What is the role of the Jones Dye test in diagnosing and managing nasolacrimal duct obstruction in patients with symptoms of excessive tearing or eye discomfort, particularly those with a history of facial trauma, nasal surgery, or conditions affecting the lacrimal apparatus?

Jones Dye Test in Nasolacrimal Duct Obstruction

Overview and Clinical Utility

The Jones dye test is a functional assessment of the nasolacrimal drainage system that helps differentiate between anatomical obstruction and functional drainage problems in patients with epiphora, though it has largely been superseded by more reliable diagnostic methods. 1

The test consists of two components that are performed sequentially to localize the site and nature of lacrimal drainage dysfunction 2:

Jones Dye Test 1 (Primary Test)

Procedure

• Instill fluorescein dye (typically 2% solution) into the inferior conjunctival fornix 2
• Wait 5 minutes to allow the lacrimal pump mechanism to function 3
• Retrieve dye from the inferior nasal meatus using a cotton-tipped applicator or have the patient blow their nose into white tissue 2

Interpretation

• Positive result (dye recovered from nose): Indicates patent and functional nasolacrimal drainage system 2
• Negative result (no dye in nose): Suggests either anatomical obstruction or functional drainage impairment, requiring Jones Dye Test 2 2

A modified version shows 91% correlation with lacrimal scintigraphy when the patient blows each nostril separately into white tissue and the degree of fluorescein staining is assessed 2

Jones Dye Test 2 (Secondary Test)

Procedure

• Performed only if Jones Dye Test 1 is negative 2
• Irrigate the lacrimal system with saline through the lower punctum using a lacrimal cannula 1
• Observe whether fluorescein-stained fluid (residual from Test 1) reaches the nose 2

Interpretation

• Positive result (fluorescein-stained fluid recovered): Indicates functional pump failure with patent anatomical system 2
• Negative result (clear saline or no fluid recovered): Suggests anatomical obstruction of the nasolacrimal duct 2

Diagnostic Accuracy and Limitations

The traditional Jones tests have significant limitations in clinical practice 3, 2:

• Sensitivity concerns: The standard Jones Dye Test 1 has variable reliability and can miss partial obstructions 3
• Specificity issues: False negatives are common, particularly in cases of incomplete obstruction 3
• Operator dependence: Results vary based on technique and timing 2

Superior Alternative: Micro-Reflux Test

The Micro-Reflux Test (MRT) demonstrates superior diagnostic accuracy with 97% sensitivity and 95% specificity for complete nasolacrimal duct obstruction, making it a more reliable screening tool than traditional Jones testing. 3

MRT Procedure

• Instill 2 drops of 0.25% sodium fluorescein in the inferior cul-de-sac 3
• Have patient blink 5 times to activate the lacrimal pump 3
• Blot excess fluorescein with tissue 3
• Position patient at slit lamp with cobalt blue filter at 5x magnification 3
• Massage tissue overlying lacrimal sac in counterclockwise direction with moderate pressure 3
• Positive test: Continued reflux of fluorescein-stained tears from inferior punctum after initial massage indicates complete obstruction 3

MRT Advantages

• Positive predictive value of 95% and negative predictive value of 97% 3
• Non-invasive compared to irrigation 3
• Rapid screening method that can be performed at the slit lamp 3

Comprehensive Diagnostic Approach

Initial Assessment

The functional evaluation of the nasolacrimal system should be part of specialized clinical evaluation, not routine comprehensive examination 1:

• External examination: Assess lacrimal apparatus, tear function, and globe position 1
• Fluorescein dye disappearance test: Abnormal if less than 10 seconds 1
• Tear break-up time: Evaluate tear film stability 1
• Schirmer testing: Assess aqueous tear production if indicated 1

Anatomical Localization

When obstruction is suspected based on history of facial trauma, nasal surgery, or conditions affecting the lacrimal apparatus 4:

• Palpation of lacrimal region: Essential for detecting dacryocystitis or lacrimal sac distension 4
• Observation for mucopurulent discharge: Suggests postsaccal obstruction 4
• Slit-lamp examination of puncta: Assess patency and position 1

Advanced Diagnostic Testing

For patients with negative or equivocal dye testing 4, 2:

• Lacrimal scintigraphy: Gold standard for functional assessment, showing 91% correlation with modified Jones testing 2
• ENT consultation: Obligate prior to lacrimal surgery to evaluate nasal anatomy 4
• Imaging: Not routinely indicated unless complications suspected 1

Clinical Decision Algorithm

1. Patient presents with epiphora → Perform external examination and assess for anatomical abnormalities (ectropion, trichiasis, corneal irritation) 4, 2

2. If anatomical causes excluded → Perform Micro-Reflux Test as initial screening 3

3. If MRT positive → Complete nasolacrimal duct obstruction confirmed; proceed to ENT consultation and surgical planning 4, 3

4. If MRT negative → Perform fluorescein dye disappearance test and modified Jones Dye Test 1 2

5. If modified Jones Dye Test 1 negative → Perform Jones Dye Test 2 to differentiate functional from anatomical obstruction 2

6. If results equivocal → Consider lacrimal scintigraphy for definitive functional assessment 2

Common Pitfalls

• Performing Jones testing without first excluding anatomical causes: Always rule out ectropion, trichiasis, and corneal pathology before functional testing 4, 2
• Inadequate waiting time: Insufficient time between dye instillation and retrieval leads to false negatives 3
• Overlooking partial obstructions: Traditional Jones Dye Test 1 may miss incomplete stenosis 3
• Proceeding to surgery without ENT evaluation: Nasal pathology must be excluded before lacrimal surgery 4
• Ignoring functional pump failure: Positive Jones Dye Test 2 indicates the drainage system is patent but not functioning, requiring different management than anatomical obstruction 2