CONGENITAL

NASOLACRIMAL DUCT
OBSTRUCTION:
An Optometric Perspective
n Rose K. Hughes, O.D.
n David E. FitzGerald, O.D.
Abstract
Congenital Nasolacrimal Duct Obstruc-
tion is a frequent occurrence in newborns.
This article discusses the incidence, etiol-
ogy and management of congenital
nasolacrimal duct obstruction. Though
surgical intervention may be needed at
times, a conservative approach is often
better.
Key Words
Congenital Nasolacrimal Duct Obstruc-
tion, massage, probing, epiphora,
mucocele, amniotocele.
F
requent reasons for parents to seek
optometric care for their new-
borns or infants are excessive tearing
(epiphora) or ocular discharge. One entity
that can cause these clinical signs is Con-
genital Nasolacrimal Duct Obstruction
(CNLDO). This condition occurs when
the connection between the nasolacrimal
duct and the nose (Valve of Hasner) fails
to open. Tears normally flow from the
puncta through the canaliculi, into the lac-
rimal sac, down the lacrimal duct, and into
the nose. See Figure 1. During develop-
ment, the last parts of this drainage system
to canalize are the connections to the sur-
face at the lid margin and in the nose.
1
Otis
Paul, et al, report that up to 50% of ducts
are not patent at birth; however, the mem-
branous obstruction at the nasal end
(valve of Hasner) tends to clear rather
quickly.
1
Symptomatic CNLDO is gener-
ally stated to occur in 1.5-6% of in-
fants.
1-11
However, a study by MacEwen
and Young places the incidence at 20%.
12
n order to determine the incidence and
natural history of epiphora, they followed
a group of 4,792 infants throughout the
first year of life. During this time , a defect
in the lacrimal drainage system was pres-
ent 20%of the time. They believe that the
previously reported statistics are low sec-
ondary to methodological problems. The
reasoning is that if newborns are not fol-
lowed from birth many cases will be
missed, because of the high rate of sponta-
neous resolution.
MacEwen and Young found that 95%
of patients with CNLDO became symp-
tomatic within the first month of life. This
would indicate that tear production, if not
present at birth, develops shortly thereaf-
ter.
12
There are a number of clinical find-
ings that can help with the diagnosis.
First, a history of early-onset epiphora
should be obtained. A discharge may be
present in the absence of conjunctival hy-
peremia.
2-17
Diagnosis
Gentle pressure applied over the lacri-
mal sac may result in a mucopurulent re-
flux from the punctum.
2-17
The dye
disappearance test can lead to a definitive
diagnosis.
6, 8, 9, 11, 12, 14, 16
According to
Katowitz and Welsh, this is done by plac-
ing one drop of 0.5% proparacaine fol-
lowed by one drop of 2% fluorescein or a
moistened fluorescein strip into the infe-
rior cul-de-sac. Excess dye should be
wiped away. In a dimly lit room, the child
is examined with a Burton lamp or with
the cobalt blue filter of the slit lamp. If
tear drainage is normal, all dye should be
gone within 5 minutes. The presence of
dye after this time indicates a non-patent
system.
6
Treatment Options
The treatment of CNLDO depends on
both the presentation and the age of the
child. The first line of treatment for most
cases of uncomplicated CNLDO is a con-
servative one.
1-8,10-16,18-20
Massage of the
lacrimal sac in a downward motion can
exert hydrostatic pressure on the lower
end of the lacrimal duct. This helps with
drainage and, in the case of a minor block-
age, may open the obstruction. This type
of massage has been found by Kushner to
Volume 11/2000/Number 4/Page 94 n Journal of Behavioral Optometry
be more effective in treating CNLDOthan
gentle pressure over the sac to express pus
from the punctum, or no massage at all.
7
Massage should be carried out four times a
day, 5-10 strokes each time.
7
The correct
method must be shown to, and demon-
strated by, the parents. If discharge is
present, a topical antibiotic needs to be
prescribed. Two good choices are
Polytrim drops every three hours or
Erythromycin ointment twice a day. Both
of these medications are approved for use
on infants. As long as the obstruction per-
sists, no topical medication will eliminate
an infection in the lacrimal tract. How-
ever, they are useful in reducing the
amount of discharge on the lid margins.
6
They can be prescribed for one-week du-
ration after initial examination, and then
as needed as discharge recurs. Ointment
may be preferable, as it can make massage
less irritating by reducing friction.
6
Nasolacrimal probing can also treat
CNLDO. Here, a #1 Bowman probe is
used to break through the obstruction and
clear the system. If successful, normal
drainage will resume.
19
The greatest con-
troversy in the treatment of CNLDO is at
what age probing should be done and
whether delay results in more complica-
tions and less effectiveness.
In cases of more complicated obstruc-
tions, such as a mucocele, or amniotocele,
there is little question that early aggres-
sive intervention is crucial. A mucocele
forms when the lacrimal sac swells due to
the pumping of amniotic fluid into the sac.
This occurs in utero and is the result of the
action of the lacrimal pump mechanism.
Consequently, the drainage system is
closed at both openings, i.e., at the lid mar-
gin and in the nose. Mucus accumulates in
the distended sac and may lead to infec-
tion. In some cases, decompression can be
achieved by simply applying external
pressure to the sac. If this fails, probing of
the canaliculi is necessary and, rarely, a
stab incision of the sac may be needed.
Delay in opening the nasolacrimal system
i n t hese cases can l ead t o a
dacryocystitis.
14
The real controversy revolves around
cases of simple CNLDO, where epiphora
and perhaps discharge are the only symp-
toms. In their study, MacEwen and Young
report that 96%of CNLDOcases resolved
spontaneously within the first year of
life.
12
This in and of itself is a strong argu-
ment for delaying probing. On the other
hand, there are those who argue that the
symptoms of tearing and discharge are un-
comfortable to the child and upsetting to
the parents,
6,9
It has also been put forth
t hat pr ol onged i nf ect i on of t he
nasolacrimal system increases the risk of
inflammation and fibrosis with a resultant
decrease in the success of probing.
2,6,9
In
addition, some authorities maintain that
probing done before 1 year of age, espe-
cially in the earlier months of life, can be
done in-office without anesthesia.
9,18
Considering that the air/precorneal
tear film interface is the largest refractive
element in the visual system, some sug-
gest that the persistent discharge and thick
tear film, along with the use of antibiotic
ointment, might cause significant image
degradation and interfere with visual de-
velopment. This argument has been
made, but not proven: Ellis, MacEwen
and Young failed to find any statistically
significant increase in amblyopia or
ametropia in children with CNLDO.
13
A study by Zwaan examined the fail-
ure rates of probing in three categories.
11
Group 1 consisted of children below 1
year of age. Thirty-seven probings were
done, with a failure rate of 3%. Group 2
was made up of children between the ages
of 1 and 2 years old. Of 43 probings, the
failure rate was 12%. In Group 3, children
over the age of 2 years, 30 probings re-
sulted in a failure rate of 7%. The differ-
ences in failure rate among the three
groups were not statistically significant.
el-Mansoury, et al performed probings on
138 eyes in children over the age of 13
months.
4
They ranged in age from 13
months to 7 years, with an average age of
22 months. Of these, 93.5% were cured
after the first probing. Mannor, et al re-
ports that success of probing is negatively
correlated with age.
14
However, they re-
port a 92% success rate at 12 months and
an 89%success rate at 24 months, which is
still quite high.
Robb performed probings on 107 eyes
in children between the ages of less than 6
months to more than 24 months, with the
oldest child being 5 years old.
20
Under 6
months of age, all three of the eyes probed
were successfully cleared. Between 6-12
months, only two of 39 eyes required a
second probing. In the children between
12-18 months, 44 were probed. Three re-
quired a second probing and two of these
subsequently required a dacryocystor-
hinostomy (DCR). Between 18-24
months, eight were probed with only one
requiring a second probing. Thirteen were
probed at greater than 24 months. Two
had second probings followed by a DCR.
His study clearly shows that late probing
is an effective tool in treating CNLDO.
There is also a convincing theory as to
the somewhat decreased success of late
probing for CNLDO. Perhaps those pa-
tients whose CNLDO didnt spontane-
ously resolve within their first year or life,
or on whom conservative measure did not
alleviate the epiphora or discharge, have
more severe obstructions. Had probing
been done earlier in these cases, perhaps it
still would have been unsuccessful.
1,10,17
In reviewing these often conflicting
studies, there are a number of problems
encountered when attempting to draw a
n Journal of Behavioral Optometry Volume 11/2000/Number 4/Page 95
La c rima l g la nd
Punc ta
C a na lic ulus
La c rima l sa c
Va lve o f Ro se nmulle r
Va lve o f Ha sne r
By Ro sa nne P. Hug he s
Figure 1.
conclusion. In the case of probing, there is
the problem of defining success and fail-
ure. Often success is simply defined as the
resolution of symptoms
10,16,20
and this in-
formation is obtained, in some cases, sim-
ply via a phone call.
9,11,20
In other studies,
failure is reported because of continued
epiphora; however a dye disappearance
test is not performed to determine whether
the system is, indeed, still obstructed.
4,15
There is also the debate as to whether per-
sistent tearing, only in the case of upper
respiratory tract infections or cold
weather, constitutes a success or a failure.
This is open to discussion and there is no
uniform agreement.
While many reports have shown that
late probing can be effective, there is
somewhat of a decrease in success with in-
creasing age. The high rate of spontane-
ous resolution within the first year is a
strong argument for conservative man-
agement during this time. However, the
decrease in spontaneous resolution after
this time, with the documented decrease in
effectiveness of probing, would seem to
suggest that to wait past the age of one
year may put the child at risk for future
complications.
Conclusion
The diagnosis of uncomplicated
CNLDOis made based upon history, clin-
ical appearance of a teary eye and, if pos-
sible, the dye disappearance test. If the
child is under 1 year of age, and discharge
is present, a topical antibiotic should be
prescribed for one week and then as
needed. The child should be seen after 1
week and the followed every six to eight
weeks to monitor for resolution. If the
condition worsens, the patient should be
seen more frequently. Parents need to be
educated on the proper method of mas-
sage and should be made aware of the high
rate of spontaneous resolution within the
first year. This will often make themmore
patient and willing to comply with conser-
vative management. However, if the child
is 1 year of age or older and the problem
persists, referral to a pediatric ophthal-
mologist for nasolacrimal probing is ap-
propriate.
Many optometrists entered the profes-
sion to help others, to fix whatever was
wrong with the patient. However, the hu-
man body has a miraculous ability to heal
itself, and sometimes it is best to allowthis
to happen.
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Corresponding author:
Rose K. Hughes, O.D.
SUNY State College of Optometry
100 East 24th Street
New York, NY 10010
Date accepted for publication:
April 7, 2000
Volume 11/2000/Number 4/Page 96 n Journal of Behavioral Optometry