Functional Obstructions of the Lacrimal System

  • Mohammad Javed Ali


Functional obstructions of lacrimal drainage systems are an underdiagnosed entity. Epiphora in the presence of a patent lacrimal pathway and absence of alternative etiology could be the simplest description. Nomenclature has been confusing since functional issues of the lacrimal system have been poorly defined. Terms used include functional block, physiologic dysfunction, and functional acquired epiphora; however, the most common terminology used is functional nasolacrimal duct obstruction (FNLDO) [1–5]. Few authors have defined FNLDO to also include partial obstructions [5] but would be misleading since there is an anatomical issue rather than a functional one. Functional epiphora can be an alternate and probably a better term [1]. It is of utmost importance to rule out other causes of epiphora before labeling a case as functional. Functional issues can be of the upper or lower lacrimal system. Altered outflow dynamics without anatomical narrowing in the upper system is known to occur in older patients (mean age 57–64 years) with a high incidence of bilaterality (86 %) [6, 7]. These findings in upper system dysfunctions supports the theory of decreasing efficiency of the lacrimal pump secondary to weakening of the orbicularis oculi with increasing age as suggested by Jones in 1957 [8] and later supported by Worst in 1971 [9]. In addition, the lower system dysfunctions also occur more frequently in younger patients. This chapter aims to describe the clinical examinations, investigations, management, and outcomes of functional epiphora.


Functional Obstruction Functional Issue Lacrimal System Tear Breakup Time Lacrimal Drainage System 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Chan W, Malhotra R, Kakizaki H, et al. Perspective: what does the term functional mean in the context of epiphora? Clin Experiment Ophthalmol. 2012;40:749–54.PubMedCrossRefGoogle Scholar
  2. 2.
    Domerest BH, Milder B. Dacryocystography. The pathologic lacrimal apparatus. AMA Arch Ophthalmol. 1955;54:410–21.CrossRefGoogle Scholar
  3. 3.
    Montanara A, Ciabattoni P, Rizzo P. Stenoses and functional disorders of the lacrimal drainage apparatus. Radiological examination. Surv Ophthalmol. 1979;23:249–58.PubMedCrossRefGoogle Scholar
  4. 4.
    Moscato EE, Dolmetsch AM, Silkiss RZ, Seiff SR. Silicone intubation for the treatment of epiphora in adults with presumed functional nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2012;28:35–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Conway ST. Evaluation and management of “functional” nasolacrimal blockage: results of a survey of the American Society of Ophthalmic Plastic and Reconstructive surgery. Ophthal Plast Reconstr Surg. 1994;10:185–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Hurwitz JJ, Welham RAN. Radiography in functional lacrimal testing. Br J Ophthalmol. 1975;59:323–31.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Cheung LM, Francis IC, Stapleton F, et al. Symptoms assessment in patients with functional and primary acquired nasolacrimal duct obstruction before and after a successful dacryocystorhinostomy surgery: a prospective study. Br J Ophthalmol. 2007;91:1671–4.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Jones LT. Epiphora. II. Its relation to the anatomic structures and surgery of the medial canthal region. Am J Ophthalmol. 1957;43:203–12.PubMedCrossRefGoogle Scholar
  9. 9.
    Worst JGF. In: Veirs ER, editor. The lacrimal system. St. Louis: Mosby; 1971. p. 98.Google Scholar
  10. 10.
    McNeill EJ, Kubba H, Bearn MA, et al. The management of rhinitis in patients with functional epiphora: a randomized controlled crossover trial. Am J Rhinol. 2005;19:588–90.PubMedGoogle Scholar
  11. 11.
    Kashkouli MB, Mirzajani H, Jamshidian-Tehrani M, et al. Reliability of fluorescein dye disappearance test in assessment of adults with nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2013;29:67–9.CrossRefGoogle Scholar
  12. 12.
    Cuthbertson FM, Webber S. Assessment of functional nasolacrimal duct obstruction–a survey of ophthalmologists in the southwest. Eye (Lond). 2004;18:20–3.CrossRefGoogle Scholar
  13. 13.
    Chung YA, Yoo IR, Oum JS, et al. The clinical value of dacryoscintigraphy in the selection of surgical approach for patients with functional lacrimal duct obstruction. Ann Nucl Med. 2005;19:479–83.PubMedCrossRefGoogle Scholar
  14. 14.
    Wearne MJ, Pitts J, Frank J, et al. Comparison of dacryocystography and lacrimal scintigraphy in the diagnosis of functional nasolacrimal duct obstruction. Br J Ophthalmol. 1999;83:1032–5.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Francis IC, Chan DG, Papalkar D, et al. Videoreflective dacryomeniscometry in normal adults and in patients with functional or primary acquired nasolacrimal duct obstruction. Am J Ophthalmol. 2005;139:493–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Athanasiov PA, Madge S, Kakizaki H, et al. A review of bypass tubes for proximal lacrimal drainage obstruction. Surv Ophthalmol. 2011;56:252–66.PubMedCrossRefGoogle Scholar
  17. 17.
    Peter NM, Pearson AR. External dacryocystorhinostomy for the treatment of epiphora in patients with patent but non-functioning lacrimal systems. Br J Ophthalmol. 2010;94:233–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Fulcher T, O’Connor M, Moriarty P. Nasolacrimal intubation in adults. Br J Ophthalmol. 1998;82:1039–41.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Connell PP, Fulcher TP, Chacko E, et al. Long term follow up of nasolacrimal intubation in adults. Br J Ophthalmol. 2006;90:435–6.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Tucker SM, Linberg JV. Measurement of the resistance to fluid flow. Ophthalmology. 1995;102:1639–45.PubMedCrossRefGoogle Scholar
  21. 21.
    Demirci H, Elner VM. Double silicone intubation for management of partial lacrimal system obstruction. Ophthalmology. 2008;115:383–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Wormald PJ, Tsirbas A. Investigation and endoscopic treatment for functional and anatomical obstruction of the nasolacrimal duct system. Clin Otolaryngol Allied Sci. 2004;29:352–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Sahlin S, Rose GE. Lacrimal drainage capacity and symptomatic improvement after dacryocystorhinostomy in adult presenting with patent lacrimal drainage systems. Orbit. 2001;20:173–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Brewis C, Yung M, Merkonidis C, et al. Endoscopic dacryocystorhinostomy in functional lacrimal obstruction. J Laryngol Otol. 2008;122:921–3.PubMedCrossRefGoogle Scholar
  25. 25.
    O’Donnell B, Shah R. Dacryocystorhinostomy for epiphora in the presence of a patent lacrimal system. Clin Experiment Ophthalmol. 2001;29:27–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Delaney YM, Khooshabeh R. External dacryocystorhinostomy for treatment of acquired partial nasolacrimal duct obstruction in adults. Br J Ophthalmol. 2002;86:533–5.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Cho WK, Paik JS, Yang SW. Surgical success rate comparison in functional nasolacrimal duct obstruction: simple lacrimal stent versus endoscopic versus external dacryocystorhinostomy. Eur Arch Otorhinolaryngol. 2013;270:535–40.PubMedCrossRefGoogle Scholar

Copyright information

© Springer India 2015

Authors and Affiliations

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

Personalised recommendations