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Provider photo for Gregg Gayre

Gregg Gayre, MD

Ophthalmology: Oculoplastic

Welcome to My Doctor Online, a web site that my colleagues and I developed to make it easier for you to take care of your healthcare needs. On this site you will find answers to many of your questions about my clinical practice. Also included are several online features that will allow you to e-mail me, check your laboratory results and refill prescriptions. I hope you find its content informative and useful.

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Nasolacrimal Duct Obstruction

Introduction
The system that produces tears in your eye is known as the lacrimal apparatus. It consists of the lacrimal gland (the gland that produces tears) and its tiny ducts, which secrete the tears and the tear drainage ducts that drain the old tears away from the eye. When you blink your eye, your eyelids push tears evenly across your eye to keep your eyes moist and healthy. Blinking also pumps your old tears into the lacrimal excretory ducts. The excretory ducts begin as two small openings called puncta, one in the upper and the other in the lower eyelid. Each of these openings leads into a small tube called the lacrimal canaliculi which, in turn, empties into a storage pouch (known as the nasolacrimal sac) at the inside corner of your eye near the bridge of your nose. An opening in this nasolacrimal sac leads into a canal called the nasolacrimal duct, through which the fluid is ultimately emptied into the back of the nose so that the tears drain into the back of your throat. The fact that your tears drain into the back of your nose and throat explains why your nose starts to run when you are crying, and why you can sometimes taste eye drops.

If the tear duct is blocked, your tears back up and spill over your eyelids as if you were crying. This condition is known as “epiphora”. Tears trapped in the tear sac can also become stagnant and infected leading to the formation of an abscess (a condition known as dacryocystitis.

The most common symptoms of a blocked nasolacrimal duct are excessive watering, mucous discharge, eye irritation, and painful swelling or infection in the inner corner of the eyelids.

A special word about tearing in infants
The term “congenital” means present at birth. Congenital (CLDO) is literally a tear duct that has failed to open at the time of birth. Around 6% of infants have CLDO, usually experiencing a persistent watery eye even when not crying. If a secondary infection occurs (Dacryocystitis), purulent (yellow / green) discharge may be present. Most cases of congenital nasolacrimal duct obstruction resolve spontaneously, with antibiotics reserved only if conjunctivitis occurs. Lacrimal sac massage is often helpful in opening the duct, although it is not always successful.  The aim of massage is to generate enough hydrostatic pressure (downward, toward the nose) to "pop" open any obstruction. Additional massage may then be performed up toward the lacrimal puncta, in order to express any infectious material out of the nasolacrimal system. When discharge or crusting is present, the lids should be gently cleaned using cooled pre-boiled water or saline.
A referral for consideration of surgery to correct a blocked tear drain in a child is indicated if symptoms are still present at 12 months of age, or sooner if significant symptoms or recurrent infections occur. Nasolacrimal duct probing with a sharp metal instrument can open the blocked tear drain in children. The success rate of probing is higher for children under 3 years of age. A plastic (silastic) tube or lacrimal stent may be inserted into the tear drain at the time of probing in order to ensure success in older children. For the minority of children who fail to respond to probing or placement of these lacrimal stents, a dacyrocystorhinostomy or balloon dacryoplasty procedure may be recommended.

Screening and Diagnosis
The diagnosis of a blocked tear drain in both children and adults requires a complete eye examination along with examination of the lacrimal apparatus and the nose.  Your doctor will rule out causes of excess tear production (such as a dry, irritated cornea) as well as determine the exact location of the blocked tear drain, if present.  Fluid may be passed into the nasolacrimal duct. In rare instances radiopaque dyes may be introduced into the tear drain so that an x-ray of the tear drains can reveal the location of the obstruction. This procedure is known as dacryocentigraphy.

Treatment
The most common surgical treatment of a blocked tear drainage system in adults is known as a dacryocystorhinostomy (DCR). DCR is a surgical procedure to restore the flow of tears into the nose from the lacrimal sac when the nasolacrimal duct does not function. Since its introduction in the early 1900s, the procedure has the highest success rate (more than 90%) for adults who have not had prior nose surgery or disease. The surgery is an outpatient procedure and is usually performed after any inflammation from a recent infection is reduced. Recovery from surgery is generally one to two weeks.

With a traditional DCR, a small incision is made on the side of the nose and some bone is removed to make a connection to the nose. A plastic (silastic) tube or stent may be inserted into the tear drain in order to prevent the surgically created opening from closing. This stent is removed after a few months. The operation can also be performed “endoscopically” entirely through the nose using a small telescope in which an opening is created in the lacrimal sac from within the nose avoiding an external scar. The success rates of an endoscopic approach may be less than that of a traditional DCR and anatomic variations within the nose may prohibit this option as an effective surgical choice.

A newer less invasive surgical option is known as balloon dacryoplasty. This procedure is best for patients with symptomatic tearing with a very narrow but still partially open tear drain. In this procedure a balloon on the tip of a wire catheter (known as a lacricath) is inserted into the nasolacrimal duct down to the site of the narrowing. The balloon is then inflated to expand the narrowing before being deflated and then removed. A plastic (silastic) tube or stent may be employed to prevent the narrowing from reoccurring and are removed after a few months.

Rarely, a tear drain obstruction may be isolated to the tiny ducts that drain the tears from the lacrimal puncta into the nasolacrimal sac. These ducts are known as the canaliculi ( singular, canaliculus). Canaiculoplasty is designed to bypass an obstruction within the tiny canaliculi. Such obstructions are notoriously difficult to resolve and surgical correction has a success rate of only about 50%. This procedure usually requires the insertion of lacrimal stents that are left in place for a minimum of six months and may be performed in conjunction with DCR.

If the nasolacrimal duct obstruction is beyond repair, it may be necessary to surgically place a tiny artificial drain called a “Jones tube” in the corner of your eye that extends inside the nasal cavity and allows tears to drain. The tube is made of Pyrex glass and remains permanently in the tear duct. This procedure is known as a conjunctivo-dacryocystorhinostomy or C-DCR.

The risks and complications of tear drain surgery are the usual risks of anesthesia and surgery, and include bleeding and infection, which are uncommon. Occasionally the body may form scar tissue that blocks the drain again, which may require repeating the procedure.

Living with the Condition
In most cases the diagnosis of a blocked tear drain surgery doesn’t necessarily mean that surgical intervention must be performed. Most of the time the existence of a blocked tear drain is mostly a nuisance and surgery to repair the blockage is considered elective. Many patients choose not to operate and can safely live with the condition. In some instances, when the blocked tear duct becomes infected, surgery becomes an important method of preventing more severe infections that can threaten your health or the function of your eye.

If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following: (1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.

This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.



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