Acquired Etiologies of Lacrimal System Obstructions
5 Acquired Etiologies of Lacrimal System Obstructions Daniel P. Schaefer Acquired obstructions of the lacrimal excretory outfl ow system will produce the symptoms of epiphora, mucopurulent discharge, pain, dacryocystitis, and even cellulitis, prompting the patient to seek the ophthalmologist for evaluation and treatment. Impaired tear outfl ow may be functional, structural, or both. The causes may be primary – those resulting from infl ammation of unknown causes that lead to occlusive fi brosis—or secondary, resulting from infections, infl amma- tion, trauma, malignancies, toxicity, or mechanical causes. Secondary acquired dacryostenosis and obstruction may result from many causes, both common and obscure. Occasionally, the precise pathogenesis of nasolacrimal duct obstruction will, despite years of investigations, be elusive. To properly evaluate and appropriately treat the patient, the ophthal- mologist must have knowledge and comprehension of the lacrimal anatomy, the lacrimal apparatus, pathophysiology, ocular and nasal relationships, ophthalmic and systemic disease process, as well as the topical and systemic medications that can affect the nasolacrimal duct system. One must be able to assess if the cause is secondary to outfl ow anomalies, hypersecretion or refl ex secretion, pseudoepiphora, eyelid malposition abnormalities, trichiasis, foreign bodies and conjunctival concretions, keratitis, tear fi lm defi ciencies or instability, dry eye syn- dromes, ocular surface abnormalities, irritation or tumors affecting the trigeminal nerve, allergy, medications, or environmental factors. Abnormalities of the lacrimal pump function can result from involu- tional changes, eyelid laxity, facial nerve paralysis, or fl oppy eyelid syndrome, all of which displace the punctum from the lacrimal lake. If the cause is secondary to obstruction of the nasolacrimal duct system, the ophthalmologist must be able to determine where the anomaly is and what the cause is, in order to provide the best treatment possible for the patient.
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