Clinical and Radiologic Lacrimal

Testing in Patients with Epiphora

1ames P. Guzek, MD, 1,2 Andrea S. Ching, BS, 2 Thu-Anh Hoang, MD/
Peter Dure-Smith, MD/· 4 ]osep G. Llaurado, MD, 5 Daniel C. Yau, MD, 2
Christopher B. Stephenson, MD, 2 Charles M. Stephenson, MD, 2
Dennis A. Elam, MS5

Objective: The purpose of the study is to assess the strengths and weaknesses of
selected clinical and radiologic lacrimal tests in patients with epiphora.
Design: The study design was a prospective clinical trial.
Participants: Fifteen patients with epiphora (N = 27 eyes) were studied.
Methods: All patients underwent Jones testing, the dye disappearance test, canalic-
ular probing, lacrimal scintigraphy, and macrodacryocystography.
Main Outcome Measures: The dye disappearance test was graded individually by
three ophthalmologists. Lacrimal scintigraphy and macrodacryocystography were evalu-
ated by a nuclear medicine specialist and a radiologist, respectively. A panel of three
ophthalmologists evaluated the data using a scoring system that relied on the preponder-
ance of evidence to arrive at a final assessment.
Results: When the Jones I test results were negative (dye recovered from the
nose), the epiphora was always from hypersecretion. When the Jones I test results were
positive (no dye recovered from the nose), obstruction was not always present. When
the dye disappearance test results were strongly abnormal, obstruction was always
present. In contrast, when the dye disappearance test results were normal, the lacrimal
drainage system was not always patent. Canalicular probing was more reliable than
scintigraphy in identifying canalicular obstruction. Marked stenosis of the sac or duct on
dacryocystography essentially confirmed nasolacrimal outflow obstruction; however, with
the authors' technique, a normal study was found in some patients with functional or
partial obstruction.
Conclusions: More than one lacrimal test may be required for a definitive diagnosis
in patients with epiphora due to partial or functional nasolacrimal outflow obstruction.
Ophthalmology 1997; 104:1875-1881

Patients with epiphora may have complete lacrimal drain-

Originally received: November 26, 1996.
Revision accepted: May 16, 1997. age obstruction, partial obstruction, or hypersecretion.
1
Department of Ophthalmology, Jerry L. Pettis Memorial VA Medical
Complete obstruction can be diagnosed when pressure on
Center, Lorna Linda, California. the lacrimal sac causes reflux of mucus or when syringing
2
Department of Ophthalmology, Inland Eye Institute, Lorna Linda Uni- shows obstruction. Partial obstruction is more difficult to
versity Medical Center, Lorna Linda, California. diagnose.
3
Department of Radiology, Jerry L. Pettis Memorial VA Medical Cen- The evaluation of patients with possible partial naso-
ter, Lorna Linda, California. lacrimal outflow obstruction varies among physicians but
4
Department of Radiology, Lorna Linda University Medical Center, may involve the Jones test, the fluorescein dye disappear-
Lorna Linda, California. ance test (DDT), lacrimal scintigraphy, and/or digital sub-
5
Department of Nuclear Medicine, Jerry L. Pettis Memorial VA Medical traction macrodacryocystography. 1 Jones testing and the
Center, Lorna Linda, California. DDT have been compared in several clinical trials in
Presented at the Jerry L. Pettis Memorial VA Medical Center, Lorna normal subjects, and both have been shown to have
Linda, California. strengths and weaknesses; the evaluation of these tests in
Supported by the George Warren Trust Fund, Lorna Linda University
School of Medicine, Lorna Linda, California.
The authors have no financial interest in any of the products mentioned Reprint requests to Peter Dure-Smith, MD, VA Medical Center, 11201
in this article. Benton Avenue, Lorna Linda, CA 92357.

1875
 Ophthalmology Volume 104, Number 11, November 1997
patients with epiphora has been hampered by the absence
of a "gold standard" for lacrimal drainage testing. 2 -~
Digital subtraction macrodacryocystography is relatively
new and shows the anatomy of the lacrimal system in
exquisite detail. 6•7 Some have claimed that macrodacryo-
cystography is superior to the Jones test and the DDT. 6
However, these tests have not been compared directly.
This study undertook a direct comparison of macrodacry-
ocystography with the Jones test, the DDT, lacrimal scin-
tigraphy, and canalicular probing to assess the strengths
and weaknesses of each test.
Methods
In July and August 1995, patients admitted to the Jerry
L. Pettis Memorial Veterans Affairs Hospital Department
of Ophthalmology who reported epiphora in either eye
were asked to participate in a study of their tear drainage
system. In addition, patients who had participated in other
lacrimal research studies at our institution who were
known to have epiphora were sent letters inviting them
to participate. Patients with lower lid ectropion were not
eligible unless tearing persisted after the lower lid position
was corrected. Patients were excluded who had Bell palsy,
distorted lid structures, ocular emergencies, inflamed
eyes, or any history of lacrimal surgery. Our intent was
to concentrate on patients with epiphora due to possible
partial nasolacrimal outflow obstruction. The protocol and
informed consent were approved by our Investigational
Review Board.
After informed consent was obtained, a detailed his-
tory, external examination, biomicroscopic examination,
a Schirmer test without anesthesia for 5 minutes, and a
lid snap-back test were performed. Modified Jones I test-
ing was performed using one drop of 2% fluorescein (Al-
con Laboratories, Fort Worth, TX) in each eye. A wooden
cotton-tipped applicator, soaked with 0.5% proparacaine,
was inserted 2 to 3 em laterally and inferiorly into each
nostril so that it was on the floor of the nose against the
anteror inferior turbinate. After 1 minute, patients were
asked to sit forward with their eyes open, head bowed,
and elbows on their knees. In patients younger than 50
years of age, the cotton-tipped applicators were removed
and checked for dye at 3 and 6 minutes; for those age 50
years and older, this was done at 3, 6, 9, and 12 minutes.
At each interval, patients were asked to blow each nostril
individually into a tissue. In equivocal cases, a Wood's
lamp was used to assess for the presence of dye. If dye
was not retrieved by 6 minutes in patients younger than
50 years of age or by 12 minutes in patients 50 years
of age and older, the lacrimal system was judged to be
obstructed. 8 ·9 After the Jones I test, the eyelids and con-
junctiva were irrigated in preparation for the DDT. Jones
II testing was performed after the DDT in eyes in which
the Jones I test results were positive.
At least 20 minutes after the Jones test, the DDT was
done. One drop of 2% sodium fluorescein was placed into
each eye with the goal of obtaining a high fluorescein
tear lake; patients were asked not to squeeze or wipe their
eyes. Photographs of the DDT using approximately 1: 1
1876
magnification were taken at 5 minutes using EPN-100
film (Eastman Kodak Co, Rochester, NY). The photo-
graphs were interpreted individually by three ophthalmol-
ogists (JPG, CMS, CBS) as either patent, equivocal, ob-
structed, or abnormal due to eyelid abnormalities.
Within 1 week, automated digital subtraction macroda-
cryocystography was done. The lower puncta were anes-
thetized using pledgets of 0.5% proparacaine, then 22-
gauge intravenous catheters (Jelko Corp, Critikon, FL)
were inserted to a hard stop and withdrawn approximately
3 mm so that they would lie in an area of the common
canaliculus. This position was chosen because our intent
was to inject the contrast oil (Ethiodol oil; Savage Labora-
tories, Melville, NY) under high pressure to obtain maxi-
mal dilation of the lacrimal sac. Bilateral simultaneous
injection, direct fluoroscopic control, 3 to 5X magnifica-
tion, and a Water's view were used. Two images per
second were captured. An oblique film was done immedi-
ately after the dacryocystogram. A radiologist (PDS) di-
agnosed lower lacrimal system obstruction when signifi-
cant stenosis with prestenotic dilation of the sac or duct
was identified.
Because of technical difficulties, lacrimal scintigraphy
was not available when this study began in July. In Octo-
ber, when it became available, patients were contacted
and asked to return. An activity of 3.7 MBq (100 f,LCi)
e
technetium 99m 9rnTc) albumin colloid in 10-f.Ll volume
of physiologic saline was placed in the inferior cul-de-
sac of one eye, and a General Electric Starcam gamma
camera (General Electric Medical Systems, Milwaukee,
WI) with a 2-mm tungsten pinhole collimator, especially
machined, was used to capture images every 15 seconds
for 6 minutes. Each eye was tested separately. A nuclear
medicine specialist (JGL) evaluated the scans. When
tracer was not identified in the sac at 30 seconds, the
upper system was judged to be obstructed or nonfunc-
tional.10 After scintigraphy, the primary investigator
(JPG) performed canalicular probing with a 00-Bowman
probe on both lower canaliculi. When a soft stop was
found, the upper canaliculus also was probed.
After the study was completed, a panel of three oph-
thalmologists assessed the data (JPG, CMS, CBS). Table
1 lists the scoring system. Unanimous agreement was
required to score the DDT, scintigraphy, and dacryocysto-
gram as follows: definite lacrimal obstruction, 1 point;
possible obstruction, 0.5 point; and definitely patent, 0
point. For the Jones test and canalicular probing, a score
of 0 or 1 was assigned based on the test results. The
history, lid snap-back results, and the Schirmer results
were not scored; however, they were taken into consider-
ation by the panel.
The final assessment of the upper system was based
on four tests: (1) the Jones I test, (2) DDT, (3) scintigra-
phy, and (4) canalicular probing. The final assessment of
the lower lacrimal system was based on three tests: (1)
the Jones I test, (2) DDT, and (3) dacryocystography.
Thus, there was a maximum of four points for the upper
system and three points for the lower system. A final
assessment of obstruction required three points for the
upper system or two points for the lower system. If both
the upper and lower systems had scores of one point or
 Guzek et al · Lacrim al Testin g

almolo gists to Assess the Upper and Lower

Table 1. Scorin g System Used by the Panel of Three Ophth
Lacrim al Draina ge Tract*
Equivo cal Patent Total Points Possibl e
Obstru ction

Upper lacrimal system 0 1

Jones I test 1
0.5 0 1
Dye disappearance test 1
0.5 0 1
Scintig raphy 1 1
1 0
Bowma nn probing s1 4
;;;:3 1.5-2.5
Total
Lower lacrimal system 0 1
Jones l 0 1
0.5
Dye disappearance test 0 1
0.5
Macrodacryocystography s1 3
1.5
Total
ography. The Jones I test was
the dye disappearance test, scintigraphy, and macrodacryocyst
*Unanim ous agreeme nt of the panel was required to score 50 years of age, or in 12 minutes or less in patients age 50 and
in 6 minutes or less in patients under
considered obstructed if dye was not harvested
the principa l investigator.
over. Bowman n probing was scored based on the findings of

Dacryocystography films were interpreted by a radiol-

less, the lacrimal system was judged to be patent. Eyes
ogist as patent in 23 eyes, common canalicular obstruction
with intermediate scores were judged to have equivocal
in 3 eyes, and obstruction at the sac-du ct junction in 1
results.
eye. Stones were found in lllacri mal systems (41 %). In
all patients, there was a free flow of dye around the stones
without prestone dilation of the sac or duct. As such, the
Results stones were considered incidental. Lacrimal scintigraphy
showed 19 eyes with tracer in the sac in 30 seconds or
Twenty-seven patients underwent a detailed history and
less, 7 eyes with no tracer in the sac at 30 seconds, and
external examination, a Schirmer test, the lid snap-back
1 eye was equivocal.
test, the Jones test, the DDT, and dacryocystography. Fif-
The results of canalicular probing showed that 20
teen patients returned for lacrimal scintigraphy and cana-
lower canaliculi had hard stops, 4 had soft stops at the
licular probing. This report analyzed the results of 27
common canaliculus, 1 had a soft stop in the inferior
symptomatic eyes from these 15 patients.
canaliculus only, and 2 had a soft stop of both the inferior
The age range of the patients was from 48 to 86 years
and superior canaliculi (N = 27).
(mean, 70.4 years). All the patients were male. There
Based on the scoring of the panel of three ophthalmolo-
were symptoms of early morning mucus in two eyes. Six
gists, the final assessment was that 11 lacrimal systems
eyes had a high tear lake, two eyelids had moderate punc-
were patent, 6 had obstruction of the canalicular system,
tal stenosis, two eyelids had mild punctal ectropion, and
and 4 had obstruction of the lower lacrimal system. There
no patients had mucus reflux with compression on the
also were 6 lacrimal systems with equivocal final assess-
lacrimal sac. The Schirmer values without anesthesia
ments, 2 of whom had significant eyelid laxity (N = 27
ranged from 4 to 35 mm (mean, 15.9 mm). The lid snap-
eyes).
back test results were normal in 23 eyes, equivocal in 2
The comparison of the final assessment with each test
eyes, and abnormal in 2 eyes.
is given ih Table 3. Two tests, the Jones I test and the
The Jones I test results were age stratified. In the one
DDT, were used to assess both the upper and lower lacri-
patient younger than 50 years, dye was recovered at 6
minutes, indicating patency. In patients 50 years of age
or older (N = 26 eyes), dye was recovered at 3 minutes
in 4 eyes and was not recovered even at 12 minutes in Table 2. Dye Disapp earanc e Test Interp retatio ns of
22 eyes. The Jones II test was done after the DDT in eyes Three Physic ians in 27 Sympt omatic Eyes*
that did not pass dye at 12 minutes. However, because
fluorescein dye from the inferior cul-de-sac was not irri- Physici an 1 Physici an 2 Physici an 3
gated after the DDT and inadvertently may have entered 17 20 15
the lacrimal system during punctal dilation, these results Patent
5 4 4
Obstruc ted
are not presented. Equivocal 4 1 7
Three physicians graded the DDT photographs inde- Eyelid abnormalities 1 2 1
pendently. Table 2 lists that the three physicians judged Total 27 27 27
the DDT to be patent in 17, 20, and 15 eyes; obstructed
in 5, 4, and 4 eyes; equivocal in 4, 1, and 7 eyes, and * Interpre tations were either patent, equivocal, obstructed, or
uninterp ret-
uninterpretable due to eyelid abnormalities in 1, 1, and 2 able because of eyelid abnormalities.
eyes, respectively (N = 27 eyes).
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 Ophthalmology Volume 104, Number 11, November 1997

Table 3. Comparison of the Final Assessment of 27 Symptomatic Eyes with the Jones I Test, the Dye
Disappearance Test Interpretations of Three Physicians, the Macrodacryocystogr aphy
Interpretation of a Radiologist, the Lacrimal Scintigraphy Interpretation
of a Nuclear Medicine Specialist, and Bowmann Probing

Final Assessment
Patent Upper Obst Lower Obst Equiv Accuracy (%)
[N = 11] [N = 6] [N = 4] [N = 6] [N = 21]*
Jones I test 15/21 (71%)
Patent 5 0 0 0
Obstructed 6 6 4 6
Dye disappearance test, physician 1 14/19 (74%)t
Patent 10 4 1 2
Equivocal 1 1 2
Obstructed 2 2 1
Eyelid abnormalities 1
Dye disappearance test, physician 2 15/20 (75%)t
Patent 11 3 2 4
Equivocal 1
Obstructed 2 2
Eyelid abnormalities 1
Dye disappearance test, physician 3 13/16 (81%)t
Patent 10 3 0 2
Equivocal 1 2 2 2
Obstructed 0 1 2 1
Eyelid abnormalities 1
Macrodacryocystography, radiologist 12/15 (80%):j:
Patent 11 4 3 5
CC obst 2 1
SDJ obst
Lacrimal scintigraphy, nuclear medicine
specialist 13/17 (76%)§
Patent 11 3 4
Equivocal 1
CC obst 2 2 2
Bowmann probing 21/21 ( 100%)
Normal 12 0 3 5
CC obst 0 4
Inferior obst 1
I&S obst 1 0

* Excludes six eyes with equivocal final assessments.

·r Excludes eyes that were assessed as equivocal by the physician.
:j: Excludes six eyes with obstruction of the upper system because tip of catheter was placed in the common canaliculus or lacrimal sac.
§ Excludes one eye with an equivocal result.

mal drainage systems. The Jones I test results were in
agreement with the final assessment in 15 (71%) of 21
eyes. The DDT results, which were interpreted by 3 physi-
cians individually, were in agreement with the final as-
sessment in from 14 of 19 eyes to 13 of 16 eyes (range,
74%-81 %). However, the denominators for each physi-
cian are different because the analysis did not include
eyes which a physician graded as equivocal.
The other lacrimal tests were used to assess either the
upper or lower lacrimal drainage system. Our technique
of dacryocystography bypassed most of the canalicular
system; therefore, we used this test to evaluate only the
lower system. Dacryocystography results were in agree-
ment with the final assessment in 12 (80%) of 15 eyes.
Lacrimal scintigraphy and canalicular probing were
used to assess the canalicular system. Scintigraphy results
were found to be in agreement with the final assessment
in 13 (7 6%) of 17 eyes, and probing results were in agree-
ment with the final assessment in 21 (100%) of 21 eyes.
A retrospective review of the data showed that the
results from the Jones test, DDT, canalicular probing, and
dacryocystography provided different, useful information
in patients with suspected nasolacrimal sac or duct ob-
struction. In contrast, lacrimal scintigraphy results pro-
vided little or no additional information.
A 1-year follow-up of the participants showed that
one patient with bilateral epiphora and moderate puncta!
stenosis had resolution of his symptoms after two-snip
punctoplasties of all four eyelids. In this patient, the final
assessment of the panel was that the lacrimal drainage
system of the right eye was patent and the left eye was
equivocal. Another patient with epiphora due to canalicu-

1878
 Guzek et al · Lacrimal Testing
lar system obstruction was without improvement after
unilateral dacryocystorhinostomy surgery with silicone
intubation.
Discussion
Some investigators have claimed that macrodacryocys-
tography is superior to the Jones test and the DDT in
determining the status of the lacrimal system. 6 However,
no direct comparison has been made. This study under-
took a direct comparison of the Jones test, DDT, canalicu-
lar probing, macrodacryocystography, and lacrimal scin-
tigraphy to assess the strengths and weaknesses of each
test.
Jones 11.1 2 stated that when dye was recovered from the
nose within an appropriate interval, the epiphora was from
hypersecretion. Other investigators have confirmed this
finding_2.4.s.s, 9 However, when dye is not recovered from
the nose during Jones I testing, an obstruction may or
may not be present. Older studies have found a false-
positive incidence of 23% to 48% in Jones testing of
normal subjects?.4 More recent reports that used longer
test times for older patients have found an error rate of
only 3% to 11% in normal subjects. 5·8 ·9·13
The DDT has been reported to be 95% to 100% accu-
rate in normal subjects or alternately to be completely
unreliable. 2 •4 •14 Recent work at our institution suggests
that this variability is because of interobserver error. In
a study of 76 patients, we found the DDT to be 95% to
100% accurate for 2 physicians but 73% accurate in the
hands of a third physician. 5 Another problem with the
DDT is that equivocal results are found in 10% to 15%
of cases. 15 Despite these limitations, the DDT is a useful
and reliable test once mastered. In particular, when there
is significant residual dye at 5 minutes (>0.8-mm tear
lake) in the absence of eyelid abnormalities, it confirms
obstruction; thus, the DDT is complementary to the Jones
I test.
Modern dacryocystography uses digital subtraction
macrodacryocystography with bilateral simultaneous in-
jection.16'17 This technique relies on distention of the lacri-
mal system, the underlying assumption being that rapid
injection of the contrast medium will show any clinically
significant stenosis. Several technical factors in this test
merit consideration.
Agents with low viscosity (water-soluble agents) drain
more rapidly and require a higher injection rate and total
volume to achieve the same amount of distention. Lower
viscosity agents, such as ethiodol oil, generally produce
better distention of the lacrimal drainage apparatus. 18 An-
other factor is that a functional stenosis can only be shown
if the flow rate exceeds the capacity of the tube to transmit
the fluid (i.e., no obstruction is detectable until the critical
flow rate is exceeded). Whether rapid injection of dye
through a 22-gauge catheter (or some larger catheter) is
adequate to define clinically significant stenoses remains
to be proved. Another factor is the position of the catheter
tip, which might influence both flow and the degree of
filling. Thus, dacryocystography is dependent on tech-
nique. Additionally, dacryocystography gives only a two-
dimensional evaluation. Finally, the forcible injection of
contrast medium in macrodacryocystography gives little
or no physiologic information.
The proper interpretation of dacryocystography films
is yet another variable. When a significant stenosis of
the lacrimal drainage system with prestenotic dilation is
identified, the significance is clear. However, when mild
or moderate stenosis without prestenotic dilation is found,
the significance is uncertain. 17 Finally, the significance
of nonobstructive dacryoliths in patients with epiphora
remains to be clarified.
Lacrimal scintigraphy was introduced in 1972. 19 The
radionuclide technetium 99m C9 mTc), either free as per-
technetate or bound to albumin colloid, has been shown
consistently to reach the lacrimal sac in 30 seconds or
less in functioning lacrimal systems. Unfortunately, the
tracer often gets hung up in the sac and duct and passes
into the nose irregularly. 10•20 '21 As a result, unless a more
suitable technique can be identified, scintigraphy may
have limited usefulness.
Finally, eyelid laxity is a common cause of epiphora
in the elderly. 5 It is our practice to perform lid-tightening
surgery in such cases before performing extensive lacri-
mal testing.
In this study, we evaluated 15 patients (N = 27 eyes)
with epiphora using the Jones test, DDT, dacryocystogra-
phy, scintigraphy, and canalicular probing. Because of
the lack of a recognized standard for lacrimal testing in
patients with epiphora, we relied on the preponderance
of evidence. Table 1 lists the scoring system that was
used. Although arbitrary, this was considered to be a first
step in the process of identifying a standard for the lacri-
mal testing of patients with epiphora. The results are listed
in Table 3. Eleven patients were patent, 6 had obstruction
of the upper system, 4 had obstruction of the lower sys-
tem, and 6 were equivocal.
Six (22%) of 27 patients had results that were equivo-
cal. This highlights that the lacrimal test results frequently
were in conflict. The relatively high number of upper
system obstructions in our series may be partly because
patients with canalicular obstruction at our institution are
informed of the relatively poor prognosis for surgical cor-
rection and many opt to defer surgery.
The Jones I test results were found to be in agreement
with the final assessment in 15 (71%) of 21 cases. All of
the false results were found in patients in whom no dye
was recovered from the nose, yet the lacrimal system was
patent. This is consistent with previous reports.
The results of the DDT were similar for the three physi-
cians (Tables 2 and 3). The DDT results were in agree-
ment with the final assessment in from 74% to 81% of
eyes (N = 21). In cases with a final assessment of patency,
the DDT results were in agreement with the final assess-
ment in 91% to 100% of eyes (N = 11). In cases in
which the final assessment showed upper or lower system
obstruction, the DDT was interpreted as obstructed in
30% to 40% of eyes (N = 10). These data suggest that
the DDT alone may miss cases of obstructive epiphora,
presumably because of a washout of dye. Finally, for all
three physicians, there were no patients in whom obstruc-
tion was diagnosed with the DDT, but the final assessment
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 Ophthalmology Volume 104, Number 11, November 1997
showed patency (Table 3). Thus, an abnormal DDT essen-
tially confirms obstructive epiphora.
For macrodacryocystography, we attempted to place
the cannula in the lacrimal sac-common canalicular area
(in a few cases, it was in the distal lower canaliculus).
As a result, this test was used to assess the lower lacrimal
system only. The dacryocystogram interpretations were
in agreement with those of the final assessment in 12
(80%) of 15 eyes. In eyes with a final assessment of
patency, the dacryocystogram was judged to be patent in
11 (100% agreement) of 11 eyes. In eyes with a final
assessment of lower system obstruction (N = 4), only
one (25%) had a dacryocystogram interpretation of ob-
struction. In the panel discussions of the ophthalmolo-
gists, one other patient (case 6) was given a grade of
equivocal due to generalized lacrimal sac and duct dila-
tion and, in addition, a large dacryolith. There were two
other patients who had completely normal dacryocysto-
grams without dacryoliths. These data suggest that a
strength of macrodacryocystography is in defining normal
subjects, that when high-grade stenosis of the sac or duct
is found, it confirms lacrimal system obstruction, and that
some patients with normal macrodacryocystograms with
our technique still may have lacrimal sac or duct outflow
obstructions.
The inability of dacryocystography to find lower lacri-
mal tract disease in some patients with obstruction may
be because of the two-dimensional nature of macrodacry-
ocystography, the technique used, or the factors related
to the physiology of tear drainage.
Of the 27 lacrimal systems in this series, dacryocystog-
raphy showed that 11 patients (41 %) had dacryoliths. In
no patient did dacryocystography confirm a lacrimal out-
flow obstruction due to a stone. In case 6 noted above, a
large stone apparently was the cause of an abnormal Jones
test result and DDT result, yet on dacryocystography,
dye passed around the stone freely. In another case, the
Ethiodol oil was seen to push two dacryoliths out of the
lacrimal tract and into the nose. These findings suggest
that dacryocystography is not ideal for assessing the pres-
ence of obstruction due to dacryoliths.
The treatment of dacryoliths in patients with epiphora
is somewhat controversial. Some of us (JPG, PDS) be-
lieve that patients with lacrimal stones should not be sub-
jected to surgery unless clinical testing proves that an
intermittent obstruction exists. Serial DDT should, at one
time or another, prove the obstruction. This approach has
the benefit of avoiding unnecessary, unsuccessful surgery
in some of these patients but the disadvantage of poten-
tially delaying the resolution of symptoms in patients who
eventually will require surgery. Others of us (CBS, CMS)
assess the patient's symptomatology and usually recom-
mend dacryocystorhinostomy surgery for patients with
epiphora and proven dacryoliths. Further work is needed
to clarify this matter.
Lacrimal scintigraphy interpretations were in agree-
ment with the final assessment in 13 (76%) of 17 eyes.
In eyes with a final assessment of patency, the scintigrams
were judged as normal in 11 (92%) of 12 eyes. In eyes
with a final assessment of canalicular obstruction, exclud-
ing one equivocal result, the scintigrams were abnormal
1880
in two (40%) of five eyes. The limited resolution of scin-
tigraphy is highlighted by one case in which a scintigram
appeared to show radiotracer in the sac, yet when the
eyelids and adnexa were wiped, it changed completely,
showing a common canalicular obstruction. In other
cases, despite significant obstruction of the upper system
as proved by canalicular probing, the Jones test, and the
DDT, some tracer was either on the skin above the sac
or somehow was able to get into the sac in 30 seconds.
These results suggest that the intrinsically limited resolu-
tion of scintigraphy hinders its usefulness.
Probing of the canalicular system with a 00-Bowman
probe also was compared with the final assessment. Prob-
ing was in agreement with the final assessment in 21
( 100%) of 21 eyes.
There was one noteworthy patient in this series. This
patient had bilateral epiphora and moderate puncta! steno-
sis of all four eyelids. Jones testing results showed pas-
sage of dye to the nose at 6 minutes in both eyes. The
DDT results were equivocal in the right eye and normal
in the left eye. Scintigraphy results were normal in both
eyes and dacryocystography showed small stones in both
lacrimal sacs. The final assessment of the panel was that
the right system was equivocal and the left was normal.
Remarkably, his symptoms of epiphora resolved after
two-snip punctoplasties of all four eyelids. This case is
mentioned to reinforce the point that patients with sus-
pected punctal stenosis should be treated with two-snip
punctoplasties before extensive lacrimal testing. It also
serves to show that some patients with lacrimal sac stones
do not require dacryocystorhinostomy.
A retrospective review of the data showed that canalic-
ular probing, the Jones test, the DDT, and the dacryocys-
tography all gave different and useful information in pa-
tients with suspected nasolacrimal outflow obstruction. In
contrast, lacrimal scintigraphy added little or no addi-
tional information.
Based on our results, we recommend the following
testing procedure for patients with epiphora. A detailed
history is taken for morning mucus, dry eye symptoms,
ocular burning, and itching. Then an external examination
is done to evaluate the height of the tear lake, the patency
of the puncta, the lid position, the lid tone, and whether
there is mucus reflux with pressure on the lacrimal sac.
If punctal stenosis or punctal ectropion is identified, it is
treated first. Lacrimal testing is done only when the puncta
are patent and the lids are in good position. A Schirmer
test and nasal examination also are done. Syringing and
canalicular probing usually are done to complete the first
visit.
On a second visit, other lacrimal tests are used. If
hypersecretion epiphora is suspected, a Jones test can be
done to prove hypersecretion. If obstructive epiphora is
suspected, a DDT is done. If this fails to prove the ob-
struction, dacryocystography is recommended. Repeat
testing may be necessary in some patients.
In summary, the Jones test, the DDT, canalicular prob-
ing, and dacryocystography were found to yield different
and useful information about the lacrimal drainage sys-
tem. Canalicular probing results were found to be in
agreement with the final assessment in 100% of cases.
 Guzek et al · Lacrimal Testing
The other test results were in agreement with the final
assessment in 70% to 80% of cases. Scintigraphy was of
little help. The percent agreement with the final assess-
ment should not be understood to be the percent accuracy
of each test. This is because the standard that we used
to assess the data (i.e., a scoring system based on the
preponderance of evidence) has itself not been proved.
In addition, there were 6 (22%) of 27 cases in which the
final assessment was equivocal. This means that there is
a potential error of 22% in our figures.
This study has shown that there is no single reliable
test or gold standard for lacrimal testing using the current
methods. Continued efforts are required to assess and
improve our scoring system, to determine the true accu-
racy of these lacrimal tests in patients with epiphora, and
to identify more reliable tests for the evaluation of patients
with epiphora.
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