This guideline last updated 06/05/2022 17:45:26

Differential diagnosis

• Canaliculitis
• Dacryocystitis
• Tumour of lacrimal sac or canaliculi (rare)
• Facial nerve palsy

Possible management by Optometrist

• Jones fluorescein dye test
  • Significant amount of fluorescein remaining in tear meniscus two minutes or more after instillation indicates restricted drainage
  • Check for appearance of fluorescein in the nose (examine tissue after nose blow; if fluorescein present, lacrimal system is patent
  • Place anaesthetic-soaked cotton bud in nose (if bud stained with fluorescein after 5 minutes, lacrimal system is patent)
• Lacrimal syringing (only to be done if appropriately trained)
  • Instil a drop of topical anaesthetic
  • Gently dilate punctum with punctal dilator
  • Syringe with normal saline via lacrimal cannula
  • If saline passes into nose (patient swallows and tastes salt) – nasolacrimal system is patent
  • If there is resistance to the passage of the cannula and reflux from opposed canaliculus – common canaliculus is stenosed
  • If no saline passes into nose – complete lacrimal duct obstruction

Treatment

• Treat any cause of dry eye to reduce secondary lacrimation
• Lacrimal lavage (saline syringing) may be effective in some case
• Topical antibiotic if clinical evidence of infection
• Ask if allergic to Chloramphenicol
• If not, supply Chloramphenicol 1% eye ointment 3 times daily for a week
• If allergic to Chloramphenicol, or pregnant, supply Fucidic acid 1% liquid gel twice a day for a week

Advice

• Surgery invasive and requires general anaesthesia
• Conservative management often best

Management Category

• Initial management (including drugs) followed by routine referral

Possible management by Ophthalmologist

• Punctal dilatation where there is stenosis
• Canalicular curettage for Actinomyces infection
• Dacryocystorhinostomy (DCR)