Nasolacrimal Duct Obstruction (NLDO)

NLDO may be either congenital or acquired and leads to excess overflow of tears called epiphora

Symptoms

Excessive tearing is the most important complaint of patients with NLDO. Pain at the side of the nose is a sign of dacryocystitis.

Causes

•  Involutional stenosis is probably the most common cause of NLDO in elderly patients. It is twice as common in women than in men. Even though the cause of the stenosis is unknown, the clinicopathologic study suggests that the compression of the lumen of the nasolacrimal duct is caused due to inflammatory cell infiltrations and edemas. These may be the result of an unknown infection or of an autoimmune disease.
• Dacryolith
• Sinus disease. Sinus disease often appears in conjunction with the NLDO, while in other cases it may contribute to the occlusion of the nasolacrimal duct.
• Trauma. Naso-orbital fractures may cause the obstruction of the nasolacrimal duct. Early treatment through fracture reduction with the placement of a stent in the entire lacrimal drainage system should be considered as treatment. However, such injuries are often not identified or are initially neglected as more serious injuries are being treated. In these cases, the delayed treatment of the persistent epiphora usually requires a DCR.
• Inflammatory disease. Granulomatous diseases including sarcoidosis, Wegener granulomatosis, and midline granuloma, can also lead to the blockage of the nasolacrimal duct.
• Punctal plugs. As with similar cases of canaliculi blockage, ectopic plugs of the lacrimal points and canaliculi may migrate and obstruct the nasolacrimal duct.
• Neoplasms. All patients with obstruction of the nasolacrimal duct need to be checked for neoplasms. In patients with atypical occurrence of the disease, and especially if the patient is young and male, further investigation of the disease is required. The presence of blood from the punctum or the enlargement of the lacrimal sac over the tendons through the canthal region is highly suggestive of a neoplasm.
• Congenital Obstruction. The congenital nasolacrimal duct obstruction is often caused due to an imperforate membrane at Hasner’s valve

Treatment

1) Intubation and stent placement
Certain clinicians believe that the partial narrowing of the nasolacrimal duct with symptomatic epiphora often responds well to surgical intubation of the entire lacrimal drainage system.

This operation can only be performed if the tubes can pass through easily. It has a low success rate (~25%) though. In case of complete nasolacrimal duct obstruction, intubation by itself is not effective, so the physician must consider performing a DCR.
2) Dacryocystorhinostomy (DCR)
DCR is the gold standard treatment for most patients with acquired nasolacrimal duct obstruction. Surgical indications include recurrent dacryocystitis, chronic mucoid reflux, painful distension of the lacrimal sac and troublesome epiphora. In patients with acute dacryocystitis, active infection should be cleaned, if possible, before it evolves to dacryocystitis.