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Lacrimal Obstruction
Proximal Lacrimal Obstruction – A Review
Carl Philpott
1
and Matthew W Yung
2
1. Rhinology and Anterior Skull Base Fellow, St Paul’s Sinus Centre, St Paul’s Hospital, Vancouver;
2. Department of Otolaryngology, Ipswich Hospital NHS Trust
Abstract
While less common than distal lacrimal obstruction, proximal obstruction causes many cases of epiphora. This article examines the
aetiology of proximal lacrimal obstruction and considers current management strategies with reference to recent literature. The
Lester Jones tube is the favoured method of dealing with most cases of severe proximal obstruction; other methods have been tried
with less success.
Keywords
Proximal lacrimal obstruction, epiphora, canalicular blockage, Lester Jones tube
Disclosure: The authors have no conflicts of interest to declare.
Received: 31 March 2009 Accepted: 14 April 2009
Correspondence: Matthew W Yung, The Ipswich Hospital, Heath Road, Ipswich, Suffolk, IP4 5PD, UK. E: matthew.yung@ipswichhospital.nhs.uk
Obstruction of the lacrimal apparatus commonly causes sufferers to dominant fashion.
3
Where absence of the punctum and papilla
present with symptoms of epiphora, for which they are commonly (congenital punctal agenesis) occurs, it is likely that more distal parts
referred to ophthalmology departments. In those units where of the lacrimal apparatus are obliterated.
collaboration with otorhinolaryngology occurs, the distal site of
obstruction is usually dealt with. However, in this article we aim to Ciactrical Conjunctival Disorders (~2%)
update the reader on the causes and current management strategies The pathological manifestation in ocular pemphigoid and Stevens-
for proximal lacrimal obstruction, which may account for approximately Johnson syndrome is subepithelial fibrosis of the conjunctiva,
only one in three cases of epiphora.
1
Lacrimal obstruction is usually which in turn causes the canaliculi and/or puncta to become
classified into proximal, distal and functional causes (see Figure 1). obstructed.
4
However, not all patients affected by this fibrotic
change will complain of epiphora owing to the fact that the lacrimal
Proximal obstruction can be defined as punctal stenosis or absence, glands may also be involved and, hence, decreased secretion of
and single canalicular or common canalicular (lateral or medial); the glands will result. The inherent problem in managing these
common medial canalicular blockage may be regarded as a distal patients is the tendency for further fibrosis to occur around any
blockage as it is usually caused by a membrane within the lacrimal indwelling devices inserted.
sac closing off the internal opening of the common canaliculus (see
Figures 2–5). Distal obstruction can be divided into sac and duct; the Drug-induced Canalicular Stenosis (2%)
third category is functional obstruction (see Figures 2–5). The main suspects for causing canalicular stenosis include glaucoma
drugs such as phospholine iodide and penicillin (Stevens-Johnson
Causes of Proximal Lacrimal Obstruction syndrome),
5
but fibrosis can occur with chemotherapeutic agents
The proximal lacrimal apparatus includes the canaliculi and their such as fluorouracil
6
(commonly given for gastrointestinal tumours
puncta with the caruncle separating the puncta. Disease processes and breast cancer).
that affect the canaliculi include infective causes, particularly viral
infections, cicatrising disorders (including pemphigoid and Stevens- Infective Causes (30%)
Johnson syndrome), drug-induced stenosis, burns, facial trauma, The most common infective agent implicated in obstruction of the
iatrogenic injury (including radiotherapy) and neoplasms. Congenital proximal apparatus is the herpes simplex virus (HSV);
7
however, it is
causes can also be attributed to proximal obstruction, including possible that in many cases where antivirals have been used this
dacrocystocoeles. Percentages quoted here are based on the figures is an iatrogenic effect of the drug rather than of the virus itself.
8
derived from 310 patients attending Moorfields Eye Hospital over a However, in cases of herpetic keratitis, HSV has been found by
25-year period.
2
testing for viral DNA in the tears passing through the lacrimal
system.
9
Herpes zoster is also associated with canalicular
Congenital Causes (10%) obstruction, as is the vaccination for chicken pox.
10
Chlamydial
Absence or imperfection of lacrimal puncta and/or canaliculi can infections have also been associated with canalicular obstruction in
occur, and in one report was found to be inherited in an autosomal endemic areas.
11
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