Lacrimal Obstructions
CONGENITAL OBSTRUCTIONS
CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION
Congenital nasolacrimal duct obstruction is seen in 2% to 6% of newborns but resolves in the first 3 to 4 weeks in most infants. The chronic purulent discharge is the main problem for caregivers, but, with additional time, a large percentage of these obstructions will resolve on their own.
Epidemiology and Etiology
• Age: Congenital
• Gender: Equal in males and females
• Etiology: Incomplete development of the distal lacrimal passage with a membranous block at the valve of Hasner
History
• Parents will note a chronic mucous discharge with matting of the eyelashes at 3 to 4 weeks of age in 2% to 6% of full-term infants in one or both of the eyes.
• Most obstructions will spontaneously resolve by the age of 6 to 12 months.
Examination
• Diagnosis is based mainly on the history.
• Examination may reveal increased tear film and some crusting of the eyelashes.
• Mucus reflux with pressure over the lacrimal sac confirms the diagnosis but is not always present. Examination must rule out a dacryocystocele or any sign of infection (Fig. 8-1).
Differential Diagnosis
• Chronic conjunctivitis
• Punctal dysgenesis
• Entropion
• Trichiasis
Treatment
• Timing of the treatment is controversial.
• Ninety percent of all congenital nasolacrimal duct obstructions will resolve by age 12 months.
• Many physicians will use conservative treatment until this time. This management consists of massage with topical antibiotics as needed to control the mucus discharge.
• Probing and irrigation under general anesthesia will successfully treat 90% of patients. Those patients not responsive to probing and irrigation may require intubation with silicone tubes with or without a balloon dacryoplasty.
• Rarely, patients will require a dacryocystorhinostomy.
 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. |
Prognosis
• Treatment is very successful. Waiting for spontaneous resolution while the child has chronic discharge is often difficult for the caregivers.
DACRYOCYSTOCELE
Adacryocystocele 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)
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