Dacryostenosis is obstruction or stenosis of the nasolacrimal duct, causing excess tearing. Causes include nasal or facial bone fractures, recurrent conjunctivitis, inflammatory diseases, tumor, and a dacryolith. Diagnosis is clinical. Treatment is with manual or surgical decompression and in acquired cases, treatment of the underlying disorder.
Nasolacrimal obstruction may be congenital or acquired. The cause of congenital obstruction is inadequate development of any part of the nasolacrimal ducts. Typically, a membrane at the distal end of the nasolacrimal duct persists (valve of Hasner). There is tearing and purulent discharge; the condition may manifest as chronic conjunctivitis, usually beginning by the age of 4 weeks (1).
There are many causes of acquired nasolacrimal duct obstruction (2, 3). Some causes include past nasal or facial bone fractures and sinus surgery, which disrupt the nasolacrimal duct; chronic or recurrent conjunctivitis, inflammatory diseases (eg, sarcoidosis, granulomatosis with polyangiitis; tumor (eg, maxillary and ethmoid sinus tumors); and dacryolith.
Causes of punctal or canalicular stenosis include chronic conjunctivitis (especially herpes simplex), certain types of chemotherapy, adverse reactions to eye drops (especially topical echothiophate iodide), autoimmune skin disease (eg, Causes of punctal or canalicular stenosis include chronic conjunctivitis (especially herpes simplex), certain types of chemotherapy, adverse reactions to eye drops (especially topical echothiophate iodide), autoimmune skin disease (eg,mucous membrane pemphigoid, lichen planus), and radiation.
General references
Błaszczyk K, Biedka K, Estreicher A, et al. Congenital Nasolacrimal Duct Obstruction: Natural Course, Diagnosis and Therapeutic Strategies. J Clin Med. 2025;14(11):3716. Published 2025 May 26. doi:10.3390/jcm14113716
2. Ali MJ. Etiopathogenesis of primary acquired nasolacrimal duct obstruction (PANDO). Prog Retin Eye Res. 2023 Sep;96:101193. doi: 10.1016/j.preteyeres.2023.101193.
3. Ramey NA, Hoang JK, Richard MJ. Multidetector CT of nasolacrimal canal morphology: normal variation by age, gender, and race. Ophthalmic Plast Reconstr Surg. 2013 Nov-Dec;29(6):475-80. doi: 10.1097/IOP.0b013e3182a230b0.
Diagnosis of Dacryostenosis
History and physical examination alone
Diagnosis is usually based on examination. Sometimes ophthalmologists probe and irrigate the lacrimal drainage system with saline, with or without fluorescein dye. Reflux indicates stenosis.Diagnosis is usually based on examination. Sometimes ophthalmologists probe and irrigate the lacrimal drainage system with saline, with or without fluorescein dye. Reflux indicates stenosis.
Treatment of Dacryostenosis
Manual or surgical decompression
Treatment of underlying disorder
Congenital nasolacrimal duct obstruction often resolves spontaneously by approximately age 6 to 9 months; before 1 year, manual compression of the lacrimal sac 4 or 5 times a day may relieve the obstruction. After age 1 year, the nasolacrimal duct may need probing, usually under general anesthesia; if obstruction is recurrent, a temporary silastic tube may be inserted.
In acquired nasolacrimal duct obstruction, the underlying disorder is treated when possible. If treatment is not possible or is ineffective, a fistula between the lacrimal sac and the nasal cavity can be created surgically (dacryocystorhinostomy).
In cases of punctal or canalicular stenosis, dilation is usually curative. If canalicular stenosis is severe and bothersome, a surgical procedure (conjunctivo-dacryocystorhinostomy or C-DCR) that places a tube made of low thermal-expansion borosilicate glass (Jones tube) leading from the caruncle (the small, pink, nodule at the medial canthus) into the nasal cavity can be considered. Injection of botulinum toxin A into the lacrimal gland is also effective in treating tearing by decreasing the production of tears by the main lacrimal gland (1).
Treatment reference
1. Alfarhan A, Alsubhi A, Daghistani G, et al. Efficacy and Safety of Botulinum Toxin Injections for Epiphora Management: A Systematic Review and Meta-Analysis. Ophthalmic Plast Reconstr Surg. 2025 Jul 3. doi: 10.1097/IOP.0000000000002986. Epub ahead of print.
Key Points
Dacryostenosis is either congenital or acquired.
Symptoms include excessive tearing.
Reflux of saline or fluorescein dye when flushing the lacrimal drainage system confirms the diagnosis. Reflux of saline or fluorescein dye when flushing the lacrimal drainage system confirms the diagnosis.
In congenital dacryostenosis, symptoms usually resolve by 9 months; manual decompression of the lacrimal sac may help.
In acquired dacryostenosis, treat the underlying disorder.
For both congenital and acquired dacryostenosis, surgery may be needed if symptoms persist.
