Tear Drain

Nasolacrimal (tear drain) surgery includes surgery on the the canaliculi (the portions of the tear drain that reside within the eyelids), the lacrimal sac, and the bony nasolacrimal duct (in the nose). Depending on the location and severity of the tear drain blockage, different procedures may be of benefit to you.
 
Punctal stenosis
Often the patients are fortunate that their tearing is only caused by punctal stenosis! The “puncta” are holes on each of the eyelids that the tears drain down.  If they are narrowed, an office procedure at the time of your initial visit may fix the problem.  Below is a photo of that procedure — the small triangle of tissue is removed, opening up the tear drain hole on the inside of the eyelid.  There is no pain afterwards.
 

 
Functional nasolacrimal obstruction
Functional obstruction implies that the tear pump mechanism is faulty, even though the actual drain is partly open.  The tear drain pump mechanism relies on the tension of the eyelids and the contraction of the muscles that close the eyelids.  It also relies on the normal function of a series of “valves” at the various junction points within the tear drain system. These obstructions are the most difficult to properly diagnose, though once the diagnosis is secure, the treatment follows a prescribed course. The reason for the diagnostic challenge is because:

  • The eyelids are usually lax to some extent, which may implicate a tear pump mechanism instead of a valvular or nasolacrimal duct problem.
  • The tear drains are demonstrably open clinically, although there may be some subjective resistance during testing.
Locations of obstructions that can occur in functional nasolacrimal duct obstruction are depicted in red below:

 

 

The most useful feature of the clinical examination in these cases is to compare the right and left sides:  for example, if both lower eyelids have similar tone and yet only the left side tears, odds are that treating the nasolacrimal system will have a better chance of success than tightening the eyelid. Nevertheless, occasionally multiple procedures will be required to completely treat these problems.The first step in treating these problems is to attempt a ballon dilation of the tear drain in the operating room.  It has  a 50/50 long term success rate but requires no incision and is well-tolerated.  If that fails, the decision must be made as to whether eyelid laxity is playing a part, or if the problem is still within the tear drain. Occasionally, Dr. Walrath requires special testing (dacryoscintigraphy) to be performed at a medical center to help with this decision-making.  The general algorithm that I use in the decision making process for fNLDO is below:

 

 

Complete acquired nasolacrimal duct obstruction
The definitive blockage of the nasolacrimal duct.  It may manifest as constant tearing or recurrent severe lacrimal sac infection.  The treatment, dacryocystorhinostomy (DCR), has upwards of a 90% success rate. It is performed under general anesthesia and involves the creation of a new tear drain, by removing bone in the nose.  The procedure can be performed internally, or it can be performed externally, with a small skin incision.  The external approach generally has a higher success rate.  As you can see here, the scar is almost entirely invisible within 3-4 weeks in almost everyone.
The obstruction is usually within the duct, somewhere in the nose, as depicted in red below:

 

 

The DCR surgery involves removing some bone from deep inside the nose, creating a new tear drain, and placing a silicone tube in the system to keep it open while it heals.  This is depicted below:

 

 

Canalicular blockage (blockage within the eyelid portion of the drain)

Canalicular blockage is probably the most difficult type of blockage to treat satisfactorily.  If the blockage is near the tear sac, a modified DCR can be attempted.  However, usually, a glass tube needs to be inserted in the inside corner of the eyelid, which bypasses the blocked system and conducts tears directly into the nose.  This tube stays in for life.

Recalcitrant tearing

Dr. Walrath has experience injected the tear glands with Botox when “all else fails” and the tear drain abnormality is recalcitrant to surgical correction.  Botox has been well-tolerated, with a low incidence of side effects, with the exception of a chance for temporary eyelid droop.  However, the botox will only last 3-4 months before it needs to be repeated.

Clinical photos

Finally, if you are wondering if you might be suffering from tear sac infection (dacryocystitis) or infection of the eyelid portion of the nasolacrimal system (canaliculitis), below are some pictures of what it might look like:
 

 

 

 

Click here to download the patient brochure on nasolacrimal duct obstruction from the American Society of Ophthalmic Plastic and Reconstructive Surgeons.