Blocked Tear Duct

A blocked tear duct is a condition in which there is a partial or complete blockage in the tear drainage system, which is a pathway that carries tears from your eyes into the nose. When there is a blocked tear duct, your tears cannot drain normally, which leaves your eye – watery and irritated. It is commonly seen in newborns, which usually resolves within the first year of life, without any treatment.

In adults, a blocked tear duct may happen due to an injury, an infection or a tumor. It is almost always correctable. Treatment depends on the cause of the blockage as well as the age of person affected.

Signs and symptoms of a blocked tear duct may include:

• Increased tearing (epiphora) resulting in watery eyes or tears overflowing down your face. In infants, this appears during the first 2-3 weeks after birth.
• Redness in the white portion of your eye.
• Recurring eye infection or inflammation (pink eye).
• Crusts on your eyelashes and eyelids
• Mucus or pus discharge from the surface of your eyes.
• Blurred vision

If tear ducts get blocked, the bacteria that get entrapped in the nasolacrimal sac can cause infection called dacryocystitis. Symptoms of this infection include:

• Inflammation or swelling associated with pain and redness at the inner corner of your eye or around the eye and nose.
• Blood in the tears
• Fever

 The symptoms of a blocked tear duct may become worse following a cold or sinus infection. Also, symptoms may  aggravate and become more noticeable after exposure to cold, wind or sunlight.

When to see a doctor

Consult your doctor if you have had constant tears in your eyes for several days or if you get repeated infections in your eyes. Sometimes, a tumor that presses on the tear drainage system may be the cause for your blocked tear duct. In such cases, early diagnosis of the tumor can give you more treatment options.

Blocked tear ducts can happen at any age, and may even be seen in newborns. Causes of this condition include:

    Congenital blockage: Some infants may be born with a blocked tear duct. The tear drainage mat not be completely developed in them or there may be a duct abnormality. The fetus growing in the uterus will have a thin membrane sealing the nasolacrimal duct. If this tissue membrane remains even after birth, a blocked tear duct may result. Craniofacial abnormalities due to abnormal development of the skull and face that occur in Down syndrome or other disorders increase the likelihood of having blocked tear ducts.

    Age-related changes: In older people, the punctal openings that drain tears may get narrower leading to blockage.

    Infection or inflammation: Chronic infection or inflammation of the conjunctival portion of eyes, tear drainage system or nose can cause your tear ducts to become blocked. Chronic sinusitis results in irritation of the tissues and formation of scars, which cause blockage in the tear duct system.

   Injury or trauma: A facial injury may cause bone damage or scarring near the tear drainage system, which disrupts the normal flow of tears through the ducts. If tiny particles of dirt or loose skin cells get entrapped in the duct, it can cause blockage. Scar tissue resulting from nose trauma, such as a broken nose, may block the tear duct.

  Tumor: A nasal polyp (a growth in the nasal lining) or tumor in the nose or anywhere along the tear drainage system can cause blockage by pressing on the ducts and preventing the flow of tears.

  Eyedrops: Long-term use of eyedrops used to treat glaucoma can cause a blocked tear duct, but is very rare.

  Cancer treatments: A blocked tear duct may sometimes occur as a side effect of chemotherapy medications and radiation treatment given for cancer.

How the tear drainage system works

   Tears are constantly produced in the lacrimal glands to protect your eye surface. These glands are located inside the upper lids above each eye. Normally, tears flow from the lacrimal glands over the surface of your eye, and then drain into a small opening called puncta, which is located in the corner of your eye near your nose. 

   Your eyelids have small canals (canaliculi) that carry tears to the lacrimal sac. From the sac, the tears travel down through the nasolacrimal duct into your nose. The tears get reabsorbed in the nose.

   A blockage can occur anywhere in this tear drainage system, from the puncta to your nose. When that happens, your tears buid up and tend to overflow onto your cheek even when you are not crying. You may have watery eyes and increase your risk of eye infections and inflammation.

Making a diagnosis of blocked tear duct is done by several tests.

You may initially consult your primary care doctor. Later, after evaluation, you may be referred to a doctor who specializes in treating disorders of the eye (ophthalmologist). In some cases, your eye doctor may refer you to someone who specializes in ophthalmic plastic surgery for the eye.

Here is some information that can help you get ready for your appointment.

What you can do

Before going to your appointment make a list of the following:

• Symptoms you are experiencing, including those that may seem unrelated to the reason for your appointment.
• All your regular medications, vitamins, and supplements, including their doses.
• Any eyedrops that you have been using.

Questions to ask your doctor

   For a blocked tear duct, some basic questions to ask your doctor include:

• What may be the most likely cause for my symptoms?
• Are there any other possible causes?
• Do I need any other tests?
• How long will this condition last?
• What treatments are available, and which one do you suggest?
• What side effects may occur after treatment?
• Is this condition related to another medical disorder?
• Are there any risks to my vision if I do not do anything to rectify this problem?
• Are there any brochures or other printed materials that I can take with me? What websites do you recommend?

What to expect from your doctor

Your doctor may ask you a number of questions, such as:

• When did you begin experiencing your symptoms?
• Are your symptoms continuous, or do they come and go?
• Is there anything that relieves your symptoms?
• Have you ever used any eyedrops for this problem?
• Did you undergo any kind of surgery on your eyes or eyelid?
• Did you suffer from facial trauma or injuries? 
• Have you undergone radiation treatment or surgery?
• Have you ever had any facial nerve conditions, such as Bell's palsy?
• Do you have any medical problems such as diabetes or long-term skin disorders, such as atopic dermatitis?
• Have you ever been diagnosed with a thyroid disorder?
• Do you use contact lenses or have you used contacts before?

To diagnose your condition, your ophthalmologist will discuss with you about your symptoms and medical history, do a thorough examination of your eyes to check whether there are any other possible causes. The inner portion of your nose will also be examined to check whether there are any structural disorders in your nasal passages that cause an obstruction. If your doctor suspects a blocked tear duct, a number of tests may be done to examine the tear drainage system and detect the exact location of the blockage. 

Tests used to diagnose a blocked tear duct include:

• Tear drainage test: This test measures how fast your tears can drain. A drop of a special dye is placed on the surface of each eye. If most of the fluid remains on your eye surface even after five minutes, you may have a blocked tear duct. 
• Irrigation and probing: Your doctor may flush a special fluid (saline solution) through your tear duct opening to check how well it is draining. A blockage in the tear duct seems to be present if the fluid cannot be tasted in your throat. Or a thin probe may be inserted through the tiny drainage holes at the corner of your lid (puncta) to check for blockages. In some cases, even this probing may solve the problem.
• Eye imaging tests: For these procedures, a contrast dye is passed from the puncta in the corner of your eye through your tear drainage system. Then X-ray, computerized tomography (CT) scan of the area of your tear duct (dacryocystogram) or magnetic resonance imaging (MRI) images are taken to find the location and cause of the blockage.

The treatment for blocked tear duct depends on the cause of obstruction in the tear drainage system. Often, more than one approach may be required to correct this problem. If a tumor is found to be the cause of your blocked tear duct, treatment is focused towards the cause of the tumor. Surgery may be needed to remove the tumor, or your doctor may consider other treatments to shrink it.

• Medications to fight infection: If an infection is present, your doctor is likely to prescribe antibiotic eyedrops or pills.
• Watch-and-wait or massage: Most babies born with congenital blocked tear duct often improve without any intervention. This happens once the drainage system matures and the extra membrane covering the entrance of the nasolacrimal duct opens up. If your baby's blocked tear duct is not improving, your ophthalmologist may recommend that you use a special massage technique to help open up the membrane. The massage should be performed once in the morning and once in the evening, and each massage should include ten strokes each. It is good to perfom a massage during diaper change.

In cases of blocked tear ducts cause by facial injury, the tear drainage system starts working on its own after a few months. As the swelling reduces, the tear ducts may get unblocked on thier own. No additional treatments would be required in such cases. For this reason, your doctor may recommend waiting for a few months after the injury before taking up surgery to open up the blocked tear duct. 

• Dilation, probing and irrigation: For infants and toddlers with blocked tear ducts that have not opened on their own or in adults with partial blockage or narrowing of the puncta, this technique is used , and is done under general anesthesia. Your doctor will enlarge the punctal opening with a special dilation instrument and insert a thin probe through the puncta, and then the tear drainage system is irrigated with a saline solution to flush out residual blockage. 
• Balloon catheter dilation: A balloon catheter dilation procedure is used if other treatments have not worked or if there is narrowing of tear drainage passages due to scarring or inflammation. It is usually performed in infants and toddlers, and may also be used in adults with partial blockage. The procedure is done under general anesthesia. Your doctor guides a thin tube with a deflated balloon attached to its end through the tear duct blockage. Your doctor inflates and deflates the balloon a few times, using a pump to open up the blockage.
• Stenting or intubation: In this procedure, which is usually done under general anesthesia, a tiny tube made up of silicone or polyurethane is threaded through one or both puncta located at the corner of your eye. These tubes then pass all the way through the tear drainage system and come out through your nose. A small loop of the tubing will stay at the corner of your eye, and these tubes are generally remain there for about three to four months after which they are removed. Possible complications include inflammation due to the presence of tube.
• Surgery: Surgery is the most preferred option for correction of blocked tear ducts. It is also recommended in infants and toddlers with blocked tear ducts, but only after other treatments become unsuccessful. If a tumor has been detected as a cause of your blocked tear duct, surgical removal of the tumor may be performed, or other treatments to shrink the tumor may be considered.

The surgical procedure that is commonly used to treat most blocked tear ducts in adults is called dacryocystorhinostomy (DAK-ree-oh-sis-toe-rye-nohs-tuh-me). But, it is rarely done in children. This procedure forms a new route for tears to drain out through your nose again. It is accomplished by developing a connection between your lacrimal sac and your nose. This new path bypasses the nasolacrimal duct, which is often the site of blockage. Stents are usually placed in this new route during healing, and then removed after three to four months of surgery. You will be given a general anesthetic or a local anesthetic if it is performed as an outpatient procedure. The steps in this procedure will vary, depending on the exact location and extent of your blockage, as well as your surgeon's experience and preferences.

•   External: With external dacryocystorhinostomy, your surgeon makes an incision on the side of your nose, where the lacrimal sac is located. After the lacrimal sac is connected to your nasal cavity and placement of a stent is done in the new passageway, the surgeon closes up the skin incision with a few stitches.
•   Endoscopic or endonasal: In this method, your surgeon makes use of a microscopic camera and other tiny instruments that are inserted through the nasal opening into your duct system. This method does not require any incision, and hence leaves no scar. However, the success rates are not as high as with the external procedure.

You will be advised to use a nasal decongestant spray and eyedrops following surgery in order to prevent infection and reduce inflammation. After three to six months, you will return to your doctor's office for removal of any stents that were placed to keep the new channel open during the healing process.

Get prompt treatment whenever you get an eye infection or inflammation in order to prevent the development of blocked tear duct later in life. To prevent eye infection, follow these tips:

•     Wash your hands frequently and thoroughly.
•     Do not rub your eyes.
•     Do not share your eyeliner and mascara with others. Replace these regularly.
•     If you use contact lenses, maintain them clean by following the instructions given by the manufacturer and your ophthalmologist.

Certain factors can increase your risk of developing a blocked tear duct. These include:

•    Age and gender: Elderly women are at a greater risk of developing blocked tear ducts as a result of age-related changes.
•   Chronic eye inflammation: If your eyes are subjected to continuous irritation, redness, and inflammation (conjunctivitis), you are at a higher risk of developing a blocked tear duct.
•    Surgery in the past: Previous surgery involving the eyes, eyelid, nose or sinus may result in some scarring of the duct system, which can result in a blocked tear duct later.
•    Glaucoma: Anti-glaucoma medications are often used administered in the form of eyedrops. If you have used these or other type of topical eye medications for a long period, you are at a higher risk of developing a blocked tear duct.
•    Previous cancer treatment: If you have undergone radiation or chemotherapy for the treatment of cancer, especially if the radiation was targeted on your face or head, you are at a higher risk of developing a blocked tear duct.

Complications

Recurring eye infection and inflammation: When your tears cannot drain normally, the tears that collect in the drainage system become stagnant. This allows multiplication of bacteria, viruses and fungi that lead to recurrent eye infections and inflammation. Any portion of the tear drainage system, including the clear membrane over your eye surface (conjunctiva) can get infected or inflamed because of a blocked tear duct.

An infection in the part of the nasolacrimal duct called the lacrimal sac is called dacryocystitis: Usually, a bump may form in the corner of your eye, on the side of the nose. Treatment for this is oral antibiotics. Sometimes, the sac will require a surgical drainage.