Optometrists’ and Patients’ guide to the Nasolacrimal (Drainage) Assessment
Jeremiah Lim, Dip. Optom (Singapore)
Do you have an excessively wet eye? Or find yourself ‘Crying’, with tears rolling down your cheek for no apparent reasons?
Do I need help? Yes, if you exhibit at least one of such symptoms:
-constantly watery eye or eyes – which can blur your vision
-tears from one eye or both, rolling onto cheeks
-worst in cold/windy conditions:
e.g. ’crying’ while walking to the market
-or hot/dry conditions:
e.g. ‘crying’ at home, while the heater is on
-sore/gritty/tired or even burning sensation in eyes, leading
to tearing.
-painful and swollen lump on the sides of your nose, just below the eyes (see practioner: fig 2)
Who do I seek for help?
Your eye care practitioner, either the optometrist or ophthalmologist, who would adequately diagnose and treat your condition.
What should I (or my child) expect during the test?
The procedures for tear drainage assessments are as follows:
1. Slit lamp and External Examination
This is where the practitioner seats you in front of a slit lamp, which is a type of microscope with a light source, which illuminates the front part of your eye. This is done to view the external part of your eye to see if there is any misalignment or abnormalities in your eyelids.
2. Fluorescein Dye Disappearance Test:
This is when the examiner instils a drop of brightly yellowish dye using a strip or eye drop. Becareful not to wear your favourite clothes!!! Fluorescein dyes may stain your clothes yellow for the rest of the day!
-The dye dissolves in your tears, and allows the examiner to better visualise how well your tears flow out from the eye.
- Dye disappearance within 3 min is considered normal
3. Palpation
As the name suggests: The examiner, while on the slit lamp, gently presses upon the upper sides of your nose, just below the eye.
- This is done to assess if there is any pus flowing trapped in the upper tear drainage system.
- If pus comes out from the drains, it means that system is infected and no further testing is performed.
4. Dilation, Probing and Irrigation.
May be considered fairly invasive by some, this procedure is both diagnostic and therapeutic. Topical anaesthetic is instilled for the following procedures, therefore, it is not painful but involves some mild degree of discomfort – probes are placed into the drainage system of your eyes, which may look intimidating. It also involves swallowing some saline (salt) water, which is harmless but may taste funny.
a)Dilation: A dilator is used to widen the puncta (drainage hole of the eye) in your lower eyelid. This serves to clear any obstruction or temporarily relieves narrowing or the puncta.
It also serves to widen the puncta for insertion of a cannula.
b)Probing: A cannula (a blunt probe – which does not hurt the eye), with an attached syringe (filled with sterile saline) is inserted horizontally into the lower eyelid, and pushed in until it stops.
-This gives the practitioner an idea if there is any obstruction in the upper drainage ‘pipes’ of your system.
c)Irrigation: The plunger of the syringe is gently depresses, allowing saline to flow into the drainage system. As a patient, you are to report when you feel saline flowing into your nose or your throat. If that happens, it’s good! It means that your drainage system still allows liquid to flow through.
-In the process, any particles responsible for blocking your drainage system are now being flushed out. Hence while testing; your condition is also ‘cured’.
Possible Test Outcomes:
1) You feel saline in your nose/throat: which means your drainage pathway is relatively clear (may have partial blockage).
i) Your watery eyes may be caused by other factors or the system gets blocked only under more natural conditions.
2) You do NOT feel saline in your throat/nose:
i)Your lower drainage ‘pipe’ is blocked.
ii) OR some saline may backflow out from the puncta, which means that your upper drainage pipes are blocked.
Additional Testing:
5. The Jones Tests – These tests are indicated to rule out a ‘functional blockage’ - blockage during normal, ‘non-test’ conditions. They are also useful in determining the location of the blockage. They are very similar to the tests mentioned before.
a)Jones 1 test: The eye(s) are ‘flooded’ with fluorescein dye as before. You are allowed to blink normally for 5 minutes while a tissue or cotton bud is placed below your nose to ‘catch’ any dye leaking out from your system.
i)if dye is found, it means that your system is not functionally blocked, and the watery eye(s) are very likely due to excessive tear production.
ii)if no dye is retrieved, it means that the dye fails to drip down into the nose and there is a blockage somewhere in part of the system; that, or the eye blinking action fails to sufficiently ‘pump’ tears out of the eye.
b)Jones 2 test: This is done immediately if NO dye is retrieved from the nose during Jones 1 test. This involves probing and irrigation of the drainage system, to flush out trapped dye(if any) out of the system.
i)if Dye is retrieved after irrigation, it means that the dye managed to seep through the puncta and upper drainage ‘pipes’ (upper drainage is clear)
-the lower drainage ‘pipe’ could be partially blocked.
ii)if just colourless saline is retrieved (no dye),
it means that dye failed to even enter the puncta and upper ‘pipes’ of the system (upper drainage blocked)
-it can also mean that the eye blinking action fails to sufficiently ‘pump’ tears out of the eye.
The part of the website has been designed with you, the patient, in mind. Do note that tests may be performed slightly differently than as described above and in a different order. All procedures are to be performed by professional eye care practitioners and this website does not constitute a ‘do-it’yourself’ guide. This site recommends that all should have their eyes checked at least once every 2 years regardless of symptoms/complaints.
References:
Textbooks:
Casser, L., Fingeret, M. and Woodcome, H.T. (1997). Atlas of Primary Eye Care Procedures. 2nd Edition. USA: Appleton and Lange.
Elliot, D.B. (2003). Clinical Procedures in Primary Eye Care. 2nd Edition. Butterworth Heinemann.
Kanski, J.J. (2003). Clinical Ophthalmology – A Systemic Approach. 5th Edition. Butterworth Heinemann.
CD- ROMs:
Tasman, W. and Jaeger, E.A. (2005). Duane's Clinical Ophthalmology on CD-ROM. 2005 Edition. USA: Lippincott Williams & Wilkins.
Websites:
Austen, D.P. (date unknown). Lacrimal Dilation and Syringing.
Available at: http://www.academy.org.uk/ [accessed 15 May 2008].
Kanski, J.J. (2007). Clinical Ophthalmology – A Systemic Approach. 6th Edition.
Available at: http://www.kanskionline.com [accessed 15 May 2008].
Monday, May 19, 2008
Lacrimal Drainage Assessment (for Optometrists)
Optometrists’ and Patients’ guide to the Nasolacrimal (Drainage) Assessment
Jeremiah Lim, Dip. Optom (Singapore)
Understanding the Use:
Indications for Lacrimal Drainage Assessment:
1) Watery eyes with epiphora
2) Lid anomalies
a) Displacement/Malposition of Puncta
b) Entropion/Ectropion
c) Lacrimal Pump failure caused by lid laxity, over-riding upper eye lids or orbicularis muscle weakness.
3) Drainage Blockage e.g. stenosed punctae
4) Dry Eyes/Inflammation/Infection (Ddx reflex tearing vs obstruction)
5) Swollen/Sore lacrimal sac
Applied Anatomy:
The lacrimal drainage system is comprised of the following structures:
IS IT EVEN BLOCKED?
Tear flow onto cheek may be caused by an excessively wet eye due to:
1) Hypersecretion of tears
-Schirmer’s Test
-Cotton Thread Tear Test (phenyl red thread)
2) Poor tear film support at inferior lid margin (tears spill over)
-punctae misalignment
-failure of tear pump mechanism
3) Drainage Occlusion (Epiphora)
1) Fluorescein Disappearance Test
2) Palpation
3) Probing and Irrigation (Lacrimal Lavage)
4) Jones Test 1,2
Drainage Occlusion Assessment Techniques
1. Fluorescein (NaFl) dye disappearance test
To be conducted prior to any manipulation of the eyelids or instillation of any drops which may affect the results.
Procedure:
1. Instil 1 drop of fluorescein into the eye using sterile fluorescein strips or 2% fluorescein drops. (Begin timing now).
2. Observe tear margins in both eyes on slit lamp
3. A tear margin of more than 1mm is generally considered to be excessive.
-Pearls: Note that many px do not have obvious overflow onto cheeks
Results and Intrepretation:
In a normal eye, little or no NaFl remains in the eye after 3 minutes, prolonged retention of dye indicates inadequate lacrimal drainage. Graded from 0 to 4+:
-Grade 0: No dye retained after 5 min. Grade 4+: All dye remains after 5 min.
2. Palpation
1. Apply gentle to moderate pressure
onto the lacrimal sac region of the face. (fig. 2)
Rarely, a tumour/cyst may be felt.
2. Punctal expression of mucopurulent
material on compression is indicative of
a. a patent canalicular and punctal system
b. an obstruction at the inferior
lacrimal sac or above.
c. A possible infection i.e. dacryocystitis,
especially if painful.
3. Infections i.e. dacryocystitis and cannaliculitis
contraindicates further assessment
i.e. dilation/probing/irrigation.
3. Probing and Irrigation – The Lacrimal Lavage
Dilation
Uses:
1. To enlarge the puncta for insertion of the cannulus.
2. To dislodge a concretion or mucous plug at the puncta or
ampulla. Also provides temporary relief of punctum stenosis.
Procedure:
1. Wash hands for hygiene.
2. Instill one drop of topical anaesthetic e.g. Alcaine into the inferior punctum.
3. Sterilise dilator with alcohol swabs.
4. Insert the small dilator vertically into the inferior punctum
up to about 2 mm. Gently twirl the dilator clockwise and
anti-clockwise. (see fig. 3)
- At this point, you may choose to switch to a medium
dilator to further open up the puncta and cannaliculi
prior to the insertion of the cannulus.
- Alternatively you may choose to carry out the
following to further dilate the inferior cannaliculi:
5. Using the other free hand index finger, pull lower
lid temporally to straighten the ampulla, lining up
the vertical and horizontal cannaliculi.
6. Rotate the dilator to the horizontal position
and insert it into the inferior punctum,
twirling it again.
Probing
Uses:
1. To assess the patency of the upper, lower and common cannaliculi.
Procedure
1. After dilation (See Step 1), open packets of disposable syringes and cannula. Connect them together.
2. Remove the plunger and fill syringe with sterile saline.
3. Replace plunger, point syringe upwards and give it a squeeze, ensuring removal of all air bubbles and some saline.
4. Insert the cannula vertically down into the inferior vertical cannaliculus.
5. Using the other free hand index finger,
pull lower lid temporally to straighten the
ampulla, lining up the vertical and horizontal
cannaliculi while you rotate the syringe horizontally.
(see fig. 4)
6. Insert the cannula horizontally
inwards until you reach a ‘Hard Stop’
or ‘Soft Stop’. (see fig. 5)
Procedure continues.. (See Step 3)..
Irrigation
Uses:
To assess patency of the cannaliculi and lacrimal sac or the nasolacrimal duct.
Procedure:
1. Upon encountering either a ‘Hard Stop’ or a ‘Soft Stop’, pull back approximately 2 mm before gently depressing the plunger.
2. Ask the patient to report when they feel saline in the nose or at the back of the throat.
Results and Interpretation Pocket Guide (as seen below), now available for downloading and printing. Click here to begin download immediately!
Probing and Irrigation
Interpretation and Results
Hard Stop
1. The cannula enters the lacrimal sac and stops at the medial wall of the sac, through which the lacrimal bone can be felt (fig. 5).
2. This excludes complete obstruction of the canaliculus.
3. Patent Lacrimal Drainage System: If saline passes through into the nose during irrigation, it means the patient has a patent lacrimal drainage system.
- Note that only complete obstruction is excluded, the patient may still have a patent but stenosed lacrimal drainage system, or subtle lacrimal pump failure.
4. Total Obstruction of Nasolacrimal Duct: Failure of saline to reach the nose indicates total obstruction of the nasolacrimal duct.
5. In such an event, the lacrimal sac becomes distended upon irrigation and there will be reflux of liquid through the upper punctum.
- Regurgitated liquid may be clear saline, mucoid, mucopurulent or frank purulent, depending on the contents of the lacrimal sac.
Soft Stop
1. The cannula fails to enter the lacrimal sac, stopping at the junction of the common canaliculus and the lateral wall of the lacrimal sac, or slightly before that.
2. A soft spongy feeling is felt as the cannula pushes the soft tissue of the common canaliculus and the lateral wall against the medial wall of the lacrimal sac and the lacrimal bone.
3. Irrigation will not cause a distention of the sac (fig. 5).
4. Lower canalicular obstruction: Reflux of saline from the lower punctum.
5. Common canalicular obstruction: Reflux of saline from the upper puntcum, indicates patency of both upper and lower canaliculi.
6. An attempt may be made to clear the obstruction by closing the
superior punctum with a dilator or cotton bud during syringing
(irrigation).
Uses:
1. For patients with suspected partial obstruction of the drainage system.
-Manifest epiphora
-No abnormalities on lacrimal syringe irrigation
2. Particularly useful to assess functional blockage, any blockage which occurs under low-pressured, natural tear drainage conditions whereby all or part of the drainage system collapses.
Procedures:
Primary (Jones 1) Test (fig. 6)
1. Instil 1 drop of 2% flurorescein, or wet 2-4 strips
of fluorescein with sterile saline into the conjunctival
sac (inferior palpebral conjunctiva).
2. After 5 min of normal blinking has elapsed, get the
patient to occlude one nose at a time and blow
into a white tissue paper. (Check tissue with Burton
lamp or slit lamp cobalt blue filter – if negative, go
to step 3.)
3. Alternatively, a cotton bud moistened with topical
anaesthesia is inserted under the inferior meatus
5 min later to test for staining. Also performed if step 2
fails.
Results and Intrepretation:
a) Positive: Fluorescein recovered from nose, indicates patency of the drainage system under normal conditions.
–watering is due to hypersecretion, also indicates that no further tests are required.
b) Negative: no fluorescein recovered from nose, indicating a partial obstruction anywhere from puncta to valve of Hasner.
– or failure of the tear pump mechanism.
– negative primary test is an indication for an immediate secondary test (Jones 2).
Author’s Note: Most textbooks agree that ‘Positive’ on Jones Tests means ‘Patent’ while a ‘Negative’ result signifies ‘Obstruction’.
However, some argue that ‘Negative’ results for a test, should mean ‘No Pathology’ in terms of medical thinking (Duane’s Clinical Opthalmology). To avoid ambiguity, record results as fluorescein detected or no fluorescein detected.
Secondary (Jones 2) Test (fig. 7)
Uses: Identifies the site of probable partial obstruction
- based on whether the dye instilled during the
primary test has entered the lacrimal sac.
Procedures
1. Immediately after Negative primary jones test,
Wash out excessive fluorescein from the
Conjunctival sac and the syringe.
2. Instil topical anaesthetic into the eye and
perform syringing (lavage) to irrigate
lacrimal system.
3. Place a cotton tip bud under the inferior turbinate
to capture the effluent or alternatively, to get the
patient to expectorate into a basin, or simply blow
nose into a white tissue.
-Inspect samples with a Burton Lamp/Cobalt
blue filter.
Results and Interpretation
a) Positive: Fluorescein stained saline recovered from nose.
- indicates fluorescein entered the lacrimal sac
- therefore confirms functional patency of puncta, superior and inferior canaliculi and common cannaliculi
- also implies that nasolacrimal duct is partially obstructed
b) Negative: Unstained saline recovered from nose.
- indicates fluorescein did not enter lacrimal sac
- implying that upper lacrimal passages blocked or partially blocked.
(cannaliculi, puncta)
- or defective tear pump mechanism.
Note: False Positives are rare in Jones Tests are rare, however false negatives are possible due to technical difficulties in retrieving the fluorescein dye. Therefore, a positive result means a patent (may be partially obstructed) and functioning lacrimal excretory system, while a Negative test is inconclusive and does not necessarily indicate that the system is obstructed (due to false negatives).
Recommend Equipment and Inventory list:
1. Lacrimal Dilators (sml and med) 2. Disposable lacrimal cannulae
3. 3-5ml disposable sterile syringes 4. Anaesthetic drops e.g. Alcaine
5. Saline (preserved/unpreserved) 6. Alcohol disinfecting swabs
7. White tissues and cotton buds 8. Surgical gloves / masks (optional)
Purchase all above mentioned equipment from our sponsors today.
Do you have an excessively wet eye? Or find yourself ‘Crying’, with tears rolling down your cheek for no apparent reasons?
Do I need help? Yes, if you exhibit at least one of such symptoms:
-constantly watery eye or eyes – which can blur your vision
-tears from one eye or both, rolling onto cheeks
-worst in cold/windy conditions:
e.g. ’crying’ while walking to the market
-or hot/dry conditions:
e.g. ‘crying’ at home, while the heater is on
-sore/gritty/tired or even burning sensation in eyes, leading
to tearing.
-painful and swollen lump on the sides of your nose, just below the eyes (see practioner: fig 2)
Who do I seek for help?
Your eye care practitioner, either the optometrist or ophthalmologist, who would adequately diagnose and treat your condition.
What should I (or my child) expect during the test?
The procedures for tear drainage assessments are as follows:
1. Slit lamp and External Examination
This is where the practitioner seats you in front of a slit lamp, which is a type of microscope with a light source, which illuminates the front part of your eye. This is done to view the external part of your eye to see if there is any misalignment or abnormalities in your eyelids.
2. Fluorescein Dye Disappearance Test:
This is when the examiner instils a drop of brightly yellowish dye using a strip or eye drop. Becareful not to wear your favourite clothes!!! Fluorescein dyes may stain your clothes yellow for the rest of the day!
-The dye dissolves in your tears, and allows the examiner to better visualise how well your tears flow out from the eye.
- Dye disappearance within 3 min is considered normal
3. Palpation
As the name suggests: The examiner, while on the slit lamp, gently presses upon the upper sides of your nose, just below the eye.
- This is done to assess if there is any pus flowing trapped in the upper tear drainage system.
- If pus comes out from the drains, it means that system is infected and no further testing is performed.
4. Dilation, Probing and Irrigation.
May be considered fairly invasive by some, this procedure is both diagnostic and therapeutic. Topical anaesthetic is instilled for the following procedures, therefore, it is not painful but involves some mild degree of discomfort – probes are placed into the drainage system of your eyes, which may look intimidating. It also involves swallowing some saline (salt) water, which is harmless but may taste funny.
a)Dilation: A dilator is used to widen the puncta (drainage hole of the eye) in your lower eyelid. This serves to clear any obstruction or temporarily relieves narrowing or the puncta.
It also serves to widen the puncta for insertion of a cannula.
b)Probing: A cannula (a blunt probe – which does not hurt the eye), with an attached syringe (filled with sterile saline) is inserted horizontally into the lower eyelid, and pushed in until it stops.
-This gives the practitioner an idea if there is any obstruction in the upper drainage ‘pipes’ of your system.
c)Irrigation: The plunger of the syringe is gently depresses, allowing saline to flow into the drainage system. As a patient, you are to report when you feel saline flowing into your nose or your throat. If that happens, it’s good! It means that your drainage system still allows liquid to flow through.
-In the process, any particles responsible for blocking your drainage system are now being flushed out. Hence while testing; your condition is also ‘cured’.
Possible Test Outcomes:
1) You feel saline in your nose/throat: which means your drainage pathway is relatively clear (may have partial blockage).
i) Your watery eyes may be caused by other factors or the system gets blocked only under more natural conditions.
2) You do NOT feel saline in your throat/nose:
i)Your lower drainage ‘pipe’ is blocked.
ii) OR some saline may backflow out from the puncta, which means that your upper drainage pipes are blocked.
Additional Testing:
5. The Jones Tests – These tests are indicated to rule out a ‘functional blockage’ - blockage during normal, ‘non-test’ conditions. They are also useful in determining the location of the blockage. They are very similar to the tests mentioned before.
a)Jones 1 test: The eye(s) are ‘flooded’ with fluorescein dye as before. You are allowed to blink normally for 5 minutes while a tissue or cotton bud is placed below your nose to ‘catch’ any dye leaking out from your system.
i)if dye is found, it means that your system is not functionally blocked, and the watery eye(s) are very likely due to excessive tear production.
ii)if no dye is retrieved, it means that the dye fails to drip down into the nose and there is a blockage somewhere in part of the system; that, or the eye blinking action fails to sufficiently ‘pump’ tears out of the eye.
b)Jones 2 test: This is done immediately if NO dye is retrieved from the nose during Jones 1 test. This involves probing and irrigation of the drainage system, to flush out trapped dye(if any) out of the system.
i)if Dye is retrieved after irrigation, it means that the dye managed to seep through the puncta and upper drainage ‘pipes’ (upper drainage is clear)
-the lower drainage ‘pipe’ could be partially blocked.
ii)if just colourless saline is retrieved (no dye),
it means that dye failed to even enter the puncta and upper ‘pipes’ of the system (upper drainage blocked)
-it can also mean that the eye blinking action fails to sufficiently ‘pump’ tears out of the eye.
The part of the website has been designed with you, the patient, in mind. Do note that tests may be performed slightly differently than as described above and in a different order. All procedures are to be performed by professional eye care practitioners and this website does not constitute a ‘do-it’yourself’ guide. This site recommends that all should have their eyes checked at least once every 2 years regardless of symptoms/complaints.
References:
Textbooks:
Casser, L., Fingeret, M. and Woodcome, H.T. (1997). Atlas of Primary Eye Care Procedures. 2nd Edition. USA: Appleton and Lange.
Elliot, D.B. (2003). Clinical Procedures in Primary Eye Care. 2nd Edition. Butterworth Heinemann.
Kanski, J.J. (2003). Clinical Ophthalmology – A Systemic Approach. 5th Edition. Butterworth Heinemann.
CD- ROMs:
Tasman, W. and Jaeger, E.A. (2005). Duane's Clinical Ophthalmology on CD-ROM. 2005 Edition. USA: Lippincott Williams & Wilkins.
Websites:
Austen, D.P. (date unknown). Lacrimal Dilation and Syringing.
Available at: http://www.academy.org.uk/ [accessed 15 May 2008].
Kanski, J.J. (2007). Clinical Ophthalmology – A Systemic Approach. 6th Edition.
Available at: http://www.kanskionline.com [accessed 15 May 2008].
Jeremiah Lim, Dip. Optom (Singapore)
Understanding the Use:
Indications for Lacrimal Drainage Assessment:
1) Watery eyes with epiphora
2) Lid anomalies
a) Displacement/Malposition of Puncta
b) Entropion/Ectropion
c) Lacrimal Pump failure caused by lid laxity, over-riding upper eye lids or orbicularis muscle weakness.
3) Drainage Blockage e.g. stenosed punctae
4) Dry Eyes/Inflammation/Infection (Ddx reflex tearing vs obstruction)
5) Swollen/Sore lacrimal sac
Applied Anatomy:
The lacrimal drainage system is comprised of the following structures:
IS IT EVEN BLOCKED?
Tear flow onto cheek may be caused by an excessively wet eye due to:
1) Hypersecretion of tears
-Schirmer’s Test
-Cotton Thread Tear Test (phenyl red thread)
2) Poor tear film support at inferior lid margin (tears spill over)
-punctae misalignment
-failure of tear pump mechanism
3) Drainage Occlusion (Epiphora)
1) Fluorescein Disappearance Test
2) Palpation
3) Probing and Irrigation (Lacrimal Lavage)
4) Jones Test 1,2
Drainage Occlusion Assessment Techniques
1. Fluorescein (NaFl) dye disappearance test
To be conducted prior to any manipulation of the eyelids or instillation of any drops which may affect the results.
Procedure:
1. Instil 1 drop of fluorescein into the eye using sterile fluorescein strips or 2% fluorescein drops. (Begin timing now).
2. Observe tear margins in both eyes on slit lamp
3. A tear margin of more than 1mm is generally considered to be excessive.
-Pearls: Note that many px do not have obvious overflow onto cheeks
Results and Intrepretation:
In a normal eye, little or no NaFl remains in the eye after 3 minutes, prolonged retention of dye indicates inadequate lacrimal drainage. Graded from 0 to 4+:
-Grade 0: No dye retained after 5 min. Grade 4+: All dye remains after 5 min.
2. Palpation
1. Apply gentle to moderate pressure
onto the lacrimal sac region of the face. (fig. 2)
Rarely, a tumour/cyst may be felt.
2. Punctal expression of mucopurulent
material on compression is indicative of
a. a patent canalicular and punctal system
b. an obstruction at the inferior
lacrimal sac or above.
c. A possible infection i.e. dacryocystitis,
especially if painful.
3. Infections i.e. dacryocystitis and cannaliculitis
contraindicates further assessment
i.e. dilation/probing/irrigation.
3. Probing and Irrigation – The Lacrimal Lavage
Dilation
Uses:
1. To enlarge the puncta for insertion of the cannulus.
2. To dislodge a concretion or mucous plug at the puncta or
ampulla. Also provides temporary relief of punctum stenosis.
Procedure:
1. Wash hands for hygiene.
2. Instill one drop of topical anaesthetic e.g. Alcaine into the inferior punctum.
3. Sterilise dilator with alcohol swabs.
4. Insert the small dilator vertically into the inferior punctum
up to about 2 mm. Gently twirl the dilator clockwise and
anti-clockwise. (see fig. 3)
- At this point, you may choose to switch to a medium
dilator to further open up the puncta and cannaliculi
prior to the insertion of the cannulus.
- Alternatively you may choose to carry out the
following to further dilate the inferior cannaliculi:
5. Using the other free hand index finger, pull lower
lid temporally to straighten the ampulla, lining up
the vertical and horizontal cannaliculi.
6. Rotate the dilator to the horizontal position
and insert it into the inferior punctum,
twirling it again.
Probing
Uses:
1. To assess the patency of the upper, lower and common cannaliculi.
Procedure
1. After dilation (See Step 1), open packets of disposable syringes and cannula. Connect them together.
2. Remove the plunger and fill syringe with sterile saline.
3. Replace plunger, point syringe upwards and give it a squeeze, ensuring removal of all air bubbles and some saline.
4. Insert the cannula vertically down into the inferior vertical cannaliculus.
5. Using the other free hand index finger,
pull lower lid temporally to straighten the
ampulla, lining up the vertical and horizontal
cannaliculi while you rotate the syringe horizontally.
(see fig. 4)
6. Insert the cannula horizontally
inwards until you reach a ‘Hard Stop’
or ‘Soft Stop’. (see fig. 5)
Procedure continues.. (See Step 3)..
Irrigation
Uses:
To assess patency of the cannaliculi and lacrimal sac or the nasolacrimal duct.
Procedure:
1. Upon encountering either a ‘Hard Stop’ or a ‘Soft Stop’, pull back approximately 2 mm before gently depressing the plunger.
2. Ask the patient to report when they feel saline in the nose or at the back of the throat.
Results and Interpretation Pocket Guide (as seen below), now available for downloading and printing. Click here to begin download immediately!
Probing and Irrigation
Interpretation and Results
Hard Stop
1. The cannula enters the lacrimal sac and stops at the medial wall of the sac, through which the lacrimal bone can be felt (fig. 5).
2. This excludes complete obstruction of the canaliculus.
3. Patent Lacrimal Drainage System: If saline passes through into the nose during irrigation, it means the patient has a patent lacrimal drainage system.
- Note that only complete obstruction is excluded, the patient may still have a patent but stenosed lacrimal drainage system, or subtle lacrimal pump failure.
4. Total Obstruction of Nasolacrimal Duct: Failure of saline to reach the nose indicates total obstruction of the nasolacrimal duct.
5. In such an event, the lacrimal sac becomes distended upon irrigation and there will be reflux of liquid through the upper punctum.
- Regurgitated liquid may be clear saline, mucoid, mucopurulent or frank purulent, depending on the contents of the lacrimal sac.
Soft Stop
1. The cannula fails to enter the lacrimal sac, stopping at the junction of the common canaliculus and the lateral wall of the lacrimal sac, or slightly before that.
2. A soft spongy feeling is felt as the cannula pushes the soft tissue of the common canaliculus and the lateral wall against the medial wall of the lacrimal sac and the lacrimal bone.
3. Irrigation will not cause a distention of the sac (fig. 5).
4. Lower canalicular obstruction: Reflux of saline from the lower punctum.
5. Common canalicular obstruction: Reflux of saline from the upper puntcum, indicates patency of both upper and lower canaliculi.
6. An attempt may be made to clear the obstruction by closing the
superior punctum with a dilator or cotton bud during syringing
(irrigation).
Uses:
1. For patients with suspected partial obstruction of the drainage system.
-Manifest epiphora
-No abnormalities on lacrimal syringe irrigation
2. Particularly useful to assess functional blockage, any blockage which occurs under low-pressured, natural tear drainage conditions whereby all or part of the drainage system collapses.
Procedures:
Primary (Jones 1) Test (fig. 6)
1. Instil 1 drop of 2% flurorescein, or wet 2-4 strips
of fluorescein with sterile saline into the conjunctival
sac (inferior palpebral conjunctiva).
2. After 5 min of normal blinking has elapsed, get the
patient to occlude one nose at a time and blow
into a white tissue paper. (Check tissue with Burton
lamp or slit lamp cobalt blue filter – if negative, go
to step 3.)
3. Alternatively, a cotton bud moistened with topical
anaesthesia is inserted under the inferior meatus
5 min later to test for staining. Also performed if step 2
fails.
Results and Intrepretation:
a) Positive: Fluorescein recovered from nose, indicates patency of the drainage system under normal conditions.
–watering is due to hypersecretion, also indicates that no further tests are required.
b) Negative: no fluorescein recovered from nose, indicating a partial obstruction anywhere from puncta to valve of Hasner.
– or failure of the tear pump mechanism.
– negative primary test is an indication for an immediate secondary test (Jones 2).
Author’s Note: Most textbooks agree that ‘Positive’ on Jones Tests means ‘Patent’ while a ‘Negative’ result signifies ‘Obstruction’.
However, some argue that ‘Negative’ results for a test, should mean ‘No Pathology’ in terms of medical thinking (Duane’s Clinical Opthalmology). To avoid ambiguity, record results as fluorescein detected or no fluorescein detected.
Secondary (Jones 2) Test (fig. 7)
Uses: Identifies the site of probable partial obstruction
- based on whether the dye instilled during the
primary test has entered the lacrimal sac.
Procedures
1. Immediately after Negative primary jones test,
Wash out excessive fluorescein from the
Conjunctival sac and the syringe.
2. Instil topical anaesthetic into the eye and
perform syringing (lavage) to irrigate
lacrimal system.
3. Place a cotton tip bud under the inferior turbinate
to capture the effluent or alternatively, to get the
patient to expectorate into a basin, or simply blow
nose into a white tissue.
-Inspect samples with a Burton Lamp/Cobalt
blue filter.
Results and Interpretation
a) Positive: Fluorescein stained saline recovered from nose.
- indicates fluorescein entered the lacrimal sac
- therefore confirms functional patency of puncta, superior and inferior canaliculi and common cannaliculi
- also implies that nasolacrimal duct is partially obstructed
b) Negative: Unstained saline recovered from nose.
- indicates fluorescein did not enter lacrimal sac
- implying that upper lacrimal passages blocked or partially blocked.
(cannaliculi, puncta)
- or defective tear pump mechanism.
Note: False Positives are rare in Jones Tests are rare, however false negatives are possible due to technical difficulties in retrieving the fluorescein dye. Therefore, a positive result means a patent (may be partially obstructed) and functioning lacrimal excretory system, while a Negative test is inconclusive and does not necessarily indicate that the system is obstructed (due to false negatives).
Recommend Equipment and Inventory list:
1. Lacrimal Dilators (sml and med) 2. Disposable lacrimal cannulae
3. 3-5ml disposable sterile syringes 4. Anaesthetic drops e.g. Alcaine
5. Saline (preserved/unpreserved) 6. Alcohol disinfecting swabs
7. White tissues and cotton buds 8. Surgical gloves / masks (optional)
Purchase all above mentioned equipment from our sponsors today.
Do you have an excessively wet eye? Or find yourself ‘Crying’, with tears rolling down your cheek for no apparent reasons?
Do I need help? Yes, if you exhibit at least one of such symptoms:
-constantly watery eye or eyes – which can blur your vision
-tears from one eye or both, rolling onto cheeks
-worst in cold/windy conditions:
e.g. ’crying’ while walking to the market
-or hot/dry conditions:
e.g. ‘crying’ at home, while the heater is on
-sore/gritty/tired or even burning sensation in eyes, leading
to tearing.
-painful and swollen lump on the sides of your nose, just below the eyes (see practioner: fig 2)
Who do I seek for help?
Your eye care practitioner, either the optometrist or ophthalmologist, who would adequately diagnose and treat your condition.
What should I (or my child) expect during the test?
The procedures for tear drainage assessments are as follows:
1. Slit lamp and External Examination
This is where the practitioner seats you in front of a slit lamp, which is a type of microscope with a light source, which illuminates the front part of your eye. This is done to view the external part of your eye to see if there is any misalignment or abnormalities in your eyelids.
2. Fluorescein Dye Disappearance Test:
This is when the examiner instils a drop of brightly yellowish dye using a strip or eye drop. Becareful not to wear your favourite clothes!!! Fluorescein dyes may stain your clothes yellow for the rest of the day!
-The dye dissolves in your tears, and allows the examiner to better visualise how well your tears flow out from the eye.
- Dye disappearance within 3 min is considered normal
3. Palpation
As the name suggests: The examiner, while on the slit lamp, gently presses upon the upper sides of your nose, just below the eye.
- This is done to assess if there is any pus flowing trapped in the upper tear drainage system.
- If pus comes out from the drains, it means that system is infected and no further testing is performed.
4. Dilation, Probing and Irrigation.
May be considered fairly invasive by some, this procedure is both diagnostic and therapeutic. Topical anaesthetic is instilled for the following procedures, therefore, it is not painful but involves some mild degree of discomfort – probes are placed into the drainage system of your eyes, which may look intimidating. It also involves swallowing some saline (salt) water, which is harmless but may taste funny.
a)Dilation: A dilator is used to widen the puncta (drainage hole of the eye) in your lower eyelid. This serves to clear any obstruction or temporarily relieves narrowing or the puncta.
It also serves to widen the puncta for insertion of a cannula.
b)Probing: A cannula (a blunt probe – which does not hurt the eye), with an attached syringe (filled with sterile saline) is inserted horizontally into the lower eyelid, and pushed in until it stops.
-This gives the practitioner an idea if there is any obstruction in the upper drainage ‘pipes’ of your system.
c)Irrigation: The plunger of the syringe is gently depresses, allowing saline to flow into the drainage system. As a patient, you are to report when you feel saline flowing into your nose or your throat. If that happens, it’s good! It means that your drainage system still allows liquid to flow through.
-In the process, any particles responsible for blocking your drainage system are now being flushed out. Hence while testing; your condition is also ‘cured’.
Possible Test Outcomes:
1) You feel saline in your nose/throat: which means your drainage pathway is relatively clear (may have partial blockage).
i) Your watery eyes may be caused by other factors or the system gets blocked only under more natural conditions.
2) You do NOT feel saline in your throat/nose:
i)Your lower drainage ‘pipe’ is blocked.
ii) OR some saline may backflow out from the puncta, which means that your upper drainage pipes are blocked.
Additional Testing:
5. The Jones Tests – These tests are indicated to rule out a ‘functional blockage’ - blockage during normal, ‘non-test’ conditions. They are also useful in determining the location of the blockage. They are very similar to the tests mentioned before.
a)Jones 1 test: The eye(s) are ‘flooded’ with fluorescein dye as before. You are allowed to blink normally for 5 minutes while a tissue or cotton bud is placed below your nose to ‘catch’ any dye leaking out from your system.
i)if dye is found, it means that your system is not functionally blocked, and the watery eye(s) are very likely due to excessive tear production.
ii)if no dye is retrieved, it means that the dye fails to drip down into the nose and there is a blockage somewhere in part of the system; that, or the eye blinking action fails to sufficiently ‘pump’ tears out of the eye.
b)Jones 2 test: This is done immediately if NO dye is retrieved from the nose during Jones 1 test. This involves probing and irrigation of the drainage system, to flush out trapped dye(if any) out of the system.
i)if Dye is retrieved after irrigation, it means that the dye managed to seep through the puncta and upper drainage ‘pipes’ (upper drainage is clear)
-the lower drainage ‘pipe’ could be partially blocked.
ii)if just colourless saline is retrieved (no dye),
it means that dye failed to even enter the puncta and upper ‘pipes’ of the system (upper drainage blocked)
-it can also mean that the eye blinking action fails to sufficiently ‘pump’ tears out of the eye.
The part of the website has been designed with you, the patient, in mind. Do note that tests may be performed slightly differently than as described above and in a different order. All procedures are to be performed by professional eye care practitioners and this website does not constitute a ‘do-it’yourself’ guide. This site recommends that all should have their eyes checked at least once every 2 years regardless of symptoms/complaints.
References:
Textbooks:
Casser, L., Fingeret, M. and Woodcome, H.T. (1997). Atlas of Primary Eye Care Procedures. 2nd Edition. USA: Appleton and Lange.
Elliot, D.B. (2003). Clinical Procedures in Primary Eye Care. 2nd Edition. Butterworth Heinemann.
Kanski, J.J. (2003). Clinical Ophthalmology – A Systemic Approach. 5th Edition. Butterworth Heinemann.
CD- ROMs:
Tasman, W. and Jaeger, E.A. (2005). Duane's Clinical Ophthalmology on CD-ROM. 2005 Edition. USA: Lippincott Williams & Wilkins.
Websites:
Austen, D.P. (date unknown). Lacrimal Dilation and Syringing.
Available at: http://www.academy.org.uk/ [accessed 15 May 2008].
Kanski, J.J. (2007). Clinical Ophthalmology – A Systemic Approach. 6th Edition.
Available at: http://www.kanskionline.com [accessed 15 May 2008].
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