Disorders of the Upper Lacrimal System



Proximal lacrimal outflow disorders are sparsely documented in the literature [1–9]. Disorders of the upper lacrimal system pose much more challenges in terms of management as compared to the lower system. These disorders can be broadly classified as congenital or acquired. In order to simplify this topic, we will broadly discuss it under the following three headings:


Nasolacrimal Duct Slit Lamp Biomicroscopy External Membrane Nasolacrimal Duct Obstruction Lacrimal System 


  1. 1.
    Ahn Yuen SJ, Oley C, Sullivan TJ. Lacrimal outflow dysgenesis. Ophthalmology. 2004;111:1782–90.CrossRefGoogle Scholar
  2. 2.
    Cahill KV, Burns JA. Management of epiphora in the presence of congenital punctal and canalicular atresia. Ophthal Plast Reconstr Surg. 1991;7:167–72.PubMedCrossRefGoogle Scholar
  3. 3.
    Lyons CJ, Rosser PM, Welham RAN. The management of punctal agenesis. Ophthalmology. 1993;100:1851–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Buerger DG, Schaefer AJ, Campbell CB, et al. Congenital lacrimal disorders. In: Nesi F, Levine MR, editors. Smith’s ophthalmic plastics and reconstructive surgery. Philadelphia: Mosby; 1998. p. 649–60.Google Scholar
  5. 5.
    Kirk RC. Developmental anomalies of the lacrimal passages. A review of the literature and presentation of three unusual cases. Am J Ophthalmol. 1956;42:227–32.PubMedCrossRefGoogle Scholar
  6. 6.
    Duke-Elder S. Development of ocular adnexa. In: Duke-Elder S, editor. System of ophthalmology, volume 1. St Louis: CV Mosby; 1938. p. 364–5.Google Scholar
  7. 7.
    Viers ER. Disorders of the nasolacrimal apparatus in infants and children. J Pediatr Ophthalmol. 1966;3:32.Google Scholar
  8. 8.
    Katowitz WR, Katowitz JA. Congenital etiologies of lacrimal system obstructions. In: Cohen AJ, Mercandetti M, Brazzo BG, editors. The lacrimal system. New York: Springer; 2006. p. 35–42.CrossRefGoogle Scholar
  9. 9.
    Whitnall SE. The lacrimal apparatus. In: Whitnall SE, editor. The anatomy of the human orbit and accessory organs of vision. London: Oxford University Press; 1921. p. 223–52.Google Scholar
  10. 10.
    Olver J. Pediatric lacrimal surgery. In: Olver J, editor. Colour atlas of lacrimal surgery. Oxford: Butterworth-Heinemann; 2002. p. 69–89.Google Scholar
  11. 11.
    Kashkouli MB. Assessment and management of proximal and incomplete symptomatic obstruction of the lacrimal system. Middle East Afr J Ophthalmol. 2012;19:60–9.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Kashkouli MB, Beigi B, Murthy R, et al. Acquired external punctal stenosis. Etiology and associated findings. Am J Ophthalmol. 2003;136:1079–84.PubMedCrossRefGoogle Scholar
  13. 13.
    Beard C. Congenital and hereditary abnormalities of the eyelids, lacrimal system and orbit. In: Symposium on surgical and medical management of congenital anomalies of the eye, Transaction of the New Orleans academy of ophthalmology. St Louis: CV Mosby; 1968. p. 412.Google Scholar
  14. 14.
    Putterman AM. Treatment of epiphora with absent lacrimal puncta. Arch Ophthalmol. 1973;89:125–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Welham RA, Hughes SM. Lacrimal surgery in children. Am J Ophthalmol. 1985;99:27–34.PubMedCrossRefGoogle Scholar
  16. 16.
    Ali MJ, Honavar SG, Naik MN. Endoscopically guided minimally invasive bypass tube intubation without DCR: evaluation of drainage and objective outcomes assessment. Minim Invasive Ther Allied Technol. 2013;22:104–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Klapper SR, Jordan DR. Jones tube insertion in children with canalicular agenesis. Ophthalmic Surg Lasers. 1999;30:495–8.PubMedGoogle Scholar
  18. 18.
    Boerner M, Seiff SR, Arroyo J. Congenital absence of lacrimal puncta. Ophthalmic Surg. 1995;26:53–6.PubMedGoogle Scholar
  19. 19.
    Henderson PN. A modified trephining technique for the insertion of Jones tube. Arch Ophthalmol. 1985;103:1582–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Rose GE, Welham RAN. Jones lacrimal canalicular bypass tubes: twenty five years experience. Eye. 1991;5:13–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Gladstone GJ, Putterman AM. A modified glass tube for conjunctivodacryocystorhinostomy. Arch Ophthalmol. 1985;103:1229–30.PubMedCrossRefGoogle Scholar
  22. 22.
    Ali MJ, Mohapatra S, Mulay K, et al. Incomplete punctal canalization: the external and internal punctal membranes. Outcomes of membranotomy and adjunctive procedures. Br J Ophthalmol. 2013;97:92–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Mainville N, Jordan DR. Etiology of tearing: a retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthal Plast Reconstr Surg. 2011;27:155–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Caesar RH, McNab AA. A brief history of punctoplasty: the three snip revisited. Eye. 2005;19:16–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Kashkouli MB, Beigi B, Astbury N. Acquired external punctal stenosis: surgical management and long-term follow up. Orbit. 2005;24:73–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Hurwitz JJ. Diseases of the punctum. In: Hurwitz JJ, editor. The lacrimal system. Philadelphia: Lippincott-Raven; 1996. p. 149–53.Google Scholar
  27. 27.
    Port AD, Chen YT, Lelli GJ. Histopathological changes in punctal stenosis. Ophthal Plast Reconstr Surg. 2013;29:201–4.PubMedCrossRefGoogle Scholar
  28. 28.
    Mathew RG, Olver JM. Mini-monoka made easy: a simple technique for mini-monoka insertion in acquired punctal stenosis. Ophthal Plast Reconstr Surg. 2011;27:293–4.PubMedCrossRefGoogle Scholar
  29. 29.
    Hussain RN, Kanani H, McMullan T. Use of mini- monoka stents for punctal and canalicular stenosis. Br J Ophthalmol. 2012;96:671–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Konuk O, Urgancioglu B, Unal M. Long term success rates of perforated punctal plugs in the management of acquired punctal stenosis. Ophthal Plast Reconstr Surg. 2008;24:399–402.PubMedCrossRefGoogle Scholar
  31. 31.
    Chalvatzis NT, Tzamalis AK, Mavrikakis I, et al. Self-retaining bicanaliculus stents as an adjunct to 3-snip punctoplasty in the management of upper lacrimal duct stenosis. A comparison to standard 3 snip procedures. Ophthal Plast Reconstr Surg. 2013;29:123–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Chak M, Irvine F. Rectangular 3 snip punctoplasty outcomes: preservation of lacrimal pump in punctoplasty surgery. Ophthal Plast Reconstr Surg. 2009;25:134–5.PubMedCrossRefGoogle Scholar
  33. 33.
    Kim SE, Lee SJ, Lee SY, et al. Outcomes of 4-snip punctoplasty for severe punctal stenosis: measurement of tear meniscus height by optical coherence tomography. Am J Ophthalmol. 2012;153:769–73.PubMedCrossRefGoogle Scholar
  34. 34.
    Ma’luf RN, Hamush NG, Awwad ST, et al. Mitomycin C as adjunct therapy in correcting punctal stenosis. Ophthal Plast Reconstr Surg. 2002;18:285–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Fraser CE, Petrakos P, Lelli Jr GJ. Adjunctive re-dilatation for early cicatrization after punctoplasty. Orbit. 2012;31:313–5.PubMedCrossRefGoogle Scholar
  36. 36.
    Ali MJ, Naik MN. Canalicular wall dysgenesis: the clinical profile of canalicular hypoplasia and aplasia, associated systemic and lacrimal anomalies and clinical implications. Ophthal Plast Reconstr Surg. 2013;29:464–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Hurwitz JJ. Embryology of the lacrimal drainage system. In: Hurwitz JJ, editor. The lacrimal system. Philadelphia: Lippincott-Raven; 1996. p. 9–13.Google Scholar
  38. 38.
    Welham RAN, Bergin DJ. Congenital lacrimal fistulas. Arch Ophthalmol. 1985;103:545–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Francois J, Bacskulin J. External congenital fistulae of the lacrimal sac. Ophthalmologica. 1969;159:249–61.PubMedCrossRefGoogle Scholar
  40. 40.
    Sullivan TJ, Clarke MP, Morin JD, et al. The surgical management of congenital lacrimal fistulae. Aust N Z J Opthalmol. 1992;20:109–14.CrossRefGoogle Scholar
  41. 41.
    Rasor C, cited by Schirmer R. Graefe-Saemisch Handbuch der Augenheilkunde, vol. 8. Leipzig: Engelmann; 1877, p. 1–58.Google Scholar
  42. 42.
    Jones LT, Wobig JL. Survey of the eyelids and lacrimal system. Birmingham: Aesculapius Publishing Co; 1976. p. 167–73.Google Scholar
  43. 43.
    Harman NB. A minimal form of fissura facialis. Trans Ophthal Soc U K. 1903;23:256–60.Google Scholar

Copyright information

© Springer India 2015

Authors and Affiliations

  1. 1.Dacryology ServiceL.V. Prasad Eye InstituteBanjara Hills, HyderabadIndia

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