Chapter 3 Diagnostics Chapter 3 29

Diagnostics
P. Komínek, R.C. Della Rocca and S. Rosenbaum
3

3.4 Diagnostic Probing and Lacrimal Syringing

Core Messages! (Irrigating) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.4.1 Syringing: Irrigation . . . . . . . . . . . . . . . . . . . . . . . . . 39
Q The proper clinical evaluation of a lacrimal 3.4.1.1 Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
function and lacrimal anatomy is an essential 3.4.1.2 Syringing: Interpretation . . . . . . . . . . . . . . . . . . . . . 39
pre-condition for suitable therapy.
3.5 Diagnostic Probing . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.5.1 Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Q The surgeon should be able to answer
whether surgery is indicated, and if that is so, 3.6 Radiological Examination . . . . . . . . . . . . . . . . . . . . 41
3.6.1 Dacryocystography . . . . . . . . . . . . . . . . . . . . . . . . . . 41
the surgery should be directed at the lacrimal 3.6.2 Indications for Dacryocystography . . . . . . . . . . . . 41
apparatus, the eyelids, and punctum, or both. 3.6.2.1 Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.6.3 Radiological Criteria for Lacrimal Pathology. . . . 43
Q Evaluation of the lacrimal system, i.e. history, 3.6.4 Nuclear Lacrimal Scintigraphy . . . . . . . . . . . . . . . . 43
palpation, FDT, syringing and proviny, may 3.6.4.1 Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
readily yield definitive results; however, at 3.6.4.2 Nuclear Lacrimal Scan Indication . . . . . . . . . . . . . 45
times, more testing, including radiography, 3.6.5 Computed Tomography and MRI. . . . . . . . . . . . . . 45
may be neccesary to arrive at a specific 3.7 Nasal Examination and Nasal Endoscopy . . . . . . 45
diagnosis and subsequent recommendations. 3.7.1 Diagnostic Nasal Endoscopy . . . . . . . . . . . . . . . . . . 45
3.8 Lacrimal System Endoscopy . . . . . . . . . . . . . . . . . . 47
Q Nuclear lacrimal scintigraphy is useful only 3.8.1 Secretory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
in those patients whose lacrimal system is 3.8.2 Schirmer’s Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
patent to syringing. 3.8.2.1 Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
3.8.2.2 Break-up Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.8.2.3 Bengal Rose Staining . . . . . . . . . . . . . . . . . . . . . . . . . 49
Q Dacryocystography and scintigraphy are not 3.8.2.4 Lysozyme Lysis Test . . . . . . . . . . . . . . . . . . . . . . . . . . 49
mutually exclusive but instead complement
3.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
each other.
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Contents

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 3.1 Introduction

3.1.1 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.2 Diagnostics Philosophy . . . . . . . . . . . . . . . . . . . . . . 31
Two basic causes of tearing exist, epiphora associated
with blockage of the lacrimal system, and excess lac-
3.3 Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 rimation which is less frequent. Lacrimation (hyper-
3.3.1 Clinical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.3.2 External Examination and Palpation . . . . . . . . . . . 33
secretion, reflex tearing, hyperlacrimation) is exces-
3.3.3 Excretory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 sive tearing caused by reflex hypersecretion due to the
3.3.3.1 Fluorescein Dye Disappearance Test . . . . . . . . . . . 36 irritation of the cornea or conjunctiva [9, 12, 19]. Uni-
3.3.3.2 Jones Fluorescein Tests and Saccharine Test. . . . . 37 lateral lacrimation is caused by trigeminal sensory
 30 P. Komínek, R.C. Della Rocca, S. Rosenbaum

nerve stimulation in corneal diseases, i.e., corneal for- 3.1.1 Terminology

eign body, abrasion, keratitis, etc. Bilateral lacrima-
tion is typically chronic and is typically associated Differentiation between anatomical obstructions and
with chronic or recurrent conjunctivitis, staphylococ- functional disorders (dysfunctions) of the lacrimal
cal lid margin diseases (blepharitis), and ocular sur- system is required before beginning a treatment
face diseases (dry eye). plan:
3 Epiphora is tearing caused by a reduced tear trans-
port or defective tear drainage outflow, i.e., epiphora Q Anatomical obstructions are those in which
is a result of a failure of tear drainage [8, 12, 14, 20]. some pathological changes and irregularity in
Epiphora is caused by mechanical obstruction to the the lacrimal drainage system are found, i.e.,
lacrimal drainage system which may include puncta, canalicular stenosis, canalicular blockade,
canaliculi, lacrimal sac, or nasolacrimal duct obstruc- lacrimal sac deformation, obstruction of the
tion. The second, but less frequent, cause is lacrimal nasolacrimal duct, diverticulus, etc. The
pump failure due to lower lid laxity or weakness of the lacrimal system can be changed primarily in
orbicularis muscle [12, 22]. Epiphora due to obstruc- inflammation of the lining inside the lacrimal
tion can occur bilaterally especially in patients with pathways, intrinsic, or the lacrimal pathways
significant sinusitis [12]. can be secondarily changed from the outside,
Epiphora can be caused by congenital and acquired extrinsic, i.e., lymphoid tumor lying around the
diseases, i.e., congenital nasolacrimal duct obstruc- lacrimal sac. Anatomical disorders are more
tions in children, primary acquired nasolacrimal duct common than functional ones.
obstructions (PANDO), dacryocystolithiasis, orbital Q Physiological dysfunction, functional epiphora
and lacrimal trauma, canalicular lacerations, actino- is caused by disorders in which tearing does
myces within the canaliculi, and canalicular obstruc- not result from anatomical changes of the
tion following herpetic infections, ectropion, etc. lacrimal pathways themselves, but from a
Symptoms of epiphora may range from a sensation failure of functional lacrimal pump mecha-
of intermittent wetness in the eye to the permanent nism. It can be caused by the anatomic abnor-
tear overflowing onto the cheek. Unilateral tearing is mality outside the lacrimal pathways, such as
felt more intensively than bilateral tearing. Epiphora eyelid malpositions within the eyelids, punctal
is typically worse in winter and windy weather (Ta- eversion, or lacrimal pump insufficiency
ble 3.1), and the incidence of epiphora increases with caused by poor orbicularis muscle tone or
age [22]. eyelid laxity as seen in the paretic eyelid caused
The main and essential goal of examination is to by Bell’s palsy.
distinguish between epiphora and lacrimation. While
epiphora is treated mostly with surgical procedures, The locations are as follows:
the lacrimation is treated mostly with medical thera-
py [12, 14]. 1. Suprasaccal (presaccular): occurs proximal to
the lacrimal sac, e.g., obstruction in the upper
or lower canaliculi or common canaliculus, for
example, following herpetic infection, trauma,
Table 3.1. Epiphora grading
post-irradiation, etc. (Fig. 3.1).Saccal (saccular)
Grade I Temporary epiphora outside in cold – occur in the lacrimal sac, e.g., diverticulus,
and windy weather trauma, tumor, etc.
Grade II Permanent epiphora outside 2. Subsaccal (nasolacrimal duct, postsaccular):
Grade III Permanent epiphora outside and inside occurs in the nasolacrimal duct; those obstruc-
tions are most common, e.g., a congenital naso-
lacrimal duct obstruction, primary acquired
nasolacrimal duct obstruction (PANDO), na-
solacrimal duct obstruction following func-
 Diagnostics Chapter 3 31

Fig. 3.1. Essential kinds of lacrimal system obstructions. a Suprasaccal obstruction. b Saccal obstruction. c Subsaccal complete
obstruction. d Nasolacrimal duct stenosis. (From [14])

and assessment of nasolacrimal system patency [21].

tional endoscopic sinus surgery, etc. Dacryo- The goals of history and clinical examinations of pa-
cystorhinostomy is indicated in the majority of tients are to define pathological processes responsible
these cases. for tearing present, to distinguish anatomical and
functional epiphora and, in an anatomical obstruc-
A controversial term, functional obstruction, is some- tion, to identify the level at which the obstruction lies
times used for findings in which the system is patent and its extension as well [24]. One should be able to
to syringing in a patient complaining of tearing; how- determine whether surgery is indicated and whether
ever, some anatomical pathologies in the lacrimal the surgery will be directed in the lacrimal apparatus,
system are usually found in dacryocystography and the eyelids, or punctum, or both [9].
other anatomical tests are needed. It is important to The goals of the examination of tearing patients
bear in mind that if a system is patent to syringing, it are as follows:
does not mean that it is normal and the drainage
function may not be working under normal physio- Q Distinguish epiphora and lacrimation
logical conditions, e.g., lacrimal system is in stenosis Q Define pathological process responsible for
of nasolacrimal duct patent for syringing with a high- tearing
er hydrostatic pressure, but under usual conditions Q Distinguish anatomical and functional
there is an insufficient drainage (it can be determined disorders
with fluorescein test or with nuclear scintigraphy). Q Evaluate block location and its extent, and
That is why the term “obstruction” should be used define a surgical approach
only for anatomical disorders and the term “function-
al obstruction” should not be used in this sense [12]. There are a lot of clinical diagnostic tests, many of
which must be used together in order to diagnose spe-
cific disease processes adequately. The choice of tests
3.2 Diagnostics Philosophy should be logical enough to reveal the cause of an ob-
struction and to recommend a proper therapy [9]. The
Tearing can be caused by hypersecretion and epipho- tests are divided into the following categories:
ra, both of which can be combined. Clinical symp-
toms occur if the balance between the tear production Q Anatomical: tests for investigation of morpho-
and drainage function of lacrimal system has changed, logical disordes and location of obstruction
i.e., the clinical picture of epiphora does not depend (Table 3.3)
on the absolute functional status of either one [9, 14]. Q Functional (physiological): tests for drainage
That is why there are no symptoms of epiphora if lac- lacrimal function under normal condition (if
rimal production is reduced and lacrimal drainage is there is no obstruction and no higher pressure
decreased, e.g., in older patients, etc. (Table 3.2). as in syringing).
The basic diagnostic evaluation of the tearing pa- Q Secretion: tests for assessment of secretion
tient should include quantification of tear production (used in the examination of dry eye)
 32 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Table 3.2. Typical causes of epiphora and lacrimation

Lacrimation Supranuclear (CNS)

Psychogenic (emotions, etc.)
Trigeminal nerve stimulation (reflex tearing)
Eyelids (blepharitis, trichiasis, etc.)
Conjunctival diseases (inflammation, a foreign body, etc.)
3 Corneal diseases (dry eye, a foreign body, contact lens, etc.)
Neuralgic (neuralgia)
Ocular inflammation (iritis, etc.)
Infranuclear
Facial nerve abberant innervation, crocodile tears
Lacrimal gland stimulation
Others
Bright lights, sneezing, etc.
Epiphora Functional (lacrimal pump insufficiency)
Incorrect eyelid closure (orbicularis muscle laxity, lagophthalmus, trauma,
following surgery, etc.)
Eyelid malposition: ectropion and entropion (involutional, mechanical, cicatricial)
Punctal eversion, punctal medialization
Anatomical lacrimal system obstructions (stenosis and obliterations)
Punctal and canalicular (congenital, inflammation; herpetic, traumatic, idiopathic,
chronic lid ectropion, burns, pharmacological, etc.)
Saccal (inflammation, sarcoidosis, tumors, trauma, etc.)
Nasolacrimal duct (congenital obstruction, primary acquired obstruction-PANDO,
trauma, tumor, etc.)
Nasal (hay fever, rhinosinusitis, surgery, tumors, etc.)
Combined lacrimation (L) Combinations 1+2
+ epiphora (E) Facial nerve palsy
Lagophthalmus (L), corneal irritation (E), lacrimal pump dysfunction (E)
Involutional lower lid entropion
Corneal irritation from the inturning lid and lashes (L), ineffective lacrimal pump (E)
Lower lid ectropion
Conjunctival irritation (L), ineffective lacrimal pump (E)
Thyroid diseases
Corneal irritation (L), defective canalicular function (E)

Table 3.3. Clinical tests in a tearing patient

Epiphora Lacrimation
Anatomical tests Physiological tests Test of secretion
Palpation of the lacrimal sac Fluorescein dye disappearance Schirmer’s test
Syringing (irrigation) Scintigraphy Bengal rose test
Diagnostic probing Jones dye I Tear-film break-up
Dacryocystography Sacharin test Tear lysozyme
Nasal examination
CT, MRI
 Diagnostics Chapter 3 33

The diagnosis is usually made by ophthalmologists. tearing prior to making a decision to recommend sur-
The otorhinolaryngologists who participate in a nasal gical repair.
examination and lacrimal surgical therapy should, Unilateral tearing often indicates a local obstruc-
however, know the principles of tests and should be tive, traumatic, inflammatory, or infectious process
able to identify the level and extension of the obstruc- in the drainage pathways, whereas bilateral tearing
tion. may denote excess secretion due to an allergic re-
sponse, iritis, or keratoconjunctivitis. Constant tear-
ing is more likely associated with the causes of uni-
3.3 Examination lateral tearing, whereas intermittent tearing is more
common in patients with problems causing seconda-
The diagnostic tests used for evaluating the nasolacri- ry unilateral or bilateral tearing.
mal system are done after an ophthalmological exa- Epiphora in a child with a history of tearing since
mination which has excluded the ocular surface birth has been caused mostly by an obstructive mem-
diseases and inflammatory diseases as causes of brane within the naso-lacrimal duct (Valve of Has-
epiphora [25]. The examination may be sometimes ner). Intermittent acquired epiphora in an adult usu-
very easy and epiphora diagnostic can be made on ally results from partial stenosis of the membranous
history only. The determination of its etiology, how- duct and/or dacryolithiasis, and may also be seen in
ever, may be exteremely difficult and often requires a patients with allergic rhinitis. The relationship of
variety of diagnostic procedures [9, 14, 28]. symptoms to the previous medical therapy (topical
Studies of the lacrimal system should be done bi- idoxuridine, phospholine iodide, systemic 5-fluoro-
laterally whenever possible, as this may help to dif- uracil), orbital trauma, and environmental factors,
ferentiate [25]. The tests vary in the extent to which however, as to the head position, stress, etc., are also
they evaluate the anatomy and physiology of the lacri- factors. Previous sinus surgery should indicate the
mal drainage system. possibility of duct injury as well. The presence of re-
current sinus disease can cause rhinitis or intranasal
polyps.
3.3.1 Clinical History

An accurate history is one of the most important as- 3.3.2 External Examination and Palpation
pects in the evaluation of the patients with tearing.
The history and external examinations may provide A careful history must be combined with the external
important clues as to the presence of canalicular dis- exmination of the lacrimal system that begins with an
ease [26]. The history must incorporate the patient’s inspection of the face, external ocular surface, and
present and past ophthalmic symptoms, nasal symp- eyelid structure including the position and contour of
toms, as well as medical and interventional histories the eyelid and eye blink (Table 3.4). Periorbital and
with special attention given to glaucoma medications. facial asymmetry are looked for, as well as the lid mal-
The intermittency and the duration of tearing is im- position, bulges in the medial canthal area, facial
portant. One must ascertain the significance of the nerve palsy, etc.

Table 3.4. Watering patients: external inspection and palpation

Eyelids Lower lid laxity, ectropion, entropion, punctal eversion, trichiasis, blepharitis, snap-back test,
pinch test, etc.
Medial canthus Lacrimal sac enlargement below the medial canthal tendon (acute dacryoccystitis, mucocele, etc.),
enlargement above the medial canthal tendon (neoplasm)
Palpation Reflux of mucopurulent material (mucocoele with an obstruction at the lower end of the sac
of the lacrimal sac or in the lacrimal duct and a patent canalicular system, or an obstruction of lower or upper canaliculi),
pressure over the sac in acute dacryocystitis causes pain
 34 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Fig. 3.2. External examination. a Involutional ectropion, a right below the medial canthal tendon (acute dacryocystitis, treated
medial ectropion with a dry inferior punctum. b Patient with with endonasal dacryocystorhinostomy). d Amniotocele in a
facial palsy and severe lid laxity paralytic ectropion. c Red mass newborn (From [14])

A slit-lamp examination is essential to determine a The absence of puncta may be a congenital trait or
position of the upper punctum in relation to the lower evidence of previous inflammatory diseases.
punctum on blinking and a change in the position be- A slit-lamp examination can reveal inferior punc-
tween the upper and lower eyelid, and to see if there is tate corneal staining, and epithelial filaments sug-
any lagophthalmus or evidence of orbicularis dys- gests an inadequate tear meniscus. There should be a
function [1, 9, 20]. The puncta should face slightly to- 1-mm marginal tear strip along the lower lid, between
wards the lacrimal lake. The puncta, normally 0.3 mm the globe and lid margin. The size and character of
in diameter, may appear phimotic, causing obstruc- the tear meniscus can be important. A small strip of
tion [7]. If puncta are present and open, the discharge fluorescein can be applied to the inferior fornix. The
from the puncta is sought. The papilla and eyelids absence of any tear strip is suggestive of a dry eye syn-
along the canaliculi, if red or swollen, may indicate drome. Conjunctival or corneal irritation, either in-
canaliculitis. Canaliculitis may be confirmed by ex- flammatory or mechanical, may cause hypersecretion
pressing yellow cheesy material from the canaliculi by with the resultant epiphora. Marginal blepharitis is a
pressing on the swelling canaliculus with a cotton common condition associated with the increased
bud. This is not possible if there is severe tenderness. lacrimation. In the absence of inflammation, an in-
 Diagnostics Chapter 3 35

creased tear meniscus is indicative of naso lacrimal

duct obstruction.
Lid laxity with ectropion may lead to the corneal
exposure and reflex lacrimal oversecretion, or to a
physiological dysfunction due to a weakened orbicu-
laris pump mechanism or punctal eversion (Figs. 3.2,
3.4).
The resiliency of the lid can be measured with the
snap-back test [9, 20]. The lower lid is pulled down
away from the globe, then released, and the speed
with which the lid “snaps back” against the globe is
observed, as well as whether there is a short gap
between the lid and globe (Fig. 3.4).
Horizontal eyelid laxity may be estimated with the
pinch test [9]. The lid is firmly pulled away from the
globe and the distance between the lid and the eye is
measured. More than 8 mm of distraction between
the lid and the cornea is suggestive of laxity and a
functional epiphora may exist.
Medial canthal tendon laxity and secondary par-
tial or medical ectropion are assessed with the help of
the lateral distraction test [20]. The lower puncta
should remain in its position while the lid is pulled
laterally. Up to 1–2 mm, the movement is normal in
the young and adult, and up to 3–4 mm in the elderly.
Mass lesion in the medial canthal region may me-
chanically obstruct a lacrimal system. Redness, swell-
ing, pain, and tenderness in the lacrimal sac area
suggest an acute dacryocystitis (Fig. 3.2). Chronic
dacryocysitis itself may manifest as the distention of
the lacrimal sac. A normal lacrimal sac is not palpa-
ble. The lacrimal sac swelling is typically confined to
the region below the medial canthal tendon; neo-
plasms usually extend above the tendon [14].
Mucopurulent material can be expressed through
the punctum and canaliculi if the canaliculi and valve
of Rosenmüller are patent and healthy, and if the lac-
rimal sac is palpated. It must be noted whether there
is regurgitation through only one canaliculus or both;
and the nature of the reflux as well: whether the re-
flux is clear, purulent, or bloody. The small finger is
applied to the anterior lacrimal crest and rolled gently
medially to expose muco-purulent reflux. When the
sac or dacryocystocele is large and hard, pressure is
not applied in order to minimize pain (Fig. 3.3).
Fig. 3.3. a Mucopurulent discharge from the lacrimal system in
chronic dacryocystitis. b Eczematized skin of the long-standing
mucoporulent discharge of the eyelids. c Chronic lower actino-
mycetes canaliculisis. Canaliculitis is confirmed by expressing
cheesy material from the canaliculus with a cotton bud. (From
[14])
 36 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Fig. 3.4. Examinations of the eyelids. a Snap-back test. If the lid traction test. The lid is grasped and pulled away from the globe.
does not immediately snap back after its pulling downward and More than 8 mm distraction between the lid and the cornea is
releasing, one can assume a lacrimal pump dysfunction. b Dis- suggestive of laxity. (From [14])

tear meniscus is measured with the help of cobalt-

3.3.3 Excretory Tests blue filter. The tears normally drain down the system
in 5 min. The test is positive if residual fluorescein is
The goal of excretory tests is to describe the drainage present. In infants, the child must be placed on a pa-
function and lacrimal system patency. rent’s knee or held in arms, and the head must be in a
vertical position.
The fluorescein dye test grading scale is as follows
3.3.3.1 Fluorescein Dye Disappearance Test [17]:

Fluorescein dye disappearance test (fluorescein dye Q 0=no fluorescence in the conjunctival sac
retention test) is a very useful essential physiological Q 1=thin fluorescing marginal tear strip persists
test in which the lacrimal system is not instrumented Q 2=more fluorescein persists, between l and 3
and the marker fluorescein flows through the system Q 3=wide, brighly fluorescing tear strip
mixed with tears [2, 18, 29, 30].
The principle of the test is in the evaluation of the Grades 0 and 1 are considered to be normal, i.e., the
residual fluorescein in the eye following instillation of drainage function is good. Grades 2 and 3 are conside-
one drop of fluorescein into the unanesthetized con- red to be abnormal and the lacrimal drainage system
junctival sac [17, 29, 30]. is not functional.
The fluorescein dye test does not distinguish ana- False-negative findings may occur due to a large
tomical and functional defect [9]. There is not, in con- lacrimal sac or mucocele, or a distal nasolacrimal duct
trast to Jones II, a higher hydrostatic pressure in this block, where the dye with fluorescein can pool in the
test. The advantages of fluorescein dye test are higher sac or duct [19].
sensitivity and ease of obtaining results with children If a drop of fluorescein is placed in the external
[14, 17]. The presence of residual fluorescein gives no canthus on the lower eyelid, its transport can be ob-
information on the localization of the obstruction, served from lateral to medial across the eyelid and
and that is why other anatomical tests, especially into each punctum, and the holes in the tear film can
probing and syringing, must be carried out (Fig. 3.5). be observed (break-up time test).
Fluorescein may be sought in the nose if a patient is
Performance asked to blow the nose or the nose is examined endo-
One drop of 0.125–2% fluorescein is instilled into the scopically.
unanesthetized lower fornix of each conjunctival sac. In most patients with epiphora the history, palpa-
After 5 min, the thickness of the fluorescence of the tion, and inspection, fluorescein dye disappearance
 Diagnostics Chapter 3 37

Fig. 3.5. Fluorescein dye disappear-

ance test. a Grade 0=no fluorescence in
the conjunctival sac. b Grade 1=thin
fluorescing marginal tear strips only.
c Grade 2=between 1 and 2. d Grade
3=brightly fluorescing tear strip.
e Asymmetry in test: retention of
fluorescein on the left side in a
congenital nasolacrimal obstruction.
(From [14])

test, diagnostic probing, and irrigation of the nasolac- mal system is patent for syringing, i.e., there is no
rimal system is sufficient for the determination of the complete obstruction in the lacrimal system. The pri-
drainage function, location, and degree of anatomical mary dye test is a physiological test, and although it is
block. limited, it has some benefit [9].
Saccharin test is a physiological test similar to flu-
orescein dye test [7]. A drop of saccharin is placed
3.3.3.2 Jones Fluorescein Tests into the anesthetized conjunctival sac and the time is
and Saccharine Test measured until the patient tastes saccharin (approxi-
mately 3.5 min; patients should not have any problem
Jones tests are rarely used because of their false nega- with tasting). As the test cannot be used in small chil-
tivity and the fluorescein dye test is preferred [9, 20, dren (in comparison with fluorescein dye test) and
29, 30]. Jones tests can be performed only if the lacri- gives us no anatomical information, we do not use it.
 38 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Fig. 3.6. Syringing and probing of the lacrimal system.

a Syringing via lower canaliculus. Reflux through the upper
punctum suggests obstruction at the common canaliculus or
more distal structures. b Bowman probes. c Tapered punctum
dilator inserted into punctum. d Diagnostic probing. The eyelid
must be gently stretched laterally. e Examination with a pig-tail
probe can help to assess the opposite canaliculus. (From [14])
 Diagnostics Chapter 3 39

3.4 Diagnostic Probing the patient is asked to look down and laterally while
and Lacrimal Syringing (Irrigating) the canaliculus is stretched laterally and is slightly
everted.
The irrigation and diagnostic probing of the proximal
lacrimal drainage system are essential anatomical
tests giving very valuable information on the pre- 3.4.1.2 Syringing: Interpretation
sence, location, and form obstruction. They may
qualitatively establish patency or stenosis of the cana- Reflux (regurgitation) through the opposite punctum
liculi, lacrimal sac, and nasolacrimal duct, but they suggests an obstruction in the common canaliculus
are not able to provide any information on functional or more distal structures. Fluid coming directly back
insufficiency [22]. through the same punctum indicates a canalicular
obstruction and the syringing must be repeated
through the opposite canaliculus. Distention of the
3.4.1 Syringing: Irrigation lacrimal sac implies an obstruction of the nasolacri-
mal duct. Irrigation into the nose indicates an ana-
The syringing is not a physiological test because of tomically patent system but not necessarily a func-
using a higher hydrostatic pressure than the normal tional system.
tear outflow [12]. The information resulting from the Partial irrigation into the nose accompanied by
tests is to be interpreted in connection with the fluo- some amount of reflux indicates a partial obstruc-
rescein dye test and clinical examination (Fig. 3.6). tion. It is necessary to assesss whether the water passes
into the nose, back out the upper canaliculus, back
out the lower canaliculus, or some combination there-
3.4.1.1 Performance of. If there is an obstruction of one or both canaliculi,
the length of residual canaliculus proximal to the
The following steps are taken: obstruction should be measured.
Patency to syringing by itself does not mean that
1. After several applications of topical anesthetic the lacrimal drainage system is normal and does not
have been instilled, the punctum and ampulla involve lacrimal functioning, and thus other tests
are dilated with a punctal dilator in case the must be run to determine the cause of epiphora before
puncta are small. The punctum and proximal surgery [14, 21]. Avoid probing or irrigation if signs of
canaliculae can be stabilized with a finger on accute dacryocystitis exist.
the lower eyelid retracting the lid inferiorly.
2. A blunt cannula is placed in the inferior cana-
liculus and the lower eyelid is pulled down and 3.5 Diagnostic Probing
laterally in order to straighten the lower cana-
liculus and evert the punctum away from the Probing is generally performed only if the syringing
ocular surface. The superior canaliculus is gen- and other tests demonstrate an obstruction and the
tly stretched laterally prior to irrigation. location and extension of the obstruction is to be de-
3. The tip of the irrigator is placed in the inferior scribed (Table 3.5). The obstructions may be located
canaliculus, first vertically and then horizon- in the canaliculi and their assessment is an essential
tally with the eyelid on stretch. The tip is ad- goal in patients with epiphora. If fluid regurgitates
vanced 3–7 mm into the canaliculus and sterile through the opposite punctum, the obstruction of
water or saline is used as an irrigant. common canaliculus or more distal structures are
suggested and it must be distinguished between them
It is important to avoid forced irrigation to limit in- with probing.
jury to canaliculi and to obtain more accurate analy- Probing can be made with blunt long curved lacri-
sis of patency, delayed patency or obstruction. If mal cannula for syringe or with Bowman probe. We
the inferior punctum is absent or there is a canalicu- prefer Bowman probes because of their different sizes,
lar obstruction, the syringing is repeated via the better holding in the hand, and better sensitivity in
upper punctum. For the upper punctum irrigation handling canaliculi. If signs of dacryocystitis with the
 40 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Table 3.5. Syringing and probing via the lower canaliculus

Pharynx Reflux lower Reflux upper Lacrimal system results
and nose canaliculus canaliculus

Hard stop Yes No No Normal

Yes No Yes Nasolacrimal duct stenosis
3 No No Yes Subsaccal obstruction (usually
mucoid or mucopurulent discharge)
Soft stop No Yes No Medial canalicular or common
canaliculus block
No No Yes Distal common canaliculus block

Fig. 3.7. Hard and soft stops. a Hard stop:

the probe passed into the sac touches its medial
wall, and the common canaliculus is patent.
b Soft stop: spongy feeling; the probe presses
the common canaliculus against the medial wall
of the sac. A medial shift in the inner canthus is
observed from the outside. (From [14])

presence of mucopurulent reflux exist when digital with the patent proximal part of canaliculi, i.e. the
pressure is applied to the anterior the anterior crest distance between the punctum and obstruction is
and lateral to the crest, neither irrigation nor probing measured. It is necessary to evaluate the opposite
are required. canaliculus as well.
If there is an obstruction near to the lacrimal sac
and the probe cannot pass into the lacrimal sac to a
3.5.1 Performance “hard stop,” one feels a “soft stop.” This spongy feel-
ing suggests that the obstruction is probably within
After topical anesthetic is instilled, the punctum is the common canaliculus and the lacrimal probe (can-
dilated and an appropriately sized lacrimal probe is nula) presses the common canaliculus and the lateral
advanced into the canaliculus. First the probe is wall against the medial wall of the sac. The probing
passed vertically through the punctum and then hori- must be done in a very gentle way. It is useful to look
zontally with the eyelid on a stretch until it encoun- at the inner canthus while one is advancing the probe
ters the lacrimal bone or meets the canalicular ob- toward the hard stop. If the obstruction is not in cana-
struction. liculi and the probe is in the lacrimal sac, the inner
If the probe (lacrimal cannula) is advanced into canthus should not shift. If there is a medial shift in
the canaliculus and encounters the lacrimal bone, the the inner canthus in advancing the probe toward the
feeling is called “hard stop”, i.e., it is suggested that lacrimal bone, it indicates that the probe is dragging
the probe passed into the sac, touched its medial wall, the common canaliculus medially toward the bone
and the common canaliculus is patent (Fig. 3.7). If and the lacrimal bone has not yet been reached. The
there was a reflux through the opposite punctum in differentiation between the hard stop and soft stop is
syringing a “hard stop” suggests an obstruction of the essential because the treatment an obstruction at the
sac or duct. sac or duct versus the common canaliculus requires
If there is canalicular block, the length of the ad- different DCR techniques (Table 3.5).
vanced probe is measured and this length accords
 Diagnostics Chapter 3 41

Hard stop is a firm feeling of the medial bone bor- ferred because it gives an image of better quality
dering the lacrimal sac in canalicular probing. It usu- (Fig. 3.8).
ally excludes a complete obstruction to the canalicu- A DCG better evaluates the lacrimal sac and duct
lar system. Soft stop is a spongy feeling that indicates anatomy, but it evaluates worse canalicular anatomy.
a common canaliculus obstruction as the probe press- It outlines diverticulae and fistulae, and shows intra-
es the common canaliculus and the lateral wall against sac pathology (dacryoliths or tumor) and the sac size.
the medial wall of the sac. A medial shift observed in A DCG is not routinely performed [9–11, 14, 16]. It
the inner canthus signifies that the lacrimal bone has is seldom necessary with a complete obstruction in
not yet been reached with the probe. the non-traumatic situation. It can be especially use-
It is important to have a mental image of what the ful in patients with previous trauma to localize the
findings taken from probing and syringing look like, position of bone fragments or, after previously unsuc-
and it is useful to record this on an outline of the lac- cessful lacrimal surgery, to determine the size of the
rimal system. sac. With patency to syringing, the DCG helps to
determine whether the stenosis is in the common
canaliculus or sac, and it can rule out the presence
3.6 Radiological Examination of a lacrimal sac diverticulum [10]. A DCG can often
find drainage abnormalities present in patients with
Radiological tests are to be performed if the decision “functional obstruction” [10].
as to the method of treatment cannot be made with-
out any radiological information [8, 11]. Radiological
examinations include dacryocystography (DCG), nu- 3.6.2 Indications for Dacryocystography
clear lacrimal scintigraphy, computed tomography
(CT), and magnetic resonance imaging (MRI). The indications for dacryocystography are as follows:
Dacryocystography is an anatomical investigation
and is indicated if there is a block on syringing in the 1. Complete obstructions: the size of the sac; de-
lacrimal system, and thus it can help in creating an termination of the exact location of an obstruc-
image of how the internal anatomy of the lacrimal tion (common canaliculus, sac)
system looks. Scintigraphy is a functional test and is 2. Incomplete obstructions and intermitent tear-
useful in assessing the site of a delayed tear transit, i. ing: location of the stenosis; diverticuli; stones;
e., it is useful only if the lacrimal system is patent on and no anatomical pathology (functional dis-
syringing. Both CT and MRI are used very seldom orders)
and are reserved only for some patients with preceded 3. Failed lacrimal surgery: size of the sac
trauma, facial surgery, tumor, or in whom sinus dis- 4. Suspicion of sac tumors
eases are suspected.
It is important to correlate the results of radiologi-
cal investigations with those of the other tests and in- 3.6.2.1 Performance
vestigations. The difficulty of radiological tests of the
lacrimal system is the tendency to consider the infor- The DCG is performed in the supine position under
mation obtained from an anatomical test to be of a topical anesthesia. The puncta are dilated and a can-
functional nature, and to consider the information nula (irrigation canula) attached with syringe con-
received from a functional test to indicate a specific taining a water-soluble contrast medium is inserted
anatomical defect. and taped into position. After an intracanalicular in-
jection under pressure, a film is taken.
Bilateral studies give a chance to compare both
3.6.1 Dacryocystography sides [10].

Dacryocystography is a method in which injection

of the radio-opaque water-soluble fluid is instilled
into either lower or upper canaliculus taking magni-
fied images. The digital subtraction technique is pre-
 42 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Fig. 3.8. Digital subtraction dacryocystography (DCG). a A a left-sided obstruction following dacryocystorhinostomy: a
DCG set-up. Patient lying on a bed; contrast material injection tiny sac is visualized. d A 35-year-old patient with intermitent
is given by examiners. b Normal lacrimal system on the right tearing. The dacryocystogram demonstrates defect, and preste-
and dilated lacrimal sac with the complete obliteration at sac– notic dilatation of the sac on the left side indicates a stone; this
duct junction on the left side. c Dacryocystography. Patient with was confirmed at DCR surgery
 Diagnostics Chapter 3 43

Fig. 3.8. (Continued) e Diverticulum of the lacrimal sac.

f Dilation of the lacrimal sac on the left side in chronic
dacryocystitis with an irregularity in contrast. A stone
was found at DCR surgery. (From [14])

3.6.3 Radiological Criteria is more physiological than DCG, anatomical infor-

for Lacrimal Pathology mation is lacking, and fine anatomical details are not
available in comparison with DCG [9]. Correlation of
The radiological criteria for lacrimal pathology are as the anatomical study (DCG) and functional study
follows [22, 23]: (scintigraphy) may be necessary in planning surgery
[20]; however, it is important to bear in mind that a
1. Regurgitation of (radio-opaque) fluid into the normal result is considered to be a contraindication
conjunctival sac (retention of fluid, absence of to any surgical intervention [9, 14, 27].
fluid in the nose, fluctuation of lumen of lacri- Nuclear lacrimal scan has been found to be helpful
mal system) especially in difficult cases with incompletely ob-
2. Irregularity in contrast structed pathways in which DCG could not be inter-
3. Cystic dilation and aneurysm preted in a safisfactory manner to determine whether
4. Deformation and drawing of the lacrimal sac surgery should be undertaken or not [11].

3.6.4 Nuclear Lacrimal Scintigraphy 3.6.4.1 Performance

Nuclear lacrimal scintigraphy is a simple, non-inva- A drop ot technetium-99m is instilled into each con-
sive physiological test that evaluates patency of the junctival sac of a patient sitting in front of a gamma
lacrimal system. Scintigraphy uses a radiotracer camera. No topical anesthesia is required, and nor-
(technetium-99m pertechnetate), which is very easily mal blinking is allowed.
detectable with a gamma camera (Fig. 3.9). The patient stares at a distant target during a
While a DCG is usually preferred especially in a 20-min test for a qualitative analysis, in the course of
complete obstruction, scintigraphy is useful only in which images are recorded (immediately following
those patients whose lacrimal system is patent to sy- instillation, after 3, 5, 10, 15, and 20 min).
ringing in the presence of constant epiphora. The test
 44 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Fig. 3.9. Nuclear lacrimal scintigraphy. a Set-up for nuclear

lacrimal scan. The patients sits upright with the head fixed in
front of the pinhole collimator of a gamma camera. Serial
images are taken as the tracer passes through the system.
b Patients with right-sided tearing and patency to syringing
and nasolacrimal duct stenosis on dacryocystogram. Scan after
10 min. c Normal scintigraphy. d Scan after 20 min demon-
strates significant decreased flow on the right and normal flow
on the left. (From [14])

A quantitative, region-of-interest analysis can be areas of interest. The analysis gives percentage of
obtained as well. There are pre-saccal, sac/nasolacri- drainage in mentioned areas with time and can assist
mal duct junction, nasolacrimal duct, and nasal cavity in determining the area of pathology.
 Diagnostics Chapter 3 45

3.6.4.2 Nuclear Lacrimal Scan Indication Diagnostic nasal endoscopy is performed with a
rigid endoscope or flexible endoscope which can be
The nuclear lacrimal scan indications are as follows: used without any difficulties in small children, too.
The rigid endoscopes are 4-mm diameter, 0 or 30°
1. Interpretation of anatomical tests: if it is not viewing angle, and the 2.7-mm diameter endoscope
possible to determine the full patency of lacri- can be advantageous, especially in children and some
mal system or functional significant stenosis, adults with narrow nasal cavities. The inferior and
surgery is indicated the middle meatus are better viewed if some decon-
2. Questionable lid laxity, punctal stenosis, facial gestants are introduced into the nose.
nerve palsy: evaluation of lacrimal pump dys-
function or significant stenosis (indicating
need for eyelid surgery) 3.7.1 Diagnostic Nasal Endoscopy
3. Questionable epiphora: evaluation of dynamics
of tear drainage; determination whether the The nasal mucosa is topically decongested and anes-
drainage system is normal or not (if normal, no thetized with a spray or pledges soaked with anes-
surgery is indicated) thetics. The patient sits or lies, and it is advantageous
especially if some endonasal manipulation with for-
ceps is assumed, e.g., in a patient’s subsequent sur-
3.6.5 Computed Tomography and MRI gery.
The examination of the nasal cavity and the lateral
Computed tomography (CT) can be helpful in assess- nasal wall is performed in a systematic fashion and
ing the structures intimately associated with the na- usually involves three steps [14]:
solacrimal drainage system (Fig. 3.10). The CT scan-
ning is used mainly when an extrinsic disease is 1. The general survey and orientation and visual
suspected and is of great help to the patients with pa- inspection of the nasal vestibule, nasopharynx,
ranasal sinus or facial pathology associated with the inferior turbinate, lower septum, and inferior
lacrimal system (tumor, rhinosinusitis, facial trauma, meatus (the nasolacrimal duct opening is some-
following facial surgery, etc.) [14]. times observed).
Magnetic resonance is not used in practice in lacri- 2. Endoscope is directed at the posterior end of
mal diagnostics and is reserved only for the special the middle turbinate to evaluate the spheno-
cases, e.g., for differentiation of masses of the lacrimal ethmoidal recess and superior nasal meatus.
sac [5, 20]. 3. Endoscopy of the middle meatus and lateral
nasal wall, including an examination of the
maxillary line and the middle meatus.
3.7 Nasal Examination
and Nasal Endoscopy However, endoscopy is very important in postopera-
tive care and after unsuccessful lacrimal surgery, e.g.,
Nasal examination, especially nasal endoscopy, unsuccessful dacryocystorhinostomy (Table 3.6).
should be obligatory for every lacrimal patient [6, 9,
10, 14, 20, 26]. The examination of the lacrimal area
with the nasal speculum and headlight provides only
a poor view of this region and is not sufficient, endos-
copy provides a clear diagnostic look for nasal polyps,
imporant anatomic variations, tumors, and other
pathological endonasal conditions such as septal
deviation (Fig. 3.10).
 46 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Fig. 3.10. Nasal examination. a Nasal endoscopy with rigid

or flexible telescope provides an excellent view and many
abnormalities are detected. b Endoscopic view of right nasal
space with the endoscope above the inferior turbinate to
examine the lacrimal ridge and view the middle turbinate.
The middle turbinate may be partially pneumatized. c Right
nasal cavity with polyps in the middle meatus and between
middle turbinate and septum. d Endoscopy of the left inferior
meatus. Well-developed ostium of the nasolacrimal duct
 Diagnostics Chapter 3 47

Table 3.6. Nasal endoscopy in lacrimal surgery

Preoperative examination Assessment of anatomical abnormalities potentially affected proposed lacrimal surgery
(nasal cavity extent, septal deviation, hypertrophic turbinate, mucosa appearance,
previous nasal surgery)
Assessment nasal pathology causing lacrimal symptoms (tumor, Wegener’s granulomatosis, etc.)
Observation of lacrimal transport (fluorescein)
Endonasal surgery Lacrimal pathways intubation (turbinate infraction, dacryocystocoele incision,
extraction of probes, etc.)
Endonasal dacryocystorhinostomy (translumination, middle turbinate resection,
septoplasty, bleeding control, laser EDCR, etc.)
Conjunctivocystorhinostomy with primary EDCR (control tube position, turbinate resection,
septoplasty, etc.)
Postoperative care Endonasal follow-up post-endonasal and external lacrimal surgery (cleaning of the nasal cavity,
size, and location of the DCR opening, Jones tube position, etc.
Failed lacrimal surgery (to determine any compromise of the opening, to diagnose
any lesions obstructing the opening such as granulomas, fibrous tissue, polyps, synechiae, etc.)
Revision lacrimal surgery Revision DCR (middle turbinate resection, anterior ethmoidectomy, removing fibrous tissue, etc.)
Conjunctivodacryocystorhinostomy (reinsertion and removing obstruction tissue)

3.8 Lacrimal System Endoscopy

3.8.1 Secretory Tests

If there is any suspicion of dry eye, the secretory tests

should be done. A dry eye is usually suspected in the
absence of any marginal tear strip, but the tear menis-
cus can be low or elevated if there is reflex tearing
and/or if the tear film contains mucin, flakes, or fila-
ments [20, 25].
Secretory tests include Schirmer’s tests, bengal rose
staining test, break-up test, and lysozyme lysis test
(Table 3.7). These tests are helpful for the evaluation
of tear production and indicate which component of
the precorneal tear film is disturbed [11]. The treat-
ment of a dry eye is quite different from anatomical or
functional obstructions of the lacrimal system.
Fig. 3.10. (Continued) e Coronal CT scan of orbits and sinuses
shows right maxillary sinus carcinoma with intraorbital grow-
ing. The patient was treated with a endonasal DCR for epifora 3.8.2 Schirmer’s Tests
and dacryocystitis. Suspected masses were found around the sac
and spinocelullar carcinoma was histologically determined.
(From [14]) Quantification of tear production in the office setting
is routinely done with Schirmer test strip.
 48 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Table 3.7. Evaluation of Schirmer tests

Test Measured tear production Normal
Schirmer I without anesthetic Basic + reflex 10−35 (under 40 years, >15 mm; over 40 years, <10 mm
Schirmer I with anesthetic Basic Under 40 years, 10 mm; over 40 years, 5 mm
Schirmer II with anesthetic Reflex 15 mm and more
3 (trigeminal nerve stimulation)

Fig. 3.11. Schirmers test

3.8.2.1 Performance pected and the Schirmer’s I is normal [9]. The princi-
ple of this test is in the elimination of the reflex
White Whatman filter paper in 35=5-mm strips is contribution from the main lacrimal gland (including
folded 5 mm from one end which is placed into the the irritation from the Schirmer test strips) with topi-
inferior fornix at the junction of the medial two- cal anesthetic instilled into the inferior formix [6].
thirds and the other lateral one-third of the lower eye- The basic, non-reflex contribution of the tear produc-
lid. tion from the accessory glands is measured.
In semi-dardened room, the patient, without any The Schirmer II test (reflex secretion) measures
eye drops, should not be stimulated verbally but is the reflex tearing derived from the main lacrimal
asked to blink normally for 5 min. gland. A topical anesthetic is applied to the eye to
The amount of wetting to the paper is measured eliminate the reflex tearing from the local inflamma-
from the fold along its length after the paper has been tion and irritation [6]. A trigeminal nerve is then
removed. stimulated either with a cotton applicator applied to
There are distinguished tests with or without anes- the nasal mucosa or with ammonium chloride on a
thetics. cotton pledget at the external nares. The amount of
Regarding performance, Schirmer I (basic + reflex paper strip wetting is more than that elicited in the
secretion) is performed without any topical anesthetic basic secretion test and represents the reflex secre-
(Table 3.6). Schirmer I with anesthetic (basic secre- tion. This test is seldom used because the reflex secre-
tion test) is performed if a dry eye syndrome is sus- tion is usually intact [12] (Fig. 3.11).
 Diagnostics Chapter 3 49

3.8.2.2 Break-up Time 3.9 Conclusion

Break-up time indicates the function of the mucin

layer or perhaps a reflex hypersecretion of an aqueous  W
component of the tears. One drop of fluorescein is in- The purpose of the examination tests is to distin-
stilled into the external canthus of a lower lid and the guish between epiphora and lacrimation, and be-
patient is instructed to blink once and then to keep tween anatomic and physiological dysfunction. In
his eyes open. The holes developed in the tear film are most patients with epiphora the history, palpation
observed at the cornea through a slit-lamp with illu- and inspection, fluorescein dye disappearance test,
mination through the cobalt filter. The normal break- diagnostic probing, and syringing are sufficient to
up time should be approximately 15–30 s. A break-up determine drainage function, location, and exten-
time of less than 10 s indicates a deficiency and the sion of the anatomical block; if not, dacryocystogra-
epiphora should be treated with libricating eye drops phy or nuclear scintigraphy can be helpful. In ana-
[9, 11]. tomical obstruction, it must be determined where
the obstruction is located (presaccal, saccal, post-
saccal) and the extent of an obstruction, if possible.
3.8.2.3 Bengal Rose Staining Assessing canaliculi is essential. If the obstruction of
one canaliculus is found, it is necessary to evaluate
Bengal rose staining test is similar to a break-up time the other canaliculus. Once an anatomical obstruc-
test. One drop of bengal rose is placed in the eye and tion in the lacrimal system has been located,
the patient blinks several times for 1 min. Interpalpe- the appropriate surgical procedure can then be
bral staining with bengal rose areas are then found in chosen (Table 3.8). If surgical therapy is indicated,
the dry eye. With both tests, staning of cornea is one should be able to say for whom the lid surgery
sought as lagophthalmos or incomplete blinking may may be more appropriate and for whom it may
exist, leading to reflex epiphora. not.
However, it is important to bear in mind that with
many diagnostic tests available to evaluate the pa-
3.8.2.4 Lysozyme Lysis Test tency of the lacrimal drainage system, there is no
rigid unchanging standard approach to a patient
The amount of a lysozyme activity and concentration with epiphora, and the treatment should not be de-
is decreased in hypersecretion and in hyposecretion, cided without thorough consideration [28]. The re-
and it usually precedes clinical symptoms. A lyso- commended surgery can be influenced by the age
zyme activity (and concentration) is estimated on the of a patient, the previous therapy, history, motiva-
basis of the inhibition of the growth of the bacterium tion for surgical procedures, as well as other rea-
Micrococcus lysodicticus. sons.
 50 P. Komínek, R.C. Della Rocca, S. Rosenbaum

Table 3.8. Management of lacrimal obstruction based on site of obstruction. DCR dacryocystorhinostomy, CDCR conjunctivodac-
ryocystorhinostomy
Obstruction Schema Other factors Recommended surgery
Saccal or subsaccal DCR
obstruction

3
Canalicular stenosis Intubation
Laser canaliculoplasty + intubation
DCR + intubation

Total common canalicular medial DCR with common internal

end obstruction puncto-plasty
Laser dacryoplasty + intubation

Total common canalicular lateral Canaliculodacryocystorhinostomy

end obstruction

Total individual canalicular obstruction, Opposite canaliculus DCR

>8 mm from punctum patent

Opposite canaliculus Canaliculodacryocystorhinostomy

obstructed

Total individual Opposite canaliculus DCR

canalicular obstruction, <8 mm from punctum patent

Opposite canaliculus CDCR

obstructed

Combined upper/lower Either canaliculus Canaliculodacryocystorhinostomy

canalicular obstruction patent >8 mm
from punctum

Neither canaliculus CDCR

patent <8 mm
from punctum

Eyelid malposition, laxity Lid surgery

 Diagnostics Chapter 3 51

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