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Blocked tear duct

Definition


Disease: Blocked tear duct Blocked tear duct
Category: Eye diseases

Disease Definition:

A complete or partial obstruction in the tear drainage system may end up causing the blockage of a tear duct.
The drainage system of tears begins inside the corner of the eye, carrying tears away from the eye surface to the nose; the place where they evaporate or are reabsorbed. A person may have a watery and irritated eye in case their tears can't drain normally due to a blocked tear duct.

Statistics show that 20% of newborn babies have a blocked tear duct, but it normally disappears in the first year of life. An infection, inflammation, an injury or a tumor could cause adult tear blockage. The disorder is correctable, but treatment depends on the main cause and the age of the person.

Work Group:


Symptoms, Causes

Symptoms:

Watery eyes and excessive tearing are the major symptoms of a blocked tear duct. Blocked tear ducts usually cause eye infections, causing other symptoms, such as:

 

  • Blurred vision
  • Bloody tears
  • Eye mucous discharge
  • Recurrent eye infections (dacrocystitis)
  • Recurrent eye inflammation (conjuctivitis)
  • Painful swelling of the inside corner of the eye.

 

A person should see a doctor in case their eyes are continually infected or irritated, or if they are watery and leaking. Sometimes, the blocked tear ducts is caused by a tumor pressing on the tear drainage system. More treatment options will be available in case the tumor is diagnosed early.

Causes:

Mostly, tears initiate from glands called Lacrimal located above each eye. Tears shower down the surface of the eyes to lubricate and protect them then drain into small holes called puncta, which are located in the corners of the eyelids.  Tears then travel down small canals in the lids (canaliculi) to a place where the side of the nose and lids are attached (lacrimal sac) to finally end in the nose through a nasolacrimal duct where they are reabsorbed or evaporated. Blockage could happen at any point on the drainage system track, from the puncta to the nose. The tears won't be able to drain properly in case blockage happens, resulting in watery eyes and increasing a person's risk of eye inflammation and infection.

Blocked tear ducts can be congenital or it may occur at any other age. Some of its causes are:

Craniofacial abnormalities:

In this condition, the skull and face aren't developed normally. The possibility of the blockage of tear ducts is increased by some craniofacial irregularities, such as Down Syndrome.

Congenital blockage at birth:

About 20% of newborns have tear blockage. Here, the tear draining system may not be fully developed when the baby was a fetus, there may be a duct irregularity. In congenital blockage, a thin tissue membrane covers the opening of the channel that pours into the nose (nasolacrimal duct). Usually, during the 1st or 2nd month of the baby's life, this layer opens.

Age-related eye changes:

Due to some changes of the eyes and eyelids that elders experience, they may suffer from blockage of tear ducts.

Eye infections or inflammation:

Sever inflammation or infection of the eyes, nose, or tear drainage system can cause blockage.

Cysts or stones:

Cysts and stones mold in the tear duct system, forming blockages.

Facial injuries or trauma:

The normal flow of tears through the ducts may be disrupted due to bone damage near the drainage system cause by an injury to the face.

Topical medications:

In some rare cases, the cause of a blocked tear duct may be the usage or long-term topical medications, such as those that are used in treating glaucoma.

Tumors:

Nasal, sinus or lacrimal sac tumors -as they grow larger- can block the duct system in case they occur along this system.

Other medications:

Docetaxel , a commonly used chemotherapy medication for breast or lung cancer, could cause side effects such as the blockage of a tear duct.

Complications

Complications:

Tears remaining in the blocked drainage system become stagnant, encouraging the growth of viruses, fungi and bacteria. This contributes to repeated eye infection or inflammation. Any part of the tear draining system including the clear layer of the eye surface (conjunctiva) could be infected because of the blockage.

Treatments:

The best treatment for a person will be decided based on the cause of their blockage.
In some cases, more than one treatment is needed to correct the tear duct blockage.

If a tumor is the main reason behind the blockage, treatment will be focused on the cause of the tumor. Shrinking or removing tumor by surgery could be recommended.

Other treatment options for non-tumor blocked tear ducts vary between surgery and simple observation.

Conservative treatment:

During the first few months of life, after the extra nasolacrimal duct opens up or after the drainage system matures, the congenital blockage of tear duct in infants usually improve.

A special massage technique is advised if the blockage does not open on its own. This is done to help open up the layer covering the lower opening in the baby's nose. While pressing on the puncta on the inside of the baby's eye to hinder tears from getting back into the eye, the inside of the baby's nose should be firmly stroked downward. This will force tears down the tear duct system, and could be enough to break through the leftover layer. Massage could be used 2 to 4 times a day. Hearing a popping sound as the layer breaks is normal. Antibiotic drops could be used along with the massage to prevent infection.

If the tear duct blockage is due to a facial injury causing tissue swelling, conservative treatment is also recommended. In such cases after injuries, blocked tear duct would start work again on its own a few (3 to 6) months later and no treatment is needed. To open the blocked tear duct when the blockage lasts more than the period mentioned above, surgical intervention may be recommended.

Minimally invasive treatment:

For babies and toddlers whose blocked tear ducts aren't opening naturally, or for adults who have a partially blocked duct or a partial narrowing (stenosis) of the puncta, minimally invasive treatment is mainly used.

Dilation, probing and irrigation:

In most infants, this procedure is used to open congenital blocked tear ducts. In the case of very young babies, general anesthesia is usually used or a restraint.
At first, a special dilation instrument is used to expand the size of the puncta openings and then a thin probe is inserted through the puncta and into the tear duct system. After that, the probe is threaded all the way out through the nasal opening. Sometimes this causes a popping noise as the probe pierces through the extra layer. Finally, after removing the probe, the tear duct system is flushed with a saline solution to clear out any remaining blockage. In infants less than one year old this treatment successfully clears the blocked tear ducts.

The same operation is done in the doctor’s office for adults with a partially narrowed puncta. The doctor will flush and irrigate the tear duct while the puncta are still enlarged. In the case of any infections, antibiotics may be used. If irrigation (watering) and dilation (expanding) doesn't work, surgery is necessary to open the narrowed puncta. In some other cases, all that it takes could be a small incision at the punctal opening.

Balloon catheter dilation:

Narrowed or blocked drainage passages resulting from scarring, inflammation and other acquired conditions could be opened by this operation. Under general anesthesia, a thin tube (catheter) with a loose balloon attached to its tip is inserted into the lower nasolacrimal duct in the nose. The balloon is filled and emptied for a few times while it is moved to different locations along the duct system. Although this procedure may sometimes be used in adults with a partial blockage, but it is more effective in infants and toddlers.

Stenting or intubation:

Here, tinny silicone or polyurethane tubes are used to pierce into narrowed or blocked tear duct systems. This procedure which is done under general anesthesia requires having a tube stringed through one or both puncta in the corner of the eye all along the way of the tear duct system and out to the nose. After the operation, a small loop of tube is visible at the corner of the eye, but it’s not usually troublesome. These tubes are left for approximately 3 to 6 months and then removed. Inflammation from the presence of the tube is usually the only complication of this procedure.

Surgery:

The most efficient way to correct acquired blocked tear ducts in older children and adults is surgery. It also proved very successful in toddlers and infants, but it’s strictly used after other treatments are tried. Surgery is also used to treat most cases of blocked tear duct ( also called dacryocystorhinostomy) and reconstruct the passageway for tears to flow and dry through the nose normally again. In this procedure, the patient will be generally or locally anaesthetized. After the surgeon accesses the tear drainage system, he/she will create a new and direct connection between the lacrimal sac of the patient and their nose.
The new pathway passes the duct that empties into the nose (nasolacrimal duct); the most common site of blockage. Typically, stents or intubation are located in the new pathway as it heals, and then removed 3 to 6 months after surgery.

The surgery steps differ relating to the exact location, extension of blockage and the surgeon’s experience.
Surgical methods include:

External:

External dacryocystorhinostomy is the most trusted, highly common and successful surgery done to open a blocked tear duct. The patient will be generally anaesthetized, and then the surgeon will create a cut on the side of the patient's nose, near the lacrimal sac. The doctor then will close the cut after connecting the lacrimal sac and the nasal cavity and placing a stent in the new passageway.

Endoscopic or endonasal:

By using endoscopic instruments, the same pathway could be made. Instead of making a cut, the doctor infixes microscopic camera attached to tiny instruments through the nasal cavity to the patient's draining system. A fiber-optic light could be inserted to the puncta to light up the surgical area. The pros of this surgery are that no scar or cut is made and the recovery is generally faster. The cons are that it requires a trained and experienced surgeon and that the success rate is not as high as in external surgery.

Bypassing the entire lacrimal duct system:

A reconstruction of the entire tear draining system called conjunctivodacryocystorhinostomy could be recommended depending on the type of blockage. In this surgery, a channel will be created between the lacrimal sac and the nose. The surgeon will create a totally different tear draining system beginning from the corner of the patient's eye to the nose, completely bypassing the original tear drainage system.

After undergoing this surgery, the patient will need to use a nasal decongestant spray, as well as topical eye-drops to avoid infection and reduce postoperative inflammation. For 2 to 3 weeks after the operation, the patient will need to continue on those medications 2 to 3 times a day. Stents that are kept to hold the new channel open while it healed are removed after 3 to 6 months after the surgery.

Prognosis:

Not available

Expert's opinion

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Yaser Habrawi , F.R.C.S.Ed

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