Nasolacrimal duct obstruction can be congenital or acquired. It results in a blockage of the lacrimal drainage system which transports tears from the eye to the nose. The document describes the anatomy of the lacrimal drainage system and classifications of NLDO. Causes include infections, inflammation, tumors, trauma, and mechanical obstruction. Diagnosis involves history, examination, Jones dye testing, and imaging. Treatment depends on the type and includes massage, probing, dacryocystorhinostomy, and occasionally intubation or stenting. Surgical treatment aims to re-establish drainage from the lacrimal sac into the nose.

1. NASOLACRIMAL DUCT
OBSTRUCTION(NLDO)
PRESENTED
BY
DR. AVURU CHUKWUNALU JAMES

2. OUTLINE
• INTRODUCTION
• LACRIMAL DRAINAGE SYSTEM BRIEF ANATOMY
• CLASSIFICATION
• ETIOLOGY
• EPIDERMIOLOGY
• MANAGEMENT

3. INTRODUCTION
• Nasolacrimal duct obstruction(NLDO) is a
blockage of the lacrimal drainage system
• It can be
1. Congenital
2. Acquired

4. LACRIMAL DRAINAGE SYSTEM
•Lacrimal punctum
•Lacrimal canaliculus
•Lacrimal sac
•Nasolacrimal duct

5. LACRIMAL DRAINAGE SYSTEM
• Punta
• Ampulla
• Canaliculi
• Common canaliculus
• Lacrimal sac
• Naso- lacrimal duct
• Inferior nasal meatus

6. PUNCTA(PUCTUM)
•6 mm temporal to the inner canthus
•Each punctum situated upon lacrimal papilla
(prominent in old age)
•Punct a dip into the lacus lacrimalis(collection
of tear fluid in the inner canthus)

7. LACRIMAL CANALICULI
• Upper and lower
• Parts:
• –– Vertical 2mm
• ---Horizontal 8 mm
• Join to form common Canaliculi canaliculus
• Open in the lacrimal Rosenmuller sac, fold of mucosa forms the
valve which prevents reflux of tears.

9. LACRIMAL SAC
• Lies in the lacrimal fossa located in the anterior part of
medial orbital wall
• The lacrimal fossa is formed by lacrimal bone and frontal
process of maxilla and separate the lacrimal sac from the
middle meatus of the nasal cavity
• When distended: 15 mm in length and 5-6 mm in breadth

10. LACRIMAL SAC CONTD
• Parts:
– fundus (portion above the opening of canaliculi),
– body (middle part)
– neck (lower small part which is narrow and continuous with the
nasolacrimal duct)
• LININGS-by nonkeratinized stratified squamous epithelium and
are surrounded by elastic tissue, which permits dilation to 2 or 3
times the normal diameter.

11. NASO – LACRIMAL DUCT
• Neck of lacrimal sac to inferior meatus in the nose
• Lies in a bony canal – mainly maxilla and inferior turbinate
• 18 mm in length
• Intraosseous part 12.5mm
• Intrameatal 5.5mm
• Diameter-3mm

12. NASOLACRIMAL DUCT CONTD
• Direction- downwards, backward & laterally
• Externally its location is represented by a line joining inner
canthus to the ala of nose
• Upper end -narrowest part
• Valve of Hasner, present at the lower end of the duct and
prevents reflux from the nose

13. PHYSIOLOGY OF LACRIMAL DRAINAGE SYSTEM
• Tears secreted by the main and accessory lacrimal glands pass laterally
across the ocular surface
• Tears evaporates depending on
– size of the palpebral aperture
– blink rate
– ambient temperature
– humidity

14. PHYSIOLOGY OF NLD SYSTEM CONTD
• Tears flow along the upper
and lower marginal strips
enter the upper(30%) and
lower(70%) canaliculi by
capillarity and also possibly
by suction

15. PHYSIOLOGY OF NLD SYSTEM CONTD
• With each blink, the pretarsal orbicularis
oculi compresses the ampullae, shortens
the horizontal canaliculi and moves the
puncta medially
• The lacrimal part of the orbicularis oculi,
which is attached to the fascia of the
lacrimal sac contracts and expands the
sac creates a negative pressure sucks the
tears from the canaliculi into the sac

16. PHYSIOLOGY OF NLD SYSTEM CONTD
• When the eyes open the muscles relax.
the sac collapses and a positive pressure
is created which forces the tears down
the nasolacrimal duct into the nose
• Gravity also plays a role.
• The puncta move laterally.
• The canaliculi lengthen and fill with
tear

17. CLASSIFICATION-NLDO
• CONGENITAL: occurs approximately 5% of normal
newborn infants.
• The blockage occurs most commonly at the valve of
Hasner
• The blockage can be unilateral or bilateral.
• Spontaneous resolution in 90% within the first year of life.

18. CLASSIFICATION CONTD
• ACQUIRED NLDO
• primary acquired nasolacrimal duct obstruction (PANDO);
inflammation or fibrosis without any precipitating cause
• Secondary acquired lacrimal drainage obstruction (SALDO);
infectious(Bacteria, viruses, fungi, and parasites),
inflammatory, neoplastic, traumatic, and mechanical.

19. ETIOLOGY- CONGENITAL NLDO
1. Most commonly a membranous obstruction at the valve
of Hasner
2. General stenosis of the duct
3. Congenital proximal lacrimal outflow dysgenesis
(maldevelopment of the punctum and canaliculus)
4. Congenital lacrimal sac mucocele or dacryocystocele

20. ETIOLOGY-ACQUIRED NLDO
•INFECTIONS
•Viral; e.g herpetic
•Fungi
•Bacteria
•Parasitic: e.g Ascaris lumbricoides(enters through valve of
hasner

21. ETIOLOGY-ACQUIRED NLDO CONTD
•INFLAMMATION; endogenous or exogenous
•Endogenous; e.g Wegener granulomatosis and
sarcoidosis
•Exogenous; causes cicatricial lacrimal drainage
obstruction e.g eye drops, radiation, systemic
chemotherapy, and bone marrow transplantation.

22. ETIOLOGY- ACQUIRED NLDO CONTD
•NEOPLASM;
•Primary neoplasms; arising from puncta,
canaliculi, lacrimal sac, or nasolacrimal duct.
•Secondary or metastatic spread; eg . eyelid
cancers, sites from the breast and prostate

23. ETIOLOGY- ACQUIRED NLDO CONTD
•TRAUMA;
•Iatrogenic; e.g lacrimal probing, orbital decompression
surgery, paranasal, nasal, and craniofacial
procedures.
•Noniatrogenic; e.g blunt or sharp trauma to the
canaliculus, lacrimal sac, and nasolacrimal duct

24. ETIOLOGY- ACQUIRED NLDO CONTD
•MECHANICAL:
•Intraluminal foreign bodies, such as dacryoliths
or casts
•External compression from rhinoliths, nasal
foreign bodies, or mucoceles.

25. EPIDEMIOLOGY
• FREQUENCY: relatively common
• Obstruction of NLD in 5% of full term newborns
• MORTALITY/ MORBIDITY; Epiphora can be a
nuisance
• RACE; No predilectionn to race has been
established

26. EPIDEMIOLOGY CONTD
•SEX; PANDO is more prevalent in women.
SALDO has no sexual predilection.
•AGE; PANDO higher in individuals aged 50-
70 years while CNLDO in new born

27. RISK FACTORS FOR CNLDO
•Children with :
•Down syndrome, craniosynostosis,
Goldenhar sequence,
•Clefting syndromes, hemifacial microsomia,
•Any midline facial anomaly

28. HISTORY
• Tearing, mucous discharge and
epiphora of one or both eyes in
a child
• Onset- birth or soon after birth
• symptoms are usually worse
with a concurrent upper
respiratory infection

29. HISTORY CONTD
• Increased tear lake and epiphora
without mattering---proximal
lacrimal drainage blockage or
dysgenesis
• Swelling and redness over the
lacrimal sac with a palpable mass
may be seen

30. HISTORY CONTD
•Tearing, mucoid, or purulent discharge with onset at
older age
•Recurrent dacryocystitis, recurrent conjunctivitis or
ocular pemphigus
•Painful, swelling medial canthus
•Bloody tears
•Epistaxis (nasal, sinus, or lacrimal sac tumor)

31. PAST OCULAR HISTORY
• Previous eye surgery (lid, DCR, periocular-nasal,
sinus)
• Glaucoma (antiglaucoma medications)
• Use of other topical medications
• Trauma

32. PAST MEDICAL/SURGICAL HISTORY
• Lymphoma, Wegener granulomatosis, Sarcoidosis
• Ocular cicatricial pemphigoid, Kawasaki disease,
Scleroderma, Sinus histiocytosis
• Previous radiation treatment to medial canthal area
systemic chemotherapy with 5-FU
• Previous ocular infections
• Previous Ocular and periocular surgeries

33. PHYSICAL EXAMINATION
•Overflow of tears
•Fluctuant tender
mass over
lacrimal sac area
or medial canthal
area

34. PHYSICAL EXAMINATION CONTD
• Mucoid or purulent eye
discharge
---Significantly distended sac
may not regurgitate with
pressure due to the
functional valve of
Rosenmüller

35. PHYSICAL EXAMINATION CONTD
•Regurgitation test -
Mucoid reflux with
lacrimal massage
indicative of lower
system obstruction

36. EXAMINATION-SLIT LAMP
•Tear meniscus
height enhanced by
fluorescein -
Meniscus height
greater than 2 mm

37. EXAMINATION-SLIT LAMP
• Punctal stenosis
• Canaliculitis - Canalicular fullness
and creamy pus when canaliculus is
pressed
• Expression of concretions from
punctum
• Pouting punctum with purulent
material at opening

38. CLINICAL TESTS
• Schirmer basic secretor testing; Ensure that epiphora is not
related to hypersecretion
• Dye disappearance testing
• Jones I dye test;
• A positive result indicates no anatomical or functional
blockage to tear
• A negative result indicates anatomical or functional
blockage).

40. CLINICAL TEST CONTD
• Tear break-up time test; Normal break-up time is 15-30
seconds. 10 seconds or less is abnormal.
• Jones II dye test
• In light of a negative Jones I dye test, a positive Jones II
dye test indicates either partial obstruction of the
nasolacrimal system or a false-negative Jones I test.
• Diagnostic probing(more useful in Children + therapeutics)

41. JONES TEST

42. INVESTIGATIONS-LABORATORY
• Gram stain/Giemsa
stain
• Cultures and
sensitivities
• KOH (suspected fungal
infection)
• Anticytoplasmic
antibodies (Wegener
granulomatosis)
• FBC
• Cultures(M/C/S); of the ocular surface
discharge, nose, and lacrimal sac discharge,
blood culture; useful in determining
appropriate antibiotics/ antimicrobial agent
• Antineutrophil cytoplasmic antibody(ANCA)
testing e.g wegener granulomatosis
• Antinuclear antibody (ANA) testing; e.g SLE

43. INVESTIGATIONS-IMAGING
• Dacryocystography (DCG);
Gadolinium-enhanced magnetic
resonance dacryocystograph,
Computed tomographic
dacryocystography (CTDCG)
• Dacryoscintigraphy ;when
anatomical abnormalities of the
nasolacrimal drainage system are
suspected
• Nasal endoscopy
• X-ray Plain films; may show facial skeletal
anomalies, mass lesion , foreign bodies ,
post traumatic etiologiesas
• CT scans ;patients suspected of harboring
an occult malignancy or mass,
posttraumatic causes
• MRI ; not as useful as CT scans
• helpful in differentiating cystic lesions
from solid mass lesions
• Lacrimal sac diverticuli.

45. TREATMENT
•Multidisciplinary; ophthalmologist,
otolaryngologists, Radiologists etc
•Medical
•surgical

46. CONSERVATIVE/ MEDICAL
•Topical antibiotics with lacrimal
massage may be adequate for early
infections.
•Systemic antibiotics may be
necessary for more chronic or severe
infections, such as those causing
dacryocystitis, canaliculitis, or
preseptal cellulitis

47. TREATMENT....CONGENITAL NLDO
• Massage of the lacrimal sac
1. To perform this manoeuvre, the index finger is placed over the
common canaliculus to block reflux through the puncta and then
massaged firmly downwards.
2. Ten strokes are applied four times a day.
3. Massage should be accompanied by lid hygiene; topical antibiotics
should be reserved for superadded bacterial conjunctivitis.

48. CRIGGLER’S MASSAGE

49. PROBING OF THE LACRIMAL SYSTEM
•Probing elayed until the age of 12–
18 months because spontaneous
canalization is likely.
•Probing performed within the first
1–2 years of life has a very high
success rate, but thereafter the
efficacy decreases

50. PROBING CONTD
• The procedure should be
carried out under a general
anaesthetic.
• The rationale is to manually
overcome the obstructive
membrane at the Hasner
valve.

51. •After probing, the lacrimal system is irrigated
with saline labelled with fluorescein.
•If fluorescein can be recovered by aspiration
from the pharynx, successful probing is
confirmed.

52. • Postoperative steroid-antibiotic drops are used q.i.d. for
up to 3 weeks.
• If, after 6 weeks, there is no improvement, repeat probing
can be arranged
• Probing usually successful in 70%–97% of cases, with
many reports around 90%.

53. NLD PROBING CONTD
• Usually excellent and 90% of children are cured by the
first probing and more than half of the remainder by
the second.
• Failure is usually the result of abnormal anatomy,
which can usually be recognized by difficulty in
passing the probe and subsequent non-patency of the
drainage system on irrigation

54. NLD PROBING CONTD
• If symptoms persist despite one to two technically
satisfactory probings, temporary intubation with fine
silastic tubes with or without balloon dilatation of the
nasolacrimal duct may effect a cure.
• Patients who fail to respond to such measures can be
treated later with DCR, provided the obstruction is distal
to the lacrimal sac.

55. CONVENTIONAL DACRYOCYSTORHINOSTOMY
• The blood vessels in the middle
nasal mucosa are constricted with
ribbon gauze or cotton buds
lightly wetted with 1 : 1000
adrenaline.
• A straight vertical incision is made
10 mm medial to the inner
canthus, avoiding the angular
vein

56. CONVENTIONAL DCR CONTD
• The anterior lacrimal crest is exposed
by blunt dissection and the superficial
portion of the medial palpebral
ligament divided.
• The periosteum is divided from the
spine on the anterior lacrimal crest to
the fundus of the sac and reflected
forwards.
• The sac is reflected laterally from the
lacrimal fossa

57. CONVENT DCR CONTD
• The anterior lacrimal crest and the bone from
the lacrimal fossa are removed
• A probe is introduced into the lacrimal sac
through the lower canaliculus and the sac is
incised in an ‘H.shaped’ manner to create two
flaps.

58. • Membranous obstruction at the common canalicular opening
or distal canalicular obstruction can be opened by excision or
trephine of obstructing tissue (canaliculo-DCR).
• A vertical incision is made in the nasal mucosa to create
anterior and posterior flaps

59. •The posterior flaps
are sutured
•Silicone intubation
may be performed

60. • The anterior flaps are
sutured
• The medial canthal
tendon is resutured to the
periosteum and the skin
incision closed with
interrupted sutures

61. CAUSES OF DCR FAILURE
• Inadequate size and position of the ostium, unrecognized
common canalicular obstruction, scarring
• The ‘sump syndrome’, in which the surgical opening in the
lacrimal bone is too small and too high.
• There is thus a dilated lacrimal sac lateral to and below the
level of the inferior margin of the ostium, in which
secretions collect, unable to gain access to the ostium and
then the nasal cavity.

62. COMPLICATIONS OF DCR
• Cutaneous scarring
• Injury to medial canthal structures
• Haemorrhage
• Cellulitis
• Cerebrospinal fluid rhinorrhoea if the subarachnoid space
is inadvertently entered.

63. ENDOSCOPIC DCR
• Pre-injection of the agger mucosa, middle turbinate and
uncinate.
• Raising mucosal flap
• Exposing the lacrimal sac,
• Lacrimal sac intubation
• Sac incision
• sac flap creation

64. ENDOSCOPIC DCR CONTD
• The nasal mucosa is decongested with 0.1%
xylometazoline nasal spray,
• Pledgets soaked in 1:1,000 adrenaline
• The lateral nasal wall, middle turbinate and uncinate
are injected with lidocaine hydrochloride 2% with
adrenaline 1:80,000.

65. Raising mucosal flap
•A mucosal flap is
fashioned with a
crescent knife, by
creating an ‘H’ shaped
incision in the agger
mucosa

66. • Exposing the lacrimal sac
• A frontal sinus probe is used to
develop a plane between the lacrimal
sac and the lateral aspect of the
lacrimal crest of the maxilla. The
inferior aspect of frontal process of
the maxilla is removed

67. • Lacrimal sac intubation
• When lacrimal sac exposure
seems adequate, an
O’Donaghue probe and stent
is passed down the inferior
canaliculi to tent the medial
wall of the sac.

68. • Stenting/marsupialisation
and creation of the sac wall
flap
• The medial wall of the sac is
tented medially using the
end of the O’Donaghue
probe and incised vertically
using a sharp pointed Phaco
knife at its most anterior
aspect

69. ENDOSCOPIC DCR
•The aim is to create a large posterior based
sac flap, which can later be folded back
towards the uncinate process, facilitating full
sac marsupialisation.

70. OTHER SURGICAL OPTIONS
• Conjunctivo-dacryocystorhinostomy
• Balloon catheter dilatation
• Stents; silicon, hydrogel stents

71. CONCLUSION
• NLDO has a high rate for resolution by one or more
surgical procedures.
• The success rate of simple probing is excellent.
• Children with conditions that increase their risk of probing
failure have a poorer prognosis but can often be
successfully treated with additional procedure.

72. • THANK YOU

73. REFERENCES
• Linberg JV, McCormick SA. Primary acquired nasolacrimal duct obstruction. A
clinicopathologic report and biopsy technique. Ophthalmology. 1986 Aug.
93(8):1055-63.
• Bartley GB. Acquired lacrimal drainage obstruction: an etiologic classification
system, case reports, and a review of the literature. Part 1. Ophthal Plast
Reconstr Surg. 1992. 8(4):237-42.
• Paul TO. Medical management of congenital nasolacrimal duct obstruction. J
Pediatr Ophthalmol and Strabismus. 1985; 22:68-70.
• Nelson, LB, Calhoun, JH, Menduke, H. Medical management of congenital
nasolacrimal duct obstruction.Ophthalmology. 1985; 92:1187-1190.
• Petersen, RA, Robb, RM. The natural history of congenital obstruction of the
nasolacrimal duct. J Pediatr Ophthalmol and Strabismus. 1978; 15:246-250.