Variety of treatment approaches used for blocked tear ducts
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In cases of infants with blocked tear ducts, treatment approaches vary from practitioner to practitioner. However, given the tendency of nasolacrimal duct obstruction (NLDO) to resolve itself naturally, as well as the potential risk factors involved in probing, many practitioners tend to take a conservative stance.
I always tell parents that no surgery is safer than safe surgery, said Michael J. Bartiss, OD, MD, FAAO, FAAP, FACS, a pediatric optometrist/ophthalmologist based in Pinehurst, N.C., and a Primary Care Optometry News Editorial Board member. So I will wait on this if I can. But if the sac itself is infected, I will treat that systemically with antibiotics and topicals. Once that gets better, I will do a probing.
Digital massage
One of the first approaches in contemporary care for blocked tear ducts in infants is hydrostatic massage, according to Rachel A. Coulter, OD, FAAO, of Nova Southeastern University in Ft. Lauderdale, Fla. This involves using the fingertip on the medial canthal region and using firm pressure on the sac, with a short downward-sliding motion to increase pressure in the duct, Dr. Coulter told Primary Care Optometry News. That is performed once or more per day.
Dr. Coulter said each massage takes a few minutes, enough time for 5 to 10 strokes.
According to Robert Gold, MD, pediatric/strabismus section editor for Primary Care Optometry News sister publication, Ocular Surgery News, studies have found that massage with or without antibiotic eye drops are effective in 75% to 95% of cases. It depends on which study you look at, but in about 75% of the cases, the duct will become unblocked with conservative therapy. The usual referral to me occurs between 6 and 12 months of age, he said in an interview.
According to Dr. Bartiss, the theory behind digital massage as a treatment modality is that if enough pressure can be created by compressing the lacrimal sac and forcing the pressure head inferiorly, the imperforate membrane can be blown open, he told Primary Care Optometry News. This requires significant pressure, however, and I have found that neither patients nor caregivers enjoy this maneuver very much, he said. More importantly, I am aware of no data in the literature that demonstrates that digital massage works any better than tincture of time alone.
When to probe?
Opinions differ among pediatric ophthalmologists on when to surgically intervene in these cases. Some feel that if the condition still exists at the age of 6 months, probing should be pursued, because the literature shows a 95% success rate when it is performed at this age, said Dr. Bartiss.
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However, because 90% of NLDO cases will spontaneously resolve by the age of 12 months, I try to postpone surgical intervention until then, he said. By the age of 1 year, the statistical probability of spontaneous resolution is quite small, and the risk:benefit analysis at this point makes surgery a very reasonable and sound option, because its success rate is still about 85%. Success rates with probing decrease after age 3 by about 5% per year.
Dr. Gold said he recommends nasolacrimal duct probing between 6 and 12 months of age if the condition has not improved. At that point, I will evaluate a child by performing a complete eye exam, including dilation, he said. Usually, if the tear duct obstruction has not gone away, I will recommend nasolacrimal duct probing.
According to Dr. Bartiss, excess tearing in an infant is not always secondary to NLDO.
Congenital glaucoma, corneal defects, keratitis, foreign bodies under the upper lid and trichiasis must all be ruled out in the work-up, he said. Sodium fluorescein can be very helpful here, and it can also be used as part of a dye disappearance test.
Dr. Bartiss explained that in this test, fluorescein is instilled into the eyes, either on a strip wetted with 0.5% proparacaine or with a prepared anesthetic/fluorescein mixture.
Getting infants up to the slit lamp can be challenging, so I will often use the blue filter on my ophthalmoscope to evaluate the cornea and the height of the tear lake on the lower lid while the child is sitting on Moms lap, he said. If no corneal abnormalities exist, I will wait 5 minutes and reassess the height of the tear lake.
Dr. Bartiss said most, if not all, of the fluorescein should disappear from the tear lake if the nasolacrimal system is open and draining properly. If the stained tear lake disappears after 5 minutes, you must look for another explanation for the epiphora, he said.
The probing procedure
The probing procedure is usually performed with general anesthesia, Dr. Gold said. Some pediatric ophthalmologists will probe patients in the office. They will hold patients down or papoose them, he said. I dont believe in that; I think it is extreme. It is usually done under inhalation anesthesia or laryngeal mask airway anesthesia.
Dr. Bartiss said he uses a punctal dilator in the involved eye(s). I then use an OO Bowman, which is a thin, flexible, blunted metal probe, he said. I introduce the probe into the punctum and, with the lid put on stretch, advance the probe through the canaliculus until I feel a hard stop at the nasal bone.
Dr. Bartiss then rotates the probe, keeping it in contact with the superior orbital rim. He then gently directs it inferiorly through the lacrimal sac and nasolacrimal duct.
A little resistance is sometimes felt as the probe passes through the membrane obstruction, he said. I then direct another probe through the nostril and under the inferior turbanate.
Dr. Bartiss said if he feels metal-to-metal contact or sees the initial probe moving when contacted by the second probe, he knows the system has been opened.
This technique allows me to do the procedure with masked general anesthesia, he said. There is no risk of fluid aspiration and, therefore, neither an endotracheal tube nor a laryngeal mask is required to protect the patients airway.
Dr. Golds technique adds irrigating the tear duct system after he removes the probe and collecting the fluorescein stained saline solution with a suction catheter placed into the nose.
The procedure generally takes only a few minutes to perform, Dr. Bartiss said. He added that children leave the recovery room acting normally and with no restrictions on their activities.
For Your Information:
- Michael J. Bartiss, OD, MD, FAAO, FAAP, FACS, a Primary Care Optometry News Editorial Board member, practices in Pinehurst, N.C. He can be reached at 5 Regional Circle, Pinehurst, NC 28374; (910) 235-3700; fax: (910) 235-4447; e-mail: kidseyes@earthlink.net.
- Rachel A. Coulter, OD, FAAO, teaches at NOVA Southeastern University. She can be reached at 3200 S. University Drive, Ft. Lauderdale, FL 33328; (954) 262-1438; fax: (954) 262-1818; e-mail: staceyco@nsu.nova.edu.
- Robert Gold, MD, is pediatrics/strabismus section editor for Ocular Surgery News. He can be reached at 225 W. State Road, Ste. 111, Longwood, FL 32750; (407) 767-6411; fax: (407) 767-8160.