Overview
Definition:
Congenital nasolacrimal duct obstruction (CNLDO) is a common condition in infants characterized by a blockage of the tear drainage system, typically at the level of the valve of Hasner at the nasal meatus
This leads to epiphora (excessive tearing) and can predispose to infection.
Epidemiology:
CNLDO affects approximately 2-6% of term infants
It is bilateral in about 20% of cases and more common in females
Most cases (over 90%) resolve spontaneously within the first year of life.
Clinical Significance:
While often benign and self-limiting, untreated or persistent CNLDO can lead to chronic dacryocystitis, preseptal cellulitis, and visual impairment due to persistent discharge and potential corneal abrasion
Early recognition and appropriate management are crucial for patient comfort and preventing complications.
Clinical Presentation
Symptoms:
Persistent watery or Tearing from one or both eyes, especially noticeable in the first few weeks of life
Mucopurulent discharge, particularly after waking or if the eye area is rubbed
Crusting of the eyelids
Recurrent episodes of dacryocystitis (redness, swelling, pain over the lacrimal sac).
Signs:
Epiphora
Mild to moderate conjunctival injection
Discharge that can be clear, mucoid, or purulent
Swelling and tenderness over the lacrimal sac area (if infected).
Diagnostic Criteria:
Diagnosis is primarily clinical, based on history and physical examination
Characteristic symptoms of chronic epiphora and discharge in an infant are usually sufficient
Imaging is rarely indicated for uncomplicated cases.
Diagnostic Approach
History Taking:
Inquire about the onset and duration of tearing and discharge
Note any history of eye rubbing, trauma, or recurrent conjunctivitis
Ask about the presence of fever or significant redness indicating infection
Assess for bilateral involvement.
Physical Examination:
Perform a thorough ocular examination to rule out other causes of epiphora like conjunctivitis or corneal abrasion
Gently palpate the lacrimal sac area for tenderness or swelling
Assess the patency of the puncta and canaliculi
Observe the discharge characteristics.
Investigations:
Generally not required for routine diagnosis
In persistent or complicated cases, a lacrimal system irrigation or syringing can be performed to assess patency and locate the obstruction
Dye disappearance test can also be used
Imaging like dacryocystography is rarely needed.
Differential Diagnosis:
Congenital glaucoma (usually presents with photophobia and buphthalmos)
Keratitis or corneal ulcer (usually involves significant redness and pain)
Bacterial or viral conjunctivitis (typically acute onset with more pronounced injection)
Eyelid abnormalities (e.g., entropion).
Management
Initial Management:
Conservative management is the mainstay for CNLDO
This begins with parental education on appropriate care
Medical management focuses on hygiene and preventing infection, while mechanical methods aim to relieve the obstruction.
Medical Management:
Gentle massage of the lacrimal sac: Apply firm pressure over the lacrimal sac, directed inferiorly and medially towards the nose, several times a day
This helps to milk the tear film and potentially open the obstructed duct
Topical antibiotic eye drops or ointments: Prescribed for acute dacryocystitis to treat infection
Cleanse discharge with sterile saline or lukewarm water and cotton balls.
Surgical Management:
Probing of the nasolacrimal duct: Indicated if conservative management fails after 6-12 months of age or if there are recurrent episodes of acute dacryocystitis
Performed under anesthesia, a fine probe (e.g., Bowman probe) is introduced through the punctum and canaliculi to break through the obstruction at the nasal meatus
Syringing after probing confirms patency.
Age Considerations:
Infants under 6 months with symptoms often benefit from massage and waiting for spontaneous resolution
Probing is typically considered after 6-12 months of age if symptoms persist or if there are complications
Very young infants might be managed conservatively for longer if mild.
Key Points:
Conservative measures like massage are effective in a high percentage of cases
Probing is a safe and effective second-line treatment when conservative measures fail
Early recognition and management can prevent complications like dacryocystitis and cellulitis.
Complications
Early Complications:
Acute dacryocystitis: Infection of the lacrimal sac presenting as painful swelling, erythema, and purulent discharge
Preseptal cellulitis: Infection of the tissues surrounding the eye, appearing as eyelid swelling and redness
Corneal abrasion: From chronic irritation by discharge.
Late Complications:
Chronic dacryocystitis: Persistent low-grade inflammation of the lacrimal sac
Sclerosing dacryocystitis: Rare complication with fibrotic changes in the sac
Persistent epiphora causing social and aesthetic concerns.
Prevention Strategies:
Regular and correct technique of lacrimal sac massage
Prompt treatment of acute dacryocystitis with antibiotics to prevent spread
Diligent hygiene to keep the affected eye clean and free of discharge.
Prognosis
Factors Affecting Prognosis:
Spontaneous resolution rate is high, especially within the first year
The success of probing is generally excellent, with high rates of symptom relief
Recurrence is uncommon but possible.
Outcomes:
Most infants with CNLDO experience complete resolution with conservative management or surgical probing
Prompt intervention leads to resolution of symptoms and prevention of complications
Long-term visual impairment is rare when managed appropriately.
Follow Up:
Regular follow-up is recommended to monitor symptom resolution and assess the need for intervention
After probing, a short period of follow-up is usually sufficient to confirm patency and resolution of symptoms
Long-term monitoring may be needed for recurrent cases.
Key Points
Exam Focus:
Understand the primary management strategies: massage vs
probing
Know the indications for each
Be aware of the common complications of CNLDO and their management
Remember the age at which probing is usually considered.
Clinical Pearls:
Instruct parents on proper massage technique: pressure towards the nose, not the punctum
If purulent discharge is present, always consider topical antibiotics
Differentiate CNLDO from other causes of epiphora in infants.
Common Mistakes:
Delaying probing in cases with recurrent severe dacryocystitis
Incorrectly performing massage, which can worsen symptoms
Over-reliance on syringing without proper probing for persistent obstruction.