Residency · Residency · Ophthalmology
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.
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.
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
- Woog JJ. The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota. Ophthalmology. 1999;106(2):301-305.
- 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.
- Petris C, Liu D. Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev. 2017;7:CD011109.
- American Academy of Ophthalmology. Orbit, Eyelids, and Lacrimal System. BCSC Section 7. 2023-2024.
For the intern
When the ophthalmology resident calls about a patient with tearing at 3am, focus on ruling out acute dacryocystitis—a true emergency requiring urgent antibiotics and possible incision and drainage. Look for fever, painful erythematous swelling below the medial canthal tendon, and mucopurulent discharge on sac pressure. Start broad-spectrum IV antibiotics covering skin flora. Everything else—chronic epiphora, punctal stenosis evaluation, irrigation testing—waits until morning clinic. The patient complaining of watery eyes for months does not need midnight evaluation.
Common pitfalls
- Assuming all tearing means nasolacrimal duct obstruction (NLDO). Most epiphora is actually reflex tearing from dry eye, blepharitis, or conjunctivochalasis. Check the ocular surface first before ordering imaging or surgery consults.
- Confusing anatomic landmarks. A mass above the medial canthal tendon is not the lacrimal sac (which sits in the lacrimal fossa below and posterior to the tendon). Consider dermoid cyst or encephalocele instead.
- Rushing to probe congenital NLDO before 12 months. Ninety percent resolve spontaneously with massage by one year. Early probing increases trauma risk without improving outcomes.
- Missing lacrimal sac tumors. Bloody reflux on irrigation is never normal—always biopsy. Tumors are rare but devastating if diagnosis is delayed.
Make it stick
You're a junior resident covering the emergency department. A 60-year-old woman presents with a red, painful eye and swelling near her nose. Your initial thought is "cellulitis," but on closer inspection, the swelling is localized below the medial canthal tendon, tender, and firm. You gently press on the area, and thick, yellow pus refluxes from the punctum. This is a classic presentation of acute dacryocystitis, an infection of the lacrimal sac. You quickly start broad-spectrum intravenous antibiotics and arrange for ophthalmology consultation. This rapid diagnosis and treatment can prevent serious complications like orbital cellulitis, showing how understanding the lacrimal system impacts real-time patient care.
If you remember one thing
Acute dacryocystitis is an infection of the lacrimal sac, presenting as a painful, erythematous mass below the medial canthal tendon, often with purulent reflux from the puncta. It requires urgent systemic antibiotics and ophthalmology consultation, sometimes incision and drainage, to prevent severe complications.