|Year : 2020 | Volume
| Issue : 4 | Page : 268-274
Symptomatic acquired lacrimal passage obstruction: clinical evaluation of the level of obstruction in adult patients
Mohamed F.K Ibrahiem, Ahmed M Sabry, Sahar T.A Abdelaziz
Department of Ophthalmology, Minia University Hospital, Minia University, Minia, Egypt
|Date of Submission||12-Feb-2020|
|Date of Decision||27-Mar-2020|
|Date of Acceptance||23-Jun-2020|
|Date of Web Publication||28-Dec-2020|
MD Mohamed F.K Ibrahiem
Department of Ophthalmology, Faculty of Medicine, Minia University Hospital, Minia University, 98 Korneesh El Nile Street, Minia 61111
Source of Support: None, Conflict of Interest: None
Purpose The aim of this study was to detect the anatomical level of acquired lacrimal passage obstruction among adult patients with epiphora.
Patients and methods In a 3-year period, 266 eyes of 223 adult patients with obstructive epiphora were evaluated clinically by probing/irrigation of the lacrimal passages to detect the anatomical level of obstruction. Patients were divided into four groups: punctal, canalicular, nasolacrimal duct (NLD), and mixed groups according to the level of obstruction.
Results The age of the patients ranged from 18 to 75 years, and 83.46% of the patients were living in rural areas. Overall, 82% of the patients were females, and 78.99% of them used to apply Kohl as eyeliner cosmetic for an average of 15.62 years. Punctal disorders were detected in 14.67% of the patients, of whom 9.78% had isolated punctal disorders and 4.89% were in the mixed multiple level subgroup. Punctal obstruction represented 69% of the patients with isolated punctal disorders. Canalicular disorders represented 65.4% of all patients, where 70% had isolated canalicular disorder and 30% were in the mixed subgroup. Overall, 39% of all patients had acquired NLD obstruction; 63.5% of them had isolated NLD disorder and 36.5% had multifocal obstruction. Multifocal obstruction of the lacrimal passages was reported in 19.17% of all patients.
Conclusion The main site of obstruction was the common canaliculus as two-thirds of the patients had canalicular problems. The second common site of obstruction was the NLD followed by the puncta.
Keywords: canalicular obstruction, lacrimal passages, nasolacrimal duct, probing
|How to cite this article:|
Ibrahiem MF, Sabry AM, Abdelaziz ST. Symptomatic acquired lacrimal passage obstruction: clinical evaluation of the level of obstruction in adult patients. Delta J Ophthalmol 2020;21:268-74
|How to cite this URL:|
Ibrahiem MF, Sabry AM, Abdelaziz ST. Symptomatic acquired lacrimal passage obstruction: clinical evaluation of the level of obstruction in adult patients. Delta J Ophthalmol [serial online] 2020 [cited 2022 Jul 5];21:268-74. Available from: http://www.djo.eg.net/text.asp?2020/21/4/268/305283
| Introduction|| |
Lacrimal drainage system obstruction is a disease where the obliteration may occur at any point along the lacrimal outflow apparatus . Acquired lacrimal passage obstructions produce symptoms of epiphora, mucopurulent discharge, pain, dacryocystitis, and orbital cellulitis .
Few articles reported the frequency of the anatomical level of obstruction among symptomatic patients ,. In Egypt, three factors should be considered including the low socioeconomic standards and its effect on eye care services, the use of traditional kohl, and the endemic trachoma with its lacrimal system complications.
The aim of this study was to detect the level of acquired lacrimal passage obstruction among adult patients.
| Patients and methods|| |
This is a prospective study that was carried out at the Oculoplastic Clinic of Ophthalmology Department, Minia University. All adult patients experiencing watering of their eyes and attending the Outpatient Clinic of Oculoplastic Unit were evaluated thoroughly.
The study was conducted in accordance with the 1964 Helsinki declaration and was approved by the Ethics Committee of the Faculty of Medicine, Minia University (NCT04240431 in clinicaltrials.gov). All patients signed a written informed consent to participate in the study and for publication of data before enrollment in the study.
Evaluation of patients included routine ophthalmic examination in addition to evaluation of the lacrimal system, which included history of eye watering regarding onset, duration, and with watery or sticky discharge; history of chronic use of topical drugs that may affect punctal patency, such as topical anti-glaucoma medications; history of systemic and topical cytotoxic drugs that might affect the patency of the canaliculi such as mitomycin C and 5 fluorouracil; history of facial exposure to radiotherapy that might affect the patency of the canaliculi; and history of eye cosmetics application in females and its duration.
Only cases with obstructive epiphora were enrolled in this study. Cases with other causes outside the lacrimal passages such as over-lacrimation, lower lid laxity or ectropion, and lacrimal pump failure as in Bell’s palsy were excluded. In addition, cases with previous lacrimal passage surgery were excluded.
A total of 266 eyes of 223 patients (180 unilateral and 43 bilateral) met the inclusion criteria. All patients were clinically examined to evaluate the lacrimal passages by the following:
- Dye disappearance test in which two drops of fluorescein 2% eye drops were applied in the inferior conjunctival fornix, and its disappearance from the fornix into the lacrimal passages was observed against time. In all patients, the test was retarded more than 5 min.
- Slit lamp examination of the puncta to document the size of the punctum. The size of the punctum was graded as follows:
- Grade 0: totally occluded.
- Grade 1: narrow but not totally occluded and needs punctal dilation to admit #26-G (0.41 mm) lacrimal cannula.
- Grade 2: normal, that is, it can admit #26-G cannula without punctal dilatation.
- Probing/irrigation of the lacrimal passages:
- Probing of the lacrimal passages was done using #00 Bowman’s lacrimal probe (Katena Products, Parsippany, New Jersey, USA) which can reveal any narrowing (resistance) or obstruction (soft stop) of the canaliculi during its advancement from the punctum toward the lacrimal sac. If the probe was advanced smoothly from the punctum to the sac (where hard stop was felt), the canaliculus was considered to be free. If advancement of the probe was faced by resistance but still can be advanced to feel a hard stop, narrowing was diagnosed. If the probe was faced by soft stop, canalicular obstruction was the case and the site of narrowing or obstruction can be measured as follows: once the probe reached the site of narrowing or obstruction, a toothed tissue forceps was used to grasp the probe just at the punctum and then the probe was withdrawn with the probe still grasped by the forceps. The distance between the tip of the probe and the site of grasping forceps was measured in mm by a ruler, which reflected the site of obstruction or narrowing. Proximal canalicular obstruction was diagnosed when there was less than 8 mm of patent canaliculus measured from the punctum, whereas distal canalicular obstruction was considered if there was 8 mm or more of patent canaliculus measured from the punctum.
Syringing of the lacrimal drainage system was done using normal saline-filled syringe with #26-G lacrimal cannula.
- In soft stop: if saline regurges from the same punctum, that particular canaliculus was considered to be obstructed. If saline regurges through the other punctum, a common canalicular obstruction was diagnosed.
- In hard stop: if saline regurges totally through the other punctum, total nasolacrimal duct (NLD) obstruction was considered. If some saline regurges from the other punctum and some saline passed to the patient’s nose, narrowing of the NLD was the case.
From the aforementioned examinations, the level of obstruction or narrowing of the lacrimal passages was detected.
Patients were divided into four subgroups according to the site of narrowing or obstruction:
- Punctal subgroup: it included patients with only punctal problems.
- Canalicular subgroup: it included patients with only canalicular problems.
- NLD subgroup: it included patients with NLD narrowing or obstruction.
- Mixed subgroup: it included patients who had two or more levels of narrowing orObstruction.
All data were collected and subjected to statistical analysis using SPSS statistical program (Version 19; SPSS Inc., IBM Corp., Armonk, New York, USA). P less than 0.05 was considered the cutoff value for significance.
| Results|| |
The current study included 266 eyes of 223 patients. The age of the patients ranged from 18 to 75 years (mean=41.39±14.31 years). Regarding sex, 82.33% of the patients were females and 78.99% of them used the traditional eyeliner cosmetic (kohl) for a mean period of 15.62±9.582 years. The patient’s demographic data showed near equal distribution of the lacrimal passage disorders between right and left sides (51 vs 49%, respectively), and 83.46% of all patients were living in rural areas ([Table 1]).
Patients in the canalicular and NLD subgroups had lower mean age (39.07 and 38.18 years, respectively) compared with patients in the punctal and mixed subgroups (45.5 and 49.03 years, respectively). There were statistically significant differences when either the canalicular or NLD subgroups were compared with the mixed subgroup (P<0.0001) or the punctal subgroup (P≤0.0122) ([Table 1]).
Regarding sex, the percentage of female patients to the total number of patients (82.33%) was statistically significant (P<0.0001), but when we compared each two subgroups regarding the percentage of female patients, there was no statistically significant difference between the subgroups (P≥0.0580) ([Table 1]).
The percentage of patients living in rural areas to the total number of patients (83.46%) was statistically significant (P<0.0001), but comparing each two subgroups regarding the percentage of patients living in rural areas, there was no statistically significant difference between the subgroups (P≥0.2858) ([Table 1]).
The percentage of female patients using kohl eye cosmetics to the total number of female patients (78.99%) was statistically significant (P<0.0001), but comparing each two subgroups, there was no statistically significant difference between the subgroups (P≥0.2325) ([Table 1]).
Regarding the side of lacrimal passage disorder, the mixed subgroup compared with other subgroups showed statistically significant difference (P˂0.0028), whereas comparing the other three subgroups, the difference was statistically insignificant (P>0.2302) ([Table 1]).
None of the patients had history of chronic use of topical antiglaucoma drugs or topical cytotoxic drugs for treatment of ocular surface malignancy. In addition, there were no patients with history of systemic cytotoxic therapy or facial radiotherapy.
In each subgroup, the pathology was either narrowing or obstruction ([Table 2]).
|Table 2 Anatomical level of narrowing or obstruction of the lacrimal passages|
Click here to view
Punctal disorders affected 39 (14.67%) of the 266 eyes, of whom 9.78% were in the isolated punctal subgroup and 4.89% were in the mixed multiple level subgroup. Punctal obstruction represented 69% (18/26) of the eyes with isolated punctal disorders ([Table 2]).
Canalicular disorders represented 65.4% (174/266) of all eyes, where 70% (123/174) had isolated canalicular disorder and 30% (51/174) were in the mixed subgroup. Moreover, 89.4% (110/123) of the eyes in the isolated canalicular subgroup had distal and common canalicular narrowing or obstruction ([Table 2]).
Overall, 39% (104/266) of all eyes had acquired nasolacrimal duct obstruction (NLDO); 63.5% of them (66/104) had isolated NLD disorder and 36.5% (38/104) had multifocal obstruction ([Table 2]).
Multifocal obstruction of the lacrimal passages was reported in 19.17%% of all eyes and 58.8% (30/51) of them had encysted dacryocystoceles ([Table 2]).
Regarding whether the lacrimal passage disorder involved the upper or the lower lacrimal drainage system, 60.15% of the patients had upper lacrimal passage disorder and 24.81% had lower lacrimal passage disorder. In addition, 15.04% of the patients experienced mixed upper and lower passage narrowing and/or obstruction ([Table 3]).
| Discussion|| |
There are few reports worldwide regarding the anatomical level of obstruction of the lacrimal passages in cases of acquired obstructive epiphora and its relation to traditional eye cosmetics and endemic eye diseases.
In the current study, 266 eyes of 223 adult patients with obstructive epiphora were evaluated clinically to detect the anatomical level of narrowing or obstruction of the lacrimal passages using the probing/irrigation technique. The patients were categorized according to the anatomical level of obstruction found into four subgroups.
Punctal and mixed lacrimal passage disorders occurred in older patients as compared with canalicular and NLD subgroups, and the difference was statistically significant. This can be explained by the age-related punctal narrowing or obstruction, which was reported by other authors .
Predisposition to laterality was not noted as the patients had near equal distribution in right and left sides (51 vs 49%, respectively), with statistically insignificant difference. Das et al.  in their very large cohort study in India (which included congenital and acquired lacrimal passage obstruction) reported similar results in patients with acquired NLDO . Comparing each two subgroups, there was no statistically significant difference between the subgroups regarding the affected side. Only the mixed subgroup showed statistically significantly higher incidence of left-sided lacrimal passage disorders with no explanation for such finding.
Overall, 82% of our patients were females, which was statistically significant. There was no statistically significant difference between the four subgroups regarding sex. This matched the concept that lacrimal passage obstructions are more common in females, as Woog in USA reported that 69% of his 587 patients were females . Tirakunwichcha et al.  in Thailand found that 87.4% of 111 patients were females. In addition, Das et al.  reported that 68.3% of their patients with acquired NLDO were females.
In this study, the majority of the patients (83%) were living in rural areas where the socioeconomic standards are low with reduced eye care services with existence of endemic trachoma and its complications in addition to the widespread use of Kohl as traditional eyeliner cosmetic. Although the percentage of patients living in rural area was high and statistically significant, comparing the four subgroups showed no statistically significant difference between them regarding the percentage of patients living in rural areas and those living in urban area. Das et al.  reported that 73% of their patients were living in urban areas and this was totally different from the present study, most probably because they recorded patients referred to their tertiary eye center, which was located in an urban area away from the rural patients who were usually referred to primary and secondary referral centers.
In this study, 14.67% of the patients had punctal stenosis or obstruction either isolated (9.78%) or combined (4.89%) with narrowing or obstruction at other levels and 69% of the patients with isolated punctal disorders had obstruction rather than stenosis. A study conducted in Saudi Arabia by Bukhari reported that 77.8% (178/229) of the patients referred to her center with lacrimal passage obstruction had punctal problems either stenosis (76%) or obstruction (24%), but she did not mention whether patients had multifocal obstruction of the lacrimal passages or not, and she attributed the higher incidence of punctal narrowing or obstruction in her population to the higher incidence of blepharitis in Saudi Arabia . Das et al.  reported punctal stenosis as the most frequent proximal lacrimal disorder (3% of all patients), whereas Starks and Yoon  in their observational retrospective study for proximal lacrimal drainage system detected 12 patients with lacrimal punctal obliteration. One-third of their patients had associated canalicular obstruction, and only one patient had associated dacryocystocele owing to NLDO . They attributed the cause of obstruction to topical ophthalmic medications in 75% of the patients, which is totally different from our causes.
Patients with canalicular disorders represented 65.4% of all patients, in this study, either as isolated canalicular disorder (70%) or associated with narrowing or obstruction at other levels of the lacrimal passage (30%). In the isolated canalicular subgroup of patients, most of the obstructions were around the common canaliculus, as 89.4% had distal and common canalicular narrowing or obstruction. Bukhari  reported only 6.5% (15/229) of her patients to have canalicular obstruction, and this percentage was much lower than that of the present study. The possible explanation is that she might not consider another level of obstruction in cases diagnosed as punctal stenosis or obstruction.
Patients with acquired NLDO represented 39% of all patients in the present study, with 63.5% having isolated NLD narrowing or obstruction and 36.5% having mixed obstruction including the NLD. These results were midway between what was reported by Bukhari  in Saudi Arabia (15.7%=36/229) and Woog  in USA (68.3%=397/587) in patients with acquired symptomatic lacrimal outflow obstruction.
Patients of the mixed subgroup accounted for 19.17% of patients in this study. It included patients with multifocal obstructions of the lacrimal passages. Encysted dacryocystocele due to combined NLD obstruction and distal bicanalicular or common canalicular obstruction was reported in 58.8% (30/51) of patients in the mixed subgroup.
In case of encysted dacryocystocele, distal and/or common canalicular obstruction was a true fibrous obstruction and not only kinking of the distal or common canaliculus as evidenced by:
- Lacrimal sac mucocele developed secondary to chronic dacryocystitis, and most cases of chronic dacryocystitis had positive regurgitation without mucocele where the common canaliculi were patent. So, mucus goes back toward the conjunctival sac upon pressure over the lacrimal sac which did not happen in cases of lacrimal sac mucocele.
- Diagnostic probing revealed soft stop at different distances from the punctum in different cases of mucocele which means common and distal canalicular obstruction. If the common canaliculus was only kinked, so gentle advancement of the Bowman’s probe toward the lacrimal sac would result in evacuation of the sac which did not happen.
- Intraoperative finding revealed distal canalicular or common canalicular fibrous obstruction in all cases of lacrimal sac mucocele managed using canaliculodaryocystorhinostomy.
In this study, 60% of the patients had upper or presaccal obstruction, whereas 25% had lower or postsaccal obstruction, and only 15% had mixed presaccal and postsaccal obstruction.
Tirakunwichcha et al. in Thailand, in their study in 2010, which included 111 patients with acquired lacrimal system obstruction, reported that 71 (64%) patients had presaccal obstruction and 40 (36%) patients had postsaccal obstruction . However, in USA, Woog  in his retrospective study which retrieved the records of 587 patients with symptomatic acquired lacrimal outflow obstruction in Olmsted County, Minnesota, from 1976 to 2000, found that 67.6% of the patients had postsaccal obstruction.
The main site of obstruction, in the present study, was the common canaliculus, which is the same finding reported by Tirakunwichcha et al . However, Woog  reported that NLD was the main site of obstruction in 2/3 of his patients. This can be attributed to that in developed countries like USA with a better medical care and a higher socioeconomic status, the main cause of lacrimal passage obstruction is primary NLD obstruction, whereas in developing countries like Egypt and Thailand, the socioeconomic status is low and trachoma is endemic. It is well known that trachoma can cause multiple lacrimal passage complications, including punctal phimosis, punctal occlusion, canalicular occlusion, NLDO, dacryocystitis, dacryocystocele, and dacryocutaneous fistula. In addition, histopathologic examination of the lacrimal sac biopsies performed during dacryocystorhinostomies has shown the same cicatrizing changes seen in the conjunctival biopsies and of the epithelial lining in the lacrimal sac [8-10].
Moreover, in Egypt, the very common use of Kohl as an eye cosmetic, which is a very old cultural custom since the ancient empire, is mostly a second reason . We interestingly reported that 78.99% of the female patients, included in the present study, used to apply Kohl as eyeliner cosmetic for a period ranging from 1 to 35 years, with an average of 15.62 years. Comparing the four subgroups regarding the percentage of females using Kohl yielded no statistically significant difference between the subgroups. Previous studies that tested Kohl samples reported a significant amount of lead, which sometimes accounts for more than half of the weight of a sample of Kohl. Kohl may also contain aluminum, antimony, carbon, iron, titanium, calcium, magnesium, oxygen, silver, silicon, sulfur, and zinc compounds, as well as camphor and menthol ,.The effect of Kohl on the lacrimal passages was documented by Hidaya et al.  who reported eight patients with chronic dacryocystitis using Kohl as eyeliner cosmetics, and during dacryocystorhinostomy, focal to diffuse black pigmentation was found in the lacrimal sac, scar tissue obstructing the common canaliculus, in the subcutaneous tissues around the fistula and in the periosteum of the lacrimal sac fossa. Histologically, chronic inflammatory infiltrate, mainly lymphocytes, surrounded the fine to coarse extracellular pigment. In addition, energy-dispersive analysis of X-rays of all biopsy specimens revealed a high lead content. Other less frequent elements included silicon, carbon, sulfur, silver, magnesium, iron, and aluminum. The Kohl used by the patients was also tested and showed the same elements as detected in the biopsy specimens.
| Conclusion|| |
The main site of obstruction was the common canaliculus as 65.4% of the patients had canalicular problems. The second most common site of obstruction was NLD followed by the puncta.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Amato J, Hartstein ME. Evaluation of the tearing patient. In: Cohen AJ, Mercandetti M, Brazzo BG, editors. The Lacrimal System Diagnosis, Management and Surgery. New York, NY: Springer 2006. 66–73
Schaefer DP. Acquired etiologies of lacrimal system obstructions. In: Cohen AJ, Mercandetti M, Brazzo BG, editors. The Lacrimal System Diagnosis, Management and Surgery. New York, NY: Springer 2006. 46–49
Tirakunwichcha S, Rengwanidchakul E, Asawaphureekorn S, Tengtrisorn S, Juangphanich K, Suramethakul P et al.
Incidence of acquired lacrimal drainage system obstruction in epiphoric patients in Thailand. Asian Biomed 2010; 4:159–162.
Woog JJ. The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota, 1976-2000 (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc 2007; 105:649–666.
Bukhari A. Etiology of tearing in patients seen in an oculoplastic clinic in Saudi Arabia. Middle East Afr J Ophthalmol 2013; 20:198–200.
] [Full text]
Das AV, Rath S, Naik MN, Ali MJ. The incidence of lacrimal drainage disorders across a tertiary eye care network: customization of an indigenously developed electronic medical record system-eyeSmart. Ophthalmic Plast Reconstr Surg 2019; 35:354–356.
Starks VS, Yoon MK. Acquired obliteration of the proximal lacrimal drainage system. Ophthalmic Plast Reconstr Surg 2019; 35:342–345.
Tabbara KF, Bobb AA. Lacrimal system complications in trachoma. Ophthalmology 1980; 87:298–301.
Rice CD, Kersten RC. Absence of Chlamydia in trachomatous lacrimal sacs. Am J Ophthalmol. 1988; 105:203–206.
Janssen K, Gerding H, Busse H. Recurrent canaliculitis and dacryocystitis as a sequela of persistent infection with Chlamydia trachomatis. Ophthalmologe 1993; 90:17–20.
De Caluwé JP. Lead poisoning caused by prolonged use of kohl, an underestimated cause in French-speaking countries. J Fr Ophtalmol 2009; 32:459–463.
Al-Hazzaa SA, Krahn PM. Kohl: a hazardous eyeliner. Int Ophthalmol 1995; 19:83–88.
Hardy AD, Walton RI, Myers KA, Vaishnav R. Availability and chemical composition of traditional eye cosmetics (‘kohls’) used in the United Arab Emirates of Dubai, Sharjah, Ajman, Umm Al-Quwain, Ras Al-Khaimah, and Fujairah. J Cosmet Sci 2006; 57:107–125.
Hidayat AA, Weatherhead RG, Al-Rajhi A, Johnson FB. Conjunctival and lacrimal sac pigmentation by kohl (eyeliner). Br J Ophthalmol 1997; 81:4.
[Table 1], [Table 2], [Table 3]