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Signs ⬇

Critical

Wet-looking eye or tears flowing over the eyelid, moist or dried mucopurulent material on the eyelashes (predominantly medially), and reflux of mucoid or mucopurulent material from the punctum when pressure is applied over the lacrimal sac (where the lower eyelid abuts the nose). The eye is otherwise white. Symptoms usually appear in the first 3 months of life.

Other

Erythema of the surrounding skin, redness and swelling of the medial canthus, and increased size of tear meniscus. May become infected and occasionally spread from the nasolacrimal duct, resulting in conjunctivitis (possibly recurrent). Preseptal cellulitis or dacryocystitis may rarely develop.

Differential Diagnosis ⬆ ⬇

  • Conjunctivitis: See 5.1, ACUTE CONJUNCTIVITIS.
  • Congenital anomalies of the upper lacrimal drainage system: Atresia of the lacrimal puncta or canaliculus.
  • Dacryocele: Bluish, cystic, firm mass located just below the medial canthal angle. Caused by both distal and proximal obstruction of the nasolacrimal apparatus. Most often presents within the first week of life.
  • Congenital glaucoma: Classic findings are tearing, blepharospasm, corneal clouding, and a large eye (buphthalmos). See 8.11, CONGENITAL/INFANTILE GLAUCOMA.
  • Other causes of tearing: Entropion/trichiasis, corneal defects, foreign body under the upper eyelid.

Etiology ⬆ ⬇

Usually the result of a congenitally imperforate membrane at the distal end of the nasolacrimal duct over the valve of Hasner.

Work Up ⬆ ⬇

Workup
  1. Exclude other causes of tearing, particularly congenital glaucoma. See 8.11, CONGENITAL/INFANTILE GLAUCOMA.
  2. Palpate over the lacrimal sac; reflux of mucoid or mucopurulent discharge from the punctum confirms the diagnosis. May also use the dye disappearance test. Place fluorescein in both eyes. Check in 10 minutes; fluorescein can be noted in the nose in a normal eye and will remain pooling in the eye with congenital nasolacrimal duct obstruction.

Treatment ⬆ ⬇

  1. Digital pressure to lacrimal sac q.i.d. The parent is taught to place his or her index finger over the child’s common canaliculus (inner corner of the eye) and apply pressure in an inward and downward fashion.
  2. Topical antibiotic (e.g., polymyxin/trimethoprim q.i.d.) as needed to control mucopurulent discharge if present.
  3. In the presence of acute dacryocystitis (red, swollen lacrimal sac), a systemic antibiotic is needed. See 6.9, DACRYOCYSTITIS/INFLAMMATION OF THE LACRIMAL SAC.
  4. Most cases open spontaneously with this regimen by 6 months to 1 year of age. Probing should be considered if the nasolacrimal duct obstruction persists beyond a year of age. Probe earlier if recurrent or persistent infections of the lacrimal system develop or at the request of the parents. Most obstructions are corrected after the initial probing, but repeat sessions are sometimes needed. If primary and secondary probings fail, use of balloon dacryoplasty or silicone tubing placement into the nasolacrimal duct (left in place for weeks to months) may be necessary. Consider dacryocystorhinostomy as a last resort.

Follow Up ⬆

Routine follow up unless surgery is indicated, sooner if the situation worsens or acute dacryocystitis is present. Monitor for the development of anisometropic amblyopia.