Tearing is a common symptom in infants and may cause a great deal of anxiety for their parents. After initial treatment by the pediatrician or family physician, parents usually are frustrated by the time they bring their child to the ophthalmologist for an evaluation. A thorough examination with a systematic approach will ensure successful management of the tearing infant.
The most common etiology for congenital epiphora is a nasolacrimal duct obstruction. Approximately 6 percent of all newborns do not have patent lacrimal drainage systems. Of this group, the vast majority has an obstruction from a residual membrane at the valve of Hasner at the end of the nasolacrimal duct. About 80 to 90 percent of these obstructions resolve spontaneously in the first six months of life with medical treatment only. Less often, congenital epiphora may be caused by obstruction elsewhere in the nasolacrimal drainage system, as in maldevelopment of the tear sac or canalicular system, imperforate puncta or punctal atresia, obstruction from bony abnormalities and congenital lacrimal sac fistulas.
When confronted with a tearing infant, the ophthalmologist also must consider other ocular disorders, including corneal abnormalities, congenital glaucoma and intraocular inflammation. A complete examination should be performed. External eyelid abnormalities such as epiblepharon or entropion causing misdirection of the eyelashes—or other forms of ocular irritation—may lead to tearing. An enlarged or cloudy cornea, anisometropia, conjunctival injection, photophobia, breaks in Descemet’s membrane or optic nerve cupping are some signs to look for when investigating other causes of epiphora.
Clinically, a nasolacrimal duct obstruction in an infant manifests most commonly as tearing and mattering of the child’s eye. The parents usually describe a mucopurulent discharge. The eyelids are often stuck together after awakening, and these symptoms may be associated with chronic epiphora that is exacerbated by an upper respiratory infection or wind exposure. Mild cases can be associated with an increased tear lake or a wet look of the affected eye. Gentle pressure over the lacrimal sac may produce reflux of mucoid material.
Some newborns present with a dacryocele, which manifests as a bluish, cystic mass in a characteristic location below the medial canthus in the area of the nasolacrimal sac. The dacryocele is a distention of the lacrimal sac with amniotic fluid. The presence of a pulsatile mass should raise suspicion of a meningocele, and ultrasound or CT scan examination is warranted to evaluate this type of lesion. Although some dacryoceles can resolve with gentle massage, many evolve to dacryocystitis.
Dacryocystitis manifests first as erythema over the cystic mass followed by acute distention and inflammation in the lacrimal sac region. In these cases, antibiotics followed by a probing procedure are necessary to establish drainage as soon as possible. Lack of treatment can lead to cellulitis as the infection spreads beyond the lacrimal sac.
Examination. During the initial visit, the patency and position of the puncta should be examined, and the lacrimal sac should be palpated to see if there is any inflammation or purulence. Lacrimal sac compression and massage can be demonstrated to the parents. Compression of the sac is performed by applying downward pressure over the sac with a finger and rocking the finger over the tear sac area for 30 seconds to one minute.
Antibiotics. Topical antibiotics can be applied for seven to 10 days in the case of acute infection. Oral antibiotics should be administered in the presence of dacryocystitis, with amoxicillin (Amoxil) being the antibiotic of choice. Severe or unresponsive dacryocystitis often requires intravenous antibiotics and surgical intervention. This should occur after the acute dacryocystitis has been treated with antibiotics, generally after 24 to 72 hours of treatment.
Questions of timing. Although the majority of obstructed nasolacrimal ducts will open during the first six months of life, some studies suggest that resolution may occur as late as 12 to 24 months of age.
Advocates of early office-based probing cite the benefits of avoiding the risk of general anesthesia, relieving the parents of waiting to see if the obstruction resolves, and the potential of decreasing the long-term risks associated with chronic inflammation. Those who prefer waiting until the child is older and probing in the OR cite the high percentage of cases that resolve spontaneously and feel that general anesthesia offers better control during the probing procedure. We prefer to offer probing to all children over 6 months of age who have persistent tearing, discharge, or recurrent infection despite conservative management. Children under 6 months of age should generally be considered for probing only if recurrent infections or severe symptoms are present.
Probing. When conservative treatment has been unsuccessful, then probing of the nasolacrimal duct is indicated. There is no set age limit for this procedure. An initial probing may be performed in the office with the child papoosed (to prevent motion) even up to 12 months of age if the physician is comfortable doing this and has the appropriate support. An able assistant should be present to restrain the child’s head.
When probing a child who is under anesthesia, the surgeon should examine the nose for polyps and turbinate hypertrophy or impaction. Shrinking the nasal mucosa with cottonoids moistened with oxymetazoline hydrochloride 0.05 percent (Afrin) or cocaine 4 percent can facilitate visualization of the probe as well as minimize nasal bleeding.
Dilation of the puncta should be achieved with a tapered punctal dilator. A Bowman probe, generally size 00 or 0, is passed to the nose. In most children up to 2 years of age, the floor of the nose is reached when less than half of the length of the probe from the tip to the center part of the handle has been passed, about 20 to 25 millimeters. The gold standard of a successful probing is to confirm metal-on-metal contact in the nose by passing a larger probe under the inferior turbinate. The probe can often be directly visualized under the inferior turbinate with the aid of a headlight. Probing is facilitated if the surgeon bends a slight anterior curve in the metal probe prior to the procedure, allowing the probe to be more easily visualized and located when confirming metal-on-metal sensation. Irrigating fluorescein-stained saline through the lacrimal system and aspirating the fluid out of the nose with a clear suction catheter can confirm patency under general anesthesia. Infracture or medialization of the inferior nasal turbinate should be performed if the turbinate appears to be obstructing the exit site of the nasolacrimal duct or is impacted against the lateral nasal wall.
While some studies have demonstrated that initial probing and irrigation resolves 90 to 95 percent of congenital nasolacrimal obstructions in children up to 36 months of age, many surgeons feel that the success rate of probing and irrigation decreases significantly after 13 to 18 months of age.
Silicone intubation. We place silicone lacrimal tubes in children who have failed initial office probing or for initial probing performed under general anesthesia. Intubation should also be performed in the case of any canalicular or bony abnormality, if technical difficulty is encountered during probing, or in the case of dacryocystitis.
Retrieval of the tubes from the nose may be performed using the traditional Crawford hook or a groove director. A groove director minimizes trauma to the nasal mucosa and also can be used to infracture the inferior turbinate during the procedure. Silicone tubing should be left in place in the nasolacrimal duct system for at least three months. During follow-up, the surgeon should observe for punctual erosion, granuloama formation or corneal or conjunctival irritation, in which case the tubes should be removed immediately. Removal of the tubes can be performed easily and quickly in the office.
Balloon catheter dilatation. A 2- or 3-mm balloon is inflated for several minutes in both the distal and proximal nasolacrimal duct. We perform balloon catheter dilation in patients who have failed previous probings with silicone intubation or in patients with craniofacial anomalies. Although the medical literature has not shown a distinct advantage of balloon dacryocystopasty over tadional probing and intubation, it may be considered an alternative or adjunct procedure.
Dacryocystorhinostomy. In patients in whom the symptoms of nasolacrimal duct obstruction persist after silicone tubes have been removed and/or balloon catheter dilation has been performed, dacryocystorhinostomy may then be required.
Drs. Kimberly and Michael Yen are assistant professors of ophthalmolgy; both are at Baylor College of Medicine, Houston.