Adult nasolacrimal duct obstruction (NLDO) is a condition in which the tear drainage system becomes blocked, so tears cannot pass into the nose. It causes watering, discharge and recurrent eye infections. It is common in adults, particularly in women and in older age groups, and it can be managed successfully with accurate diagnosis and appropriate treatment.
After washing the ocular surface, tears enter the puncta at the inner corner of the eye and travel through the canaliculi, the lacrimal sac and the nasolacrimal duct into the nasal cavity. In adults, obstruction most often occurs where the duct opens into the nose.
When the duct is blocked, tears have nowhere to go and spill over the lid margin onto the cheek. This is called epiphora. Tears stagnating in the sac eventually create a favourable environment for infection, so obstruction is not only a problem of watering but a source of recurrent infection.
Dacryocystitis is inflammation of the lacrimal sac, and there is almost always an underlying obstruction. It presents in two forms.
In the acute phase the priority is controlling the infection, but this is only temporary: unless the obstruction is relieved, the picture recurs. Definitive surgical treatment is therefore planned once the acute episode has settled. In chronic dacryocystitis the sac acts as a reservoir of bacteria, so if another operation such as cataract surgery is planned for that eye, the drainage problem should be dealt with first.
I am asked this often, and the answer depends on the picture. In an adult with complete nasolacrimal duct obstruction, no drop, tablet or massage will open the passage permanently. Unlike congenital obstruction in infants, spontaneous resolution does not occur here, because the narrowing is structural.
Non-surgical measures have the following roles:
In short, if the watering is not caused by complete obstruction, a non-surgical solution is possible. Examination and syringing are essential to make that distinction.
Complete obstruction is treated surgically. A new passage is created between the lacrimal sac and the nasal cavity, above the level of the blockage. This operation is called dacryocystorhinostomy (DCR).
Surgery is performed under local anaesthesia in most patients and they are discharged the same day. The great majority of patients have resolution of watering after the first operation. The likelihood of re-obstruction is higher after laser-assisted and intranasal procedures.
DCR is a commonly performed operation, but like any surgical procedure it carries risk. I explain these to my patients clearly beforehand:
Because they increase the risk of bleeding, blood-thinning medicines must be reported before surgery. Whether they are stopped is decided together with the doctor who prescribed them.
Seek advice without delay for uncontrolled nosebleed, increasing pain and swelling, fever, or reduced vision.
Options are not exhausted for patients whose symptoms persist after previous tear duct surgery. Most are relieved of their complaints after a second procedure. Revision surgery is more demanding than the first operation: the anatomy has changed and scar tissue is present. These operations are therefore usually carried out by surgeons experienced in lacrimal and oculoplastic surgery, and your ophthalmologist will refer you to one when needed.
For the causes of failure and the revision options, see revisional surgery for failed nasolacrimal duct obstruction treatment.
For general information on the tear system see lacrimal system disorders, and for infants and children see congenital nasolacrimal duct obstruction.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist, Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
The most common early problem is a nosebleed, which is usually mild and settles within the first days. Less often there may be wound infection, re-narrowing of the new passage by scar tissue, displacement of the silicone tube, or adhesions inside the nose. The external technique leaves a fine line beside the bridge of the nose, which becomes inconspicuous over time in most patients. Blood-thinning medicines must be reported before surgery.
In an adult with complete obstruction, no drop, tablet or massage will open the passage permanently; unlike congenital obstruction in infants, it does not resolve on its own. If the watering is not caused by complete obstruction, however, a non-surgical solution is possible. A narrowed punctum can be dilated, partial narrowing can be managed with a silicone tube or balloon, and watering caused by dry eye or lid malposition is treated at the ocular surface. Examination and syringing establish which applies.
Light blood-stained discharge from the nose and swelling around the eye are usual in the first days. During the first week you should not blow your nose and should keep your mouth open when sneezing. Skin sutures are usually removed within the first week and the swelling settles over a few weeks. Some patients notice the watering improve from the first day, others as the swelling resolves. If a silicone tube was placed, it is generally removed in clinic within two to six months.
Dacryocystitis is inflammation of the lacrimal sac, and there is almost always an underlying duct obstruction. The acute form presents as a sudden painful, red and warm swelling beside the bridge of the nose; the chronic form as persistent watering with discharge on pressing the sac. Antibiotics settle the inflammation, but because the obstruction remains, tears stagnate again and the picture recurs. The lasting solution is tear duct surgery once the acute episode has passed.
No. There are two mechanisms. The first is inadequate drainage: tears are produced normally but cannot drain away. The second is reflex tearing: the ocular surface is irritated, so more tears are produced. Dry eye, blepharitis, allergy, ingrown lashes and lid malposition belong to this second group. Patients are often surprised that dry eye causes watering, but it is common. Treatment given without making this distinction does not work.
Options are not exhausted. Most patients are relieved of their complaints after a second procedure. Revision surgery is more demanding than the first operation, because the anatomy has changed and scar tissue is present. These procedures are therefore usually carried out by surgeons experienced in lacrimal and oculoplastic surgery. See the page on revisional surgery for failed nasolacrimal duct obstruction treatment for detail.
The endoscopic approach through the nose leaves no skin incision at all. The external approach involves a fine incision of about one centimetre beside the bridge of the nose. Placed along the natural skin lines and closed with an appropriate technique, it fades over time and in most patients is no longer noticeable after a few months.
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