List of Abbreviations
CT - computed tomography (computed tomography of the facial skeleton) (A06.03.002)
MRI - magnetic resonance imaging (magnetic resonance imaging of the facial skeleton) (A05.03.004)
IT - inferior turbinate
IMN - inferior meatus of nose
NP - nasal septum
NLC - nasolacrimal canal
NLD - nasolacrimal duct
LC - lacrimal canaliculus
LS - lacrimal sac
MT - middle turbinate
MMN - middle meatus of nose
LDP - lacrimal drainage pathways
LPy - lacrimal punctum
Terms and Definitions
Lacrimation = epiphora - overflow of tears beyond the palpebral fissure
Lacrimal ducts - a complex of anatomical structures of the lacrimal drainage system
Atresia - developmental defect, absence of an opening or canal
Dacryostenosis - narrowing of the lacrimal ducts
Dacryostasis - stagnation of tears in the lacrimal ducts
Dacryocele - enlargement of the lacrimal duct resulting from tear stasis in the lacrimal sac (dacryocystocele) or nasolacrimal duct (dacryoductocele)
Dacryops - cystic dilatation of the lacrimal gland excretory duct due to obliteration of its orifice
Obliteration - closure or obliteration of a hollow or tubular organ due to tissue proliferation (mostly connective tissue) originating from its walls
Obstruction - localized barrier along the course of a canal or within a cavity
Probing - diagnostic procedure, passing a probe through the lacrimal ducts
Bougienage - therapeutic and diagnostic procedure, passing a probe through the lacrimal ducts with perforation of obstructions
Pyocele - accumulation of pus in a blocked lacrimal sac
Mucocele - accumulation of mucus in a blocked lacrimal sac
Empyema - active purulent process in a blocked lacrimal sac
Phlegmonous dacryocystitis - spread of the purulent-inflammatory process to the tissue surrounding the lacrimal sac
Stenting, intubation - introduction of an intubating material into the lacrimal ducts
Lacrimal meniscus = lacrimal lake - accumulation of tears between the lower eyelid and the eyeball
1. Brief information on the disease or condition
A group of diseases (conditions) grouped by a common feature: impaired lacrimal drainage with possible secondary infectious inflammation.
Normally, tear outflow occurs through patent LDPs due to the pumping action of the muscle fibers surrounding the lacrimal sac and the relatively low air pressure in the nasal cavity during breathing.
1.1 Definition of the disease or condition
Lacrimal duct insufficiency is a pathological condition manifested by delayed tear outflow through natural anatomical pathways. Obstacles to normal tear flow may include: pathology of the lacrimal puncta in the form of atresia, stricture, dystopia, entropion, or ectropion; pathology of the lacrimal canaliculi in the form of atresia, stricture, obstruction, or obliteration; pathology of the lacrimal sac in the form of atresia, lumen stricture, obstruction, or obliteration; pathology of the nasolacrimal duct in the form of atresia, stricture, obstruction, or obliteration.
The pathological condition of the LDP can be complicated by catarrhal-inflammatory and purulent-inflammatory diseases due to infection of the stagnant contents.
In the presence of an obstruction in the NLD and the development of infectious inflammation, acute or chronic dacryocystitis develops.
In case of obstruction of the LS entrance from the side of the LC and the exit from the side of the NLD, a dacryocele develops – a cystic dilatation of the LS filled with mucus or pus. Activation of infection in the LS can lead to the spread of the purulent process beyond the LS in the form of phlegmon of the surrounding tissues with possible abscess formation and the creation of a skin fistula.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Inflammation of the lacrimal ducts develops as a result of delayed tear outflow and activation of intraductal infection.
Delayed tear outflow may be caused by developmental defects, dystopia of anatomical structures, presence of foreign bodies, narrowing of the lumen, or obliteration of the lacrimal ducts.
1.3 Epidemiology of the Disease or Condition
Diseases of the lacrimal drainage pathways represent a significant medical problem affecting a wide range of patients. Their prevalence may vary depending on various factors such as age, sex, geographical location, and concomitant diseases.
According to various studies, lacrimal drainage pathway diseases, such as dacryocystitis and lacrimal duct obstructions, occur in 5-10% of the population. According to other estimates, about 10-20% of people over 60 years of age may experience various problems associated with impaired tear fluid outflow. At the same time, women suffer from lacrimal drainage pathway diseases several times more often [1-5].
Diseases of the lacrimal drainage pathways are often comorbid with other conditions, such as allergic rhinitis, sinusitis, and various infectious processes. Chronic inflammatory conditions can exacerbate symptoms and increase the risk of secondary infections.
Epidemiological data show that the prevalence of lacrimal drainage pathway diseases can vary depending on the region and ecology. For example, in areas with high levels of environmental pollution or high humidity, a higher number of inflammatory disease cases is observed.
1.4 Features of Coding the Disease or Condition
H04.3 Acute and unspecified inflammation of lacrimal passages
H04.4 Chronic inflammation of lacrimal passages
H04.5 Stenosis and insufficiency of lacrimal passages
H04.8 Other disorders of lacrimal system
1.5 Classification of the disease or condition
Classification by clinical manifestation:
Acute and unspecified inflammation of lacrimal passages:
Dacryocystitis (phlegmonous) acute, subacute, or unspecified
Dacryopericystitis acute, subacute, or unspecified
Canaliculitis lacrimal acute, subacute, or unspecified
Chronic inflammation of lacrimal passages:
Dacryocystitis chronic
Lacrimal ducts:
canaliculitis chronic
mucocele chronic
Stenosis and insufficiency of lacrimal passages:
Dacryolith
Eversion of the lacrimal punctum
Stenosis of the lacrimal:
canaliculus
duct
sac
Etiological classification of the pathology:
Anomalous
Senile
Traumatic
Obstructive
Postmorbid (as a complication of necrotic, degenerative, or oncological diseases)
Anatomical localization classification of the pathology:
Lacrimal puncta
Lacrimal canaliculi
Lacrimal sac
Nasolacrimal duct
Pathogenetic classification of the pathology:
Generalized epithelial (SJS, pemphigoid, etc.)
Inflammatory fibro-infiltrative (chronic inflammation)
Localized cicatricial
Classification of the pathology by degree of lumen restriction:
Narrowing (stricture)
Closure (obstruction)
Obliteration
Classification of the pathology by progression:
Stationary
Progressive
1.6 Clinical presentation of the disease or condition
Clinical manifestations depend on the localization of the pathology and its pathogenesis.
Dystopia of the lacrimal puncta, both eversion and inversion, impedes tear drainage into the lacrimal ducts, resulting in widening of the tear meniscus and lacrimal lake.
Atresia or obliteration of the lacrimal puncta and/or canaliculi and/or all elements of the lacrimal ducts is accompanied by epiphora or pooling of tears.
In infectious involvement, a local and/or perifocal inflammatory reaction with purulent discharge is observed. The amount of pus depends on the site of inflammation, the caliber of the duct lumen, and the virulence of the infection. Canaliculitis typically manifests as localized inflammation within the canaliculus and the accumulation of cheesy masses or calculi in its lumen. Expression of the canalicular contents is difficult, but lacrimal passage irrigation remains patent.
In dacryocystitis, pressure on the lacrimal sac region is accompanied by the discharge of mucus and/or pus from the lacrimal puncta. Typically, the pus is creamy in consistency and yellowish in color. In some cases, purulent discharge is not observed despite palpably increased volume of the lacrimal sac. This may be due to the simultaneous blockage of both the canalicular orifices and the nasolacrimal duct.
Accumulation of mucus (mucocele) and/or pus (pyocele) in the lacrimal sac with its cyst-like dilation may persist for a long time.
When infection in the sac is activated, acute purulent dacryocystitis develops with skin erythema over the projection of the lacrimal sac and continuous discharge of a significant amount of pus from the lacrimal puncta.
In cases where the orifices of the lacrimal canaliculi are closed, infectious inflammation develops within the cavity of the sac (empyema).
The spread of the purulent-inflammatory process beyond the lacrimal sac into the surrounding cellular spaces (phlegmonous dacryocystitis) worsens the clinical picture, with marked edema up to complete closure of the palpebral fissure, skin hyperemia, pain, and possible symptoms of systemic intoxication and fever.
Purulent melting of the lacrimal sac wall usually occurs toward the skin surface. The clinical picture is characterized by diffuse hyperemia, pronounced local bulging, gradual skin thinning, and ultimately the formation of a cutaneous fistula.
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis is established based on:
complaints of epiphora with or without purulent discharge from the lacrimal puncta;
external examination revealing abnormalities in the anatomy and position of the eyelids and lacrimal puncta;
impaired lacrimal outflow detected during the dye lacrimal-nasal test;
identification of a physical obstruction in the lacrimal pathways using probing of the lacrimal drainage system;
visualization of a contrast shadow cutoff in the lacrimal pathways during X-ray dacryocystography (A06.26.004 Contrast X-ray examination of the lacrimal gland and lacrimal duct).
2.1 Complaints and Anamnesis
It is recommended to take the history of present illness and complaints in eye pathology (A01.26.001) for all patients with epiphora [1-5] for disease diagnosis.
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: when taking complaints, it is necessary to clarify the presence of epiphora, dryness, accumulation of dried exudate on the eyelashes after sleep, purulent discharge from the lacrimal puncta, and to note the amount and nature of the discharge. Nasal breathing difficulties and their coincidence with increased epiphora are noted.
The medical history should ascertain the duration of complaints, potential causes, temporal correlations with other diseases, and a history of rhinosinusitis.
2.2 Physical Examination
It is recommended for all patients with epiphora to undergo an external examination of the maxillofacial region (A01.07.005) and visual examination of the eyes (A01.26.002) to assess changes in eyelid position, shape of the palpebral fissure, inner canthus, lacrimal puncta, and eyelid movements [1-9].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended for all patients with suspected lacrimal duct pathology to undergo palpation of the maxillofacial region (A01.07.006) and ocular palpation (A01.26.003), specifically in the projection of the lacrimal sac—a compression test evaluating discharge from the lacrimal puncta [1-5].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: palpation is used to determine the position and mobility of the eyelids, changes in the volume and consistency of the lacrimal sac, and the feasibility of expressing its contents.
It is recommended for all patients with epiphora to undergo the canalicular test (nasal test, lacrimal-nasal test) (A02.26.019) to check lacrimal duct patency and assess active tear outflow [1-5, 10-16, 34].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: the dye lacrimal-nasal test (West's test) involves the instillation of a dye solution (e.g., fluorescein, collargol, etc.) and evaluation of two parameters: disappearance of the dye from the conjunctival sac (visual observation) and appearance of the dye in the nasal cavity (staining of a cotton wick inserted into the inferior nasal meatus, rhinoendoscopy). Normally, the dye passes from the conjunctival cavity to the nasal cavity within 5-10 min.
The double West's test can be performed to determine the contribution of rhinitis to the clinical picture. After instilling vasoconstrictors into the nose, dye instillation into the conjunctival sac is repeated and the result is compared with the first West's test. A decrease in the transit time of the dye through the lacrimal ducts into the nose indicates a rhinogenic origin of epiphora.
2.3 Laboratory Diagnostics
It is recommended for patients with purulent dacryocystitis who fail to respond to initially prescribed topical broad-spectrum antimicrobial drugs (S01A) within 2 weeks to undergo microscopy of the conjunctival cavity contents (A12.26.022) and microbiological (culture) examination of conjunctival discharge for aerobic and facultatively anaerobic opportunistic microorganisms (A26.26.004) to identify the infectious microflora and determine the susceptibility of microorganisms to antimicrobial chemotherapeutic agents (A26.30.004) [17, 18, 22].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.4 Instrumental Diagnostics
It is recommended for all patients with epiphora to undergo biomicroscopy of the eye (A03.26.001) to evaluate the shape, position, and size of the lacrimal puncta, the state of the conjunctiva and cornea, and to assess the tear film and tear meniscus [1-5].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform irrigation of the lacrimal pathways (A11.26.004) in patients with epiphora using neutral solutions to confirm or exclude lacrimal drainage system insufficiency and to evaluate the contents of the lacrimal sac [1-5, 19-21].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: lacrimal duct irrigation is performed through a blunt-tipped lacrimal cannula (RZN 2018/7824) using solutions neutral to the mucosal epithelium. The irrigation result is assessed by the ratio of antegrade to retrograde flow of the irrigating fluid, the appearance of fluid in the nasal cavity, and the presence of pus in case of retrograde flow [1, 2].
Diagnostic probing of the lacrimal canaliculi, activation of the lacrimal puncta (A16.26.011), and probing of the nasolacrimal duct (A11.26.005) may be performed according to indications.
Conical and cylindrical probes (RZN 2024/24284 "Probing Instrument") are used for probing the canaliculi, lacrimal sac, and nasolacrimal duct. Particular attention is paid to the atraumatic nature of the procedure due to the risk of creating false passages, avoiding excessive force [5, 8, 35, 36].
After dilation of the lacrimal punctum with a conical probe, a cylindrical probe is inserted into the target lacrimal canaliculus. When probing the canaliculi, it is necessary to ensure that the probe rests against the medial wall of the lacrimal sac without encountering soft tissue obstacles along its path; it should be remembered that the formation of a "false passage" in case of insufficiently delicate probing may create a distorted impression of the study results.
The procedure should be performed carefully without damaging the mucosa; to this end, it is advisable to lubricate the probe with eye ointment or eye gel, and slightly rotate the probe as it advances along the lacrimal canaliculus. To prevent the probe from pressing against the mucosal lining of the canaliculus, the eyelid should be continuously held in a slightly outward-tracted position. After the probe passes through the canaliculus and rests against the inner wall of the lacrimal sac (felt as the bony density of the underlying lacrimal fossa), the eyelid is released. The probe is moved into a vertical position and gently advanced along the inner wall of the lacrimal sac towards the upper part of the nasolabial fold into the nasolacrimal duct. Here, the probe passes into the nasolacrimal duct, becoming fixed within it. It is advisable to probe the nasolacrimal duct (especially in adult patients) through the upper lacrimal canaliculus. During probing, the presence of obstacles (such as narrowing or complete stenosis) in the lacrimal canaliculus or nasolacrimal duct is assessed as the probe advances. With normal patency of the tear-drainage pathways, the probe freely reaches the bony wall of the lacrimal fossa, and then, as it advances along the nasolacrimal duct, also encounters no obstacles. Ultimately, the probe rests against the floor of the inferior nasal meatus. An obstruction may appear along the probe's path, either as a narrowing of the lumen or as complete obliteration of the studied segment of the tear-drainage pathways. In such cases, the distance to the stenotic segment is localized by measuring the length of the probe segment inserted into the tear-drainage pathways. Difficulties usually arise when diagnosing stenosis of the lacrimal punctum. In this case, the probe rests against a dense, elastic obstruction, typically pressed by the probe against the bone of the lacrimal fossa. Pulling the eyelid outward can help, after which the segment of the canaliculus suspected of stenosis is displaced toward the probe and is more easily detected [1, 23].
It is recommended to perform rhinoscopy (A03.08.004) in patients with tear-drainage pathway obstruction to identify the anatomical features of the nasal cavity in the region of the lacrimal sac and nasolacrimal duct [24].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.5 Other Procedures
It is recommended to consult an otorhinolaryngologist for patients with a history of nasal and/or paranasal sinus pathology, with concomitant factors initiating nasal breathing difficulty, such as nasal septum deviation, chronic rhinitis of various etiologies, diseases of the paranasal sinuses and dentofacial system, tumor processes, and specific diseases, in order to determine a rational complex treatment strategy [23, 25].
URR CLeD 5Level of Recommendation Confidence C (Level of Evidence Doughnut – 5)
It is recommended to perform contrast dacryocystography (A06.26.007), computed tomography of the facial skull (A06.03.002) including contrast-enhanced imaging of the lacrimal ducts, and magnetic resonance imaging of the facial skull (A05.03.004) in patients with impaired tear-drainage pathway patency as additional instrumental diagnostic procedures to clarify the anatomical features of the nasoorbital region and the shape of the lacrimal ducts, and to identify pathological areas [26-29].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Treatment aims to restore tear-drainage pathway patency, eliminate infectious inflammation, and form alternative tear outflow pathways.
3.1 Conservative Treatment
It is recommended for patients with purulent discharge to undergo anti-infective therapy with broad-spectrum local antimicrobial agents (S01A) to counteract purulent inflammation and local complications [76-79].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the following may be used locally as instillations into the conjunctival sac:
- fluoroquinolones (S01AE):
ofloxacin** (S01AE01) – instill 1 drop into the conjunctival sac 2-4 times a day for no more than 14 days. Used in children from 1 year of age, 1-2 drops every 4-6 hours.
Ciprofloxacin** - 1-2 drops 4 times a day. In severe infections, the dosing regimen in the first 2 days may include instillations of 1 or 2 drops every 2 hours while awake. The duration of therapy with the drug for the stated indications should not exceed 21 days. Used in newborns and older children, 1-2 drops every 4 hours.
Levofloxacin** - 1-2 drops into the affected eye(s) every two hours up to 8 times a day while awake for the first 2 days, then 4 times a day from days 3 to 5 of treatment. The average duration of the course of therapy is 5 days. Used in children from 1 year of age, 1-2 drops every 2 hours up to 8 times a day.
Moxifloxacin** - 1 drop 3 times a day. The duration of the course of therapy depends on the severity of the patient's condition, as well as the clinical and bacteriological characteristics of the infectious process. Used in children from 1 year of age, 1 drop 3 times a day; the course of treatment may last 7-10 days.
- antibiotics (S01AA):
netilmicin (S01FF23) – 0.3% eye drops – 1-2 drops 3 times a day. Used in children from 3 years of age, 1-2 drops 3 times a day.
Tobramycin** (S01AA12) - 1-2 drops every 4 hours for a mild infectious process. In an acute severe infectious process, 2 drops into the conjunctival sac every 60 minutes, with a decrease in the frequency of instillations as inflammatory symptoms subside. For the prevention of infectious complications after ophthalmic surgery, 1-2 drops 3-4 times a day for a month after surgery. The duration of treatment depends on the etiology of the infection and can vary from several days to several weeks. Used in children from 2 months of age - course of treatment is 5-10 days.
Chloramphenicol is prescribed as 1 drop 3-4 times a day, used in adults and children from 4 weeks of age. Course of treatment is 7-10 days.
Tetracycline** eye ointment is prescribed as 0.5-1 cm 3-4 times a day. Used in adults and children from 8 years of age. The course of treatment may last 5-7 days.
Erythromycin eye ointment is prescribed as 0.5-1 cm placed as a strip behind the lower eyelid 3 times a day. The duration of treatment should not exceed 14 days. Used in adults and children from 0 years of age.
- other antimicrobial agents (S01AX):
picloxydine (S01AX16) – 2-6 times a day, duration of treatment 10 days; in children from 0 years of age; benzyldimethylmyristoylaminopropylammonium (S03AA) - 1 drop up to 6 times a day for 7-10 days.
Following bacteriological testing, targeted drugs are prescribed based on the determination of flora susceptibility.
It is advisable for patients with an exacerbation of chronic dacryocystitis, provided that lacrimal puncta are present and the patency of the lacrimal ducts is restored, to undergo a course of tear-duct irrigation (A11.26.004) with systemic antibacterial drugs (J01) (1-3 sessions).
It is recommended for patients with mucus or pus accumulation in the absence of signs of phlegmonous/abscess-forming dacryocystitis to perform compression of the lacrimal sac to evacuate its contents along with the local application of antimicrobial agents (S01A) [1, 5, 79].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended for patients with signs of acute purulent dacryocystitis to use systemic antibacterial drugs (J01) to prevent distant complications [1, 32, 33].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended for patients with chronic purulent dacryocystitis prior to surgical treatment to perform irrigation of the tear ducts (A11.26.004) with anti-infective drugs 1 to 4 times a month [1, 24, 32, 76, 77].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3.2 Surgical Treatment
It is recommended for patients with signs of dacryocystitis/canaliculitis who lack a long-term response to conservative treatment to undergo surgical treatment aimed at establishing tear outflow pathways [2, 3, 23, 32].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: patients with epiphora and insufficiency of the tear-drainage ducts without signs of dacryocystitis may undergo surgical treatment aimed at restoring tear drainage to reduce lacrimation.
Surgical treatment of lacrimal puncta:
Patients with dystopia, narrowing, or obliteration of the lacrimal puncta and/or canaliculi may undergo surgical treatment aimed at restoring the lumen of the lacrimal puncta and/or canaliculi: A16.26.005 Removal of lacrimal canaliculus stones, A16.26.136 Slitting of lacrimal puncta and canaliculi, A16.26.144 Incision of lacrimal puncta and lacrimal canaliculi, A16.26.007.003 Lacrimal punctum plug implantation, A16.26.007.002 Lacrimal duct intubation, A16.26.011 Probing of lacrimal canaliculi, activation of lacrimal puncta, A16.26.020 Correction of entropion or ectropion, A16.26.127.002 Medial canthoplasty [1, 5, 8, 37-42].
Surgical treatment for dislocation of the lacrimal puncta aims to restore their apposition to the eyeball. Depending on the causes of dislocation, surgical methods vary.
In cases of lacrimal punctum dislocation caused by lower eyelid atony, the surgery is performed from the tarsal conjunctiva side. Flaps of various sizes and configurations are excised from the conjunctiva below the lacrimal punctum. The wound edges are sutured. For lacrimal punctum dislocations resulting from cicatricial changes in the eyelid skin, free skin grafting of the lower eyelid is used.
In lacrimal punctum stenosis, a series of bougienages (A16.26.011 Lacrimal canaliculus probing, lacrimal punctum activation) may be performed to dilate them, or a perforated lacrimal punctum plug can be used (RZN 2019/9297 Premounted lacrimal punctum obturator) [37]. If the result is unsatisfactory, surgical dilation of the punctum is performed. This procedure has numerous modifications, which generally involve dissecting the lacrimal punctum sphincter or dissecting the punctum with excision of a fragment of the internal canalicular wall. In cases of lacrimal punctum obliteration with a patent lacrimal canaliculus, a new punctum is formed 1.0–1.5 mm medial to its presumed normal location [37–42].
Surgical treatment of the lacrimal canaliculi
It is recommended to perform surgical treatment—opening and sanitation of the lacrimal canaliculus (A16.26.136 Division of lacrimal puncta and canaliculi, A16.26.144 Incision of lacrimal puncta and lacrimal canaliculi) in patients with canaliculitis to resolve purulent inflammation [1, 3, 38, 43–45].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: local canalicular obstructions can be eliminated using courses of bougienage (Lacrimal canal probing A16.26.011) with cylindrical probes (RZN 2024/24284). Treatment efficacy depends on the intensity of scarring and the extent of the obstruction.
Treatment of canalicular obliteration using bougienage is generally ineffective.
Canalicular obliterating conditions can be anatomically classified as proximal (up to 3 mm from the punctum), mid-level (3 mm to 6 mm), and distal (> 6 mm from the punctum).
Proximal lacrimal canaliculus obliteration can be treated by performing punctoplasty (A16.26.007 Plastic repair of lacrimal puncta and canaliculi): a transverse incision is made in the projection of the patent canaliculus, its lumen is identified, and a new punctum is formed at this site by excising the posterior wall of the canaliculus. An implant is temporarily placed into the canalicular lumen (A16.26.007002 Lacrimal duct intubation) [45].
The following can be used as lacrimal canalicular implants: ophthalmological microdrains for the correction of tear drainage pathways (RZS 2020/13101 dated 31.12.2020), silicone ophthalmological microdrains (FSR 2010/07232 dated 3.08.2017).
For obliteration of the middle third of the canaliculus, an attempt is made to break down the stricture using probes (A16.26.011 Lacrimal canaliculus probing). If bougienage is ineffective, partial graded dissection of the canaliculus (Incision of lacrimal puncta and lacrimal canaliculi A16.26.144), formation of a new lacrimal punctum medial to the obliteration zone, and canalicular stenting with implants (A16.26.007002 Lacrimal duct intubation) may be performed.
Balloon dacryoplasty (A16.26.007.001 Dilation of lacrimal ducts with expanders) has demonstrated efficacy in obliteration of the distal part of the lacrimal canaliculi [57–62].
Plastic repair of lacrimal puncta and canaliculi (A16.26.007) performed using endoscopic equipment (Video endoscopic system for diagnosis and treatment of the lacrimal duct LAC-29FY RZN 2017/5868)—dacryoendoscopy—allows canalicular recanalization via microendoscopically controlled trepanation, as well as dacryorhinotomy, microdrill dacryoplasty, or laser dacryoplasty [59, 63–65].
If restoration of lacrimal canaliculus patency is impossible, lacorhinostomy (A16.26.010.002) is performed.
In patients with complete obliteration or atresia of the lacrimal canaliculi, surgical treatment via bypass outflow pathways is possible using the following methods: 1) creation of an anastomosis between the conjunctival cavity and the lacrimal sac/nasal cavity; 2) lacrimal prosthesis implantation [8, 67].
A16.26.010 Conjunctivodacryostomy, conjunctivorhinostomy
A16.26.010.001 Lacocystostomy with permanent intubation
A16.26.010.002 Lacorhinostomy with lacrimal prosthesis implantation
Surgical treatment of the nasolacrimal duct
It is recommended to perform duct dilation, tear drainage pathway recanalization with intubation—dilation of lacrimal ducts with expanders for adults (A16.26.007.001) and/or lacrimal duct intubation to restore tear drainage pathway patency in all patients with nasolacrimal duct stenosis or short obstruction [48, 51, 54, 55, 57, 58, 62, 68, 83].
GCR BLoE 3Level of Evidence B (Level of Confidence of Evidence – 3)
Treatment of abscessing dacryocystitis
It is recommended to perform percutaneous abscess incision, sanitation, and drainage of the purulent cavity (incision of lacrimal sac phlegmon, incision of lacrimal puncta and lacrimal canaliculi A16.26.006) in patients with abscessing dacryocystitis to resolve purulent inflammation [5, 30, 79].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Dacryocystorhinostomy
It is recommended to perform dacryocystorhinostomy (A16.26.008), which can be performed via an external or endoscopic approach (dacryocystorhinostomy using endoscopic technologies A16.26.009.001, dacryocystorhinostomy with intubation and endoscopic technologies A16.26.009.001), in patients with signs of dacryocystitis and lack of response to conservative treatment, in order to restore tear drainage pathway patency [1–5, 23, 24, 32, 35, 74].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comment: external dacryocystorhinostomy is performed after the resolution of acute purulent dacryocystitis.
Endoscopic dacryocystorhinostomy can be performed even in the presence of active purulent dacryocystitis.
During tear drainage pathway intubation, various guides included in lacrimal intubation kits (RZN 2019/9292 dated 27.11.2019) are used to pass the stent through all segments of the tear drainage pathways: a hollow probe with a guidewire, Ritleng system, Crawford system, Binkhorst, Monoka, etc.
Dacryocystectomy
It is recommended to perform excision of the lacrimal sac (dacryocystectomy A16.26.009) in patients with recurrent purulent dacryocystitis and lack of response to dacryocystorhinostomy, or when dacryocystorhinostomy is contraindicated due to the general clinical condition [75, 80–82].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: in patients with a complicated somatic status and severe anatomical impairment of the nasoorbital region, excision of the lacrimal sac without prior dacryocystorhinostomy is possible.
3.3 Other Treatment
– not applicable.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Medical rehabilitation is not performed.
5. Prevention and Dispensary Observation
Specific prevention methods do not exist.
It is recommended to have a repeat consultation (examination, consultation) by an ophthalmologist (B01.029.002) for patients with signs of dacryocystitis receiving conservative treatment, to monitor treatment efficacy and prevent complications [76, 77, 78, 79].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: following the initial examination and prescription of antimicrobial drugs for acute inflammation or exacerbation of chronic inflammation of the tear drainage pathways, treatment efficacy must be monitored, and treatment may be adjusted based on bacteriological testing results and targeted medications prescribed according to flora sensitivity testing.
It is advisable to administer a course of tear duct irrigation (A11.26.004) with systemic antibacterial drugs (J01) (1–3 sessions) in patients with an exacerbation of chronic dacryocystitis who have patent puncta and restored lacrimal duct patency.
It is recommended to perform a repeat consultation (examination, consultation) by an ophthalmologist (B01.029.002) for patients with tear drainage pathway pathology following surgical treatment, including an external examination of the maxillofacial region (A01.07.005) and visual examination of the eyes (A01.26.002) [1–6, 23, 24, 32, 35].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comment: it is necessary to monitor the condition of the sutures, the position of the intubation material, and the state of the nasal cavity and anastomotic site.
Skin sutures are removed on days 10–14.
Endorhinoscopy (A03.08.004.001 Endoscopic endonasal revision of the nasal cavity and nasopharynx) is regularly performed for 1–1.5 months after dacryocystorhinostomy to sanitize the nasal cavity in the area of the anastomosis.
The intubation material is removed 6 months after tear duct intubation, followed by irrigation of the tear ducts (A11.26.004) with neutral solutions.
To subjectively assess the severity of epiphora in patients with epiphora before and during treatment, the Munk epiphora grading scale may be used (Appendix G1) [3, 84–90].
It is recommended to provide long-term follow-up care—dispensary consultation (examination) by an ophthalmologist (B04.029.001) for patients with tear drainage pathway obstruction in the postoperative period to prevent recurrence [1–5, 8, 10].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
6. Organization of Medical Care
The pediatrician (initial primary examination (inspection, consultation) by a district pediatrician B01.031.003) and general practitioner (initial primary examination (inspection, consultation) by a general practitioner B01.047.001) refer the patient presenting with complaints of tearing to an ophthalmologist at the ophthalmology outpatient consultation clinic.
Initial diagnostics are performed by the ophthalmologist at the ophthalmology office.
Minor surgical interventions, including the incision and drainage of an abscess and the treatment of canaliculitis, are performed by the ophthalmologist in a dressing room or day care unit.
Complex surgical interventions are performed by the ophthalmologist in an inpatient ophthalmology setting.
Indications for admission to the ophthalmology inpatient department: planning a complex surgical intervention.
Indications for patient discharge from the ophthalmology inpatient department: absence of complications, absence of purulent inflammation.
7. Additional Information
No additional information.
Criteria for Evaluating the Quality of Medical Care
References
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Appendix A1. Working Group Composition
Atkova E.L. – Head of the Department of Lacrimal Apparatus Pathology, M.N. Krasnov Research Institute of Eye Diseases, DSc (Medicine). All-Russian Public Organization "Glaucoma Society of Russia" [note: contextually Association of Ophthalmologists of Russia], All-Russian Public Organization "Russian Rhinologic Society".
Brzheskiy V.V. – Head of the Department of Ophthalmology, Saint Petersburg State Pediatric Medical University, DSc (Medicine), Professor. All-Russian Public Organization "Society of Ophthalmologists of Russia", All-Russian Public Organization "Association of Ophthalmologists".
Zakharova M.A. – Researcher, Department of Reconstructive and Plastic Oculurgery, S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Russian Ministry of Health, PhD (Medicine). All-Russian Public Organization "Society of Ophthalmologists of Russia".
Karpischenko S.A. – Head of the Department of Otorhinolaryngology with Clinic, First Pavlov State Medical University of St. Petersburg, DSc (Medicine), Professor. All-Russian Public Organization "Russian Rhinologic Society".
Kataev M.G. – Head of the Department of Reconstructive and Plastic Oculurgery, S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Russian Ministry of Health, Professor of the Department of Ophthalmology, Institute of Professional Education, DSc (Medicine), Professor. All-Russian Public Organization "Society of Ophthalmologists of Russia".
Krasnogen V.N. – Head of the Department of Otorhinolaryngology, Kazan State Medical Academy, DSc (Medicine), Professor. All-Russian Public Organization "Russian Rhinologic Society".
Kulikov A.N. – Head of the Department of Ophthalmology, S.M. Kirov Military Medical Academy, Honored Doctor of the Russian Federation, DSc (Medicine), Professor. All-Russian Public Organization "Society of Ophthalmologists of Russia".
Poritskiy Yu.V. – Associate Professor, Department of Ophthalmology, S.M. Kirov Military Medical Academy, PhD (Medicine). All-Russian Public Organization "Society of Ophthalmologists of Russia".
Shkolnik G.S. – Head of the Department of Reconstructive Oculoplastic and Laser Surgery, PhD (Medicine), Ophthalmologist of the Highest Qualification Category, Cheboksary Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Russian Ministry of Health. All-Russian Public Organization "Society of Ophthalmologists of Russia".
Yartsev V.D. – Leading Researcher, Department of Lacrimal Apparatus Pathology, M.N. Krasnov Research Institute of Eye Diseases, DSc (Medicine). All-Russian Public Organization "Society of Ophthalmologists of Russia". All-Russian Public Organization "Russian Rhinologic Society".
There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience of these clinical guidelines:
1. Pediatricians
2. General practitioners (family physicians)
2. Ophthalmologists
3. Otorhinolaryngologists
Methods used for collecting/selecting evidence: search in electronic databases, analysis of modern scientific developments on the problem of acquired lacrimal pathway disorders in Russia and abroad; generalization of practical experience of Russian and foreign specialists; library resources. Description of methods used for collecting/selecting evidence: the evidence base for the recommendations includes publications included in the Cochrane Library, EMBASE and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on this topic. The search depth was 10 years. Methods used to assess the quality and strength of evidence: expert consensus, significance assessment according to the rating scheme.
Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic review of randomized clinical trials using meta-analysis |
2 | Individual studies with reference standard control or individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials, using meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing the levels of evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, rehabilitation interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials using meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Current package leaflets for the drugs mentioned in these clinical guidelines can be found on the website http://grls.rosminzdrav.ru
International Statistical Classification of Diseases and Related Health Problems (10th Revision) (ICD-10) (Version 2.27 dated September 2, 2024)
Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services". Order of the Russian Ministry of Health No. 804n dated October 13, 2017 (as amended on September 24, 2020, with rev. dated October 26, 2022) "On Approval of the Nomenclature of Medical Services" (Registered with the Ministry of Justice of Russia on November 7, 2017, No. 48808).
Federal Law No. 323-FZ dated November 21, 2011 (as amended on July 23, 2025) "On the Fundamentals of Public Health Protection in the Russian Federation" (with rev. and add., effective from September 1, 2025).
Order of the Ministry of Health of the Russian Federation No. 902n dated November 12, 2012 (as amended on February 1, 2022) "On Approval of the Procedure for Providing Medical Care to Adults with Diseases of the Eye, Its Adnexa, and Orbit" (Registered with the Ministry of Justice of Russia on December 13, 2012, No. 26116).
List of Vital and Essential Medicines for Medical Use for 2025. Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019 (as amended on January 15, 2025) "On Approval of the List of Vital and Essential Medicines for 2025, as well as Lists of Medicines for Medical Use and the Minimum Assortment of Medicines Required for Medical Care".
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Complaints of lacrimation, among other eye diseases, may be associated with the narrowing or occlusion of the lacrimal ducts. Lacrimal stasis and secondary infection are often accompanied by purulent discharge from the lacrimal puncta and can lead to a severe inflammatory process in the tissues around the lacrimal sac – an abscess or phlegmon of the lacrimal sac, which requires active therapeutic measures, including surgical ones. Most often, lacrimal pathway disorders manifest as chronic dacryocystitis. The presence of pus can lead to ocular complications and is a contraindication for intraocular surgeries, such as cataract extraction. As a rule, treatment of dacryocystitis requires surgical intervention. To determine the causes of lacrimation, a thorough examination using instrumental methods is necessary. However, in some cases, lacrimal overflow is caused by the occlusion of the lacrimal pathways and is not accompanied by purulent inflammation. In such cases, conservative and surgical treatment may be ineffective, but the clinical condition does not pose a threat to the eye.
The effectiveness of conservative and surgical treatment depends on many factors, individual anatomical and physiological characteristics, the activity of the secondary infection, and concomitant diseases.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1.
Russian title: Munk epiphora grading scale
Original title (if any): The Munk score for grading of epiphora
Sources: [3, 84-90]
Type (underline):
Type: rating scale, index, questionnaire
Purpose: assessment of the severity of lacrimation (epiphora)
Assessment tool, content:
The Munk scale implies grading the degree of lacrimation in points:
0 points — no lacrimation;
1 point — rare lacrimation requiring wiping tears less than 2 times a day;
2 points — lacrimation requiring wiping tears 2–4 times a day;
3 points — lacrimation requiring wiping tears 5–10 times a day;
4 points — lacrimation requiring wiping tears more than 10 times a day, or constant lacrimation.
Notes: the values of this scale can be used for subjective evaluation of the treatment performed in patients with epiphora.