KEY TAKEAWAYS
- Ocular surface toxic soup syndrome describes a proposed mechanism in which reduced tear turnover allows inflammatory mediators, allergens, and debris to build up on the ocular surface, causing irritation and inflammation.
- Nasolacrimal lavage is a therapeutic adaptation of dilation and irrigation that aims to restore tear clearance by flushing inflammatory mediators, allergens, and debris from the nasolacrimal drainage system.
- By improving tear clearance or preventing reflux, both nasolacrimal lavage and punctal occlusion may reduce ocular surface inflammation through different but potentially complementary mechanisms.
Dry eye disease (DED) is nothing new, but when caring for patients who have persistent ocular irritation, itchiness, or epiphora, eyecare providers may be overlooking a simple mechanical explanation: poor tear drainage.
THE TOXIC SOUP HYPOTHESIS
Tears are biologically complex and dynamic secretions composed of lipids, mucins, proteins, cytokines, and cellular debris that form a metabolically active, multilayered barrier to support ocular surface homeostasis, immune defense, lubrication, epithelial nutrition, and visual clarity.1-3
The nasolacrimal system is essential not only for clearing tears, but also for regulating the biochemical environment on the ocular surface. When tear flow is adequate, tears are continuously refreshed, allowing for inflammatory mediators and allergens to be diluted and flushed away.4,5 Poor production or drainage reduces the tear turnover rate. Anatomic narrowing, subclinical obstruction, mucus, or dacryoliths can cause the lacrimal sac and lower tear drainage system to become reservoirs for stagnant, poor-quality tears that reflux onto the ocular surface. This fluid may contain inflammatory cytokines, allergens, preservatives from topical drops, or bacterial metabolites.6,7 The tear film subsequently becomes proinflammatory and irritating to the ocular surface, potentially resulting in discomfort or redness,and the eye or lacrimal sac may become itchy.6,7
Peter Pham, MD, and I coined the term ocular surface toxic soup syndrome (OSTSS) to describe this inflammatory stew on the ocular surface and proposed a procedure to treat it, nasolacrimal lavage.8 Although more research is necessary, OSTSS may represent an important clinical phenotype in the spectrum of DED and ocular allergy.
Symptoms of OSTSS include itchiness, conjunctival injection, epiphora, grittiness, irritation, and foreign body sensation. Signs include bulbar injection, papillary reaction, tear pooling, corneal staining, and mucus in the caruncle.
AN OVERVIEW OF NASOLACRIMAL LAVAGE
Nasolacrimal lavage is a minimally invasive procedure that typically takes less than 5 minutes to perform. A topical anesthetic can be instilled before lavage. The lower punctum is then dilated and cannulated with a blunt 25-gauge cannula. Next, the nasolacrimal system is flushed with 3 mL of saline. If the duct is patent, the patient may taste saline in their throat (head back) or feel it in their nose (head forward). The procedure is generally well-tolerated, with minor and rare side effects. It may be repeated every 2 to 6 months as needed.
NASOLACRIMAL LAVAGE
Nasolacrimal lavage is a therapeutic adaptation of the traditional dilation and irrigation procedure (Figures 1 and 2). Whereas the latter is typically used diagnostically to evaluate the nasolacrimal duct for obstruction, the goal of nasolacrimal lavage is to flush out allergens, inflammatory mediators, and debris from the tear drainage system (see An Overview of Nasolacrimal Lavage). The procedure poses no long-term risks and is reversible. It may also have broader applications for the management of conditions such as ocular allergy, epiphora, and mucous accumulation, where tear stasis plays a role.
In my experience, nasolacrimal lavage can provide substantial and sustained symptom relief in patients who have refractory ocular surface inflammation, particularly when conventional medical therapies have been unsuccessful, as illustrated by the following case:
A CASE OF SOUP SYNDROME
A 26-year-old woman who had a longstanding history of severe allergic conjunctivitis and allergic rhinitis presented with persistent bilateral conjunctival injection, grade 3+ papillae, mild eyelid edema, and eyelid erythema. Her symptoms were poorly controlled despite extensive medical therapy, including oral therapeutics, antihistamines, mast cell stabilizers, intranasal corticosteroids, and intermittent topical corticosteroids.
A regimen of therapeutic nasolacrimal lavage 2 to 3 times per year was initiated. After each treatment, the patient experienced complete resolution of her symptoms, including medial canthal itchiness, grittiness, conjunctival injection, and episodic epiphora. This relief typically lasts up to 6 months. An improvement in clinical signs was also observed: Conjunctival injection resolved, papillae regressed to trace levels, and the patient’s eyelid inflammation and erythema subsided. Symptom recurrence correlated with tear stagnation, and resolution has reliably followed nasolacrimal lavage, suggesting a relationship between impaired tear clearance and ocular surface inflammatory burden.
For this patient—and others in my practice who have similar ocular profiles—nasolacrimal lavage has offered them effective and sustained relief. These results highlight the procedure’s potential as a low-risk treatment option for inflammatory disorders of the ocular surface.
FORWARD-THINKING OUTLOOK
This treatment gives clinicians another powerful tool in their treatment arsenal for ocular surface disease and, potentially, allergy management, while opening the door to addressing previously underrecognized contributors to signs and symptoms.
PUNCTAL PLUGS
Punctal occlusion has long been used to retain tears on the ocular surface in aqueous tear deficient patients.9,10 Theoretically, plugging the drain boosts tear volume. The paradox is that 1% to 6% of patients who have punctal plugs develop epiphora, and many of these patients experience no change in tear meniscus volume.11,12 A compensatory mechanism must therefore reduce tear production after plug placement.
Perhaps plugs and, by extension, canalicular hyaluronic acid gel work not by retaining more tears, but by preventing the backflow of inflammatory substances from the lacrimal sac onto the ocular surface. Thus, punctal occlusion and nasolacrimal lavage may both seek to accomplish the same overall result: active removal of inflammatory buildup. In short, punctal plugs close the drain, and nasolacrimal lavage flushes it; both strategies may be beneficial to patients.
The decision between draining and retaining tears depends on the patient. Punctal occlusion may be the best option for patients who have poor tear production and for those in need of greater tear volume. For those who have excessive tear or mucous buildup and stagnant tears, nasolacrimal lavage may be the better option.
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