Tear duct obstruction: causes, symptoms, diagnosis, treatment

Obstruction of the lacrimal canals develops more often due to inflammation of the mucous membrane of the eyelids and canals in conjunctivitis. Small obliterations (1-1.5 mm) can be eliminated by probing with subsequent insertion of bougienage threads and tubes into the lumen of the canal using an Alekseev probe for several weeks.

In case of irreparable dysfunction of the lower lacrimal canal, an operation is indicated - activation of the upper lacrimal canal. The essence of the operation is that, starting from the upper lacrimal point, a strip of the inner wall of the canal is excised to the inner corner of the eye slit. In this case, the tear from the lacrimal lake will immediately enter the opened upper lacrimal canal, which will prevent lacrimation.

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Treatment of obstruction of lacrimal canals

Treatment for tear duct obstruction depends on the location and severity of the obstruction.

• partial obstruction of the common, individual canaliculi or along the course of the post-lacrimal duct can be resolved by intubation. The two ends of a long silicone tube are inserted into the superior and inferior lacrimal puncta through the lacrimal sac down to the nose, where they are secured with a special Watzke sleeve and left in place for 3-6 months;
• In case of complete obstruction of the canaliculus with a minimum length of the passable section of 8 mm between the lacrimal punctum and the site of blockage, an anastomosis is created between the passable part of the canaliculus and the lacrimal sac (canaliculodacryocystorhinostomy) and intubation is performed. If the block is located at a distance of less than 8 mm from the lacrimal punctum, treatment includes co-junctiva-dacryocystorhinostomy and the installation of special Lester Jones tubes;
• Complete obstruction of the lateral part of the common canaliculi is usually found in idiopathic pericacial fibrosis, when the entire common canaliculi is obstructed. Dacryocystography shows areas of impaired filling of the common lacrimal canaliculi. Treatment: resection of the obstructed common canaliculi and application of a canaliculodacryocystorhinostomy. The duration of lacrimal duct intubation is 3-6 months;
• Complete obstruction of the medial portion of the common canaliculi is often caused by a thin membrane at the junction with the lacrimal sac as a consequence of chronic dacryocystitis. Dacryocystography shows filling of the common canaliculi. Treatment: lacrimocystorhinostomy and excision of the membrane from the area related to the lacrimal sac. In this case, the lacrimal system is intubated for 3-6 months.

Obstruction of the nasolacrimal duct

Reasons

• Idiopathic stenosis.
• Nasoorbital trauma.
• Wegener granulomatosis.
• Germination of nasopharyngeal tumors.

Treatment depends on the degree of obstruction:

• In case of complete obstruction, dacryocystorhinostomy is performed.
• Partial obstruction is resolved by intubation of the lacrimal drainage system with a silicone tube or stent if the tube or stent passes easily. If difficulties arise during intubation, dacryocystorhinostomy is performed. In some cases, balloon dilation is used.

Principles of lacrimal duct surgery

Traditional dacryocystorhinostomy

It is performed in case of obstruction localized after the medial course of the common lacrimal canal (i.e. the canal system is accessible). This operation consists of creating an anastomosis between the lacrimal sac and the middle nasal passage. The procedure is performed under general anesthesia with hypothesis.

Technique for performing traditional dacryocystorhinostomy

• the mucous membrane of the middle nasal passage is tamponed with a gauze swab with a 2% solution of ligdocaine with 1:200000 adrenaline to achieve vasoconstriction of the mucous membrane;
• a straight vertical incision is made 10 mm medial to the inner corner of the eye slit, avoiding damage to the angular vein;
• The anterior lacrimal crest is dissected using a blunt method and the superficial part of the middle palpebral ligament is isolated;
• the periosteum is retracted from the ridge on the anterior lacrimal crest to the bottom of the sac and brought forward. The sac is retracted lateral to the lacrimal fossa;
• the anterior lacrimal crest and bone from the lacrimal fossa are removed;
• A probe is inserted through the lower canal into the lacrimal sac, in which an H-shaped incision is made to create two flaps;
• in the nasal mucosa, a vertical incision is also made to form the anterior and posterior valves;
• the back flaps are sewn together;
• the front flaps are sewn together;
• The medial part of the tendon of the internal commissure is sutured to the periosteum, and interrupted sutures are applied to the skin.

The results are usually satisfactory in more than 90% of cases.

Reasons for failure: inadequate size and position of the lacrimal bone, unrecognized obstruction of the common canal, scarring and congestion syndrome, in which the surgical opening in the lacrimal bone is too small and high. In this case, the lacrimal sac, which is widened and located medially and below the level of the lower edge of the bone, accumulates secretion, not finding access to the nasal cavity.

Possible complications: skin scar, damage to the internal ligament, bleeding, cellulitis and cerebrospinal fluid rhinorrhea if the subarachnoid space is accidentally opened.

Endoscopic dacryocystorhinostomy

It can be used in cases of obstruction below the medial opening of the common canal, especially after failed traditional dacryocystorhinostomy. The procedure can be performed under local or general anesthesia (without hypotension). The advantages over conventional dacryocystorhinostomy include a small skin incision, reduced surgical time and risk of disruption of the physiological mechanism of lacrimation, minimal blood loss, and no risk of cerebrospinal rhinorrhea.

Technique for performing endoscopic dacryocystorhinostomy

A straight light tube is passed through the lacrimal point and canals into the lacrimal sac, and the nasal cavity is examined from the inside with an endoscope. The remaining manipulations are performed from the side of the nasal cavity.

• the mucous membrane is separated along the frontal process of the maxilla;
• part of the nasal process of the upper jaw is removed;
• the lacrimal bone is opened;
• open the lacrimal sac;
• Then silicone tubes are passed through the upper and lower lacrimal points, through a hole in the bone and fixed in the nasal cavity.

The result is positive in approximately 85% of cases.

Endolaser dacryocystorhinostomy

Endolaser dacryocystorhinostomy is performed using a holmium YAG laser. It is a quick procedure that can be performed under local anesthesia, which is preferable, especially in elderly patients. Positive results are achieved in approximately 70% of cases. Preservation of normal anatomy in case of failure allows subsequent surgical intervention.

Lester Jones Pipe

The placement of a Lester Jones tube is indicated in the absence of canalicular function due to obstruction at a distance of less than 8 mm from the lacrimal point or a disruption of the tear suction mechanism.

• perform dacryocystorhinostomy before suturing the posterior valves;
• the lacrimal caruncle is partially excised;
• a through incision is made with a Graefe knife from a point approximately 2 mm behind the inner corner of the eye slit (at the site of the removed caruncle) in a medial direction so that the tip of the knife appears only behind the anterior valve of the lacrimal sac;
• the passage is widened with a microtrephine to allow free insertion of the polyethylene tube;
• sutures are applied as in dacryocystorhinostomy:
• After 2 weeks, the polyethylene tube is replaced with a glass one.

Balloon dacryocystoplasty

May be effective in adults as a first step in the treatment of partial obstruction of the nasolacrimal duct without signs of chronic infection.