Congenital nasolacrimal duct obstruction (NLDO) is a relatively common problem, occurring in up to 20% of infants in the first year of life.¹ Although most patients are affected in one eye, NLDO is frequently bilateral. 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 (valve of Hasner). Other causes of epiphora/discharge should be ruled out (including primary congenital glaucoma, dacryocystitis, conjunctivitis, or corneal infections) prior to 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 is either asymmetric clearing from the suspected involved eye or failure to clear in cases of bilateral NLDO.

Therapeutic interventions for NLDO can be classified according to timing/location of therapy as well as intervention chosen. Infants <6 months are generally observed (unless additional clinical information is available, which favors earlier intervention, ie, dacryocele (Fig. 32.1), recurrent dacryocystitis). The Crigler massage (described below) is a noninvasive treatment option that parents can perform prior to surgical intervention. 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.³ Earlier probing may obviate the need for general anesthesia, as 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, earlier in-office probing was as successful and less costly than observation/probing under general anesthesia (with the downside that 66% of patients would be probed in-office who would otherwise resolve spontaneously).⁴

Crigler massage: 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 nasolacrimal duct. After the massage, upward pressure can be applied to empty the sac and give temporary relief of mucoid discharge.

Indications for surgical intervention are (1) clinical signs and symptoms consistent with NLDO and (2) failure to spontaneously resolve.