OVERVIEW: What every practitioner needs to know

Are you sure your patient has nasolacrimal duct obstruction? What are the typical findings for this disease?

Nasolacrimal duct obstruction is a common disorder affecting newborns. 80%-90% of infants experience spontaneous resolution over the first year of life. For those whose symptoms require treatment, most will be successfully cured with nasolacrimal probing. A minority will require multiple surgeries for complete resolution. The typical symptoms of excess tearing and matting are relatively benign, but frequent infections can occur. Symptoms must be distinguished from infantile glaucoma, which can also present with tearing. Symptoms are:

  • Excess tearing

  • Matting of lids and lashes

    Continue Reading

  • Cloudy discharge from punctum

What other disease/condition shares some of these symptoms?

Infantile glaucoma is a potentially blinding condition that also causes excess tearing. It differs from nasolacrimal duct obstruction by the findings of photosensitivity, blepharospasm, clouding of the cornea, and buphthalmos. Infantile glaucoma also generally lacks matting and discharge from the punctum.

Blepharitis can also mimic nasolacrimal duct obstruction with its associated matting and redness of the lids. Blepharitis may also be identified by the presence of flaky crusts on the lids and stye formation. Blepharitis generally does not cause tearing or discharge from the punctum.

Conjunctivitis differs from nasolacrimal duct obstruction by the history of discreet episodes of tearing and discharge and the presence of conjunctival injection.

What caused this disease to develop at this time?

The nasolacrimal system consists of the upper and lower punctum and canaliculus, common canaliculus, lacrimal sac, and nasolacrimal duct. Nasolacrimal duct obstruction is a congenital disorder, caused by either a failure of the distal nasolacrimal duct to cannulate or by redundant nasal mucosa obstructing the duct. The usual site of obstruction is at the valve of Hasner, located at the distal end of the nasolacrimal duct.

Infants with disorders of the ectoderm, clefting syndromes, or midline facial anomalies have a higher likelihood of developing nasolacrimal duct obstruction. Children with Down syndrome have a higher rate of nasolacrimal duct obstruction and a higher rate of multiple surgeries. Acquired forms of nasolacrimal duct obstruction are associated with chronic eye drop use, infections, systemic chemotherapy, and facial trauma.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

The dye disappearance test can be helpful to confirm the presence of delayed tear drainage. A drop of fluorescein dye is placed in the eye. After 5 minutes, a significant amount of dye remaining in the eye indicates an obstruction of outflow.

Would imaging studies be helpful? If so, which ones?

Although generally not needed, a computed tomography (CT) scan may be helpful to evaluate for dacryocystocele.

If you are able to confirm that the patient has nasolacrimal duct obstruction, what treatment should be initiated?

Initial treatment is supportive. Reassure parents that often the condition spontaneously resolves. Instruct parents to provide nasolacrimal massage. Gentle massage often simply rids the nasolacrimal sac of excess discharge. A finger placed on the medial canthus and firmly directed down the side of the nose is thought to increase pressure in the nasolacrimal sac, leading to a rupture of the occluding membrane. Parents may report a “popping” sensation.

Topical antibiotics are used for episodes of secondary infection, rather than routine prophylaxis. Remind parents that antibiotics will not cure the condition. Daycare centers may need to be informed that the condition is not contagious.

When nasolacrimal duct obstruction does not resolve spontaneously, nasolacrimal duct probing is performed. Some ophthalmologists perform in-office probings on infants younger than 15 months of age. The advantages of office probing are the avoidance of risks associated with general anesthesia, earlier treatment of the condition, less time required for the patient’s family and surgeon, and overall lower healthcare costs. General anesthesia is often required in infants older than 15 months of age. The advantages of operating room probing are improved pain control, greater treatment success, and fewer infants undergoing treatment.

Infracture of the inferior turbinate can be performed in conjunction with a probing. In some cases of nasolacrimal duct obstruction, the inferior turbinate blocks the exit of the nasolacrimal duct along the lateral wall of the nose. The turbinate can be infractured by applying gentle pressure in towards the medial aspect of the nose. If the nasolacrimal duct probing is not successful, a second probing is performed in conjunction with a balloon dilation or silicone stent placement.

If the nasolacrimal duct obstruction is resistant to multiple surgeries, dacryocystorhinostomy (DCR) is performed to create a direct conduit from the nasolacrimal sac to the middle meatus, bypassing the lower nasolacrimal duct. A DCR can be performed in an “open” or external fashion, by nasal endoscopy, or by endocanalicular laser.

What are the adverse effects associated with each treatment option?

Nasolacrimal duct surgery is commonly associated with bloody discharge from the nose or bloody tears. Pain and irritability can be managed with acetaminophen. About 20% of children may need reoperation for failure. A stent carries the risk of punctal erosion and ocular irritation, and may require general anesthesia for removal. Ocular injury, excessive nose bleed, and anesthetic reactions are rare.

The dacryocystorhinostomy (DCR) generally causes more pain and swelling, although still usually manageable with acetaminophen or ibuprofen. If performed externally, a scar may be apparent. The endoscopic and laser approaches eliminate the risk of scarring, but tend to have a higher recurrence rate.

What are the possible outcomes of nasolacrimal duct obstruction?

The prognosis after nasolacrimal duct probing is generally good, with complete resolution of symptoms in about 80% of children. Most of the children who initially fail a probing will have success with balloon dilation or stenting. A minority of children will require the more invasive dacryocystorhinostomy (DCR).

What causes this disease and how frequent is it?

Nasolacrimal duct obstruction is congenital, affecting about 20% of healthy newborns. 80-90% of those affected will improve spontaneously.

Other clinical manifestations that might help with diagnosis and management

The lacrimal sac can become distended early in life, a condition called a dacryocystocele (or amniotocele). This is a congenital lacrimal sac enlargement resulting from an obstruction at not only the exiting valve of Hasner, but also at the entrance valve of Rosenmuller. This junction of the common canaliculus to the lacrimal sac acts as a one-way valve, permitting entry of tears but no exit. The lacrimal sac distends rapidly over the first few weeks of life. It initially presents as a bluish (red, if infected) cystic mass in the inner corner of the lower lid. As it enlarges, the medial canthus is displaced superiorly.

An ophthalmologist should be consulted on a newborn with signs of a dacryocystocele. An uninfected dacryocystocele can be closely observed with instructions given to caregivers to provide firm massage of the lacrimal sac. Alternatively, many ophthalmologists probe the dacryocystocele in the first few days of life for fear of complications. An infected lacrimal sac can lead to sepsis, spontaneous rupture with fistula formation, or prolapse into the nasal cavity (intranasal mucocele) causing respiratory distress. Treatment of the dacryocystocele consists of probing the nasolacrimal system and intranasal cyst removal as needed. Admission and intravenous antibiotics are necessary for an infected dacryocystocele.

A hemangioma or frontal encephalocele may also present with a similar mass of the inner canthal region. These entities can often be distinguished by the vascular appearance of the hemangioma and by the pulsatile nature of the encephalocele. Imaging may also be helpful.

What complications might you expect from the disease or treatment of the disease?

There is emerging evidence to suggest an association of increased amblyopia risk factors with unilateral nasolacrimal duct obstruction. Some children will require treatment with glasses and/or patching at an early age. It is unknown if this association is caused by early defocus from mucoid discharge or other factors. It is recommended that children with nasolacrimal duct obstruction have a full examination with cycloplegic refraction to identify amblyopia risk factors and follow up with treatment.

What is the evidence?

Kushner, BJ. “Congenital nasolacrimal system obstruction”. Arch Ophthalmol. vol. 100. 1982. pp. 597-600. (This prospective randomized controlled trial of 132 children with typical nasolacrimal duct symptoms found that firm nasolacrimal massage [in a manner that increased hydrostatic pressure] was significantly more effective than gentle massage or no massage [p<0.0005]. Outpatient probing without general anesthesia was safe and effective when performed before 8 months of age [site of surgery was not part of the analysis]. Of children requiring probing, canalicular obstructions and narrowed nasolacrimal ducts were more likely to fail [statistical significance not reported].)

Matta, NS, Silbert, DI. “High prevalence of amblyopia risk factors in preverbal children with nasolacrimal duct obstruction”. J AAPOS. vol. 15. 2011. pp. 350-52. (This retrospective study of 375 children with nasolacrimal duct obstruction found 82 children (22%) had amblyopia risk factors. Of the children with follow-up examination, 44 (63%) were later treated for amblyopia with a combination of spectacles and occlusion therapy, as indicated.)

Miller, AM, Chandler, DL, Repka, MX, Hoover, DL, Lee, KA, Melia, M. “Pediatric Eye Disease Investigator Group. Office probing for treatment of nasolacrimal duct obstruction in infants”. J AAPOS. vol. 18. 2014. pp. 26-30. (This multicenter prospective study of 384 eyes of 304 children determined whether demographic or clinical factors were associated with the outcome of the treatment of congenital nasolacrimal duct obstruction. Office probing was successful in 75% of eyes overall. The procedure was less successful with bilateral nasolacrimal duct obstruction compared to unilateral nasolacrimal duct obstruction [63% vs 80%]).

Repka, MX, Chandler, DL, Beck, RW, Crouch, ER, Donahue, S, Holmes, JM. “Primary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years”. Ophthalmol. vol. 115. 2008. pp. 577-84. (This prospective, nonrandomized multicenter study of 718 children with congenital nasolacrimal duct obstruction evaluated probing as a primary treatment. Treatment success was found in 78% of eyes. No significant difference was found in success rates when analyzed by age, although too few children were included in the 36-48 month age range. Success was better when performed in a surgical facility as compared to an office setting [80%; 95% CI, 77%-84% for the former and 72%; 95% CI, 66%-78% for the latter].)

Repka, MX, Chandler, DL, Holmes, JM, Hoover, DL, Morse, CL, Schloff, S. “Balloon catheter dilation and nasolacrimal duct intubation for the treatment of nasolacrimal duct obstruction after failed probing”. Arch Ophthalmol. vol. 127. 2009. pp. 633-9. (This prospective, nonrandomized multicenter study of 159 children, aged 6-48 months, found no significant difference in successfully treating nasolacrimal duct obstruction after a single failed probing with either balloon catheter dilation or stent placement. Balloon catheter dilation successfully resolved symptoms 6 months postoperatively in 65 of 84 eyes [77%; 95% CI, 65%-85%] and stent placement was successful in 72 of 88 eyes [84%; 95% CI, 74%-91%].)

Wong, RK, Vanderveen, DK. “Presentation and management of congenital dacryocystocele”. Pediatrics. vol. 122. 2008. pp. e1108-12. (This retrospective chart review of 42 infants [46 eyes] presenting with congenital dacryocystocele at Boston Children's Hospital from 1997-2006 found 78% of eyes required surgical intervention. 37% received probing in the office or nursery setting, with a 76% success rate. 19% required marsupialization of an intranasal cyst.)

Anijeet, D, Dolan, L, Macewen, CJ. “Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction”. Cochrane Database Syst Rev. 2011 Jan. pp. CD007097(This Cochrane systematic review of the literature found a single randomized controlled study comparing endoscopic versus external DCR. The endoscopic DCR had 4 times the failure rate of the external approach.)

Ongoing controversies regarding etiology, diagnosis, treatment

Ongoing research continues to investigate optimal timing of probing, type of stents, and antifibrotic use to enhance nasolacrimal duct surgery.