• Congenital absence/fistula
• Trauma/ Post radiation Trauma/ Post radiation
• Compression by adjacent tumours
Lacrimal Sac Abnormality
o Sac inflammation
o Perilacrimal fibrosis
o Sac tumors (rare in pediatric age group)
o Adnexal tumors pressing on lacrimal sac or drainage
NASOLACRIMAL DUCT OCCLUSION
• NLD obstruction
• Delayed opening of Hasner’s valve,
• Cranio facial anomalies
• Primary obstruction
• Secondary obstruction: tumour, trauma
o Severe Deviated Nasal Septum or Turbinate Hypertrophy
Excessive tears production
Reflex lacrimation in response to various factors
Trichiatic cilia severe entropion,
raised IOP allergic conjunctivitis,
corneal exposure, drug irritation
environmental irritants like pollution
• Ocular surface disorders like chronic KCS,
conjunctivochalasis, cicatricial ocular surface
• Neurogenic hypersecretory disorders like
compressive irritation of parasympathetic lacrimal
fibres, Aberrant regeneration of facial nerve
• Facial palsy
OF A PATIENT WITH
• Careful history
• External examination
• Slit lamp biomicroscopy
• Syringing and probing
• constant versus intermittent tearing
• periods of remission versus no remission
• unilateral or bilateral condition
• subjective ocular surface discomfort
• history of allergies
• use of topical medications
• history of probing during childhood
• prior ocular surface infections
• prior sinus disease or surgery, midfacial trauma, or nasal fracture
• previous episodes of lacrimal sac inflammation
• clear tears versus tears with discharge or blood
The eyelids : malpositions, entropion, ectropion,or
The puncta : malpositions, stenosis, agenesis,atresia
or accessory puncta.
SLIT LAMP BIOMICROSCOPY:
• abnormalities of eyelids,
• position of punctas,size and patency,discharge,
• size of caruncle,
• eyelid laxity, blinking mechanism,
• marginal tear strip,
• Tearfilm debris,
• papillae or follicles
• pinguecula,pterygium, conjunctival chelosis.
• Ocular cicatricial pemphigoid.
These tests helps in localization of
● Syringing / irrigation
● Diagnostic probing
● To access functioning of lacrimal apparatus
under physiologic conditions
● Performed only when there is no evidence
of obstruction in anatomical tests
Flourescein dye disappearance test
Jones dye test I
DYE DISAPPERANCE TEST
• heavily relied upon in children, in whom lacrimal
irrigation is impossible without deep sedation
• Instillation of fluorescein drops 2% into the
conjunctiva of both eyes then examine after 5
• Normally, very little or no dye present
• significant residual dye or prolonged retention is an
indication of inadequate drainage of the dye
Dye test grading
• 0=No fluorescein in the conjunctival sac
• 1=Thin flurescing marginal tear drop persists
• 2=More fluorescein persists somewhere between 1
and 3 grades
• 3=Wide brightly fluorescein tear strip
• Grades 0 and 1 are considered normal
JONES DYE TESTING
Jones I test, or primary dye test:
• Differentiates partial obstruction from
hypersecretion of tears.
• Fluorescein 2% drops instilled into the conjunctiva.
• After about 5 minutes, cotton tipped applicator
inserted under the inferior turbinate.
• Positive: Detection of fluorescein from the nose
means patency of the system.
• Negative: No dye detected, means either a partial or
absolute obstruction or failure of the lacrimal pump.
Jones II test, or secondary dye test:
• the residual fluoresce in is flushed from the
conjunctival sac following an negative jones 1 test.
• clear saline is placed in to the inferior canaliculus
• irrigant is retreived from nasal cavity
• Positive: Recovery of dye stained saline from the
nose meaning a partial obstruction of the NLD.
• Negative: Recovery of unstained saline through the
nose means total obstruction of the upper drainage
system or a defective lacrimal pump mechanism.
• After topical anaesthesia, curved lacrimal cannula
on a saline filled syringe is gently inserted into lower
punctum & advanced
• Canula comes to either hard or soft stop
• Hard stop:it comes to stop at medial wall of sac
through which rigid lacrimal bone is felt…this
indicates obstruction of nasolacrimal duct
• Soft stop:it comes to stop at junction of common
canaliculus & lacrimal sac(lateral wall)….
it indicates common canalicular block
Lacrimal Sac Syringing
• most frequently performed immediately after a DDT
to determine the level of lacrimal drainage system
• After instillation of topical anesthesia, the lower
eyelid punctum is dilated
• The irrigating cannula is placed in the canalicular
• To prevent canalicular kinking and difficulty in
advancing the irrigating cannula ,lateral traction of
the lower eye lid
• clear saline is injected and the results noted
Complete canalicular obstruction. The cannula is advanced with difficulty,
and irrigation fluid refluxes from the same canaliculus
Complete common canalicular obstruction. A "soft stop" is encountered at the
level of the lacrimal sac, and irrigated fluid ref luxes through the opposite
Soft stop is a spongy feeling due to canalicular obstruction
Complete nasolacrimal duct obstruction. The cannula is easily advanced to the
medial wall of the lacrimal sac, then a "hard stop" is felt, and irrigation fluid ref
luxes through the opposite punctum.
If the probe touches the medial orbital wall, this means Hard Stop.
Partial nasolacrimal duct obstruction. The cannula is easily placed, and
irrigation fluid passes into the nose as well as refluxing through the opposite
Patent la crimal drainage system. The cannula is placed with ease, and
most of the irrigation fluid passes into the nose .
Contrast Dacryocystography (DCG)
• Technique: Plastic catheters are placed into one
canaliculus in both eyes, 1ml lipidol is
simultaneously injected through both catheters
• Water's view radiographs are taken, 5 minutes later,
an erect oblique film is taken.
• Results: The site of obstruction is usually evident.
Diverticula, filling defects due to stones and
strictures can be diagnosed.
• Scintillography is used to assess the lacrimal
drainage system under physiological conditions.
• Technique: Tchnetium-99 is delivered by a
micropipette to the inferior conjunctival sac. The
tracer is imaged using a gamma camera.
● Epiphora foll. Trauma with NLD obst.
R/o orb. Rim/ max. #
● Infant with cystic mass at med. Can.
Amniocele v/s meningocele
● Suspected malignancy
• 1.0 mm diameter rigid endoscope or fibroptic
flexible endoscopes was inserted through the puncti
and canaliculi to inspect the lining mucosa of
lacrimal system, its contents and investigating DCR