Evaluation of Distal Occlusions accompanying Punctal Stenosis using Radionuclide Imaging in patients with Unilateral Epiphora

Main Article Content

Sule Ceylan
Necati Yilmaz


Objective: Our objective was to evaluate distal occlusions accompanying punctal stenosis, which can lead to impaired nasolacrimal drainage in patients with punctal stenosis, using radionuclide imaging.

Material and Methods: Our study enrolled 42 patients who had unilateral punctal stenosis and experienced epiphora on the same side. None of the patients had previously undergone surgical intervention for this condition. Ophthalmological examination results were normal on the unaffected side. Dacryoscintigraphy was performed bilaterally, and specific regions of interest were identified. The scintigraphic images were assessed quantitatively and qualitatively by two nuclear medicine specialists. Evaluation between the nuclear medicine specialists was conducted using the McNemar Bowker test and the Kappa test.

Results: Eighty-one percent (34) of the patients were female. The mean age of the patients was 68.23±9.67 years. In patients with punctal stenosis, the punctal area exhibited edematous features. The lacrimal drainage pathway from the punctum was assessed by two nuclear medicine specialists using two different methods. In the visual quantitative evaluation to determine the localization of the stenosis, there was a low to moderate agreement between the two observers (p=0.018, kappa value=0.252). In the quantitative evaluation, there was excellent agreement between the observers (p=0.0001, kappa value=1).

Conclusion: Dacryoscintigraphy is preferred as an imaging method due to its non-invasive nature that does not disturb the physiological processes. It offers advantages such as lower radiation exposure and higher patient compliance compared to dacryocystography. However, it should be noted that the anatomical correlation in dacryoscintigraphy is relatively low compared to radiological methods. By incorporating quantitative data into the visual assessment of dacryoscintigraphy, it may be possible to enhance anatomical correlation and improve observer agreement, particularly in patients presenting with a combination of functional and anatomical obstructions.


Download data is not yet available.

Article Details

How to Cite
Ceylan, S., & Yilmaz, N. (2023). Evaluation of Distal Occlusions accompanying Punctal Stenosis using Radionuclide Imaging in patients with Unilateral Epiphora. Medical Science and Discovery, 10(6), 410–416. https://doi.org/10.36472/msd.v10i6.971
Research Article
Received 2023-06-09
Accepted 2023-06-20
Published 2023-06-24


Eldaya RW, Deolankar R, Orlowski HLP, Miller-Thomas MM, Wippold FJ 2nd, Parsons MS. Neuroimaging of Adult Lacrimal Drainage System. Curr Probl Diagn Radiol. 2020;49(1):1-16.

Barnaa S, Garaia I, Gesztelyi R, Kemeny-Beke A. Evaluation of the tear clearance rate by dacryoscintigraphy in patients with obstructive meibomian gland dysfunction. Contact Lens Anterior Eye. 2019;42(4):359-365.

Çelen Z, Özçelik N, Bülbül M, Cilban S. Dakriosintigrafi Uygulamasında Farklı Protokol. Turk J Nucl Med. 1997;6(3):174-177.

Közer L. Boşaltıcı Sistem Hastalıkları. XI. Ulusal Oftalmoloji Kursu, Ankara, 1991;44-49.

Grayson JW, Harvey RJ, Sacks R. Endoscopic Dacryocystorhinostomy. In: Sindwani R, editor. Endoscopic Surgery of the Orbit. 2020;94-98.

Detorakis ET, Zissimopoulos A, Ionnakis K. Lacrimal Outflow Mechanisms and the Role of Scintigraphy: Current Trends. World J Nucl Med. 2014;13:16-20.

Perry JD. Dysfunctional Epiphora: A Critique of Our Current Construct of "Functional Epiphora". Am J Ophthalmol. 2012;154(1):3-5.

Salmon JF. Lacrimal Drainage System. In: Kanski's Clinical Ophthalmology. 9th ed. 2020; Chapter 3:99-111.

Kassel EE, Schatz CJ. Anatomy, Imaging, and Pathology of the Lacrimal Apparatus. In: Som PM, Curtin HD, editors. Head and Neck Imaging. 5th ed. Mosby, 2011;757-853.

Peter NM, Pearson AR. Comparison of Dacryocystography and Lacrimal Scintigraphy in the Investigation of Epiphora in Patients With Patent but Nonfunctioning Lacrimal Systems. Ophthal Plast Reconstr Surg. 2009;25(3):201-205.

Wearne MJ, Pitts J, Frank J, Rose GE. Comparison Dacryocsytography and Lacrimal Scintigraphy in the Diagnosis of Functional Nasolacrimal Duct Obstruction. Br J Ophthalmol. 1999;83(9):1032-1035.

Nixon J, Birchall IWJ, Virjee J. The Role of Dacryocystography in the Management of Patients with Epiphora. Br J Radiol. 1990;63(754):337-339.

Palaniswamy SS, Subramanyam P. Dacryoscintigraphy: An Effective Tool in the Evaluation of Postoperative Epiphora. Nucl Med Commun. 2021;42(3):262-267.

Galloway JE, Kavic TA, Raflo GT. Digital Subtraction Macrodacryocystography: A New Method of Lacrimal System Imaging. Ophthalmology. 1984;91(8):956-962.

Von Denffer H, Dressler J, Pabst HW. Lacrimal Dacryoscintigraphy. Semin Nucl Med. 1984;14(1):8-15.

Detorakis ET, Zissimopoulos A, Ioannakis K, Kozobolis VP. Lacrimal Outflow Mechanisms and the Role of Scintigraphy: Current Trends. World J Nucl Med. 2014;13(1):16-21.

Detorakis ET, Zissimopoulos A, Katernellis G, Drokonaki EE, Ganasouli DL, Kozobolis VP. Lower Eyelid Laxity in Functional Acquired Epiphora: Evaluation with Quantitative Scintigraphy. Ophthal Plast Reconstr Surg. 2006;22(1):25-29.

Sia PI, Curragh D, Howell S, Franzco DS. Interobserver Agreement on Interpretation of Conventional Dacryocystography and Dacryoscintigraphy Findings: A Retrospective Single-Centre Study. Clin Exp Ophthalmol. 2019;47(6):713-717.

Hurwiitz J, Maisey M, Welham R. Quantitative Lacrimal Scintillography: Method and Physiological Application. Br J Ophthalmol. 1975;59(5):308-312.

Ayub M, Thale AB, Hedderich J, Tillmann BN, Paulsen FP. The Cavernous Body of the Human Efferent Tear Ducts Contributes to the Regulation of Tear Outflow. Invest Ophthalmol Vis Sci. 2003;44(11):4900-4907.

Tucker NA, Codere F. The Effect of Fluorescein Volume on Lacrimal Outflow Transit Time. Ophthal Plast Reconstr Surg. 1994;10(4):256-259.

Viso E, RodriguezAres MT, Gude F. Prevalence and associations of external punctal stenosis in a general population in Spain. Cornea. 2012;31(11):1240-1245. https://doi.org/10.1097/ICO.0b013e31823f8eca

Bukhari A. Prevalence of punctal stenosis among ophthalmology patients. Middle East Afr J Ophthalmol. 2009;16(2):85-87. https://doi.org/10.4103/0974-9233.53867

Mainville N, Jordan DR. Etiology of tearing: a retrospective analysis of referrals to a tertiary care oculoplastics practice. Ophthalmic Plast Reconstr Surg. 2011;27(3):155-157. https://doi.org/10.1097/IOP.0b013e3181ef728d

Patel S, Wallace I. Tear meniscus height, lower punctum lacrimal, and the tear lipid layer in normal aging. Optom Vis Sci. 2006;83(10):731-739. https://doi.org/10.1097/01.opx.0000236810.17338.cf

Carter KD, Nelson CC, Martonyi CL. Size variation of the lacrimal punctum in adults. Ophthal Plast Reconstr Surg. 1988;4(4):231-233. https://doi.org/10.1097/00002341-198804040-00006

Kashkouli MB, Beigi B, Murthy R, Astbury N. Acquired external punctal stenosis: etiology and associated findings. Am J Ophthalmol. 2003;136(6):1079-1084. https://doi.org/10.1016/s0002-9394(03)00664-0

Offutt WN, Cowen DE. Stenotic puncta: microsurgical punctoplasty. Ophthalmic Plast Reconstr Surg. 1993;9(3):201-205. https://doi.org/10.1097/00002341-199309000-00006

Kornhauser T, Segal A, Walter E, Lifshitz T, Hartstein M, Tsumi E. Idiopathic edematous punctal stenosis with chronic epiphora: preponderance in young women. Int Ophthalmol. 2019;39(8):1981-1986. https://doi.org/10.1007/s10792-018-1031-y

Kashkouli MB, Beigi B, Astbury N. Acquired external punctal stenosis: surgical management and long-term follow-up. Orbit. 2005;24(2):73-78. https://doi.org/10.1080/01676830490916055

Ali MJ, Ayyar A, Naik MN. Outcomes of rectangular 3-snip punctoplasty in acquired punctal stenosis: is there a need to be minimally invasive? Eye (Lond). 2015;29(4):515-518. https://doi.org/10.1038/eye.2014.342

Rosenstock T, Hurwitz JJ. Functional obstruction of the lacrimal passages. Can J Ophthalmol. 1982;17(6):249-255.

Cuthbertson FM, Webber S. Assessment of functional nasolacrimal duct obstruction-a survey of ophthalmologists in the southwest. Eye (Lond). 2004;18(1):20-23.

Caesar RH, McNab AA. A brief history of punctoplasty: the 3-snip revisited. Eye (Lond). 2005;19(1):16-18.

Guercio B, Keyhani K, Weinberg DA. Snip punctoplasty offers little additive benefit to lower eyelid tightening in the treatment of pure lacrimal pump failure. Ophthalmic Plast Reconstr Surg. 2007;23(1):15-18.

Dr. Ishan G. Acharya, Dr. Jitendra Jethani. Effectiveness of Snip Procedure in Functional Epiphora. AIOC 2008 Proceedings.

Hurwitz JJ, Victor WH. The role of sophisticated radiological testing in the assessment and management of epiphora. Ophthalmology. 1985;92(3):407-413.

Dutton JJ, White JJ. Imaging and clinical evaluation of the lacrimal drainage system. In: Cohen AJ, Mercandetti M, Brazzo BG, eds. The Lacrimal System: Diagnosis, Management, and Surgery. Springer; 2006. pp. 74-95.

Ayati NK, Malekshahi RG, Zakavi SR, et al. Systemic absorption of Tc-99m-pertechnetate during dacryoscintigraphy: a note of caution. Orbit. 2010;29(5):269-270.

Chavis RM, Welham RA, Maisey MN. Quantitative lacrimal scintillography. Arch Ophthalmol. 1978;96(11):2066-2068.

Hilditch TE, Kwok CS, Amanat LA. Lacrimal scintigraphy. I. Compartmental analysis of data. Br J Ophthalmol. 1983;67:713-719.

Peter NM, Pearson AR. Comparison of dacryocystography and lacrimal scintigraphy in the investigation of epiphora in patients with patent but nonfunctioning lacrimal systems. Ophthal Plast Reconstr Surg. 2009;25:201-205.

Jabbour J, Van der Wall H, Katelaris L, et al. Quantitative lacrimal scintigraphy in the assessment of epiphora. Clin Nucl Med. 2008;33:535-541.

Jager PL, Mansour K, Vrakkink-de Zoete H, et al. Clinical value of dacryoscintigraphy using a simplified analysis. Graefes Arch Clin Exp Ophthalmol. 2005;243:1134-1140.

Hurwitz JJ, Maisey MN, Welham RA. Quantitative lacrimal scintillography. I. Method and physiological application. Br J Ophthalmol. 1975;59:308-312.

Demirel S, Derya K, Doganay S, Orman G, Cumurcu T, Gunduz A, et al. Reply re: "Endoscopic transcanalicular diode laser dacryocystorhinostomy. Is it an alternative method to conventional external dacryocystorhinostomy?". Ophthal Plast Reconstr Surg. 2013;29:145.

Waly MA, Shalaby OE, Elbakary MA, Hashish AA. The cosmetic outcome of external dacryocystorhinostomy scar and factors affecting it. Indian J Ophthalmol. 2016;64:261-265.

Rosique López L, Lajara Blesa J, Rosique Arias M. Usefulness of local postoperative care after laser dacryocystorhinostomy. Acta Otorrinolaringol Esp. 2013;64:279-282.

Malbouisson JM, Bittar MD, Obeid HN, Guimarães FC, Velasco e Cruz AA. Quantitative study of the effect of dacryocystorhinostomy on lacrimal drainage. Acta Ophthalmol Scand. 1997;75:290-294.

Hartikainen J, Antila J, Varpula M, Puukka P, Seppä H, Grénman R, et al. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope. 1998;108:1861-1866..

Fard Esfahani A, Gholamrezanezhad A, Mirpour S, Tari AS, Saghari M, Beiki D, et al. Assessment of the accuracy of lacrimal scintigraphy based on a prospective analysis of patients' symptomatology. Orbit. 2008;27:237-241.

Peter NM, Pearson AR. Comparison of dacryocystography and lacrimal scintigraphy in the investigation of epiphora in patients with patent but nonfunctioning lacrimal systems. Ophthal Plast Reconstr Surg. 2009;25:201-205.

Drnovsek Olup B, Beltram M. Transcanalicular diode laser-assisted dacryocystorhinostomy. Indian J Ophthalmol. 2010;58:213-217.

Alanon Fernandez FJ, Alanon Fernandez MA, Martínez Fernández A, Cárdenas Lara M. Transcanalicular dacryocystorhinostomy technique using diode laser. Arch Soc Esp Oftalmol. 2004;79:325-330.

Choi CJ, Jin HR, Moon YE, et al. The surgical outcome of endoscopic dacryocystorhinostomy according to the obstruction levels of the lacrimal drainage system. Clin Exp Otorhinolaryngol. 2009;2:141-144.

Most read articles by the same author(s)