2.7 Nasolacrimal Duct Obstruction, Acquired

Date of last review: Due to be updated

Differential diagnosis

  • Canaliculitis
  • Dacryocystitis
  • Tumour of lacrimal sac or canaliculi (rare)
  • Facial nerve palsy

Possible management by Optometrist

  • Jones fluorescein dye test
    • Significant amount of fluorescein remaining in tear meniscus two minutes or more after instillation indicates restricted drainage
    • Check for appearance of fluorescein in the nose (examine tissue after nose blow; if fluorescein present, lacrimal system is patent
    • Place anaesthetic-soaked cotton bud in nose (if bud stained with fluorescein after 5 minutes, lacrimal system is patent)
  • Lacrimal syringing (only to be done if appropriately trained)
    • Instil a drop of topical anaesthetic
    • Gently dilate punctum with punctal dilator
    • Syringe with normal saline via lacrimal cannula
    • If saline passes into nose (patient swallows and tastes salt) – nasolacrimal system is patent
    • If there is resistance to the passage of the cannula and reflux from opposed canaliculus – common canaliculus is stenosed
    • If no saline passes into nose – complete lacrimal duct obstruction

Treatment

  • Treat any cause of dry eye to reduce secondary lacrimation
  • Lacrimal lavage (saline syringing) may be effective in some case
  • Topical antibiotic if clinical evidence of infection
    • Ask if allergic to Chloramphenicol
    • If not, supply Chloramphenicol 1% eye ointment 3 times daily for a week
    • If allergic to Chloramphenicol, or pregnant, supply Fusidic acid 1% liquid gel twice a day for a week

Advice

  • Surgery invasive and requires general anaesthesia
  • Conservative management often best

Management Category

  • Initial management (including drugs) followed by routine referral

Possible management by Ophthalmologist

  • Punctal dilatation where there is stenosis
  • Canalicular curettage for Actinomyces infection
  • Dacryocystorhinostomy (DCR)