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Nasolacrimal duct obstruction a common condition in children
Patients are often treated conservatively at first, with probing and irrigation employed if the initial treatment fails.
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Nasolacrimal duct obstruction, or NLDO, is a commonly encountered pathology in pediatric ophthalmology clinics, with an estimated prevalence of 20%. NLDO in children results from failure of canalization of the nasolacrimal duct. The site of obstruction is commonly at the valve of Hasner where the nasolacrimal duct would enter the nose. The obstruction can be membranous or bony stenosis or be the result of narrowing of the inferior meatus.
Evaluation
A child usually presents with epiphora, mucous discharge, and matting and crusting of the eyelashes without photophobia and conjunctival injection. An inquiry should be made about difficulty in breathing while feeding or sleeping, which may suggest a diagnosis of dacryocystocele. Bilateral involvement is common. Ocular examination includes height of the tear meniscus and inspection and palpation of the lacrimal sac, with special attention to any signs of inflammation or infection.
Ellen B. Mitchell
Modified fluorescein dye disappearance test performed by instilling 2% fluorescein in the eye and observing the washout of the dye over 5 minutes can be helpful in confirming the diagnosis. It is essential to rule out congenital NLDO from congenital glaucoma, in which epiphora is accompanied by photophobia and buphthalmos.
Recently, various studies have shown that NLDO can be associated with refractive errors (usually hyperopia) and anisometropic amblyopia, more so in the unilateral cases, necessitating the documentation of visual acuity and refraction at the initial and follow-up visits in these children.
Management
Traditionally, conservative treatment of NLDO consists primarily of observation, digital massage of the lacrimal area (Crigler massage) and topical antibiotics. Approximately more than 90% of patients show spontaneous resolution within the first year of life. The maneuver of firmly massaging the medial canthal area in a downward motion, alongside the lacrimal sac and nasolacrimal duct, increases the hydrostatic pressure within the sac and nasolacrimal duct, which helps in relieving the obstruction. Also, by emptying the sac, it decreases the chances of bacterial growth and subsequent infection. Parents should be instructed in the correct massage technique and asked to perform it a few times per day. Topical antibiotics are recommended if the child has significant discharge. If the child presents early in infancy, a reassessment should be made at 10 to 12 months of age.
Surgery
Generally, probing and irrigation is the preferred modality of surgical intervention in infants with NLDO who do not show spontaneous resolution or fail to respond to the conservative approach and in children presenting after 12 months of age. However, there are two schools of thought. Some ophthalmologists advocate early probing at 3 to 6 months of age as an office procedure, whereas others recommend late probing (beyond 1 year of age). Office probing results in early resolution of symptoms and is considered more cost-effective than probing under general anesthesia, but it is highly dependent on the surgeon’s expertise. The advantages of later surgery are that it avoids unnecessary procedures in an infant, in case NLDO resolves with a nonsurgical approach, and that additional intervention such as stenting, if needed, can be performed concurrently. I prefer probing and irrigation in the operating room, after a trial of conservative treatment.
Primary probing with or without intubation
The Pediatric Eye Disease Investigator Group has shown that the success rate of primary probing is 78% in children between the ages of 6 and 36 months. The success of simple probing declines slightly as a child ages. The decision to perform intubation, either monocanalicular or bicanalicular, is based on the surgeon’s intraoperative assessment of the diameter of the nasolacrimal duct. Nasolacrimal duct patency should be confirmed with irrigation after probing. Postoperatively, topical steroids plus antibiotic drops four times daily for 1 week are prescribed. The patient is seen again within 2 to 3 months to reassess the symptoms. The stents are usually removed after 2 to 6 months if placed during probing. The patient is followed up 3 months after stent removal.
Failed probing
If symptoms recur after initial probing, the available treatment options include repeat probing with monocanalicular or bicanalicular intubation, balloon dacryoplasty and nasal endoscopy. Repeat nasolacrimal duct probing is generally not successful, with reported success rates of 40% to 60%. Because of the reduced cost of treatment, nasolacrimal duct stenting is preferred over balloon dacryoplasty by the majority of ophthalmologists. Furthermore, there is no proven benefit of balloon catheter dilatation over intubation.
Nasal endoscopy performed alone or in conjunction with an otolaryngologist is sometimes useful to identify the cause for failure of initial probing. Abnormalities such as intranasal cysts and mucosal membranes have been reported in children who failed the initial probing and in children who undergo the first probing after 18 months of age. Nasal endoscopy is also useful in the treatment of congenital dacryocystocele and in recognizing a false passage.
External or endoscopic dacryocystorhinostomy is the last option for children who have failed the treatment modalities mentioned earlier.
References:
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Kipp MA, et al. J AAPOS. 2013;doi:10.1016/j.jaapos.2012.11.022.
MacEwen CJ, et al. Eye (Lond). 1991;doi:10.1038/eye.1991.103.
Pediatric Eye Disease Investigator Group. Arch Ophthalmol. 2012;doi:10.1001/archophthalmol.2012.2853.
Pediatric Eye Disease Investigator Group. Ophthalmology. 2008;doi:10.1016/j.ophtha.2007.07.030.
Repka MX, et al. Arch Ophthalmol. 2009;doi:10.1001/archophthalmol.2009.66.
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For more information:
Ellen B. Mitchell, MD, is an assistant professor, Pediatric Ophthalmology Service, Neuro-Ophthalmology Service, at the University of Pittsburgh School of Medicine Children’s Hospital of Pittsburgh of UPMC. She can be reached at Division of Pediatric Ophthalmology, 4401 Penn Ave., Floor 3, Pittsburgh, PA 15224; 412-692-8940; email: mitchelleb@upmc.edu.Disclosure: Mitchell has no relevant financial disclosures.