the blockage a pseudo punctum is fashioned. A silicone tube is then inserted through the same route.

b) Canalicular stenosis
Silicone tube insertion during DCR is necessary. Alternatively canaliculoplasty by closed technique bicanalicular silicone tube insertion can be performed. A success rate of up to 70% has been reported. 15,16 Early anecdotal reports indicate that endocanalicular Erbium laser, used prior to intubation, has an arguably (but as yet unproven) better outcome.

In cases of failure of the above procedures, a by-pass operation is the only remaining option. Conjunctivo-DCR with a Lester-Jones tube can be performed as a closed technique in the presence of a previous osteotomy

Functional blockage

Functional blockage due to preductal or ductal narrowing, identified by delayed MDCG or scintigraphy can be treated by DCR and a silicone stent. Many cases of functional blockage have also been successfully treated using lid shortening and punctal snip procedures.16 It seems that in such cases other underlying causes have been responsible such as punctal phimosis. Functional blockage due to pump failure (facial nerve palsy) might require by-pass lacrimal surgery. Treatment remains controversial.

SUMMARY

• Ocular surface irritation and lid mal-positions should be addressed initially. After identification of the site of blockage an appropriate plan of action should be adopted.
• Probing of the canaliculi in experienced hands is an effective diagnostic tool.
• Partial canalicular blockage can be treated by either DCR and silicone tube insertion or by closed technique canaliculoplasty involving bicanalicular insertion of a stent into the naso-lacrimal duct.
• Extensive canalicular blockage requires more complex surgery. Canaliculo-DCR for distal obstruction and DCR with retrograde intubation for proximal obstruction.
• Lacrimal by-pass surgery with a Lester-Jones tube is the last resort when other techniques have failed to achieve recanalisation of the drainage system.

Bijan Beigi, Norwich Hospital.

References:

1 Paul TO, Shepherd R. Congenital Nasolacrimal Duct Obstruction. J Pediatr Ophthalmol Strabismus 1995 Jul-Aug; 32 (4): 270-1.

2 Maini R, MacEwen CJ Young JD. The Natural History of Epiphora in Childhood. Eye 1998; 12: 669-71.

3 Mannor GE, Rose GE, Frimpon-Ansah, Ezra E. Factors Affecting the Success of Nasolacrimal Duct Probing for Congenital Nasolacrimal Duct Obstruction. AmJ Ophthalmol 1999 May; 127 (5):616-7.

4 Aggarwal RK, Misson GP, Donaldson L Willshaw HE. The Role of Nasolacrimil Intubation in the Management of Childhood Epiphora. Eye 1993, 7: 760-2.

5 Beigi B,Okeefe M.Results of Crawford lntubation in Children. Acta 0phthlmol 1993:71:405-07.

6 Beigi B, Westlake W, Chang B, Marsh C, Jacob J. Dacmcystorhinostomy in South West England. Eye 1998; 12: 358-62.

7 Guzek JP, Ching AS, Joang TA, Dure-Smith P, Llaurado JG, Yau DC, Stephenson CB, Stcphemon CM, Elam DA. Clinical and Radiologic Lacrimal Testing in Patients with Epiphora. Ophthalmology 1997 Nov; 104 (11); 1875-81.

8 Irfan S, Cassels-Brown A, Nelson M. Comparison Between Nasolacrimal Syringing/Probing /Macrodacryocystography and Surgical Findings in the Management of Epiphora. Eye 1998; 12; 197-202.

9 Wearne MJ, Pitts J, Frank J, Rose GE. Comparison of Dacryocystography and Lacrimal Scifigraphy in the Diagnosis of Functional Nasolacrimal Duct Obstruction. Br. J Ophthalmol 1999; 83:1032-1035.

10 Bakri SJ, Carney AS, Downes RN, Jones NS. Endonasal Lasar-Assisted Dacryocystorhinostomy. Hosp-Med 1998 M@; 59 (3): 210-5.

11 Shun-Shin GA. Endoscopic Dacryocystorhinostomy: A Personal Technique. Eye 1998; 12:467-70.

12 Perry JD, Maus M, Nowimki TS, Penne RB. Balloon Catheter Dilation for Treatment of Adults with Partial Nasolacrimal Duct Obstruction: A Preliminary Report. AMJ Ophthalmol 1998 Dec; 126 (6): 811-6.

13 Wearne MJ, Beigi B, Davis G, Rose GE. Retrograde Intubation. Dacryocystorhinostomy for Proximal and Midcanalicular Obstruction. Ophthalmology 1999; 106: 2325-2329.

14 Fulcher T, O'Connor M, Moriarty P Nasolacrimal Intubation in Adults. Br J Ophthalmol 1998 Sep; 82 (9):1039-41.

15 Psilas K Eftaxias V Kastanioudakis J, Kalogeropoulos C. Silicone Intubation as an alternative to Dacryocystorhinostomy for Nasolacrimal Drainage Obstruction in Adults. EurJ Ophthalmol 1993 April-June; 3 (2): 71-6.

16 Sadiq SA, Downes RN. Epiphora: A Quick Fix Eye 1998; 12:417-8.

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