Lacrimal Drainage Obstruction Causes Wet Eyes Too

 

Epiphora or chronically wet, irritated eyes is most commonly caused by infection, atopy or lid-lash abnormality and frequently associated with dry eyes. This counter-intuitive reason is related to reflex lacrimation from a disruption of the tear surface due to a deficiency of one or more of the components of the tears. 

Occasionally, there could be other less common causes for these symptoms, including the obstruction of the lacrimal drainage system. The pathology may occur at different levels; involving the lacrimal punctum (obstruction, stenosis, ectropion), canaliculus (foreign body, infection, stricture) or naso-lacrimal duct.

Unfortunately, most of these conditions are not easily managed outside of a specialist setting, since they commonly require some form of surgical procedure. However, early recognition by the family physician or general ophthalmologist will facilitate the initiation of appropriate therapy.

Punctal Problems

 

Punctal pathology such as stenosis (Figure 1) or occlusion is recognised as a reduction in the size of the punctal aperture. A minor surgical procedure such as a simple two-snip or three-snip procedure can reverse the occlusion and enable the further examination of the distal canaliculus. Presence of an epithelial-lined canalicular cyst usually implies distal occlusion of the canaliculus, with accumulation within the lumen of mucin produced by goblet cells. Treatment for aesthetic reasons requires excision of the cyst and the sacrificing of the involved canaliculus.

Epiphora can also result from the malpositioning of the punctum such as in cases of lower lid ectropion, where the punctum is separated from the tear lake. In these cases, punctal reappositioning to the globe can be achieved with a lid-tightening procedure with inverting sutures.

Tumours such as compound naevi may also involve the punctum (Figure 2). Treatment for this is surgical excision and possibly canalicularnasolacrimal duct stenting with a Crawford tube.

Canalicular Problems

Infection of the canaliculus (canaliculitis) results in a localised area of erythema with only very mild infero-nasal swelling and tenderness to the lower punctum. It is most commonly idiopathic in etiology and results in characteristic sulphur granule formation by Gram-positive Acinetobacter or the Nocardia species of bacteria.

Treatment requires mechanical removal of the sulphur granules with a micro-curette and instillation of appropriate antibiotics. Not infrequently, a cause of obstruction should be sought as retained punctal plugs may cause mechanical obstruction and predisposition to canaliculitis.

NasoLacrimal Duct Problems

Nasolacrimal duct obstructions can be recognised when fluorescein dye is retained for longer periods in the tear lake. The obstruction leads to accumulation of tears and mucus in the nasolacrimal sac and when this occurs, application of pressure over the medial canthal region may result in retrograde passage of tears and mucus through the lower punctum.

Syringing of the canalicular system will show reflux of irrigating fluid through the opposite paired canaliculus. The chronic tear stasis will predispose to lacrimal sac infection (dacryocystitis) (Figure 3) with localised swelling, tenderness and erythema at the infero-nasal quadrant of the eye. Treatment is with systemic antibiotics and possibly percutaneous drainage and/or emergent dacryo-cystorhinostomy.

 

Dr Goh E-Shawn
Dr Goh E-Shawn is a Consultant with National Healthcare Group Eye Institute at Tan Tock Seng Hospital and a member of the Oculoplastics Service. After completing his fellowship at the Mayo Clinic, Rochester, Minnesota, USA, he returned with an interest in surgery, orbital tumours and oculofacial plastic surgery for orbital tumours and oculofacial plastic surgery. He has been invited regionally and internationally to participate in meetings on these topics.