Nasolacrimal Duct Obstruction: The Right Way to Teach Parents

Karen E. Revere, MD


October 12, 2018

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I'm Karen Revere, one of the ophthalmologists at the Children's Hospital of Philadelphia (CHOP). Specifically, I am an oculoplastics and orbital surgeon. I am also an assistant professor at the University of Pennsylvania.

I am going to discuss briefly nasolacrimal duct obstruction in children, which is a problem that we see quite frequently here at CHOP. We have a large population of kids referred to us by local pediatricians with a chief complaint of tearing.

The symptoms of nasolacrimal duct obstruction include clear tearing, mucousy discharge, and crusting and mattering of the lashes. These symptoms are generally constant. While they may be worse in the morning or at a certain time of day, usually parents describe them as being constant, and they generally start at birth or soon after birth.

From an eye standpoint, there are some things that are on the differential diagnosis that we shouldn't miss when we see a child with tearing. We should not automatically assume that it's nasolacrimal duct obstruction. Other diagnoses to consider include glaucoma, which can cause tearing in combination with some other symptoms, corneal infections or conjunctivitis, and corneal foreign bodies. A child with tearing, regardless of what you suspect is the cause, should be referred to an ophthalmologist for further evaluation to make sure none of these more serious issues are going on.

We make the diagnosis of nasolacrimal duct obstruction in the office by doing a dye test, in which we put in a little fluorescein dye and see how quickly it drains from the surface of the eye. If there is no blockage of the nasolacrimal duct, this process should happen with complete drainage within 5 minutes.

A finding of blockage—dye left on the surface of the eye—in addition to the parent's report of the symptoms helps to confirm the diagnosis. The cause of nasolacrimal duct obstruction is a blockage of the nasolacrimal duct which is, at least in congenital cases, usually at the bottom, at the level of the valve of Hasner.

In terms of treatment, until the child is 1 year of age, we recommend Crigler massage, which is a massage technique whereby a parent uses their finger and pushes to bone, decompressing the top of the nasolacrimal sac, and then moves their finger downwards. This maneuver is very important. A lot of parents come to me having been instructed incorrectly on how to do this. I recommend that parents do that three times a day, 10 motions each time. I often prescribe erythromycin or polymyxin bacitracin ophthalmic ointment, which they can put on their finger to allow smoother movements of their finger and less irritation to the child's skin.

The massage technique, in combination with waiting a year, usually results in complete symptom resolution of nasolacrimal duct obstruction in 90% of children.

In the 10% of children who do not improve, we offer probing and irrigation with stent placement, which is done in the operating room under general anesthesia. I use a small metal rod and go into what I describe to parents as the natural piping of the child's tear system. I am not making any incisions and no stitches are required. I pop through that little blockage and then place a plastic stent, which stays there for 3 months. I later remove it in the office without any anesthesia or sedation.

This procedure offers about 98% success and most kids do very well after this procedure. If it is not successful, there are some other procedures that we can offer, including a balloon dacryoplasty or a dacryocystorhinostomy procedure.

What are some questions that I hear in the office? One common question is whether breast milk helps with this issue. Parents will hear family members tell them that they should put a small amount of breast milk inside the eye and that will help. There is no evidence that that helps, and usually I do not recommend that they do that.

The other important question that parents ask is whether symptoms will improve immediately after the procedure. The answer to that is, sometimes. In some cases, the symptoms do completely go away even though the stent is still in place. In other cases, the stent actually blocks the tears from going down. I tell families that they shouldn't become disconcerted if there's still tearing after the procedure because we may not know if the procedure was successful until the stent is fully removed and that drainage passageway is open.

Thank you.