**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:**  
  

  1. 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.
  2. 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.
  3. Reimbursement for CPT 68801 and 68810 is limited to only the specific eye(s), right or left, for which these procedures are considered reasonable and necessary. Payment for performance of a bilateral procedure may be denied or reduced to a unilateral procedure if medical record documentation fails to support that both eyes had qualifying signs or symptoms and had undergone proper pre-procedural evaluation as described above.  
  

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

  5. CPT 68810, 68811 or 68815 are primarily pediatric procedures, and are only rarely required in adults, whereas CPT 68840 is more commonly performed in the adult population. The submitted CPT code must reflect the true extent of a reasonable and necessary procedure. Thus, if it is only medically necessary to dilate the punctum or probe the canaliculi it would be inappropriate to submit 68810, for example.   
  

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

  
  
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