FIGURE 8-1. Congenital nasolacrimal duct obstruction. There is redness, crusting, and irritation of the right eyelids from the chronic discharge. The tear film is also increased. In many patients with congenital nasolacrimal duct obstruction, there will be no external signs and the diagnosis is based on the history the caregivers report.

DACRYOCYSTOCELE

A dacryocystocele is a rare lesion noted at birth in the medial canthal area. It represents fluid and mucus trapped in the lacrimal sac. Dacryocystoceles will resolve but must be observed carefully because they can become infected.

Epidemiology and Etiology

• Age: Congenital

• Gender: Equal in males and females

• Etiology: Blockage of the lacrimal system distally, at the valve of Hasner, and proximally, at the valve of Rosenmüller, resulting in trapped amniotic fluid and/or mucus produced by the lacrimal sac goblet cells.

History

• Cystic swelling of the medial canthus below the tendon noted at birth

Examination

• Prominent cystic mass below the medial canthal tendon (Fig. 8-2)

• If a mass is noted above the medial canthal tendon, another etiology must be considered.

• If bilateral consider nasal exam and chance of respiratory obstruction.

Differential Diagnosis

• Hemangioma

• Meningoencephalocele

• Dacryocystitis

Treatment

• Observation for the first 1 to 2 weeks with massage

• Many will resolve on their own.

• Probing is required if there is any sign of infection or if there is no resolution after 2 weeks.

Prognosis

• Excellent

FIGURE 8-2. Dacryocystocele. The large, distended right lacrimal sac is easily seen and is firm to palpation. This child underwent probing and irrigation, which resolved the obstruction.

LACRIMAL FISTULA

A lacrimal fistula is an extra opening of the lacrimal system onto the skin usually located inferior-nasal to the lacrimal punctum. One third of fistulas will have an associated lacrimal obstruction with chronic mucous discharge. The other patients are often asymptomatic.

Epidemiology and Etiology

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