Nasolacrimal duct obstruction

Nasolacrimal duct obstruction (NLDO) is the obstruction of nasolacrimal duct (NLD) and may be either congenital or acquired. Obstruction of the nasolacrimal duct leads to the excess overflow of tears called epiphora.

Symptoms
Excessive tearing is the most important complaint of patients with NLDO. Pain at the side of the nose suggests dacryocystitis.

Aetiology

• Involutional stenosis
  Involutional stenosis is probably the most common cause of NLDO in older persons. It affects women twice as frequently as men. Although the inciting event in this process is unknown clinicopathologic studies suggest that compression of the lumen of the NLD is caused by inflammatory infiltrates and oedema. This may be the result of an unidentified infection or possibly an autoimmune disease.
• Dacryolith
• Sinus disease
  Sinus disease often occurs in conjunction with NLDO, and in other instances may contribute to the development of NLDO.
• Trauma
  Naso-orbital fractures may involve the NLD. Early treatment by fracture reduction with stenting of the entire lacrimal drainage system should be considered. However, such injuries are often not recognized or are initially neglected as more serious injuries are managed. In such cases, late treatment of persistent epiphora usually requires DCR.
• Inflammatory disease
  Granulomatous disease, including sarcoidosis and Wegener granulomatosis may also lead to NLDO.
• Lacrimal plugs
  As with similar cases of canalicular obstruction, dislodged punctal and canalicular plugs can migrate to and occlude the NLD.
• Neoplasm
  Neoplasm should be considered in any patient presenting with NLD obstruction.In patients with an atypical presentation, including younger age and male gender,further workup is appropriate. Bloody punctal discharge or lacrimal sac distension above the medial canthal tendon is also highly suggestive of neoplasm.
• Congenital
  Congenital nasolacrimal duct obstruction is most often due to an imperforate membrane at the valve of Hasner.

Management

• Intubation and stenting
  Some clinicians believe that partial stenosis of the NLD with symptomatic epiphora sometimes responds to surgical intubation of the entire lacrimal drainage system. This procedure should be performed only if the tubes can be passed easily. In complete NLD obstruction, intubation alone is not effective, and a DCR should be considered.
• Dacryocyctorhinostomy (DCR)
  A DCR is the treatment of choice for most patients with acquired NLD obstruction. Surgical indications include recurrent dacryocystitis, chronic mucoid reflux, painful distension of the lacrimal sac, and bothersome epiphora. For patients with dacryocystitis, active infection should be cleared, if possible, before DCR is performed.