LCD L34171: Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation

Abstract:

Dilation of nasolacrimal punctum and probing of nasolacrimal duct, with or without irrigation are useful treatments when mechanical, inflammatory or infectious processes cause or contribute to obstruction of normal tear drainage resulting in epiphora (excess tearing) or persistent infection.

The most common cause of obstruction in adults is primary acquired nasolacrimal duct obstruction (PANDO). Epiphora (excess tearing) is the most common symptom of obstruction of the nasolacrimal system. Tear duct obstruction in adults can occur at any point in the nasolacrimal system including the punctum, nasolacrimal sac, and nasolacrimal duct. Obstruction most commonly occurs in the puncta or nasolacrimal duct and sac. Disease of the canalicular system is less common.

It is important to differentiate between chronic epiphora, acute epiphora, and normal tearing. Chronic epiphora results from a persistent or continuous disorder and usually presents a more challenging clinical problem. Acute epiphora usually results from irritative ocular conditions such as corneal foreign bodies, allergic conjunctivitis, environmental factors such as wind, pollen, eyestrain, emotional stress, and sleep deprivation. One of the most common causes of excess tearing in older adults is dry eye syndrome. Acute epiphora usually resolves with treatment of the associated disorder and may not require dilation or probing.

Before dilation and/or probing are performed, pre-punctal disturbances of ocular surface tear flow such as lid malposition and non-obstructive causes (allergy, dry eye, blepharitis, etc.) should be excluded. Tear production measurement (Schirmer test), and tear break-up time (TBUT) can indicate insufficiency or instability of tears, which can cause or contribute to epiphora. Dye disappearance testing (sodium fluorescein), Jones dye testing or saccharine testing can be used to exclude significant obstruction and/or help identify the site and degree of obstruction.

If after the history, physical examination (including slit lamp), and other appropriate non-invasive tests have been completed, the site of obstruction is suspected to be at or distal to the punctum, dilation may proceed. Local anesthetic is instilled, and then the punctum is gradually dilated using probes of increasing size. If simple dilation fails to establish patency, lacrimal probing may be performed by passing a malleable wire probe through the punctum, into the canaliculus, lacrimal sac and down the nasolacrimal duct until patency is established. Irrigation may be used during both dilation and probing.

For patients in whom nasolacrimal duct probing has failed, further surgical treatment is available.

Punctal dilation and lacrimal duct probing is contraindicated in the following circumstances:

• Anatomic malformations in the lacrimal duct or bony lacrimal canal;

• Recurrent episodes of active dacryocystitis;

• Post-traumatic strictures with bony narrowing;

• Tumor of the lacrimal sac.

For procedural illustration for probing of nasolacrimal duct, please refer to Current Procedural Terminology (CPT) 2021, pg 502.

Indications:

Nasolacrimal punctal dilation and nasolacrimal duct probing may be reasonable and necessary when obstruction at or distal to the lacrimal puncta is reasonably suspected to be causing or contributing to the patient's symptoms (usually excessive tearing (epiphora) or chronic dacryocystitis), and when such measures are required to alleviate the patient's symptoms and reduce the likelihood of infection or damage to the lacrimal drainage apparatus.

Probing of the nasolacrimal duct and/or dilation of the nasolacrimal punctum can be carried out for any of the following indications:

• Epiphora (excessive tearing) due to acquired obstruction within the nasolacrimal sac and duct;

• A mucocele of the lacrimal sac;

• Chronic dacryocystitis or conjunctivitis due to lacrimal sac obstruction;

• Lacrimal sac infection that must be relieved before intra-ocular surgery.

Limitations:

• Payment for these procedures for treatment of epiphora is limited to patients whose medical records indicate they have first undergone a thorough lacrimal evaluation that includes at least the following:

• Consideration by history and physical examination (including slit lamp), of likely pre-punctal and/or non-obstructive causes for epiphora such as disturbances of ocular surface tear flow by lid malposition, allergy, dry eye, blepharitis; and

• Non-invasive testing to diagnose punctal or post-punctal obstruction and to identify the site and degree of obstruction, such as by using dye disappearance testing when appropriate; followed by

• Initiation of appropriate treatment.

• Separate reimbursement for tear production measurement (Schirmer test), tear break-up time (TBUT), dye disappearance testing (sodium fluorescein), Jones dye testing or saccharine testing is not available. These are considered part of a general opthalmological examination or E&M service.

• Punctal dilation and lacrimal duct probing are not indicated for dacryocystolithiasis.

• Provision of any of these services is subject to state regulations, and individual providers’ scopes of practice.

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