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Lacrimal Obstruction
Figure 1: The Lacrimal System this indicates a patent system. Absence of dye indicates the
anatomical obstruction between the punctum and valve of Hasner.
A Jones II dye test is performed after a negative Jones I test. The
lacrimal system is flushed by syringing and washing of excess
fluorescein from the conjunctival sac. The test is positive if dye is
detected on the cotton bud, which suggests functional obstruction
of the nasolacrimal duct. A negative Jones II test indicates punctal
or canalicular stenosis, whereas regurgitation indicates complete
nasolacrimal duct obstruction or complete common canaliculus
block. If no saline appears in the nose, there is a source of complete
obstruction somewhere in the lacrimal drainage system.
Lacrimal Probing
Lacrimal irrigation and probing of the canaliculi are two investigations
that may be part diagnostic and part therapeutic, for example by
dislodging a stone. Probing may be used in an attempt to palpate or
localise the site of obstruction. With probing, the length of canalicular
patency distal to the punctum can be measured, and from that the
Thermal and Traumatic Injuries and length of the canalicular blockage can be estimated.
Radiotherapy-induced Injury (34%)
Radiotherapy treatment can induce stenosis of any part of the Dacryocystography
lacrimal system and is seen particularly with dosing to basal cell This radiological technique enables visualisation of the anatomical
carcinomas in the inner canthal area and for sino-nasal tumours. details of the lacrimal drainage system using contrast material
Surgical removal of such skin lesions may also give rise to injury of the injected into one or both canaliculi. It helps to determine the
nasolacrimal apparatus.
12
Other thermal injuries to the face will have surgical plan and remains the most common and definitive test for
similar effects. Traumatic injury to the proximal nasolacrimal assessing the nasolacrimal system. Digital subtraction techniques
apparatus is more common in men.
2
are now usually employed as this reduces the radiation dose to the
lens of the eye.
14
Canalicular Neoplasms (2%)
These are rare occurrences but may include papillomas and basal Dacryoscintigraphy
cell carcinomas.
13
The causes cited above can cause lateral common Nuclear lacrimal scanning is a simple non-invasive test where a 10µl
canalicular obstructions in the same manner as they affect the drop of technetium-99 pertechnetate is placed onto the marginal tear
individual canaliculi. strip with the patient situated on a head rest opposite a gamma
Other Miscellaneous Causes
Other causes of canalicular obstruction or malfunction include failed
lacrimal surgery (10%), facial nerve palsy (2%), maxillary sinusitis
(0.3%), lid abscess (0.3%) and sarcoidosis (nasal) (0.3%).
2
Idiopathic
If sclera show is evident on examining
cases appear to occur not infrequently (9%), and while there are
the relationship of the lower lid to the
theories that this is due to chronic wiping in some patients, in women
post-menopausally or that there may even be a history of prior
inferior limbus, a lacrimal pump problem
conjunctivitis,
14
there are many cases in this category where there is
may be present.
no identifiable underlying pathology predisposing towards stenosis of
the proximal lacrimal apparatus.
Investigation of Lacrimal Obstruction
Examination – Inspection of the Lid camera. It is useful for assessing functional lacrimal duct obstruction
The lid should be carefully inspected to look for signs of punctal and it is for this purpose that it has most merit as an investigation.
involvement. Ptosis may obstruct the punctum or change the While scintigraphy does not provide as detailed anatomical imaging
dynamics between the two puncta. Any sign of weakness in as contrast double-contrast gastrography (DCG), the two may be
opening and closing the eyelid should be noted, as well as any used as complementary investigations.
15
laxity. Holding the eyebrow against the bone and asking the patient
to look down can help to demonstrate floppy lid syndrome. The Computed Tomography Scan
position of the puncta should also be noted. If sclera show is This may be indicated if trauma or neoplasms are suspected, or in
evident on examining the relationship of the lower lid to the inferior certain cases where dacryocystorhinostomy (DCR) is performed.
limbus, a lacrimal pump problem may be present.
Current Management Strategies
Jones Dye Tests Punctal
In a Jones I test, dye is instilled in a patient’s eye and a cotton bud Incomplete punctal stenosis and membrane occlusion can be
is placed in the inferior meatus. If dye is present after five minutes, treated with simple dilating, but should probably not be repeated
82 EUROPEAN OPHTHALMIC REVIEW
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