Congenital Nasolacrimal Duct Obstruction
Ryan E. Davis, MD*
*The views expressed are those of the author and do not reflect the official views or policy of the Department of Defense or its Components.
DISEASE DESCRIPTION
Congenital nasolacrimal duct obstruction (NLDO) is a relatively common problem encountered in the pediatric population, occurring in up to 20% of infants in the first year of life.
Symptoms range from mild epiphora to frank mattering of the eyelids with a mucopurulent discharge.
The site of the obstruction is most commonly at the distal end of the nasolacrimal duct (NLD) at the valve of Hasner.
Although most patients are affected in one eye, NLDO may present bilaterally.
Other causes of epiphora/discharge should be ruled out (including primary congenital glaucoma, conjunctivitis, or corneal infections, as well as determining progression to frank dacryocystitis) before making the diagnosis of NLDO.
Clinical findings of NLDO include increased tear lake as well as asymmetric or positive dye disappearance test. The dye disappearance test is performed by placing fluorescein dye in both eyes and waiting for 5 minutes. A positive test finding is either asymmetrically decreased clearing from the suspected involved eye or failure to clear in cases of bilateral NLDO.
MANAGEMENT OPTIONS
Therapeutic interventions for NLDO can be classified according to timing/location of therapy as well as intervention chosen.
Infants younger than 6 months of age are generally observed (unless additional clinical information is available, which favors earlier intervention, ie, dacryocele).
Crigler massage is a noninvasive treatment option that parents can perform before surgical intervention. Parents are instructed to place the thumb or forefinger in the medial canthus at the level of the nasolacrimal sac and with firm pressure rub the finger down along the path of the NLD.
This may be performed with warm moist compresses to help clear away mucous discharge.
After 6 months of age, the timing of treatment is provider dependent.
Spontaneous resolution is less likely after 9 months of age, and probing efficacy decreases after 15 months of age.
Earlier probing may obviate the need for general anesthesia, because younger infants can be safely swaddled and probed in the office.
The Pediatric Eye Disease Investigator Group found that among infants aged 6 to 10 months who were observed for 6 months with Crigler massage, 66% resolved spontaneously. However, in this prospective randomized clinical trial, they found that earlier in-office probing is as successful and less costly than observation/probing under general anesthesia is (with the downside that 66% of patients would be probed in-office who would otherwise resolve spontaneously).
INDICATIONS FOR SURGERY
Clinical signs and symptoms consistent with NLDO that fail to resolve spontaneously
SURGICAL DESCRIPTION
Nasolacrimal Duct Probing and Irrigation
Using a nasal speculum, place intranasal oxymetazoline-soaked cottonoid pledgets into the involved nostril along the nasal floor and inferior meatus with bayonet forceps.
Using a punctal dilator, dilate the superior or inferior puncta. Although either punctum can be used, probing through the superior canaliculus and irrigating through the inferior punctum ensures both are open while avoiding potential iatrogenic trauma to the inferior canaliculus, through which the majority of tear drainage occurs.
A #0 or #00 Bowman probe is placed into the punctum and passed through the canaliculus until the hard stop of the bony lacrimal fossa is felt (Figure 25.1).
Hold the probe perpendicular to the lid while inserting it into the punctum, then rotate it parallel to the lid to follow the canaliculus.
Lateral traction of the lid facilitates passing the probe and decreases the risk of trauma to the canaliculus.
FIGURE 25.1. A hard stop is encountered when the tip of the Bowman probe abuts the bony wall of the lacrimal sac fossa from within the lacrimal sac.
It is important to ensure the probe is resting against the bone without tissue between the probe and the bony wall, because this tissue may be torn or injured during the next step. Surgeon experience is crucial because proper placement is determined with “feel,” as opposed to probe position.
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