Nasolacrimal duct obstruction

Congenital nasolacrimal duct obstruction is the most common abnormality of the infant’s lacrimal system. Almost 5% of infants manifest nasolacrimal duct obstruction, and 30% of affected infants have bilateral obstruction. The obstruction is usually at the distal end of the nasolacrimal system. Most typically, infants present with tearing and crusting of the eyelashes. Massage of the duct will reveal clear-to-mucopurulent material. Conjunctival inflammation, photophobia, blepharospasm, corneal clouding, or other eye abnormalities are notably absent.

Natural resolution rates as high as 95% have been reported by 13 months of age. Complications are rare and include development of nasolacrimal duct cysts with nasal obstruction or dacryocystitis.

Because of the favorable natural history, recommended treatment is conservative. Digital massage of the duct two to three times a day may help to open the occluded system.

Topical antibiotics are indicated only for mucopurulent conjunctivitis. Silver nitrate is indicated for the prevention of gonococcal ophthalmia, but may cause chemical conjunctivitis. Systemic antibiotics may be necessary for treatment of dacryocystitis, a bacterial infection of the lacrimal sac manifested by edema, erythema, and tenderness over the sac.

Nasolacrimal duct probing is appropriate if symptoms persist beyond 13 months of age. Probing usually is performed under general anesthesia and generally is curative. Tube placement or dacrocystorhinostomy (surgical opening of the lacrimal system into the lateral nasal wall) are indicated for persistent duct obstruction that does not respond to conservative medical and surgical management.
 

References:
Korn E. Oculoplastic update. Pediatr Ann. 1990;19:316-322
Lavrich JB, Nelson LB. Disorders of the lacrimal system apparatus. Pediatr Clin North Am. 1993;40:767-776
Ogawa GS, Gonnering RS. Congenital nasolacrimal duct obstruction. J Pediatr. 1991;119:12-17
Olitsky SE, Nelson LB. Disorders of the lacrimal system. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co; 2000:1911
Poole SR. Corneal abrasion in infants. Pediatr Emerg Care. 1995; 11:25-26
Trobe JD, American Academy of Family Physicians. Dacryocystitis. In: The Physician’s Guide to Eye Care. San Francisco, Calif: American Academy of Ophthalmology; 1993:45-46