Diagnostic imaging of the nasolacrimal

drainage system

Excessive watering of the eye is a common condition in ophthalmological practice. It may be the
result of excessive production of tear fluid or obstruction and insufficiency of efferent tear
pathways. The differentiation between obstruction and insufficiency of the lacrimal pathways is still
clinically questionable. In the diagnostic process it is necessary to perform clinical tests and
additional diagnostic imaging is often needed.

Dacryocystography, with or without the extension of the dynamic phase or subtraction option, still
remains

the criterion standard for diagnostic imaging of the lacrimal obstruction. It may help to clarify the
cause and

exact place of the obstruction and provide information for further management, especially surgical
treatment.

Increasingly, new techniques are used in diagnostic imaging of the lacrimal tract, such as computed
tomography, magnetic resonance, and isotopic methods.

Adequate knowledge of the anatomy and physiology of the lacrimal system and the secretion and
outflow of

tears is the basis for proper diagnostic imaging. The purpose of this paper is to present the exact
anatomy of

the lacrimal system, with particular emphasis on the radiological anatomy and the current state of
knowledge

about the physiology of tear secretion and drainage.

Epiphora is a common condition in ophthalmological practice.

It may be the result of an excessive production of tear fluid, or

the obstruction or insufficiency of the efferent tear pathways.

Diagnosis of the latter problem, as well as differentiation between obstruction and insufficiency of
lacrimal pathways, still

is clinically questionable. In the diagnostic process, it is necessary to investigate various causes of

epiphora and perform additional clinical tests. The ophthalmologist must have a thorough
knowledge of anatomy, physiology, and pathophysiology

of the lacrimal apparatus in order to make an adequate diagnosis, determine the causes of excessive
watering of the eye,

and to implement effective medical treatment. In doubtful cases it is necessary to perform

additional tests, including radiology and diagnostic imaging. Dacryocystography (DCG), performed as
a conventional radiology procedure with the use of

contrast media, is considered to be the criterion standard in

the diagnosis of lacrimal tracts pathology. Supported by advanced image processing algorithms and
high-quality modern

contrast media, it enables accurate diagnosis of pathology in

small structures such as the lacrimal duct with fewer adverse

effects. Both dacryocystography and modern diagnostic methods, which are more commonly used in
the lacrimal pathway

imaging, can not only provide answers to questions crucial in

choosing the appropriate treatment method, but also significantly impact the scope of possible
surgical treatment. However,

the radiologist must have a broad knowledge on this particular ailment, be able to select an
adequate imaging method,

have appropriate skills and experience to perform diagnostic procedures, and closely cooperate with
the clinician. Good

knowledge of radiographic anatomy of the orbit and lacrimal

pathways, as well as the physiology of tears outflow, is an essential factor in proper interpretation of
test results.

Radiographic Anatomy of the Orbit and

Lateral Nasal Wall

The normal anatomical structure of an organ usually determines its physiological efficiency. The
visual organ, located

mainly within the facial skeleton, consists of an eye and accessory organs. The eye is made up of the
eyeball, placed in a
4-sided pyramid known as the orbit, and an optic nerve, which

is the only connection between this sense organ and the encephalon. The system of accessory
organs is formed by orbital

fasciae, eyelids, conjunctiva, the lacrimal apparatus, and muscles of the eyeball. The volume of the
orbit is usually about 30

ml, of which the eye occupies only 6–7 ml.

In each orbit, 4 walls, the inlet of the orbit, and its apex, directed medially and posteriorly, can be
identified. The floor

(inferior wall) of the orbit is formed by the orbital surface

of the body of the maxilla, and the anterolateral part of the

floor is filled by the orbital surface of the zygomatic bone and

the posteromedial part by the orbital process of the palatine

bone. In the anteromedial part of the inferior wall, the superior foramen of the nasolacrimal canal,
running along the lateral nasal wall, can be found. The nasolacrimal duct, draining

tears from the lacrimal sac to the nasopharynx, passes through

this bony canal. The inferior ostium of the canal is located on

the surface of the inferior nasal concha. The vertically oriented lateral wall of the orbit is formed by
orbital surfaces of the

zygomatic bone and the greater wing of the sphenoid bone.

The orbital roof is composed of the orbital part of the frontal

bone and the lesser wing of the sphenoid bone. The depression located in the anterolateral part of
the roof is known as

the fossa of the lacrimal gland, named after a gland that is

situated there [1].

Pathological processes leading to the destruction of the bones

forming the scaffold for the lacrimal pathways may cause their

blockage. Knowledge of the anatomy of the medial orbital wall

is particularly important for the radiologist conducting the assessment of the lacrimal pathways. Its
anterior part is formed

by the posterior surface of the frontal process of maxilla and

the lacrimal bone, while the posterior part is formed by the

orbital plate of the ethmoid bone and the lateral surface of

the sphenoid bone. The lacrimal bone, which is the smallest

bone of the facial skeleton (viscerocranium), plays an important role in the construction of the
anterior part of the medial orbital wall. Its orbital surface is divided into 2 parts by the

vertical posterior lacrimal crest. The smooth posterior composes the orbital wall. Located in the
anterior part, the vertical lacrimal sulcus (which, with the similar lacrimal sulcus

of the frontal process of maxilla, forms the fossa of the lacrimal sac), has an average length of 16
mm, width of 8 mm,

and depth of 2–4 mm. This depression is usually slightly less

narrow in women than in men [2]. The lacrimal sac is located

in the superior part of the fossa, while the initial section of

the nasolacrimal duct is in the inferior part of the fossa. The

posterior nasal crest divides the inferior margin of the lacrimal bone into 2 parts: the posterior part
is connected to the

orbital process of maxilla, and anterior part descends lower

and is connected to the lacrimal process of the inferior nasal concha. Due to that latter connection,
the lacrimal bone

helps form the nasolacrimal canal (the bony scaffold for the

nasolacrimal duct, which begins on the medial orbital wall,

runs along the lateral wall of the nasal cavity and enters the

inferior nasal meatus just behind the anterior end of the inferior nasal concha. The nasolacrimal
canal is formed laterally and anteriorly by the lacrimal sulcus of the frontal process

and the body of maxilla, and is formed medially and posteriorly by the lacrimal sulcus of the lacrimal
bone and the lacrimal process of the inferior nasal concha. The lacrimal part

of the orbiculus oculi muscle attaches to the posterior nasal

crest. Insufficiency of this muscle can be the cause of insuffi-ciency of the tear pump or the
insufficiency of lacrimal pathways as a functional block [1,3,4]. Equally important for the

radiological diagnosis of the orbit and lacrimal passages is

the correct assessment of the sutures fusing the bones of the

viscerocranium, especially if trauma of this area is suspected. Looking at the inferior orbital wall, 2
sutures can be seen:

one connecting the orbital process of the palatine bone and

the maxilla (palatomaxillary), and the other one connecting

the zygomatic bone and maxilla (zygomaticomaxillary). The

sphenozygomatic suture connects the greater wing of the

sphenoid bone and the zygomatic bone on the lateral wall.

The connection between the frontal process of the zygomatic bone and the zygomatic process of the
frontal bone is

formed by the frontozygomatic suture, to which the sphenofrontal suture adheres, slightly medially,
forming a horizontal line and the sphenoethmoidal suture on the medial orbital wall. Injuries to
these sutures are encountered in Lefort III

fractures. In this case, the fissure of the fracture runs through

the frontonasal sutures, injuring the medial wall, through the

central parts of the orbit, often with injuries of the superior

orbital fissure, and through the frontozygomatic and temporozygomatic sutures. In this kind of
fracture, the main massif

of the viscerocranium with the zygomatic and nasal bones is

detached from the cranium as a whole. In Lefort II fractures,

injuries of the inferior walls and inferior margins of the orbits

near the zygomaticomaxillary sutures, lacrimal bones, nasal

bridge, fractures of the frontal processes of maxilla, and lateral walls of the maxillary sinuses occur.
Shadowing of the

maxillary sinus can also be seen on radiograms. This type of

fracture can lead to posttraumatic obstruction of the lacrimal pathways (Figures 1 and 2) [5–9].

Fractures of the medial wall of the orbit are also concomitant

with direct injuries of the nasal bone. The fractures are also

the effects of blowout trauma, in which a large, round object

(e.g., a ball) hits the eyeball directly with great force

Anatomy of Nasolacrimal Duct

Giovanni Battista Carcano Leone, the Italian professor of anatomy, was the first to provide an
adequate description of the

nasolacrimal ducts, which he presented in the publication

“Anatomici Libri II” in 1574 in Padua. The research was further carried on by the Danish scholar Niels
Stensen, who in

1662 produced a reliable study on the structure of the whole

lacrimal system [10]. The key function of lacrimal apparatus

is to provide sufficient moisturization of the cornea and retina. It consists of secretory and drainage
sections. The first

section, known as the glandular section, consists of the lacrimal gland and accessory lacrimal glands
known as the glands

of Krause and Wolfirng, sebaceous glands of Zeiss, and meibomian tarsal gland. The second section
consists of lacrimal

pathways that commence near the medial angle of palpebral

fissure with 2 lacrimal puncta – the upper and lower – located on the summits of the lacrimal papilla.
Accessory glands,

which are 40 up to 50 in number, are mainly found in the superior fornix of the conjunctiva. Only a
few of them, usually 5–6, are found in the inferior fornix of the conjunctiva [3]

Lacrimal gland

The lacrimal gland is located in the superolateral part of the

orbit, above the lateral angle of the eyelids. The tendon of the

levator palpebrae superioris muscle divides the gland into a

visibly larger superior part, known as the orbital, with dimensions of 20×12mm. It lies in the fossa of
the lacrimal gland,

which is a small depression in the orbital surface of the frontal bone, right under the zygomatic
process. The much smaller inferior part, known as the palpebral, is located near the
superior fornix of the conjunctiva and can be seen after unrolling the superior eyelid. In normal
conditions, the lacrimal

gland is not visible on a viscerocranium radiogram because

osseous structures, which produce a much stronger shadow,

effectively shade its more subtle shadow. The situation can

differ if there are lumpy changes in the lacrimal gland. When

low-voltage (less than 70 kV) radiation is used, the radiogram

may show a subtle shadowing, which is the basis for further

testing. Nowadays, magnetic resonance and computer tomography are used to image such
pathologies. Ten to 12 excretory

glands come out of the lacrimal gland and drain into the lateral part of the superior fornix of the
conjunctiva [11].

Anatomy of the conjunctival sac and eyelid margins

Eyelids, formed by movable folds of facial skin, protect the eyeball, covering it from the front. Their
function is to provide protection from mechanical injuries and to keep the cornea and

conjunctiva of the eye constantly moisturized. In both superior and inferior eyelids, the anterior
(cutaneous) and posterior (conjunctival) surfaces can be distinguished. Both surfaces

bind with each other on their 2-mm-width free margins, forming anterior and posterior edges of the
eyelid. Orifices of the

tarsal glands, located in the tarsal plate (the connective tissue

scaffold of the eyelids) are positioned near the posterior edge.

The eyelids meet each other on both ends of the palpebral fissure, forming the lateral and medial
angles of the eye. The conjunctiva, which lines the posterior palpebral surface and the

anterior surface of the eyeball, forms the common conjunctival sac. Tears, secreted by lacrimal
glands, do not flow down

unobstructed on the corneal surface, but are spread over it

by blinking, with support of the groove formed by the anterior

surface of the eyeball and free margin of the eyelids, known

also as the rivus lacrimalis [12]. Some tears evaporate, other

gather in the lacrimal lake, surrounding the lacrimal caruncle

situated in the medial angle of the eye. The normal structure

of margins of the eyelids determines the physiological distribution of tear film and normal tear
drainage. Small anatomical abnormalities or excessively loose eyelids cause lacrimal

passage obstruction.

Anatomy of lacrimal passages

The key function of the lacrimal apparatus is to maintain adequate cornea and conjunctiva
moisturization, but also to provide the correct the balance between inflow and outflow of

tears to the lacrimal sac. This specific tear balance guarantees

normal function of the cornea, which mainly refracts light rays

in the vision process. The lacrimal fluid produced by the lacrimal glands is spread across the surface
of the cornea and conjunctiva and penetrates through lacrimal puncta into the lacrimal drainage
system formed by lacrimal canaliculi, the lacrimal

sac, and nasolacrimal ducts. Lacrimal system shapes and sizes

are presented in Figure 3. Lacrimal puncta and canaliculi form

the upper part of the lacrimal pathways (the so-called upper

lacrimal pathways). Its lumen is lined with stratified cuboidal

epithelium. The lacrimal sac and nasolacrimal ducts compose

the lower floor of the lacrimal drainage system (the so-called

lower lacrimal pathways), whose interior membrane is formed

by double-layered columnar epithelium.

Figure 1. Le Fort fracture, type II scheme. Based

on RosarioVanTulpe scheme

Figure 2. Le Fort fracture, type II. CT volume reconstruction

Figure 3. Lacrimal system shapes and sizes.

Med Sci Monit. 2014 Apr 17;20:628-38. doi:

10.12659/MSM.890098.
Diagnostic imaging of the nasolacrimal drainage system.
Part I. Radiological anatomy of lacrimal pathways.
Physiology of tear secretion and tear outflow.

Maliborski A1, Różycki R2.

Dacryocystography
Once clinical testing has confirmed obstruction

of the lacrimal excretory system,

dacryocystography is a practical method to

locate the exact site of the blockage.

Dacryocystography is a form of lacrimal system

imaging and often confirms the diagnosis of

anomalies of the lacrimal passageways.

Dacryocystography is of greatest value in

the following selected disorders of the lacrimal

system:

• It is helpful in outlining common

canalicular stenosis in patients in whom it

is not clear, if this is the only site of

obstruction. It is also helpful in cases of

persistent canaliculitis

• Obstruction at the level of the lacrimal

sac

15

. This information would be critical if

dacryocystorhinostomy surgery was being

contemplated. A small, shrunken lacrimal

sac is indicative of long-standing infection

and inflammation, while a dilated sac

suggests chronic dacryocystitis (Figure 2).

All such findings are consistent with

chronic obstruction or functional blockage

as opposed to a functional obstruction

• Diverticula and fistulas originating from the

canaliculi, the sinus of Maier, the lacrimal

sac, or the membranous portion of the

nasolacrimal duct. Dacryocystography

helps delineate their extent and size

2,4

• Intraluminal masses such a concretions,

dacryoliths, polyps, tumours or foreign

bodies

15

• The condition of the paranasal sinuses, the

position of the nasal septum, the amount

of hypertrophy of the nasal turbinates, the

presence of osteomyelitis in the

surrounding bony structures, the condition

of the orbital and nasal bones following

trauma, in which fracture might be

present, and the presence of tumours of

bone or soft tissue in the vicinity of the

nasolacrimal passages can be identified

(Figure 3)

• Persistent discharge may occasionally

remain after dacryocystorhinostomy

surgery. If this results, dacryocystography

will show the site of the new obstruction

• Cases with functional obstruction in which

the system irrigates through but does not

permit free passage of tears under normal

circumstances

15

. Dacryocystography will
show a normal contoured sac

• The location of obstruction of the lacrimal

passageways can be classified into three

broad categories – high, middle and low

15

High level obstructions are those located

in the canaliculi or sinus of Maier.

A blockage at this location may be

diagnosed easily by gentle probing.

A dacryocystogram may further help

differentiate between an obstruction at the

common canaliculus or a mid-level block

with a shrunken lacrimal sac. Mid-level

obstructions are those located in the

region from the neck of the sac to the

lower third of the bony canal (Figure 4).

This is the most commonly seen

obstruction in adults. Low-level

obstructions are located at the lower end

of the nasolacrimal duct. This type of

blockage is mostly seen in infants and is

known as congenital dacryostenosis

16
Figure 2

Dacryocystogram showing bilateral lacrimal

sac dilation

Figure 3

Scan showing blow-out fracture of right

orbital floor with blood in floor of maxillary

sinus and nasal passages

Figure 4

Mid-level obstruction (curved arrows)

Figure 6

Dacryocystogram under fluoroscopy –

normal passage of dye through the

nasolacrimal system into the nose and to

the back of the throat (curved arrows)

Leonid Skorin Jr, OD, DO, FAAO, FAOCO

http://www.optometry.co.uk/uploads/articles/f30602da113e1af29f530015e82f88a3_skorin200207
26.pdf.

July 26, 2002 OT

Comparison of dacryocystography and lacrimal

scintigraphy in the ...
Wearne, Michael J;Pitts, John;Frank, John;Rose,
Geoffrey E
British Journal of Ophthalmology; Sep 1999; 83, 9;
ProQuest Health & Medical Complete
pg. 1032
/
Book Chapter

Lacrimal Drainage System

Clinical Ophthalmology: A Systematic Approach.

Published January 1, 2011. Pages 65-78. © 2011.

Jack J. Kanski - 2009 - Medical

Contrast Dacryocystography

The first attempt to visualize the lacrimal drainage

system radiographically was made by Ewing in

1909. He used bismuth paste for retrograde filling

of the nasolacrimal duct. Such early attempts

proved unsatisfactory, and the technique was

used infrequently until the introduction of better

aqueous contrast media such as Sinografin and

Angiografin, and especially the low-viscosity

iodized oils such as Pantopaque, Ethiodol, and

ultrafluid Lipiodol. In a standard dacryocystography (DCG) study, the canaliculi are intubated

with intravenous catheters. Contrast material is

injected into the lower canaliculus on each side

and films are taken immediately in Caldwell’s

posteroanterior frontal projection and in both lateral

projections. Repeat films are obtained at 5 and

15 min and upright films may be taken to evaluate the effects of gravity on lacrimal drainage.
DCG can also be combined with CT or MR imaging

to give further information on the nasolacrimal

system.

In 1968, Iba and Hanafee described the technique of distension dacryocystography, first used

by Barrie Jones in 1959 [ 32]. Here, films are

taken during injection of 0.5–1.0 mL of contrast

material so that the lacrimal system is imaged in

the distended state. Both sides are studied simultaneously and injection is accomplished through

the placement of canalicular indwelling tapered

Teflon catheters or IV catheter tubing. This

method provides maximum visualization of the

anatomic structure of the system and, because of

the back pressure, gives good filling of the canaliculi. It is the best technique for demonstration

of fistulae, diverticulae, supernumerary canaliculi,

and the presence of concretions and sac tumors.

However, it does not reveal sac and duct dimensions under normal physiologic conditions. This

test also requires either the ophthalmologist or a

skilled technician to be in the radiology suite to

inject the material and can lead to some patient

discomfort.

Improved imaging is achieved with a technique

adopted from subtraction angiography that eliminates confusing bony shadows (Fig. 7.8). A scout

film is taken before injecting contrast material and

is used to produce bone-free images of the dacryocystogram. More sophisticated computer- assisted

digital subtraction images can be produced using

fluoroscopically controlled angiographic equipment and an image intensifier [ 32, 33].

The dacryocystogram of a normal lacrimal

drainage system will usually show the canaliculi

when less viscous aqueous contrast media are

used [ 34]. The sac appears as a smooth narrow

duct to the sac–duct junction. The duct widens at

the level of the bony rim and its inner surface

becomes more irregular because of the presence

of mucosal folds. Such folds may be exceptionally

well developed in younger children. Further

constrictions are seen in the duct’s mid-portion in

the region of Hytle’s and Taillefers’ valves.

Finally, in its lower third, the duct widens again.

Visualization by DCG reveals considerable variations in the structure of the sac and duct among

normal individuals. Atypical narrowing and

widening of the sac and duct, as well as unusual

angulations and diverticula, may all be seen in

the absence of clinical symptoms.

A combination of subtraction, distension, and

macrodacryocystography provides the best visualization of the anatomic structure of the lacrimal

drainage system. This approach will provide

accurate localization of any anatomic obstruction

in the majority of cases. Imaging of the canaliculi

with dye failing to pass into the sac or duct

implies obstruction at the common canaliculus.

Obstruction at the sac–duct junction usually

results in a dilated sac with no dye reaching the

duct or nose, even on late films. Obstruction at

the level of the nasolacrimal duct will show dilatation of the sac, with dye in the duct, but not

reaching the nose. A patent dacryocystorhinostomy ostium is easily demonstrated by passage

of contrast into the nose at the level of the middle

meatus. Demonstration of patent lacrimal passages by DCG in the face of epiphora suggests

physiological dysfunction or a mild incomplete

anatomic block.

DCG is considered the gold standard for

imaging of the nasolacrimal system, but it does

not allow for imaging of the soft tissue or bony

structures surrounding the nasolacrimal sac or

duct. DCG can be combined with CT and MR

studies to get a complete picture of the nasolacrimal

system and the surrounding anatomy.

In a recent study, Lee et al. used fluoroscopic

dacryocystography to evaluate dynamic changes

in lacrimal drainage system anatomy during the

blink cycle [ 35]. This study showed that with

eyelid closure the canaliculi contract while the

lacrimal sac dilates, both contributing to the pump

mechanism. This has expanded to our knowledge

of lacrimal physiology under normal conditions,

and may add to an understanding of proximal system pathology

Fig. 7.9 ( a) Axial bone window CT-DCG demonstrating

contrast filled lacrimal sacs ( arrowheads). The left system

is dilated compared with the right. (Courtesy of Susan K.

Freitag, M.D., reprinted with permission from Lippincott,

Williams & Wilkins ©2002). ( b) Axial soft tissue window

CT with a dilated left lacrimal sac from dacryosystitis. ( c)

Coronal soft tissue CT showing a dilated lacrimal sac and

duct from dacryocystitis

Fig. 7.10 CT-DCG three-dimensional reconstruction in

the left oblique projection confirms the left complete

obstruction and proximal dilation. Right system is normal

Fig. 7.11 CT-DCG threedimensional reconstruction

demonstrates bilateral filling defects ( arrows) in distorted and dilated lacrimal

systems
Adam J. Cohen • Michael Mercandetti
Brian Brazzo
Editors
The Lacrimal System
Diagnosis, Management,
and Surgery
Second Edition
© Springer International Publishing
Switzerland 2015
Clinical Evaluation and Imaging
of Lacrimal Drainage Obstruction
Jonathan J. Dutton

Radionuclide Dacryoscintigraphy
The first use of radionuclide tracer to image the

lacrimal drainage system was by Bozoky and

Korchmaros, who used radioactive 198

Au and measured the buildup of activity over the sac and duct
Rossomondo et al. [ 53] introduced the first modern

nuclear imaging technique for the lacrimal drainage system. They instilled a drop of saline
with

[99mTc] sodium pertechnetate, and imaged the

system with a gamma camera. In the first clinical

evaluation of the technique, Carlton et al. [ 54]

demonstrated its value in visualizing the lacrimal

system, and in measuring some physiological

parameters of tear flow. In their study of 28

asymptomatic volunteers they recorded a transit

time for the nuclide of 4–43 s to the sac, and

4–323 s to the nose. While there is a high degree

of correlation between dacryoscintigraphy and

contrast dacryocystography, the former is more

sensitive to incomplete blocks, especially in the

upper system. Since dacryoscintigraphy is a

physiologic test it is very sensitive in localizing

the site of anatomic blockage as well as finding

abnormalities in patients with physiologic pump

dysfunction [ 55, 56]. A high correlation has been

shown between symptomatic epiphora and quantitative lacrimal scintigraphy measures as

tracer

flow times [ 57].

The technique commonly employed today

uses [99mTc] sodium pertechnetate in saline or

technetium sulfur colloid delivered as a 10 μL

drop to the lateral conjunctival sac by micropipette. The patient is advised to blink normally,
and the nasolacrimal system is imaged every 10 s

for the first 2–3 min. Late images are obtained

every 5 min thereafter for a total of 20 min

(Fig. 7.12). The specific activity of this dose is in

the range of 50–150 μCi, and results in radiation

exposure to the lens of less than 2 % of that for a

complete contrast dacryocystogram.

Dacryoscintigraphy does not provide the

detailed anatomic visualization available with

contrast DCG. In standard nuclear studies the

proximal canalicular system is usually poorly

imaged unless dilated, but the lacrimal sac and

duct are usually well outlined [ 58]. Complete or

partial obstructions of the drainage system are

easily seen, with a sensitivity of better than 90 %

[ 59]. Although the precise site of obstruction is

difficult to determine with scintigraphy alone, the

approximate level, such as presac, preduct, or

intraduct, can often be determined [ 57].

Generation of dynamic activity curves for specific regions of interest will demonstrate
incomplete anatomic obstructions as well as rather

subtle degrees of functional impairment [ 58, 60].

This technique is most accurate and reproducible

for the upper lacrimal system. Transit times

become quite variable for the lower system, with

25–32 % of asymptomatic individuals showing

no tracer in the nose after 12 min. This is consistent with findings on the primary Jones dye
test.

By using more sophisticated rapid sequence display and computer interfacing for image
optimization by contrast enhancement, background

subtraction, and frame arithmetic, quantitative

evaluation of tracer movement provides the most

revealing interpretation of lacrimal function and

tear flow dynamics currently available

Fig. 7.12 Dacryoscintigraphy in a patient with unilateral

epiphora on the left side. The right lacrimal drainage system fills normally,
with tracer concentrated in the canaliculi (C), sac (S), and duct (D). The left
system shows no

tracer below the sac–duct junction (S/D)

Adam J. Cohen • Michael Mercandetti

Brian Brazzo

Editors

The Lacrimal System

Diagnosis, Management,

and Surgery Second Edition

© Springer International Publishing Switzerland 2015

Clinical Evaluation and Imaging of Lacrimal Drainage Obstruction

Jonathan J. Dutton

dynamic magnetic resonance imaging

The fact that orbicularis contraction aids tear drainage is

indisputable from clinical evidence. However, very few

studies actually demonstrate the dynamics involved. Two

diametrically opposite theories exist from various anatomical and physiological studies based on
whether the lacrimal sac expands or collapses during blinking. Jones’s[10]

lacrimal pump theory postulates that blinking moves the

tear strip towards the puncta. The tears enter the puncta

mainly by capillary action (Fig.1a).

The tears are then propelled through the canaliculi into

the sac by the same blink. Contraction of the superficial

heads of pretarsal and preseptal orbicularis and Duverney–

Horner’s[16] muscle (Horner’s muscle) during blinking

draws off the puncta medially, squeezes the ampulla and

shortens the canaliculi. In addition, contraction of the deep

head of the preseptal orbicularis muscle pulls on the

lacrimal diaphragm, which subsequently creates negative

pressure that draws the tears into the lacrimal sac. (Fig.1b)

When the eyelids open, the sac collapses to empty into the
nasolacrimal duct, and, simultaneously, the tears are drawn

into the puncta (Fig. 1c).

The second theory of passive tear flow [6,17] states that

the powerful canalicular pump mechanism is the prime

driving force for tear drainage.

Very fast magnetic resonance imaging can be done to

see fluid movement and has been applied to different parts

of the body such as the liver and breast.

The aim of the study was to ascertain if it is possible to

see the tear movement in the nasolacrimal system after

flooding it with either balanced salt solution (BSS) or

topical 0.5% gadolinium.

Fig. 1 Tear flow with lid movement:abetween blinks,bwith eye

closed,cwith eye reopening

Fig. 2 Black arrowspoint to

the bolus of tears in the sac.

Blocked arrowsshow tears

in the nasolacrimal duct. Note

that the cornea is pointing up

when the eye is closed

Graefes Arch Clin Exp Ophthalmol. 2005 Feb;243(2):127-31. Epub
2004 Dec 17.

Tear flow dynamics in the human nasolacrimal ducts--a pilot

study using dynamic magnetic resonance imaging.

Amrith S1, Goh PS, Wang SC.

AAMJ, Vol.5, N. 3, September, 2007

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53

C.T. AND MRI DACRYOCYSTOGRAPHY USING VISCOELASTIC

CONTRAST MEDIUM

Ehab I Wasfi; Ayman M Seleim and Hasan I Megally

CT-anatomy of the nasolacrimal sac

and duct

Tears collect at the lacrimal lake at the inner canthus and are drained through the lacrimal puncta,
the lacrimal canaliculi, the

nasolacrimal sac and the nasolacrimal duct into the inferior nasal meatus. The nasolacrimal duct
runs through the (osseous)

nasolacrimal canal. This lower lacrimal drainage system may be involved in various pathologic
processes that frequently result in

obstruction [1, 3]. Recent diagnostic and therapeutic developmentssuch as endoscopy, stent
impantation and balloon dilatation of

the nasolacrimal sac and duct require a detailed anatomical knowledge of the drainage system
toplan the intervention exactly [4,

5, 7, 8]. The purpose of this study was to establish baseline anatomic standards and describe
anatomicalvariations of the

nasolacrimal sac and duct with thin-section computed tomography (CT).

Recent developments in ophthalmology such as balloon dilatation, stent implantation, laser therapy
and endoscopy of the lacrimal
drainage system raise the need for a detailed anatomical knowledge of this system. In this study
morphometric measurements of

the lacrimal drainage system were performed with thin-section axial computed tomography (CT)
examinations in 147 patients

with no signs of pathology related to the lacrimal drainage system. The mean length of the
nasolacrimal duct measured 11.2 ±

2.6mm (range: 6-21 mm), the narrowest diameter was 3.7 ± 0.7 mm(range: 2-7 mm). The mean
length of the nasolacrimal sac

was 11.8 ± 2.5 mm (range: 6-18 mm). The width of the nasolacrimal sac did not exceed 4 mm unless
filled with air. In 43 (29.3%)

of the subjects air was visible within the nasolacrimal sac or duct. The knowledgeof the
morphometry of the lacrimal drainage

system enables the ophthalmologist to plan intervention on the lacrimal drainage system precisely
and avoid unnecessary

manipulations.

Minimal invasive techniques in the management of pathologies related to the lower lacrimal
drainage system have to be based on

a detailed anatomical knowledge of the system. This study may contribute to the establishment of
morphometric baseline

standards that are necessary for the preciseplanning of the intervention and for the construction
and use of adequate technical

devices.

Fig. 1The nasolacrimal duct (arrow) inside the nasolacrimal canal

Fig. 2

The left nasolacrimal sac (short arrow) appears as a soft tissue density in the lacrimal fossa. Normal
finding of an aerated and

extended right nasolacrimal sac (long arrow)

Fig. 3

Coronal reformatted image ofthe nasolacrimal canal (arrow)

Fig. 4

The lacrimal fossa (short arrow) lies between the anterior (long arrow) and the posterior (curved
arrow) lacrimal crest

Surg Radiol Anat (1997) 19: 189 - 191

© Springer-Verlag France 1997
Radiologic anatomy
CT-anatomy of the nasolacrimal sac and duct
R. Groell1
, G. J. Schaffler
1
, M. Uggowitzer
1
, D. H. Szolar
1and K. Muellner
2

Evaluation of lacrimal drainage system

obstruction
using combined multidetector CT and instillation
dacryocystography
Mohamed Shweela,
*, Ahmed Elshafei
b
, Raafat Mohy El-Din AbdelRahman
b
,
Mahmoud Nassarb
The Egyptian Journal of Radiology and Nuclear
Medicine (2012)43, 413–420

AAMJ, Vol.5, N. 3, September, 2007

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53
C.T. AND MRI DACRYOCYSTOGRAPHY USING
VISCOELASTIC
CONTRAST MEDIUM
Ehab I Wasfi; Ayman M Seleim and Hasan I
Megally
Diagnostic Ultrasonography
The techniques of A- and B-mode ultrasonography

provide a simple, noninvasive method of evaluating the normal lacrimal sac and duct (Fig. 7.5a, b)

[ 24]. It has also proved useful in the evaluation of

gross anatomic lacrimal system abnormalities

[ 25, 26]. Physiological dysfunction cannot be

evaluated, nor can the precise site of anatomic

obstruction be localized in most cases. However,

a dilated lacrimal sac can easily be distinguished

from one of normal dimensions (Fig. 7.6a, b). It is

also possible to differentiate air from mucus or

solid masses, making the identification of lacrimal sac neoplasms possible [ 27]. Lacrimal sac

concretions can be visualized, and these may

occur in 6–7 % of patients with NLD obstruction

[ 28]. Tost et al. [ 29] reported visualization of the

canaliculi, but this requires intracanalicular injection of sodium hyaluronate.

With the B-mode probe placed in the medial

canthus, oriented vertically and aimed toward

the lacrimal sac fossa, an oblique longitudinal

cross section of the lacrimal sac and upper duct

is obtained. The canaliculi cannot usually be

visualized unless they are significantly dilated.

The diameter of the sac and upper duct may be

evaluated and the thickness of the walls can

often be appreciated [ 30]. Diverticuli may also

be identified and a variety of echogenic densities

within the system such as inflammatory membranes, tumors, and concretions can be detected.

The position and size of a surgically created

ostium may also be imaged with this technique

(Fig. 7.7), although its patency cannot easily be

evaluated [ 31].

For precise measurements of the sac and evaluation of the internal reflectivity of sac contents,

A-mode scanning is used. The A-probe is first

oriented as for a periocular orbital study, but

with the beam aimed just behind the anterior

lacrimal crest toward the sac fossa. An oblique

anterolateral–posteromedial transit of the sac is

thus obtained. If the sac is fi lled with air it appears

as an echolucent defect bounded by sharply

defined vertical anterior and posterior sac walls.

Often the presence of dilated diverticula can be

detected. Mucus in the sac produces uniform,

homogeneous, low-density internal echoes, and

infl ammatory exudates and membranes show

stronger, more irregular echoes. Multiple strongly

echogenic, irregular echoes with infiltration of the

sac walls suggest a sac tumor. A transocular

A-mode image of the sac is obtained with the

probe held above the lateral canthus and directed

toward the lacrimal sac fossa through the eye.

This technique gives an approximate horizontal

cross section of the sac. The average dimensions

of the sac in normal individuals is 2.5 mm

(SD = 0.95 mm) in horizontal diameter and

4.0 mm (SD = 1.49 mm) in anteroposterior extent.

A sac more than 4.5 mm wide or 7.0 mm deep

should be considered abnormally dilated.

Fig. 7.4 Probing of the inferior canaliculus with a number 0

Bowman probe

Fig. 7.5 ( a) B-scan ultrasound of a nasolacrimal system

with a normal nasolacrimal sac (S). The anterior lacrimal

crest can be visualized anteriorly and inferiorly and the

lacrimal bone is seen posteriorly. ( b) A-scan ultrasound of

a normal nasolacrimal system. Nasolacrimal sac with low

reflectivity (S) and sharply defined anterior and posterior

walls. The smaller peak represents lacrimal bon

Fig. 7.6 ( a) B-scan ultrasound of a patient with acute

dacryocystitis demonstrating a massively enlarged nasolacrimal sac (S) and thickened anterior and
posterior

walls. ( b) A-scan ultrasound of the same patient as

Fig. 7.2ashowing dilated nasolacrimal sac (S) with irregular, medium reflectivity indicating the
presence of mucopurulent exudates
Fig. 7.7 Post-dacryocystorhinostomy B-scan ultrasonography showing the surgically created
lacrimal-nasal

ostium (OS). The lacrimal sac (S) is somewhat dilated

because of soft tissue closure of the ostium

Presurgical and postsurgical ultrasound assessment of lacrimal drainage dysfunction

Stupp, Tobias; Pavlidis, Mitrofanis; Busse, Holger; Thanos, Solon. American Journal of
Ophthalmology 138.5 (Nov 2004): 764-771.

Adam J. Cohen • Michael Mercandetti

Brian Brazzo

Editors

The Lacrimal System

Diagnosis, Management,

and Surgery Second Edition

© Springer International Publishing Switzerland 2015

Clinical Evaluation and Imaging of Lacrimal Drainage Obstruction

Jonathan J. Dutton

AJNR Am J Neuroradiol21:1145–1150, June/July 2000

MR Dacryocystography: Comparison with
Dacryocystography and CT Dacryocystography
Luigi Manfre`, Marcello de Maria, Enzo Todaro, Adriana
Mangiameli, Francesco Ponte, and Roberto Lagalla
Percutaneous Contrast
Dacryocystography
The common canaliculus is a common site of

obstruction seen on radiographic imaging in

patients with epiphora. When such blockages are

complete, routine DCG of the lower system is not

possible, and the concomitant presence of lower

sac or duct pathology cannot easily be demonstrated unless echography is used to detect a

dilated sac. In 1972, Putterman [ 62] described a

technique of percutaneous injection of aqueous

contrast material directly into the lacrimal sac to

bypass the occluded common canaliculus. In his

small series of four patients there were no complications and results were good.

Neuroradiology

March 1999, Volume 41, Issue 3, pp 208-213

High-resolution conjunctival contrast-

enhanced MRI dacryocystography
1. K. T. Hoffmann,
2. N. Hosten,
3. N. Anders,
4. C. Stroszczynski,
5. T. Liebig,
6. C. Hartmann,
7. R. Felix

Fig 1.

DS and MR DCG 12-year follow-up after balloon DCG in an asymptomatic patient. A, DS

DCG reveals occlusion of the distal NLD (arrow) and reflux of iodinated contrast material to
the conjunctival sac (asterisk). B, DS DCG immediately after transluminal balloon dilation
shows passage of the contrast media to the inferior meatus of the nasal cavity (arrow). Note
that there is no reflux to the conjunctival sac after successful balloon DCG. C, Twelve-year
DS-DCG follow-up with bilateral simultaneous contrast media injection reveals a completely
normal LDS. The anatomic regions of the normal left LDS are the following: 1) inferior
canaliculus, 2) lacrimal sac, 3) NLD, and 4) contrast media in the nasal cavity. D, Bilateral
topical contrast-enhanced coronal MIP DCG image from 3D FSPGR sequence demonstrates
patency of the LDSs both on the intervened right side and normal left side. 1 indicates the
canaliculi; 2, lacrimal sac; 3, nasolacrimal duct; 4, contrast media in the nasal cavity.

1. Head and Neck

MR Dacryocystography in the Evaluation

of Patients with Obstructive Epiphora
Treated by Means of Interventional
Radiologic Procedures
1. B. Coskuna,
2. E. Ilgita,
3. B. Onala,
4. O. Konukb and
5. G. Erbasa

Adam J. Cohen • Michael Mercandetti

Brian Brazzo

Editors

The Lacrimal System

Diagnosis, Management,

and Surgery Second Edition

© Springer International Publishing Switzerland 2015

Clinical Evaluation and Imaging of Lacrimal Drainage Obstruction

Jonathan J. Dutton

Treating Epiphora in Adults With the Wilhelm Plastic Nasolacrimal Stent: Mid-Term Results of a
Prospective Study

Ciampi, Juan J; Lanciego, Carlos; Navarro, Sofia; Cuena, Rafael; Velasco, Javier; et al. Cardiovascular
and Interventional Radiology 34.1 (Feb 2011): 124-31.

Br J Ophthalmol. 2007 Jan; 91(1): 43–46.

doi: 10.1136/bjo.2005.088187

PMCID: PMC1857553

Evaluation of 1000 lacrimal ducts by

dacryocystography
F C Francisco, A C P Carvalho, V F M Francisco, M C Francisco, and G T Neto
Chemiluminescence
Chemiluminescent materials can provide a nonradiologic technique for demonstrating the outline of

the lacrimal drainage system and verifying its

patency. The luminescent agents are dimethylphthalate and tertiary butyl alcohol activated by

dibutlphthalate, which produce an intense cold

light. When these agents were injected into the lacrimal drainage system of monkeys, the glow was

visible through the skin and clearly outlined the

lacrimal sac [ 63]. The lacrimal duct was not readily

demonstrated. The compounds are safe and nontoxic if confi ned within the lacrimal system, but

extravasation into tissues or onto the globe can produce severe complications of corneal scarring
and

vascularization, purulent infection, granuloma formation, and fibrosis [ 64]. Chemiluminescence has

not yet been used in humans so that its clinical

effectiveness as an alternative or adjunct to other

procedures cannot be evaluated.

Lacrimal outflow patency demonstrated by chemiluminescence.

Arch. Ophthalmol.

Arch Ophthalmol 1980 Jan;98(1):126-7

S W Cohen, M Sherman, G G Schwartz, W Banko, H H Cohen, C F Mahl

Adam J. Cohen • Michael Mercandetti

Brian Brazzo

Editors

The Lacrimal System

Diagnosis, Management,
and Surgery Second Edition

© Springer International Publishing Switzerland 2015

Clinical Evaluation and Imaging of Lacrimal Drainage Obstruction

Jonathan J. Dutton
Assessment of the Efficacy of Chemiluminescent Evaluation
of the Human Lacrimal Drainage Syste
Raflo, Gary T, MD;Hurwitz, Jeffrey J, MD, FRCS (C)
Ophthalmic Surgery; Jan 1982; 13, 1; ProQuest
pg. 36
Lacrimal Thermography
The canaliculi and lacrimal sac have been visualized by thermography, using an infrared scanner

and color monitor with a resolution of 0.5° [ 65].

The lacrimal system is easily differentiated from

surrounding tissues by irrigation with cold water,

and decreased temperature in the nose demonstrates patency. A large dilated sac can be visualized,
and persistent inflammation will produce

increased temperature within the sac. The duct is

not demonstrated with this method.

In a related technique, a mini-thermocouple

probe has been used to detect temperature differences with the lacrimal sac. Increased
temperatures are seen with vascularity and infl ammation,

and decreased temperatures with hemorrhage and

mucocele formation. Nasolacrimal duct obstruction without associated inflammation shows no

difference in temperature compared with the contralateral uninvolved side.

Adam J. Cohen • Michael Mercandetti

Brian Brazzo

Editors

The Lacrimal System

Diagnosis, Management,

and Surgery Second Edition

© Springer International Publishing Switzerland 2015

Clinical Evaluation and Imaging of Lacrimal Drainage Obstruction

Jonathan J. Dutton
Thermographic Evaluation of the Human Lacrimal Drainage
System
Raflo, Gary T, MD;Chart, Pamela, MD, BSc, MDCM;Hurwitz,
Jeffrey J, MD, FRCS C
Ophthalmic Surgery; Feb 1982; 13, 2; ProQuest
pg. 119
Endoscopy
Nasal endoscopy using a rigid telescope is useful to observe the anatomy of the opening of the nasal
lacrimal duct in the inferior meatus and

to diagnose any disease within the nose itself (Fig. 12-15-5). If a lacrimal drainage operation is
contemplated, the endoscope is the best

method to assess the future surgical site. Should tearing persist following lacrimal surgery, it is useful
to view the size and location of the

previous dacryocystorhinostomy (DCR) opening using an endoscope to

determine whether the opening is obstructed by fibrous tissue, polyps,

granuloma, or foreign bodies.

Book Chapter
The Lacrimal Drainage System
Ophthalmology.
Hurwitz, Jeffrey J.. Published January 2, 2014. Pages
1346-1351.e1. © 2014.
© 2007

Atlas of Lacrimal Surgery

Editors: Weber, R.K., Keerl, R., Schaefer, S.D., Rocca, R.C. (Eds.)

63Chapter downloads/week on SpringerLink

Chapter 3

Diagnostics

P. Komínek, R.C. Della Rocca and S. Rosenbaum

Nuclear lacrimal scan
This is an adjunctive physiological test of lacrimal function; it does not

demonstrate anatomical structures. A drop of technetium-99m pertechnetate is placed into the

palpebral aperture, and a pinhole collimator of

a gamma camera is used to record its transit to the nose. The lacrimal

scan can help determine the extent of stenosis from a physiological

point of view (Fig. 12-15-6). It also can help evaluate the flow of tears

to determine whether lid or punctal malpositions contribute to drainage dysfunction.

Book Chapter
The Lacrimal Drainage System
Ophthalmology.
Hurwitz, Jeffrey J.. Published January 2, 2014. Pages 1346-
1351.e1. © 2014.

3.2 Diagnostics Philosophy

Tearing can be caused by hypersecretion and epiphora, both of which can be combined. Clinical
symptoms occur if the balance between the tear production

and drainage function of lacrimal system has changed,

i.e., the clinical picture of epiphora does not depend

on the absolute functional status of either one [9, 14].

That is why there are no symptoms of epiphora if lacrimal production is reduced and lacrimal
drainage is

decreased, e.g., in older patients, etc. (Table 3.2).

The basic diagnostic evaluation of the tearing patient should include quantification of tear
production

and assessment of nasolacrimal system patency [21].

The goals of history and clinical examinations of patients are to define pathological processes
responsible

for tearing present, to distinguish anatomical and

functional epiphora and, in an anatomical obstruction, to identify the level at which the obstruction
lies

and its extension as well [24]. One should be able to

determine whether surgery is indicated and whether

the surgery will be directed in the lacrimal apparatus,

the eyelids, or punctum, or both [9].

The goals of the examination of tearing patients

are as follows

© 2007

Atlas of Lacrimal Surgery

Editors: Weber, R.K., Keerl, R., Schaefer, S.D., Rocca, R.C. (Eds.)

63Chapter downloads/week on SpringerLink

Chapter 3

Diagnostics

P. Komínek, R.C. Della Rocca and S. Rosenbaum

© 2007

Atlas of Lacrimal Surgery

Editors: Weber, R.K., Keerl, R., Schaefer, S.D., Rocca, R.C. (Eds.)

63Chapter downloads/week on SpringerLink

Chapter 3

Diagnostics

P. Komínek, R.C. Della Rocca and S. Rosenbaum