What is the preferred initial procedure for diagnosing and treating nasolacrimal duct obstruction, ROPLAS (Rapid Orthostatic Pulse-Lowering Assessment and System) or lacrimal syringing?

From the Research

Lacrimal syringing is the preferred initial procedure for diagnosing and treating nasolacrimal duct obstruction, not ROPLAS. The most recent and highest quality study, 1, compared the diagnostic accuracy of manual regurgitation on pressure over the lacrimal sac (ROPLAS) versus lacrimal irrigation for screening nasolacrimal duct obstruction (NLDO) in adults prior to intraocular surgeries. The study found that ROPLAS had a low sensitivity of 54.5% and a low positive predictive value in detecting NLDO, whereas lacrimal irrigation was more accurate.

Key Points:

• Lacrimal syringing involves irrigating the tear drainage system with saline solution using a blunt cannula inserted into the punctum.
• The procedure confirms the obstruction and may therapeutically clear minor blockages.
• Before syringing, topical anesthetic drops should be applied to the eye.
• For complete obstructions that don't resolve with syringing, patients may require more advanced interventions such as balloon dacryoplasty or dacryocystorhinostomy (DCR).
• Lacrimal syringing is effective because it directly tests the physical patency of the nasolacrimal system while potentially clearing mucus plugs or debris that may be causing the obstruction, as supported by 2 and 3.

Procedure:

• Gently dilate the punctum
• Insert the cannula
• Slowly inject saline while observing for reflux or passage into the throat
• If the patient tastes the saline in the back of the throat, the duct is patent; if fluid refluxes through the opposite punctum, an obstruction exists. The study 4 also compared the post-cataract endophthalmitis rates among eyes undergoing syringing or ROPLAS test prior to cataract surgery and found that the rates were comparable, but this does not change the fact that lacrimal syringing is more accurate for diagnosing NLDO. In summary, lacrimal syringing is the preferred initial procedure for diagnosing and treating nasolacrimal duct obstruction due to its higher accuracy and effectiveness in testing the physical patency of the nasolacrimal system.