Many chronic dry eye patients will experience flare-ups, despite our best efforts. Since inflammation propagates the vicious cycle of dry eye disease (DED), maintaining proper tear flow and drainage is of utmost importance in preventing stagnant inflammatory mediators from accumulating on the ocular surface. Additionally, it can be challenging to determine the root cause or chronicity of DED, due to its multifactorial nature, and epiphora is no exception. Understanding the nasolacrimal system and its anatomy can help us navigate these sometimes “turbulent waters.”

Case Example

A 49-year-old female presented with an intermittent, asymmetric epiphora (OS > OD) that had intensified over a three-month period. She also noticed gritty debris OS upon waking, but denied photophobia, pain, swelling, discharge, or tenderness. Although similar symptoms had occurred in the past, they always resolved with topical ophthalmic antihistamines and digital massage. Her current therapy included lifitegrast ophthalmic solution 5% b.i.d., hyaluronic-based artificial tears, and fish-derived EPA/DHA supplementation.

Biomicroscopy revealed an increased tear meniscus OS, trace superficial punctate keratitis, tear breakup of five seconds OD and OS, and a negative dye disappearance test OS. No pericanalicular edema, erythema, or “pouting punctum” was noted, and both lids demonstrated normal apposition. The patient was diagnosed with chronic epiphora secondary to a nasolacrimal duct or canalicular obstruction.

Topical ophthalmic anesthesia was given, and dilation of the inferior punctum was performed with a straight lacrimal dilator, followed by saline irrigation of the lacrimal system using a 25-gauge cannula attached to a 3cc syringe. There was obvious resistance to irrigation with retrograde flow.

A second attempt resulted in immediate ejection of a gelatinous brown mucous plug (Figure 1) from the superior punctum, followed by a mixture of saline and mucus, indicating that flow between the inferior and superior canaliculi was restored. However, since the patient did not report saline drainage to her throat, a blockage at the common canaliculus remained. The procedure was repeated three more times until irrigation was no longer forceful and the patient confirmed fluid drainage in her throat.

A topical antibiotic-steroid suspension was prescribed t.i.d. OS for five days and she was instructed to continue her current dry eye regimen. Although an oral antibiotic is sometimes prescribed for prophylaxis treatment of soft tissue infection, it was not warranted in this case as no significant signs of acute infection were observed. The patient had complete resolution of epiphora at her two-week follow-up and also reported an improvement in her dry eye symptoms.

We discussed the likelihood of recurrence and the possible need for culturing and imaging and/or an oculoplastic consultation to rule out secondary causes of nasolacrimal duct obstruction including infectious, inflammatory, neoplastic, mechanical, and traumatic etiologies.

Future Considerations

Take a second look at the medial canthus on your next dry eye evaluation. Pay close attention to tear flow and blink mechanics. Remember that dilation and irrigation is another valuable and efficient procedure in our toolbox to improve dry eye symptoms by restoring normal tear flow on the ocular surface, even in cases of non-obvious epiphora. CLS