Taking the crying out of an epiphora exam

Take Home: Michael S. Ehrlich, MD, explains how a simple lacrimal irrigation technique not only can avoid unnecessary discomfort for patients, but also adds diagnostic value for ophthalmologists.

Plastics Pearls By Michael S. Ehrlich, MD

New Haven, CT-Excessive tearing, or epiphora, is a common chief complaint in general and subspecialty oculoplastics practice.

Causes of epiphora can be broadly classified into ocular surface disorders, eyelid malposition, nasolacrimal duct obstruction, and canalicular obstruction. Extensive history taking should be undertaken to narrow down the differential diagnosis. Specific questions of medication history, sinus disease, trauma, infection, and chronicity can be helpful.

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Even after a careful history, however, the majority of these patients require lacrimal irrigation to determine the anatomic cause of the patients’ symptoms, as well as to formulate a medical and/or surgical plan.

Patients are often referred to our subspecialty practice having previously undergone diagnostic lacrimal irrigation in the past. After explaining that it is necessary to irrigate their lacrimal system not only to confirm a blockage, but also to observe the pattern of reflux, patients are often still hesitant. Why?

The traditional method of dilation and irrigation can be quite uncomfortable. A simple irrigation technique is one that patients report to be comfortable and that I find to add diagnostic value.

Traditional lacrimal irrigation cannulas range in size from 21 to 25 gauge. This large size often requires the punctum and upper canaliculus to be dilated before the cannula will fit. Once dilated, the large size of the cannula requires a 90° turn laterally to allow laminar flow into the lacrimal system. Patients may report significant painful pressure during both dilation and irrigation.

Next: Eliminating unnecessary step

In 90% of cases, the dilation step is unnecessary. Instead, I use the following technique:

Place a drop of proparacaine into the fornix. Screw a 30-gauge disposable anterior chamber cannula with a 6-mm bend (Wilson Ophthalmic) onto a luer-lock 3-cc syringe. Fill the syringe with irrigating fluid. A sterile contact lens solution is my preference, because it is easy for the patient to taste in the throat.

The 30-gauge cannula fits directly into the puncta (Figure 1). Fluid can be passed into the lacrimal system without the traditional dilation and 90° lateral turn. If resistance is met, the bent cannula can be advanced in the usual manner.

This technique is particularly informative in cases where there is an initial partial blockage noted with the 30-gauge cannula. The punctum is dilated and irrigation is repeated. If improved flow is noted, the patient will benefit from a punctual-enlarging procedure, such as a three-snip punctoplasty.

After performing irrigation without dilation, patients often wonder “why it had to hurt so much when the other doctor did it.”

Michael S. Ehrlich, MD, is assistant professor of ophthalmology, and director, oculoplastics and orbital surgery, Yale Eye Center, New Haven, CT. He did not indicate a financial interest in the subject matter.