NASOLACRIMAL DUCT OBSTRUCTION (BLOCKED TEAR DUCT) AND TEARY EYE - PATIENT INFORMATION

Transcription

1 NASOLACRIMAL DUCT OBSTRUCTION (BLOCKED TEAR DUCT) AND TEARY EYE - PATIENT INFORMATION What is lacrimal sac and nasolacrimal duct? The lacrimal apparatus is composed of a lacrimal gland (tear producing gland) and the lacrimal drainage system. The lacrimal gland is located near the outer corner of each eye. The lacrimal drainage system is located in the inner corner of each eye. The lacrimal drainage system is composed of the upper and lower punctum located on inner aspect of the upper and lower eyelid, which drains into the upper and lower canaliculus. The upper and lower canaliculus joins together to form the common canaliculus. This is connected to the lacrimal sac, which drains into the nasolacrimal duct. What are the functions of the lacrimal sac and nasolacrimal duct? The lacrimal sac and nasolacrimal duct serve as a conduit to drain the tears from the eye into the nose. Normally, tears are produced in the lacrimal gland and are swept across the eye, moisturizing, protecting, and cleaning the surface of the eye. When tears reach the inner corner of the eye, they Figure 1. Lacrimal apparatus anatomy. Source: Seely et. al. Anatomy & Physiology, 8th Ed. enter the upper and lower punctum and drain into upper and lower canaliculus, which join to form the common canaliculus. The tears are pumped from the common canaliculus into the lacrimal sac by the blinking action of the eye and drain into the nasal cavity via the nasolacrimal duct.

2 What is nasolacrimal duct obstruction and how does it cause epiphora (teary eyes)? Nasolacrimal duct obstruction (blocked tear duct) occurs when the lumen of the nasolacrimal duct is narrowed from scarring or swelling. As a result, the tears cannot be adequately drained from the eye into the nose. The overflow of tears can lead to excessive tearing. Figure 2: Diagram of normal tear flow (left) and overflow of tear from nasolacrimal duct obstruction (right). Source: Modified from Seely et. al. Anatomy & Physiology, 8th Ed. How does a nasolacrimal duct obstruction typically present? The most common presentation of lacrimal duct obstruction is excessive tearing that can occur frequently and spontaneously without any apparent cause. The quality of the tears can be clear or mucoid. The patient may also have chronic irritation of the eyelid and the skin from frequent wiping and cleaning. With simple obstruction, there is typically no other significant finding. Periodically, the patient may develop dacryocystitis (infection of the lacrimal sac) with swelling, pain, redness, and drainage of puss near the inner corner of the eye.

3 What should you expect during your visit with your ENT doctor for a lacrimal duct obstruction? There are multiple causes epiphora (teary eyes) related to lacrimal drainage obstruction. During your visit, your ENT doctor will perform a complete history and physical exam to determine the cause of your nasolacrimal duct obstruction. The puncta are dilated, probed, and irrigated to confirm the presence of and site of an obstruction. A procedure called a nasal endoscopy with a fiberoptic endoscope may be performed to further evaluate the nasal anatomy and sinus pathology deep inside your nose, particularly if you have had previous sinus or nasal surgery. Depending on your history and examination, your physician may refer you to obtain additional studies including blood tests, culture, and radiographic exams. Figure 3. Diagram of a lacrimal interrogation with a lacrimal probe (left) and nasal endoscopy (right). Source: Tasman et. al. Duane's Ophthalmology & JAMA.com While epiphora (teary eyes) related to lacrimal drainage obstruction can usually be discerned with a thorough history and physical examination, other common causes of teary eye should be evaluated prior any surgical intervention. If you have not yet been evaluated by your eye doctor, then a referral to an eye doctor may be indicated to rule out other causes of teary eyes including excessive production of tears, dry eye (which may reflexively produce excessive, but abnormal tear quality), and eyelid malpositioning.

4 How is nasolacrimal duct obstruction classified? Nasolacrimal duct obstruction falls into three different categories: 1. Congenital nasolacrimal duct obstruction: Nasolacrimal obstruction occurs in about 2-4% of neonates. Common causes of persistent congenital lacrimal obstruction include nasolacrimal duct obstruction (35% of cases), punctual agenesis (15%), congenital fistula (10%), and craniofacial anomalies (5%). 2. Primary acquired nasolacrimal duct obstruction (PANDO): Primary acquired nasolacrimal duct obstruction results from inflammation and fibrosis of the nasolacrimal duct without a known cause. It most often seen in middle aged and elderly women and may be related to hormonal fluctuation and osteoporotic changes. 3. Secondary acquired lacrimal drainage obstruction (SALDO): Secondary acquired lacrimal drainage obstruction can be caused by chronic infection, autoimmune conditions, eye drops, radiation treatment, radioactive iodine treatment, chemotherapy treatment, trauma, lacrimal cyst, and local tumors. How is nasolacrimal duct obstruction treated? With an acute infection and inflammation, topical and oral antibiotics along with warm compress and massage may be the first line of treatment. For patient with chronic nasolacrimal duct obstruction the treatment options include dilation and irrigation, temporary stent placement, balloon catheter dilation, conjunctivodacryocystorhinostomy (CDCR, placement of a tube and connecting the conjunctiva to the nose), and dacryocystorhinostomy (DCR). Traditionally, a dacryocystorhinostomy (DCR) is performed externally by making an incision on the side of the nose, near the corner of the eye. Recently, the endoscopic dacryocystorhinostomy approach has become popular as the success rate of 97%. Unlike the external approach, the endoscopic approach is performed entirely through the nose without an external skin incision, thus avoiding a facial scar. Pain from the endoscopic approach is minimal and the recovery is short. Figure 4. Endoscopic DCR (blocked tear duct surgery). Source: Kennedy et. al. Rhinology: Diseases of the Nose, Sinus, and Skull Base.

5 When is an endoscopic dacryocystorhinostomy surgery indicated? Epiphora (teary eye) related to nasolacrimal duct obstruction can have a significant impact on quality of life and affect social interaction. Endoscopic dacryocystorhinostomy offers a high cure rate while avoiding a facial scar. In general, the decision to proceed with surgery is one that the patient and ENT surgeon makes together. Surgery is usually reserved for patients who are symptomatic and refractory to medical treatment. The surgery is performed on an outpatient basis without an external skin incision. Learn more about an endoscopic dacryocystorhinostomy as well as post-operative care after lacrimal duct surgery. Source: JAMA.com