Commentary: Rule out lacrimal duct obstruction before every intraocular procedure.

Abstract

The age of presentation often overlaps for a person with acquired cataracts and acquired nasolacrimal duct obstruction (NLDO). Hence, there is more probability of having an asymptomatic NLDO and a cataract in the same person. Ipsilateral NLDO is considered an important risk factor for postoperative endophthalmitis in an intraocular procedure. Therefore, it becomes mandatory to rule out ipsilateral NLDO in all patients planned for cataract surgery.[1] Overall, the reported incidence of NLDO is 3–6.6%, with a mean age range of 48–59.5 years.[12] The ophthalmic evaluation of cataract surgery focuses on the factors affecting the visual acuity outcomes, like the health of tear-film, cornea, and anterior and posterior segments. Similarly, the ocular investigations are also targeted mainly at calculating and computing the refractive indices directly involved in the outcome of cataract surgery. Regurgitation on pressing lacrimal sac (ROPLaS) and lacrimal irrigation are generally not included in the routine examination of most ophthalmic cases. Hence, an asymptomatic lacrimal patient with a cataract tends to get his/her NLDO missed. ROPLaS and/or lacrimal irrigation must be included in the preoperative workup of a cataract patient to avoid the chance of postoperative endophthalmitis.[3] Lacrimal irrigation is an invasive diagnostic procedure requiring the desired skill-set to avoid any iatrogenic injury to the delicate lacrimal drainage system and interpret the results. Moreover, the patient and examiner must be in specific positions for lacrimal irrigation rather than sitting on an examination chair and slit lamp. Each step requires patient co-operation, like topical anesthesia, gaze positioning of the patient, punctum dilatation (preferably superior), lacrimal cannula insertion in horizontal canaliculus, and perception of gently forced injection of fluid in nose or throat. A significant part of lacrimal irrigation is dependent on the patient’s co-operation and systemic condition. ROPLaS, on the other hand, is a simple test that can be easily performed in the sitting position (any position) of the patient without consuming much time in the workup period. All those beneficial parameters are vital in high-volume centers and screening camps in remote areas. The examiner desires no special instrumentation or patient co-operation. In a survey involving members of the Oculoplastics Association of India, ROPLaS (59.6%) was opted as the preferred modality compared to lacrimal irrigation/syringing (32.6%), for checking NLDO before cataract surgery.[3] The sensitivity and specificity of ROPLaS have been reported to be 93.2% and 99.3%, respectively.[1] They recommended preoperative lacrimal irrigation to be unnecessary in case of a negative ROPLaS test. A recent retrospective, single-center study from India, including a large sample size (87,144 eyes), compared postcataract surgery endophthalmitis rates among eyes undergoing syringing (48,071 eyes) or ROPLAS (39,073 eyes) test before cataract surgery.[4] They found that the rates of post-cataract endophthalmitis (PCE) were comparable among the eyes undergoing either syringing test or ROPLAS before cataract surgery. This study was performed to avoid lacrimal irrigation, an aerosol-generating procedure, during COVID-19 times. However, when the safety of a vision-restoring surgical procedure (elective cataract surgery) is in question, more details in the ophthalmic examination will add to the safety value. As per the current study by Kim et al.,[5] the ROPLaS and lacrimal irrigation are both recommended to be performed in the preoperative workup of a cataract patient.[5] In their study, the ROPLaS was performed by an ophthalmologist, while a trained ophthalmic technician performed the lacrimal irrigation. We want to emphasize that ophthalmologists should first train the technician adequately before performing an invasive procedure (lacrimal irrigation) on a patient. This would ensure the desired outcomes from the lacrimal irrigation procedure without iatrogenic trauma to the lacrimal punctum and canaliculus. Additionally, a history of significant epiphora ± discharge goes a long way in suspecting lacrimal obstructions. Slit-lamp examination of the tear film and inferior conjunctival fornix is a must to rule out any debris/discharge. The fluorescein dye staining provides basic information about the health of corneal epithelium, and the simultaneous observation of the fluorescein dye disappearance test can provide an additional dimension in ruling out lacrimal duct obstruction. We believe that if a patient has a positive ROPLaS test, lacrimal irrigation is not necessary. However, in a patient with negative ROPLaS, lacrimal irrigation should be performed before any intraocular procedure to avoid the most-dreaded complication of endophthalmitis due to a treatable cause - NLDO.