A blocked tear duct (nasolacrimal duct obstruction, dacryostenosis) sometimes occurs in infants and young children. It results in chronic tearing (epiphora) and mucous discharge from the affect eye(s). The parents have to constantly wipe away the tears and clean the mucous from the eyelid. The discharge can be severe enough where it “glues” the eye shut, especially upon waking up in the morning time or after a nap. Occasionally periocular dermatitis can develop from this chronic problem, especially on the lower eyelid and lateral corner (canthus) of the eye.
Facts About Blocked Tear Ducts (Nasolacrimal Duct Obstruction)
- The majority of nasolacrimal duct obstructions will resolve spontaneously.
- Antibiotic eye drops/ointment will decrease the discharge but not clear the obstruction. The symptoms will usually recur once the antibiotics are stopped.
- If the obstruction does not clear by 5 or 6 months of age, an in-office probing may be performed at that time (and occasionally sooner in severe cases).
- A dacryocystocele in an infant will require an early in-office probing if it does not resolve within a short period of time with conservative management.
Tear Formation by the Lacrimal Gland
Tears are produced by the lacrimal gland, which is located superior-temporally to the eye. The tears then flow toward the medial canthus and into the lacrimal drainage system. The nasolacrimal duct obstruction is usually caused by a membrane in the interosseus portion of the tear duct system (within the maxillary bone) or more inferiorly at the valve of Hasner. This blocks the drainage of tears from the eyes resulting in the aforementioned symptoms.
Conservative treatment measures include observation and lacrimal sac massage. With massaging, the goal is to increase the hydrostatic pressure within the lacrimal duct system to open the blockage. The parent should use a clean finger to press down firmly on the lacrimal sac several times a day.
Nasolacrimal Duct Infection
Sometimes a significant amount of yellowish or greenish mucopurulent discharge may develop. In such cases, ophthalmic antibiotic eye drops or ointment can be applied to clear the discharge. However the parents should be advised that the antibiotic will not open the blockage and that the symptoms (tearing and mucous) will usually return to its normal baseline once the medication is stopped.
The nasolacrimal duct obstruction will resolve spontaneously in the majority of the children. However if it is still present when the child is 5 or 6 months old, a tear duct probing may be performed in the office to open the blockage. Occasionally, in severe cases, the tear duct probing may be performed earlier than this. The procedure takes several minutes and uses topical anesthetics. There is some pain associated with the procedure, such as with an immunization injection; however most children stop crying shortly after the probing is completed. Often times the in-office probing can be performed on the same day as the initial consultation, saving the parents time and missed days off work. A follow-up examination is scheduled several weeks after the probing to evaluate for recurrence of the blockage. The vast majority of obstruction will remain clear after the probing. For those blockages which recur, a repeat in-office probing may be performed.
Nasolacrimal Duct Probing and Tear Duct Stent Placement
For children 12 months or older, or for those few where the obstruction recurs after 2 in-office probings, a tear duct stent procedure is performed to open the blockage. This is performed under several minutes of general anesthesia in an outpatient setting at a surgery center. The stent usually falls out spontaneously in a few months.
An exception to extended conservative management is the development of a dacryocystocele (mucocele, amniotocele) in an infant. This appears as a firm, raised nodule medial to the lower eyelid that is present at birth or develops shortly after birth. It has a higher incidence of developing acute cellulitis or dacryocystitis. If a short course of topical antibiotics, warm compress and gentle massaging does not resolve the dacryocystocele, then early lacrimal duct probing may be indicated.
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