Stenosis of the Tear Duct

How the tear drainage system works

Tears are made by the lacrimal gland above the outer corner of the eye. They wash across the eye and drain through two tiny openings (puncta) at the inner corners of the upper and lower eyelids. From there they pass along small canals (canaliculi) into the tear sac beside the nose, and then down the nasolacrimal duct into the nose. That is why your nose runs when you cry.

Stenosis can occur at any of these levels:

Symptoms

• Watery eye (epiphora), with tears spilling onto the cheek, worse in cold or windy weather
• Sticky, mucus-like discharge and crusting of the lashes, especially in the morning
• Blurred vision from a pool of tears
• Sore, red skin on the lower eyelid from constant wiping
• Repeated eye infections or conjunctivitis on the same side
• A swelling at the inner corner of the eye if the tear sac fills up

Causes

In babies (congenital)

The nasolacrimal duct forms before birth and the end into the nose is usually opened by a thin membrane breaking down. In about 1 in 20 babies the membrane stays closed. A watery, sometimes sticky eye appears in the first weeks of life. It resolves by itself by 12 months in about 9 out of 10 babies. It is more common in babies with Down syndrome and facial differences such as cleft palate.

Stenosis of the tear duct in adults

• Primary acquired nasolacrimal duct obstruction: gradual scarring and narrowing of the duct with age, with no clear cause. It is more common in women over 50, perhaps because the duct is narrower.
• Sinus and nasal disease: chronic sinusitis, nasal polyps and sinus surgery.
• Injury: broken nose or cheekbone, or a cut through the inner eyelid.
• Infection and inflammation: repeated dacryocystitis, canaliculitis, conjunctivitis, sarcoidosis and granulomatosis with polyangiitis.
• Medicines: some chemotherapy drugs (for example docetaxel and 5-fluorouracil), long-term glaucoma drops and radioactive iodine.
• Tumors: rarely, a tumor of the tear sac or nose. Blood-stained tears are a warning sign.

Bilateral tear duct stenosis

Stenosis in both eyes is common in babies and in age-related narrowing. In adults, bilateral blockage may also point to a body-wide cause, such as sinus disease, inflammatory conditions, or chemotherapy. Both sides are assessed separately, because each may be blocked at a different level.

Diagnosis

An eye doctor will first exclude other causes of watering, such as dry eye (which paradoxically causes reflex tearing), blepharitis, an inward- or outward-turning eyelid, and eyelashes rubbing the eye. Tests include:

1. Dye disappearance test: a drop of fluorescein dye normally drains from the eye within 5 minutes. Dye that lingers suggests a blockage.
2. Examining the puncta with a slit lamp to see if they are narrowed.
3. Syringing (irrigation): saline is gently flushed through the punctum. If it reaches the throat, the system is open. If it refluxes back out, it shows where the block is.
4. Imaging: dacryocystography or CT in complex cases, after injury, or if a tumor is suspected.

Treatment

For babies

• Massage: gentle downward pressure over the tear sac, at the inner corner of the eye beside the nose, a few times a day.
• Cleaning: wipe away discharge with cooled boiled water and clean cotton, inner corner outward.
• Antibiotic drops only for a clearly infected eye.
• Probing: if the blockage persists, usually after about 12 months, a thin probe is passed through the duct to open it, often under brief general anesthesia. It succeeds in most children. Silicone tubes or balloon dilation are used if it fails.

For adults

• Punctal stenosis: a small procedure (punctoplasty) to widen the opening, done under local anesthetic.
• Partial duct narrowing: balloon dilation or silicone stents may help.
• Complete nasolacrimal duct obstruction: dacryocystorhinostomy (DCR) creates a new opening between the tear sac and the nose. It can be done through a small skin incision near the nose or from inside the nose (endoscopic). Success rates are high, around 9 in 10.
• Canalicular blockage: may need a Lester Jones tube, a small glass tube that drains tears directly into the nose.

Treating mild symptoms is optional. Many adults with only occasional watering choose not to have surgery.

Complications

The main complication is infection of the tear sac (dacryocystitis), which causes a painful, red swelling beside the nose and can spread to the eyelid tissues. Chronic watering also causes skin irritation and blurred vision. Before cataract or other eye surgery, a blocked, infected tear duct is usually treated first.

Frequently asked questions

What is tear duct stenosis?

Tear duct stenosis is a narrowing of the tear drainage openings, canals or duct between the eye and the nose. Tears cannot drain normally, so the eye waters, and stagnant tears can cause sticky discharge and infection.

What causes stenosis of the tear duct in adults?

The commonest cause is gradual age-related narrowing of the nasolacrimal duct, especially in women over 50. Other causes include sinus disease, facial injury, repeated infections, some chemotherapy drugs and long-term eye drops. Rarely, a tumor narrows the duct.

Can a blocked tear duct clear on its own?

In babies, yes: about 9 in 10 clear by the first birthday. In adults, age-related narrowing does not usually reverse, though a blockage caused by temporary swelling from infection may improve once it settles.

Is DCR surgery painful?

DCR is done under general or local anesthetic, so the operation itself is not painful. Afterward, most people have mild discomfort, some bruising and a stuffy nose for a week or two, managed with simple pain relievers.