Treatment of Clogged Tear Duct (Nasolacrimal Duct Obstruction) in Adults
For adults with primary acquired nasolacrimal duct obstruction causing epiphora, dacryocystorhinostomy (DCR) remains the standard surgical treatment, with success rates exceeding 90%, while less invasive options like polyurethane stent placement can be considered in select patients with appropriate anatomy. 1, 2
Initial Conservative Management
Before proceeding to definitive treatment, conservative measures should be attempted:
- Warm compresses and massage of the lacrimal sac area may provide temporary relief by promoting drainage 1
- Topical antibiotics if signs of dacryocystitis (infection of the lacrimal sac) are present 1
- These measures rarely resolve complete obstruction but can manage acute inflammatory episodes 1
Diagnostic Evaluation
The workup should establish:
- Complete versus partial obstruction through irrigation testing - saline injected through the punctum should flow freely into the nose if patent 2
- Lacrimal sac size via dacryocystography or imaging - normal or enlarged sacs are more amenable to stenting procedures 2
- Presence of dacryocystitis - recurrent infections indicate need for more urgent intervention 1
Definitive Treatment Algorithm
First-Line: Dacryocystorhinostomy (DCR)
DCR is the gold standard surgical procedure for primary acquired nasolacrimal duct obstruction in adults 1:
- Creates a new drainage pathway between the lacrimal sac and nasal cavity, bypassing the obstructed nasolacrimal duct 1
- Requires thorough understanding of lacrimal apparatus anatomy and its relationship to surrounding nasal structures 1
- Should be performed by surgeons experienced in oculoplastic or otolaryngologic procedures 1
Alternative: Polyurethane Stent Placement
For select patients, minimally invasive stent placement may be considered 2:
Ideal candidates include:
- Patients with normal or large lacrimal sac size on imaging 2
- Complete or partial nasolacrimal duct obstruction 2
- Those preferring nonsurgical approach or with contraindications to DCR 2
Technical approach:
- Performed under fluoroscopic guidance with mean screening time of 3.2 minutes 2
- Ritleng probe advanced through upper punctum past the obstruction 2
- Hollow polyurethane stent placed retrograde over guide wire into lacrimal sac and duct 2
- Technical success rate of 93% with overall clinical success of 82% 2
Limitations and complications:
- Stent occlusion can occur (7% complete occlusion rate) 2
- Requires appropriate lacrimal sac anatomy - not suitable for small or fibrotic sacs 2
- Long-term patency data limited compared to DCR 2
Important Caveats
Avoid punctal plugs in the setting of nasolacrimal duct obstruction - while punctal plugs are used for dry eye management, they can worsen epiphora when outflow obstruction exists and have been associated with canaliculitis and dacryocystitis 3, 4. The American Academy of Ophthalmology specifically notes that thermal labile polymer plugs placed intracanalicularly have been associated with these infectious complications 4.
Address underlying inflammation - chronic inflammation from either ascending nasal disease or descending ocular disease can initiate the pathophysiologic cascade leading to permanent obstruction through mucosal swelling, connective tissue remodeling, and eventual fibrous closure 5. Repeated episodes of dacryocystitis accelerate this process 5.
Consider anatomic factors - the nasolacrimal system contains a cavernous body with vegetative innervation that regulates tear outflow 5. Malfunctions in this system, whether from inflammation or autonomic dysregulation, can contribute to obstruction 5.