ORIGINAL INVESTIGATION
Idiopathic Acquired Lacrimal Canalicular Obstruction
Khami Satchi, M.B. B.Chir, F.R.C.Ophth and Alan A. McNab, D.Med.Sc., F.R.A.N.Z.C.O.
Orbital, Plastic and Lacrimal Clinic, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
Purpose: Acquired lacrimal canalicular obstruction has a
variety of causes. In a small proportion of patients, no cause
can be identified. This article describes a cohort of 27 patients
with idiopathic acquired lacrimal canalicular obstruction
encountered over a 28-year period.
Methods: The diagnostic database of the senior author was
analyzed to identify all cases of idiopathic acquired lacrimal
canalicular obstruction seen from 1990 to 2017. Demographic,
clinical, and treatment details were analyzed. Patients with
primary lacrimal punctal stenosis or closure were excluded
from the analysis.
Results: The authors encountered 27 patients with idiopathic
acquired lacrimal canalicular obstruction (17 female, 63%)
aged 34 to 91 years (median: 65 years). The level of canalicular
obstruction ranged from 1 to 10  mm from the punctum.
Canalicular obstruction involved 1 canaliculus in 4 patients,
2 in 14 (ipsilateral in all except one), 3 in 3, and all 4 in 6.
One patient who presented with ipsilateral upper and lower
canalicular obstructions developed contralateral upper and lower
obstructions several years later, and another patient redeveloped
obstructions after initial successful surgical repair. In all cases,
there were no features on history or examination to suggest a
cause for the canalicular obstruction. Follow up ranged from 1
to 260 months (mean: 39 months). Sixteen patients underwent
surgical repair, 11 with a dacryocystorhinostomy and placement
of a Lester Jones glass bypass tube, 2 had a canaliculo-
dacryocystorhinostomy (anastomosis of the canaliculus to the
nose), 2 had dacryocystorhinostomy and trephination of the
canalicular obstruction with silicone intubation, and 1 had
a dacryocystorhinostomy alone to try and improve drainage
through a single patent canaliculus.
Conclusion: Idiopathic acquired lacrimal canalicular
obstruction is uncommon and occurs more frequently in older
women. The condition may be slowly progressive and can affect
one or more canaliculi at any level. Treatment is the same as
for any other cause of acquired lacrimal canalicular obstruction.
(Ophthal Plast Reconstr Surg XXX;XX:00–00)
L acrimal punctal and canalicular obstruction may be congeni-
tal or acquired. There is a long list of potential causes for
acquired lacrimal punctal and canalicular obstruction, and these
are detailed in Table 1. This table is based on that published by
Bartley in 1993.1 In a proportion of patients with acquired lacri-
mal canalicular obstruction, no cause can be established despite
taking a careful history and performing a detailed clinical
Accepted for publication July 31, 2018.
The authors have no financial or conflicts of interest to disclose.
Address correspondence and reprint requests to Alan A. McNab, D.Med.
Sc., F.R.A.N.Z.C.O., Suite 216, 100 Victoria Parade, East Melbourne, 3002
Victoria, Australia. E-mail: amcnab@bigpond.com
DOI: 10.1097/IOP.0000000000001225
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2018 1
Copyright © 2018 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
examination. In 2 previous studies looking at significant num-
bers of patients undergoing surgery for canalicular obstructions,
the “idiopathic” group has represented 9% of 326 eyes having
a dacryocystorhinostomy and placement of a Lester Jones glass
lacrimal bypass tube,2 and 30% of 123 eyes having a retrograde
intubation for a proximal or midcanalicular obstruction.3 While
tabulating the causes of canalicular obstruction in these stud-
ies, the authors made no other comment about the group with
idiopathic acquired lacrimal canalicular obstruction (IALCO).
This article analyzes the demographics, clinical features,
and treatment of all patients seen in the practice of the senior
author (A.A.M.) with IALCO over a 28-year period.
METHODS
The diagnostic database of all patients seen in the practice of
the senior author (A.A.M.) was queried to find all cases of IALCO seen
between 1990 and 2017. Patients with purely lacrimal punctal steno-
sis or closure were excluded from the analysis. Patient records were
then analyzed in detail for demographics (age, gender), clinical features
(level of obstruction, numbers of canaliculi affected), treatment, and
follow-up data. Clinical assessment of the level of obstruction was by
standard means. All patients with reflux of fluid via the opposite cana-
liculus (possible common canalicular or more distal obstruction) were
excluded, and only those patients with definite canalicular obstruction
included. Appropriate approval was obtained from the Human Research
and Ethics Committee of the Royal Victorian Eye and Ear Hospital.
RESULTS
A total of 27 patients were identified with IALCO. To make
this diagnosis, patients must have had no known history of exposure to
topical or systemic medications or chemicals that might lead to lacrimal
canalicular obstruction, no history consistent with herpetic or other in-
fection, and no examination features of any of the conditions listed in
Table 1. In particular, careful examination was always made to look for
any features of conjunctival scarring, which can sometimes be subtle
and easily missed and which might indicate an underlying cicatrizing
inflammatory process or reaction to topical medications.
Of the 27 patients identified with IALCO, 17 (63%) were female,
aged 34 to 91 years at presentation (median: 65 years). Canalicular ob-
struction involved one canaliculus in 4 patients, 2 in 14 (ipsilateral in all
except one), 3 in 3, and all 4 in 6 patients.
The level of the canalicular obstruction ranged from 1 to 10 mm
from the punctum. There was a fairly even distribution along the length
of the canaliculus, except for a larger number in the distal canalicu-
lus (10 mm). The levels of obstruction in the 65 canaliculi are listed in
Table 2.
Follow up ranged from 1 to 260 months (mean: 39 months), and
during follow up, one patient who presented with ipsilateral upper and
lower canalicular obstructions developed contralateral upper and low-
er obstructions several years later. Another patient redeveloped distal
canalicular obstructions several months after initial successful surgical
repair. No patient developed clinical signs of any underlying condition
that might have predisposed to lacrimal canalicular obstruction during
the follow-up period.
 K. Satchi and A.A. McNab Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2018

TABLE 1.  Causes of lacrimal punctal and canalicular DISCUSSION

obstruction Very little has been published on IALCO. In 2 large
studies looking at surgery for canalicular obstruction from one
Congenital Punctal/canalicular agenesis
institution, the “idiopathic” group represented 9% of 326 eyes
Infective
having a dacryocystorhinostomy and placement of a Lester
 Bacterial Actinomycetes
Jones glass lacrimal bypass tube,2 and 30% of 123 eyes having a
Chlamydia trachomatis
Other
retrograde intubation and dacryocystorhinostomy for a proximal
 Viral Herpes simplex or midcanalicular obstruction.3 While listing this “idiopathic”
Herpes zoster/varicella group among the causes of canalicular obstruction, the authors
Adenovirus of these articles made no further comment on this group.
Other In the group of patients described here, where no cause
 Fungal Fungal could be established for the development of the canalicular
Inflammatory obstruction, slow progression of disease occurred in 2 patients.
 Endogenous GPA One patient developed upper and lower lacrimal canalicular
Sarcoidosis obstruction in the opposite eye several years after presenting
Ocular pemphigoid with unilateral upper and lower lacrimal canalicular disease.
Lichen planus Another patient developed distal canalicular obstruction some
Stevens–Johnson syndrome months after lacrimal patent had been established with surgery.
Other mucocutaneous diseases In the majority of patients with acquired lacrimal cana-
Idiopathic licular obstruction, a cause can be established. However, there
 Exogenous Topical ocular medication remains a relatively small group in whom no apparent cause can
Systemic medication be established. It is important to try to establish a cause as this
Traumatic may lead to important diagnoses such as ocular surface cicatriz-
 Mechanical Noniatrogenic ing disease.4 The commonest of these is ocular cicatricial pem-
Iatrogenic phigoid,4 but a less well recognized cicatrizing disease, lichen
 Thermal Thermal burns planus, may also cause lacrimal canalicular obstruction.5,6 Such
 Chemical Alkali burns patients will usually have cutaneous and mucosal disease affect-
Acid burns ing the mouth or genital tract, and if not asked directly, patients
 Radiation External beam may fail to give a history of mucocutaneous disease, as they fail
Other to see its relevance.
Neoplastic An underrecognized cause of lacrimal canalicular
 Primary LDA tumors Canalicular
obstruction is a response to topical ocular medications.7 This
Lacrimal sac
may occur with short or longer term exposure to a variety of
 Eyelid tumors Basal cell carcinoma
eye drops. A careful history is needed to exclude a reaction to
Squamous cell carcinoma
Other
topical medications as a cause for acquired lacrimal canalicular
 Conjunctival tumors Conjunctival tumors
obstruction. If this relationship between the use of certain eye
Mechanical Lacrimal punctal plugs drops and canalicular obstruction can be established, for exam-
Lacrimal canalicular plugs ple, after surgery on one eye, then avoidance of the drops if
Dacryoliths surgery is performed on the opposite eye may prevent the devel-
Punctal/canalicular agenesis opment of canalicular obstruction on that side.
Possible causes for IALCO might include reaction to
GPA, granulomatosis with polyangiitis (Wegener’s granulomatosis); medications or topical medications or substances that when
LDA, lacrimal drainage apparatus. used over time might induce subepithelial fibrosis. Patients
may fail to recall or report use of medications. Another possible
cause might be a mucocutaneous cicatrizing disease that has not
Sixteen patients underwent surgical repair, 11 with a dacryocys- produced symptoms elsewhere, or is subclinical. However, in
torhinostomy (DCR) and placement of a Lester Jones glass bypass tube, the group of patients reported here, no other disease became
2 had a canaliculo-DCR (anastomosis of the canaliculus to the nose), apparent in the average follow-up period of 39 months.
2 had DCR and trephination of the canalicular obstruction with sili- Reddy et al.8 recently published an article describing the
cone intubation, and one had a DCR alone to try and improve drainage immunopathology and histopathology of conjunctival biopsies
through a single patent canaliculus. in a cohort of 23 patients with presumed idiopathic lacrimal
All patients having a DCR and Lester Jones glass bypass tube punctal stenosis. Thirty-five of 36 biopsies showed lymphocytic
had a successful outcome. Both patients who had a canaliculo-DCR infiltration and 11 of 23 patients also showed findings consistent
failed. One went on to have a Lester Jones glass bypass tube insert- with underlying immunological disorders. Additionally, 9 of
ed with a successful outcome. Of the 2 patients who had a DCR and 18 patients evaluated with direct immunofluorescence showed
trephination with silicone intubation, one failed and the other had a features characteristic of lichen planus. Mucosal lichen planus
good outcome. The patient who had a DCR alone to improve drainage most commonly affects the mouth, and in this form of the dis-
through the single patent canaliculus had partial resolution of symp- ease, women account for 60% to 75% of patients, with a mean
toms only. age at diagnosis of 50 to 60 years.9 These demographics are

TABLE 2.  Level of canalicular obstruction in 27 patients with idiopathic acquired lacrimal canalicular obstruction
Distance from punctum 1 mm 2 mm 3 mm 4 mm 5 mm 6 mm 7 mm 8 mm 9 mm 10 mm
Number 3 2 12 3 8 9 4 4 4 16

2 © 2018 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.

Copyright © 2018 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
 Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2018 Idiopathic Acquired Lacrimal Canalicular Obstruction
similar to those in this series of IALCO, and in that of Reddy et
al.,8 in which 87% of 23 patients were female, with a mean age
of 56.6 years. It would seem prudent to, therefore, ask for symp-
toms of mucocutaneous lichen planus and perform conjunctival
biopsies looking for features of lichen planus on immunopathol-
ogy and histopathology.
A recent series of tissue specimens obtained from treph-
ination of canalicular obstructions in 12 patients found that
the commonest feature was low-grade prolonged inflammation
with some fibrosis.10 In these 12 patients, there was no appar-
ent cause in 9.
Idiopathic acquired lacrimal canalicular obstruction is
uncommon but forms a significant proportion of patients with
acquired lacrimal canalicular obstruction. Treatment is no dif-
ferent to that for patients with other causes of lacrimal cana-
licular obstructions. Surgical outcome appears similar to other
groups with canalicular obstruction. Apart from the develop-
ment of new obstructions in other canaliculi over time, and the
redevelopment of obstructions after successful surgery, patients
probably should be monitored for the development of other
clinical signs that might lead to a new diagnosis, which could be
of importance to the patient’s ocular or general health. A propor-
tion of patients with IALCO may have underlying subclinical
lichen planus and a history and examination aimed at detect-
ing this condition is warranted, as well as obtaining conjuncti-
val biopsies to look for immunopathological changes consistent
© 2018 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. 3
Copyright © 2018 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
with that diagnosis, or other cicatrizing conjunctival diseases
such as ocular pemphigoid.4
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