The incidence of adult lacrimal obstructive disease accounts for about 3% of all outpatients in ophthalmology clinics. These patients carry tissues with them at all times, and in their daily lives, the distress and embarrassment caused by “washing their faces with tears and pus every day” is difficult for ordinary people to understand. At the same time, the discharge from the inflammation of the lacrimal sac is like a “dynamite pack” hanging next to the eye, and there is always a risk of intraocular and periocular infections. However, most patients are confused about the pathogenesis and progression of lacrimal obstructive diseases and make assumptions and wrong choices of treatment, which is not conducive to effective treatment and later recovery.
In retrospect, the most frequently asked question in the treatment of lacrimal duct disease is “What is lacrimal duct obstruction?” “Is lacrimal duct obstruction and dacryocystitis the same thing?” “Can dacryocystitis be cured with eye drops?” “What method can completely cure dacryocystitis?” The following is a list of questions about lacrimal duct obstructive diseases.
The direction of drainage of normal tears: tears from the tear gland secretion from the outer upper part of the eye to the inner lower part of the drainage, through the upper and lower tear dots, into the upper and lower tear duct, summary into the common tear duct after entering the tear sac, nasolacrimal duct, and finally through the nasolacrimal duct in the opening of the lower nasal tract discharge, the drainage of normal tears can not only lubricate the eye, but also has the role of sterilization and flushing. Therefore, when the tear duct is blocked, the number and composition of bacteria within the tear fluid changes, so that the eye is immersed in bacterial tears all day long, which can cause conjunctivitis, keratitis, etc. and endanger the eye. At the same time, tear drainage erodes the eyelids, resulting in dry skin, pigmentation, and lower lid ectropion.
If we compare the tear duct (the drainage system of the eye) to a “sewer”, we can understand that there is no way to solve a clogged sewer without unclogging it.
According to the different parts of the obstruction, the tear duct obstruction can be roughly divided into the following cases,.
A, the common tear duct obstruction
When the blockage of the common lacrimal duct occurs, tears can not enter the tear sac, the lacrimal pathway is blocked, tear overflow symptoms, but will not appear pus overflow situation, the best treatment plan should be: the unblocking of the common lacrimal duct (laser, electric dredging) + the implantation of linear silicone tube.
Second, nasolacrimal duct obstruction
Nasolacrimal duct obstruction means that tears can enter the tear sac through the lacrimal duct and the common lacrimal duct, but obstruction occurs at the outlet of the nasolacrimal duct to the nasal cavity. Simple nasolacrimal duct obstruction, manifested as tear overflow symptoms, acupressure tear sac area from the tear sac through the lacrimal duct reflux into the conjunctival sac. The preferred treatment option recommended for simple nasolacrimal duct obstruction is lacrimal laser + nasolacrimal duct stent implantation (no hospitalization, short treatment time, no facial trauma, success rate although not high, but treatment can be repeated after treatment failure, or optional surgery). If the lacrimal sac cavity is large (judged by lacrimal sac imaging) can also choose transdermal incision nasal lacrimal sac anastomosis (long hospitalization, facial scarring, trauma, higher success rate) and transnasal endoscopic nasal lacrimal sac anastomosis (short hospitalization, no facial scarring, small trauma, high surgical success rate, the above two treatment modalities can still be chosen after failure)
Chronic dacryocystitis
When the nasolacrimal duct is blocked and combined with infection, it is dacryocystitis. The manifestation is overflowing tears, overflowing pus, acupressure lacrimal sac area has purulent secretion from the lacrimal sac through the lacrimal duct reflux into the conjunctival sac. It is recommended to prefer: transnasal endoscopic nasal lacrimal sac anastomosis (short hospital stay, no scar on the face, less trauma, high success rate of surgery), followed by transdermal incision nasal lacrimal sac anastomosis (long hospital stay, scar on the face, more trauma, higher success rate).
Fourth, lacrimal cysts and acute dacryocystitis
When obstruction of the common lacrimal duct and nasolacrimal duct occurs at the same time, and the retention of purulent secretions in the lacrimal sac is combined with infection, it manifests as tear overflow, no pus overflow, bulging of the lacrimal sac area, fluctuating sensation in the lacrimal sac area with finger pressure, and no purulent secretion reflux forming a lacrimal cyst. In the above cases, chronic inflammation can develop into acute lacrimal cystitis, and the skin of the lacrimal sac area in the inner canthus will become red, swollen and painful, and an abscess will form under the skin, and if it is not treated effectively, the abscess will gradually be confined from the skin surface to break down and form a fistula, which will not heal for a long time.
The treatment of lacrimal cysts and acute dacryocystitis needs to be divided into two stages: 1. establishing nasal drainage channels to drain tears and pus from the nasal cavity (the purpose of this stage of treatment is to solve the problem of obstruction of the nasolacrimal ducts in the lower lacrimal tract, to release the pressure in the lacrimal sac, and to relieve and control the infection), and tearing even after this stage of treatment (at the end of this stage, many patients will ask “why Why do I still have tears after surgery?” Here is a unified answer to this question, because the obstruction of the common lacrimal duct has not been solved, and it is important to know that the lacrimal duct is a drainage channel, and any obstruction in any part will lead to tearing) 2. unblocking of the common lacrimal duct (laser, electric dredging) + implantation of a linear silicone tube (to solve the problem of obstruction of the common lacrimal duct). The above two phases of treatment should be done at an interval of 3 to 6 months, or at the same time if conditions permit.
Treatment options for lacrimal sac cysts are preferred transnasal endoscopic nasal lacrimal sac anastomosis (low position of the intranasal drainage port facilitates tear drainage), followed by transdermal incision nasal lacrimal sac anastomosis. Acute dacryocystitis is recommended to be preferred: transnasal endoscopic nasal lacrimal sac anastomosis (facilitates rapid inflammation control,) followed by skin abscess incision and drainage, and another transdermal incision nasal lacrimal sac anastomosis (poor inflammation control, long treatment time, facial scarring).
List of (recommended) treatment options for lacrimal obstructive diseases
Obstruction of the common lacrimal duct
Nasolacrimal duct obstruction
Chronic dacryocystitis
lacrimal cysts
Acute dacryocystitis
Dacryocystic laser/electrical dredging
+++
+++
+
+
lacrimal laser + lacrimal line drainage tube
+++++
+
+
+
lacrimal laser + nasolacrimal duct stent
+++
++
+++
Transdermal incision lacrimal sac nasal anastomosis
++++
++++
+++
Transnasal endoscopic lacrimal sac nasal anastomosis
+++++
+++++
+++++
+++++
Note: This table is a recommendation for the treatment plan of lacrimal obstructive disease based on clinical experience, and the “+” represents the possibility of clinical cure for reference only
In conclusion, the main objective of treatment for lacrimal obstructive disease is to unblock or establish new lacrimal drainage channels, but to maintain lacrimal drainage flow, it is necessary to counteract the pathophysiological processes such as scar formation and inflammation after treatment trauma, so that the newly established lacrimal channels do not close, which is not an easy task. The treatment of lacrimal obstruction is not easy. Therefore, patients should not only fully understand their condition before treatment, but also be prepared for the long treatment period and the tortuous treatment process, and ask the doctor to design the most suitable treatment plan in order to get rid of the tearing and pus completely.