Adult nasolacrimal duct obstruction

CARLSHERMETARO,DO GEOFFREYJ.GLADSTONE,MD

Tear production resulting from Nasolacrimal duct obstruction and its clinical obstruction of the nasolacrimal duct is a com­ characteristics will be reviewed here, together with mon ophthalmic problem. The diagnosis and an overview of the pertinent surgical anatomy. treatment of this condition require a thor­ The external approach to DCR will also be described. ough understanding of the lacrimal appa­ ratus and its ocular and nasal relationships. Anatomy Idiopathic or primary acquired nasolacrimal As already stated herein, the lacrimal system can be divid­ duct obstruction is a syndrome of unknown ed into the secretory and excretory systems. The secre­ etiology. Of all nontraumatic fonus, it accounts tory system includes the lacrimal glands, Krause's for the vast majority of cases found in adults. accessory glands, the glands ofWolfring, meibomian The authors discuss a number of potential (sebaceous) glands, Moll's (apocrine) glands, and the causes, some of them iatrogenic and discuss glands of Zeis (also a sebaceous gland). the technique of dacryocystorhinostomy, the The excretory system, or nasolacrimal drainage standard surgical treatment, in detail. system, includes the upper and lower punctum and (Key words: Nasolacrimal duct obstruction, canaliculi, common canaliculus, lacrimal sac, and naso­ dacryocystorhinostomy, lacrimal system, lacrimal duct (Figure). The canaliculi have a 2-mm ver­ epiphora, dacryocystitis) tical segment and an 8-mm to lO-mm horizontal segment that enter the lacrimal sac via the common canaliculus. The lacrimal sac lies in the fossa between the ante­ The lacrimal system has two functioning com­ rior and posterior lacrimal crests. The lacrimal bone ponents: the secretory portion, which produces forms the posterior crest and the frontal process of the tears, and the excretory portion, which drains the maxilla forms the anterior crest. The fundus measures tears into the nose. The lacrimal drainage sys­ 3 mm to 5 mm and the body measures 10 mm in length. tem, when not functioning properly, can result in The anterior ethmoid air cells and vessels are medial epiphora or a discharge of mucopurulent mater­ to the sac. The floor of the frontal sinus is superior to ial from the medial canthal region. If a diagno­ the sac. The nasolacrimal duct, which empties the sis of nasolacrimal duct obstruction is made and lacrimal sac, is composed of a 12-mm interosseous seg­ conservative treatment measures fail, a dacry­ ment and a 5-mm meatal segment. The duct drains ocystorhinostomy (DCR) should be performed. into the anterior inferior meatus via a bony canal adja­ cent to the maxillary sinus. Hasner's valve, a mucosal The objective of this procedure is to establish fold, generally covers the distal end of the duct, pre­ a mucosal continuity between the lacrimal sac venting reflux of air from the nose. and the nose. The regional anatomy lies in the fields of both otolaryngology and ophthalmology. Thus, one can find physicians in both fields who Signs and symptoms manage and treat obstruction of the lacrimal Acquired nasolacrimal duct stenosis of patients drainage system. with nasolacrimal duct obstruction can often be first seen with epiphora or a mucopurulent dis­ At the time this article was written, Dr Shermetaro was a charge. The stenosis results in stasis of tears in resident in otolaryngology, Pontiac Osteopathic Hospital, the lacrimal sac. Subsequent chronic infection Pontiac, Mich, and Dr Gladstone is co-director, oculoplastics service, William Beaumont Hospital, Royal Oak, Mich. with an accumulation of mucopurulent material fre­ Correspondence to Carl Shermetaro, DO, 50 N Perry St, quently results. Dacryocystitis (inflammation of Pontiac, MI 48342-2217. the lacrimal sac) is often seen clinically as swelling

Clinical practice • Shennetaro and Gladstone JAOA • Vol 94 • No 3 • March 1994 • 229 interosseous part ... Nasolacrimal duct 5 mm, / meatal part

Inferior meatus-20 mm

Figure. Anatomy of the lacrimal excretory system. (Reprinted with permission from Smith BC, Della Rocca RC, Nesi FA, et al: Ophthalmic Plastic and Reconstructive Surgery. St Louis, Mo, CV Mosby Co, 1987, vol 2, p 967.) and erythema :in the medial canthal region. Patients tion at the distal end of the duct. The secretory often have pain :in this region. Palpation over the system can be evaluated by the Schirmer test. 2 medial canthal swell:ing can exacerbate the pa:in The lacrimal drainage system can be evaluated in the acute sett:ing and can cause the mucopu­ with irrigation, the Jones tests, or the dye-reten­ rulent material :in the sac to be expelled via the punc­ tion test.3 Irrigation via the canaliculus can deter­ tum into the medial fornix. This expulsion can mine the approximate location of the obstruction­ happen spontaneously, causing the eyelids to be punctum/canaliculus versus lacrimal sac/duct-and "stuck together" on awakening :in the morn:ing. whether the obstruction is partial or complete. Chronic dacryocystitis manifests as a palpa­ If a tumor is suspected, dacryocystography or ble, nontender mass, often with :intermittent bouts computed tomography (CT) and an excisional biop­ of acute dacryocystitis. If bloody nasal discharge sy can be performed.1 If the patient has a history accompanies a clinical picture of chronic dacry­ of s:inus disease, CT of the paranasal s:inuses may ocystitis, the physician must suspect a lacrimal be warranted. Finally, if the patient has a history sac tumor.l offacial trauma, CT scans of the facial bones should be done in a search for midfacial fractures. Diagnosis The diagnostic modalities used will depend on the Etiology patient's history and results ofthe physical exam­ The proximity of the nasolacrimal duct to the :ination. An important part of the history is ascer­ paranasal s:inuses and the nasal chamber lends taining the nature of the periocular drainage. itself to obstruction/stenosis from disorders :in these Epiphora can be caused by an abnormality :in tear regions as well as from trauma and iatrogenic production (secretory system) or-as with mucoid causes. The most common cause of obstruction :in or mucopurulent discharge-a blockage of the adults is unknown and is characterized by a grad­ lacrimal dra:inage system. ual thickening of the nasolacrimal duct mucosa.4 The physical examination should :include a Possible nasal causes of obstruction include thorough ocular examination, including inspec­ nasal polyps, inferior turb:inate hypertrophy, devi­ tion of the eyelids for ectropion and the cornea for ated nasal septum, :intranasal foreign bodies, and keratopathy. Anterior rhinoscopy should be per­ nasal tumors.5 Potential paranasal s:inus causes are formed :in order to identifY pathologic :intranasal acute s:inusitis (frontal, ethmoid, and maxillary), conditions that have potential for caus:ing obstruc- sinus tumors, and prior sinus surgery, such as

230 • JAOA • Vol 94 • No 3 • March 1994 CJi.njcal practice ' Shennetaro and Gladstone inferior or middle meatal antrotomy. Disruption the external approach is avoidance of an external of the nasolacrimal duct can be caused by mid­ scar and disruption of the medial orbital tissues. facial fractures, occurring primarily at the junc­ As surgeons become more experienced with the tion of the lacrimal sac and proximal duct. 6 One use of nasal endoscopes, this approach should gain study7 reports a 0.2% incidence of obstruction in popularity. with nasal fractures and a 3% incidence with maxillary fractures. Procedure Iatrogenic causes of obstruction include max­ The external DCR, the more common technique, illary sinus surgery, rhinoplastic surgery, and is performed on an outpatient basis and can be complications of midfacial fracture repair. Repair done with the patient under general or local anes­ of traumatic telecanthus6 and migration of an thesia with intravenous sedation. Local anesthe­ orbital floor implantS are other causes. sia is achieved by blocking the infratrochlear and Idiopathic or primary acquired nasolacrimal infraorbital nerves. The middle meatus is packed duct obstruction (PANDO)4 is a syndrome of with 4% cocaine-soaked pledgets or gauze. A 2% unknown cause most commonly affecting women lidocaine hydrochloride (Xylocaine) or 0.75% bupi­ 40 years of age. It accounts for the vast majority vacaine hydrochloride (Marcaine) solution with of nontraumatic causes in adults. Linberg and epinephrine is injected into the medial canthal McCormick4 reported 16 cases of PANDO seen region. with clinical chronic dacryocystitis. Two of the 16 After allowing adequate time for hemostasis, cases were excluded after histopathologic study a sterile marking pen is used to create a curvilin­ showed that the obstruction was caused by chron­ ear line beginning between the medial canthal ic lymphocytic leukemia and sarcoidosis. In the region and the lateral nasal bridge and extend­ remaining 14 cases, biopsy of the nasolacrimal ing downward for 20 mm. The incision is carried duct revealed a narrowed lumen and periductal down through the periosteum. Next, the anterior tissue that was either edematous, infiltrated by limb of the medial canthal tendon, lacrimal sac, inflammatory cells, or thickened by dense fibrous and periosteum are elevated in a temporal direc­ tissue (or a combination). The vascular plexus tion, exposing the lacrimal fossa to the posterior crest. was more prominent with thick-walled vessels. Once identified, the lacrimal bone and anterior Dacryolithiasis (lacrimal stone) is another crest are removed with a drill or with rongeurs. consideration in dacryocystitis. This condition is With both the external and endoscopic techniques, marked by an accumulation of inflammatory care is taken to preserve the nasal mucosa. The debris in the lacrimal sac or duct (or both). The stone osteotomy is approximately 15 mm in diameter. causes obstruction leading to acute or chronic The puncti are dilated and Bowman lacrimal symptoms. Although not a common cause of naso­ probes are used to ensure patency of the canaliculi lacrimal obstruction, laclimal sac tumors should and to tent the medial wall of the sac. Once the probe be considered in patients with chronic dacry­ tip is identified in the sac, an anteriorly based flap ocystitis and bloody discharge. Lacrimal sac tumors is created in the lacrimal sac. The nasal mucosa is are primarily epithelial, but mesenchymal, incised to create an anteriorly based flap. A 12 melanocytic, and pseudotumor forms have been French rubber catheter is guided through the reported. 1 Other unusual causes of obstruction nares under the middle turbinate and into the are Wegener's granulomatosis,9 Stevens-Johnson osteotomy. It is sutured to the base of the lacrimal syndrome,10 sarcoidosis,4 chronic lymphocytic sac flap with a No. 4-0 chromic catgut suture. This leukemia,4 and lymphoma.11 suture tends to prevent closure of the mucosal­ lined fistula in the early postoperative period. Treatment Silastic lacrimal intubation tubes are then Nasolacrimal duct obstruction/stenosis leads to placed through the canalicular system, out of the acute or chronic dacryocystitis. This condition can sac, through the osteotomy, and out of the nares. be treated conservatively with oral antibiotics, The tubes are then tied to themselves and cut ophthalmic drops, warm compresses, and gentle mas­ within the nares. The nasal mucosal flap is sutured saging of the sac. Incision and drainage may be to the lacrimal sac flap with a horizontal mattress warranted in severe cases. Ultimately, nasolacrimal No. 4-0 chromic catgut suture. The wound is closed duct obstruction should be treated with a DCR. with inverted, interrupted subcutaneous No. 5-0 Some surgeons perform endoscopic transnasal chromic catgut sutures followed by skin closure DCR. The main advantage of this technique over with running No. 6-0 mild chromic catgut sutures.

Clinical practice • Shennetaro and Gladstone JAOA • Vol 94 • No 3 • March 1994 • 231 The rubber catheter is removed at 3 weeks, and the Silastic tubes are removed at 6 weeks. When surgery is performed meticulously, a suc­ cess rate of 90% to 95% can be anticipated.

Comment It is important for the surgeon treating adult naso­ lacrimal duct obstruction to understand both the ocular and nasal relationships to the lacrimal drainage system. Mastering the functional anato­ my of this system and performing good clinical ocular and nasal evaluations will lead to a correct diagnosis and, ultimately, an effective treatment plan in the majority of patients with epiphora or discharge from the medial canthal region.

References 1. Smith BC, Della Rocca RC, Nesi FA, et al: Ophthalmic Plastic and Reconstructive Surgery. St Louis, Mo, CV Mosby Co, 1987, vol 2, pp 955-967. 2. Schirmer 0: Studien zur Physiologie und Pathologie der Tra­ nenabsorderung und Tranenabfuhr. Groefes Arch Clin Exp Ophthalmol 1903;56:197. 3. Zappia R, Milder B: Lacrimal drainage function: I. The Jones fluorescein test. Am J Ophthalmol1972;74:154. 4. Linberg JV, McCormick SA: Primary acquired nasolacrimal duct obstruction: A clinicopathologic report and biopsy technique. Oph· thalmology 1986;93:1055-1062. 5. Holt JE, Holt GR: Nasolacrimal evaluation and surgery. Oto­ laryngol Clin North Am 1988;21:119-134. 6. Osguthorpe JD, Hoang G: Nasolacrimal injuries: Evaluation and management. Otolaryngol Clin North Am 1991;24:59-78. 7. Balle VH, Andersen R, Siim C: Incidence of lacrimal obstruc­ tion following trauma to the facial skeleton. Ear Nose Throat J 1988;67:66-70. 8. Mauriello JA, Fiore PM, Kotch M: Dacryocystitis: Late compli­ cation of orbital floor fracture repair with implant. Ophthalmolo­ gy 1987;94:248-250. 9. Glatt HJ, Putterman AM: Dacryocystorhinostomy in Wegener's granulomatosis. Ophthalmic Plast Reconstr Surg 1990;6:207-210. 10. Auran JD, Hornblass A, Gross ND: Stevens-Johnson syndrome with associated nasolacrimal duct obstruction treated with dacry­ ocystorhinostomy and Crawford silicone tube insertion. Ophthalmic Plast Reconstr Surg 1990;6:60-63. 11. Carlin R, Henderson JW: Malignant lymphoma of the naso­ lacrimal sac. Am J Ophthalmol1974;78 :511-513.

232' JAOA • Vol 94 • No 3 ' March 1994 Clinical practice • Shermetaro and Gladstone