# Lacrimal System: Evaluation and Surgery for Tearing

## Introduction

**Epiphora** (excessive tearing) is one of the most frequent complaints in ophthalmic practice. A systematic approach to evaluating the lacrimal drainage system is essential to distinguish between hypersecretion and outflow obstruction, and to guide appropriate medical or surgical management.

## Anatomy of the Lacrimal System

### Secretory System

**Main lacrimal gland** (reflex and basal tearing) -- located in the lacrimal fossa of the frontal bone. **Accessory lacrimal glands** of Krause (fornix) and Wolfring (tarsal border) **Meibomian glands**, goblet cells -- contribute to tear film stability.

### Drainage System

**Puncta** (upper and lower) -- 0.3 mm diameter openings on the medial lid margin. **Canaliculi** -- vertical (2 mm) then horizontal (8 mm); upper and lower join to form the **common canaliculus** in 90% of people. **Valve of Rosenmuller** -- at junction of common canaliculus and lacrimal sac. **Lacrimal sac** -- 12-15 mm long; lies in the lacrimal fossa between anterior and posterior lacrimal crests. **Nasolacrimal duct** -- 12 mm long; opens into the inferior meatus beneath the **valve of Hasner**.

![Anatomic diagram of the lacrimal drainage system from punctum to inferior meatus](/images/ophthalmology/lacrimal-drainage-anatomy.jpg)

## Evaluation of Tearing

### History

Duration, laterality, aggravating factors (wind, cold) History of dacryocystitis, nasal surgery, facial trauma. Medications (taxanes, topical antiglaucomadrops causing punctal stenosis) Distinguish true epiphora (overflow tearing) from lacrimation (reflex tearing)

### Examination

**External inspection** -- punctal position and patency, lid malposition, mass over lacrimal sac. **Slit-lamp exam** -- tear meniscus height (>0.3 mm suggests obstruction), punctal stenosis, conjunctivochalasis. **Digital pressure over lacrimal sac** -- reflux of mucopurulent material confirms nasolacrimal duct obstruction (NLDO) **Dye disappearance test (DDT)** -- instill fluorescein; residual dye at 5 minutes suggests poor drainage. **Diagnostic probing and irrigation** -- determines level of obstruction. Soft stop = canalicular obstruction.

Hard stop with reflux = nasolacrimal duct obstruction. Hard stop with passage to nose = functional obstruction or partial stenosis. **Jones I test** -- fluorescein recovery from nose (tests physiologic drainage) **Jones II test** -- irrigation after negative Jones I (tests anatomic patency)

### Imaging

**Dacryocystography (DCG)** -- contrast injection into canaliculi; delineates anatomy and obstruction site. **Dacryoscintigraphy** -- nuclear medicine study; physiologic test for functional obstruction. **CT/MRI** -- indicated when tumor, trauma, or complex anatomy is suspected.

## Causes of Tearing by Location

### Punctal/Canalicular

**Punctal stenosis** -- involutional, inflammatory, drug-induced (docetaxel, 5-FU) **Canaliculitis** -- Actinomyces israelii; sulfur granule concretions. **Canalicular obstruction** -- post-herpetic, post-radiation, trauma.

### Lacrimal Sac and Nasolacrimal Duct

**Primary acquired NLDO** -- most common cause in adults; involutional inflammation and fibrosis. **Acute dacryocystitis** -- painful, erythematous mass below medial canthal tendon; urgent treatment needed. **Lacrimal sac tumors** -- rare; suspect if bloody reflux on irrigation. **Congenital NLDO** -- imperforate valve of Hasner; affects 6-20% of newborns.

### Functional (Lacrimal Pump Failure)

Lid laxity, orbicularis weakness (CN VII palsy), conjunctivochalasis.

## Surgical Management

### Congenital NLDO

**Conservative management** -- lacrimal sac massage (Crigler technique), 90% resolve by age 12 months. **Probing** -- office or OR; success rate >90% for first probing. **Probing with intubation** -- for failed initial probing; silicone tube left 2-6 months. **Balloon dacryoplasty** -- alternative to repeat probing. **DCR** -- reserved for recalcitrant cases.

### Adult NLDO

**External DCR** -- gold standard; 95% success rate; creates rhinostomy between lacrimal sac and nasal mucosa with mucosal anastomosis. **Endoscopic (endonasal) DCR** -- comparable success (90-95%) in experienced hands; no external scar. **Silicone intubation** alone -- for partial obstruction or canalicular stenosis. **Conjunctivodacryocystorhinostomy (CDCR)** with Jones tube -- for canalicular obstruction where DCR alone is insufficient.

| Procedure | Indication | Success Rate | Key Advantage/Disadvantage |
|---|---|---|---|
| External DCR | Primary acquired NLDO | ~95% | Gold standard; external scar |
| Endoscopic DCR | Primary acquired NLDO | 90-95% | No scar; requires ENT expertise |
| Silicone intubation alone | Partial obstruction; canalicular stenosis | 60-75% | Less invasive; lower success |
| CDCR with Jones tube | Complete canalicular obstruction | 80-90% | Bypasses canaliculi; tube maintenance needed |
| Balloon dacryoplasty | Failed probing (pediatric); partial NLDO | 70-90% | Less invasive than DCR |

### Canalicular Surgery

**Canaliculotomy** with curettage -- for canaliculitis with concretions. **Canalicular laceration repair** -- primary repair over silicone stent within 48 hours of trauma.

![Intraoperative photograph of external DCR showing creation of rhinostomy and lacrimal sac flap anastomosis](/images/ophthalmology/external-dcr-intraoperative.jpg)

![Endoscopic view during endonasal DCR showing exposed lacrimal sac after bone removal](/images/ophthalmology/endoscopic-dcr-view.jpg)

## Key Clinical Pearls

The most common cause of tearing in adults is reflex tearing from ocular surface disease, not obstruction. Always check for punctal stenosis and lid malposition before concluding NLDO. A mass above the medial canthal tendon is not the lacrimal sac -- consider dermoid, encephalocele, or tumor. Bloody reflux on irrigation warrants biopsy to rule out lacrimal sac neoplasm. Congenital NLDO: delay surgical probing until age 12 months given high spontaneous resolution rate.

## References

1. Woog JJ. The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota. Ophthalmology. 1999;106(2):301-305.
2. Ali MJ, Psaltis AJ, Wormald PJ. Dacryocystorhinostomy: long-term outcomes and evolution of technique. Curr Opin Otolaryngol Head Neck Surg. 2019;27(1):71-77.
3. Petris C, Liu D. Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2017;7:CD011109.
4. American Academy of Ophthalmology. Orbit, Eyelids, and Lacrimal System. BCSC Section 7. 2023-2024.