Ophthalmology – Nasolacrimal Duct Obstruction in Children

Basics

Description

Congenital nasolacrimal duct obstruction (CNLDO) is the most common congenital abnormality of the lacrimal drainage system.

The nasolacrimal duct normally carries tears from the:

• Lacrimal sac
• Through the nasolacrimal duct
• Into the inferior meatus beneath the inferior turbinate

Congenital obstruction most commonly results from persistence of a thin membranous blockage at the distal duct near the:

Valve of Hasner

Typical manifestations are:

• Epiphora
• Increased tear lake
• Mucous or mucopurulent discharge
• Crusting of the eyelashes

Most cases resolve spontaneously during infancy.

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Epidemiology

Congenital NLDO is common.

Reported incidence is approximately:

6–20% of neonates

It is the most common congenital lacrimal drainage abnormality.

Approximately 90% of affected infants improve spontaneously by about 1 year of age.

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Risk Factors

Most cases occur in otherwise healthy children.

Risk may be increased in children with:

• Craniofacial malformations
• Down syndrome
• Oculonasal developmental abnormalities
• Cornelia de Lange syndrome
• Johanson-Blizzard syndrome
• Other syndromes involving craniofacial development

These patients may have more complex lacrimal drainage abnormalities in addition to simple distal NLDO.

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Genetics

No single causative genetic abnormality is responsible for most isolated cases.

However:

• Familial clustering has been reported.
• When NLDO occurs as part of a genetic syndrome, inheritance follows the pattern of that syndrome.
• Expression of the lacrimal anomaly may vary among affected family members.

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Pathophysiology

The nasolacrimal drainage system develops from a cord of surface ectoderm between the:

• Maxillary process
• Lateral nasal process

The epithelial cord later canalizes.

Failure of complete distal canalization produces a membranous obstruction, most commonly at the:

Valve of Hasner

This prevents normal drainage of tears into the nose.

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Etiology

The exact reason why distal canalization fails in individual infants is usually unknown.

Most cases are:

• Sporadic
• Congenital
• Isolated

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Commonly Associated Conditions

Associated conditions include:

• Down syndrome
• Craniofacial abnormalities
• Preauricular sinus
• Syndromes with oculofacial malformations

However, the majority of children with CNLDO have no systemic abnormality.

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Diagnosis

Diagnosis is usually clinical.

The typical infant presents with:

• Persistent tearing
• Mucous discharge
• Matted eyelashes
• Little or no conjunctival injection

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History

Parents commonly report:

• Constant or intermittent epiphora
• Mucous or mucopurulent discharge
• Eyelashes sticking together
• Symptoms worse on awakening
• Increased discharge during upper respiratory infections
• Increased tearing outdoors or in windy conditions

Symptoms may not be obvious immediately after birth because tear production is relatively low in the early neonatal period.

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Physical Examination

Typical findings include:

• Wet eyelid margin
• Matted eyelashes
• Increased tear lake
• Mucous discharge
• Minimal conjunctival redness

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Lacrimal Sac Compression

Gentle pressure over the lacrimal sac may cause:

• Mucous reflux
• Mucopurulent reflux
• Purulent material through the puncta

This strongly supports distal lacrimal drainage obstruction.

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Skin Changes

Longstanding overflow of tears may produce:

• Irritation
• Erythema
• Excoriation
• Chronic dermatitis of the lower eyelid and cheek

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Important Examination Point

A complete examination of the:

• Eyelids
• Puncta
• Conjunctiva
• Cornea

should be performed to exclude other causes of tearing.

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Diagnostic Testing

Laboratory Testing

Routine laboratory testing is unnecessary.

If frank infection is present, cultures may occasionally be useful.

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Fluorescein Dye Disappearance Test

This is a simple and useful test for lacrimal drainage.

A drop of fluorescein is placed in the conjunctival sac.

After approximately 5 minutes:

• Normal drainage → little fluorescein remains
• Obstruction → persistent pooling of fluorescein

Comparison between the two eyes is particularly helpful in unilateral disease.

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Nasal Fluorescein Recovery

If fluorescein reaches the nasal cavity, this supports a patent drainage pathway.

Historically, fluorescein may be detected with:

• A cotton-tipped applicator beneath the inferior turbinate

This is not routinely necessary in straightforward cases.

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Imaging

Most children do not require imaging.

Consider CT or other imaging when there is:

• Craniofacial abnormality
• Facial trauma
• Atypical presentation
• Suspected mass
• Complex lacrimal anatomy

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Differential Diagnosis

Important differential diagnoses include:

• Dacryocele
• Congenital entropion
• Congenital ectropion
• Epiblepharon
• Trichiasis
• Infectious conjunctivitis
• Keratitis
• Uveitis
• Corneal foreign body
• Punctal agenesis or stenosis
• Canalicular abnormalities
• Lacrimal fistula
• Congenital glaucoma

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Important Differential – Congenital Glaucoma

An infant with tearing should always be assessed for congenital glaucoma.

Features that favor glaucoma include:

• Photophobia
• Blepharospasm
• Corneal haze
• Enlarged corneal diameter
• Buphthalmos

These are not typical features of uncomplicated NLDO.

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Dacryocele

A dacryocele results from obstruction both:

• Distally at the nasolacrimal duct
• Proximally near the common canaliculus

It typically appears as a:

• Bluish
• Cystic
• Medial canthal swelling

A dacryocele may extend into the nose and cause respiratory difficulty in neonates, particularly if bilateral.

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Dacryocystitis

If an infant develops:

• Painful swelling
• Erythema
• Tenderness over the lacrimal sac
• Fever
• Purulent discharge

suspect:

Acute dacryocystitis

This requires urgent treatment.

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Treatment

First-Line – Lacrimal Sac Massage

The usual initial treatment is:

Crigler lacrimal sac massage

The goal is to increase hydrostatic pressure within the lacrimal sac and help rupture the distal membranous obstruction.

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Massage Technique

The caregiver places a finger over the lacrimal sac region just below the medial canthus.

Then:

• Apply firm pressure inward toward the lacrimal sac
• Sweep downward along the side of the nose

This compresses the lacrimal sac and increases pressure toward the distal obstruction.

Massage is commonly performed:

Several times per day

Parents should be shown the technique directly.

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Observation

Because spontaneous resolution is very common, observation with massage is appropriate for most infants during the first year of life.

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Antibiotics

Antibiotics are not routinely required for uncomplicated CNLDO.

They may be used when there is:

• Significant mucopurulent discharge
• Secondary bacterial conjunctivitis
• Dacryocystitis

Topical antibiotics may help control discharge, but they:

Do not open the obstruction itself.

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Referral

Referral to pediatric ophthalmology is appropriate when:

• Symptoms persist near or beyond 12 months
• Symptoms are severe
• Copious discharge persists
• There is recurrent infection
• Diagnosis is uncertain
• Craniofacial anomalies are present
• Massage fails to improve symptoms
• Dacryocystitis or cellulitis is suspected

Urgent referral is required for:

• Acute dacryocystitis
• Preseptal cellulitis
• Orbital cellulitis
• Infected dacryocele

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Surgical Treatment

When symptoms persist despite conservative management, intervention may be required.

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Probing

Nasolacrimal duct probing is the traditional first-line procedure for persistent congenital NLDO.

A probe is passed through:

• Punctum
• Canaliculus
• Lacrimal sac
• Nasolacrimal duct

to mechanically open the distal obstruction.

Success rates are generally high, especially in younger children with uncomplicated disease.

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Timing of Probing

Probing is commonly considered when:

• Obstruction persists beyond approximately 1 year
• Symptoms are troublesome
• There is recurrent infection

Earlier probing may be appropriate for:

• Severe disease
• Dacryocele
• Recurrent dacryocystitis
• Significant persistent discharge

Practice varies regarding office probing versus probing under general anesthesia.

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Balloon Catheter Dilation

Balloon dacryoplasty may be considered in:

• Persistent obstruction
• Older children
• Failed initial probing
• More complex stenosis

A balloon catheter is used to dilate the nasolacrimal duct.

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Silicone Intubation

Nasolacrimal intubation may be performed with:

• Monocanalicular tube
• Bicanalicular tube

The tube is left in place temporarily to maintain duct patency.

It is often used when:

• Initial probing fails
• The child is older
• There is complex obstruction
• Repeat procedures are required

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Tube-Related Issues

Potential problems include:

• Premature extrusion
• Corneal irritation
• Granuloma
• Need for later removal

Some children require sedation or anesthesia for tube removal.

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Dacryocystorhinostomy

Dacryocystorhinostomy (DCR) is rarely required in children.

It is generally reserved for:

• Multiple failed probing/intubation procedures
• Complex congenital obstruction
• Severe structural abnormalities

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In-Patient Considerations

Most children are treated as outpatients.

Hospital admission may be required for:

• Acute dacryocystitis with systemic illness
• Preseptal cellulitis
• Orbital cellulitis
• Need for intravenous antibiotics

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Follow-Up

Children undergoing conservative treatment should be monitored until symptoms resolve.

Follow-up is especially important if there is:

• Persistent discharge
• Significant tearing
• Recurrent infection
• Skin breakdown

After complete resolution, routine follow-up specifically for NLDO is generally unnecessary.

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Patient Monitoring

Parents should monitor for:

• Increasing redness
• Medial canthal swelling
• Fever
• Purulent discharge
• Rapid eyelid swelling
• Reduced visual behavior

These may suggest infection or another diagnosis.

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Patient Education

Parents should understand that:

• CNLDO is common.
• Most cases resolve spontaneously.
• Massage is often sufficient.
• Antibiotic drops do not cure the obstruction.
• Surgery, when needed, is usually highly successful.

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Prognosis

The prognosis is excellent.

Most cases resolve:

• Spontaneously
• With lacrimal sac massage
• Or after a simple probing procedure

Children with significant craniofacial abnormalities may have:

• More complex obstruction
• Lower success rates
• Greater likelihood of requiring repeat procedures

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Complications

Potential complications include:

• Persistent epiphora
• Chronic mucopurulent discharge
• Dacryocystitis
• Preseptal cellulitis
• Orbital cellulitis
• Chronic skin irritation

Procedural complications are uncommon but may include:

• Mild epistaxis
• Corneal abrasion
• Creation of a false passage
• Tube extrusion
• Granuloma formation

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Ophthalmology Pearls

• Congenital NLDO is the most common lacrimal drainage abnormality in children.
• The usual obstruction is a persistent membrane at the Valve of Hasner.
• Classic presentation: tearing + mucous discharge + matted lashes + little conjunctival injection.
• Approximately 90% resolve spontaneously by about 1 year of age.
• Crigler massage is first-line treatment.
• Antibiotics are reserved for secondary infection; they do not correct the obstruction.
• Persistent symptoms beyond infancy may require probing.
• Failed probing may be followed by balloon dilation or silicone intubation.
• DCR is rarely required in children.
• A tearing infant with photophobia, blepharospasm, or corneal haze should be evaluated urgently for congenital glaucoma.
• Medial canthal swelling with erythema or fever suggests dacryocystitis or infected dacryocele and warrants urgent ophthalmic assessment.