There is a high rate of spontaneous resolution of CNLDO, with approximately 90% of patients improving within the first 9–12 months of life. For this reason, conservative treatment is recommended initially for these patients.
Conservative treatment includes lacrimal sac massage and use of topical antibiotics. Massage serves 2 purposes: it empties the sac, thereby reducing the opportunity for bacterial growth, and it applies hydrostatic pressure to the obstruction, which may open the duct and resolve the condition. Massage is performed by applying pressure to the lacrimal sac, at the medial canthus, a few times per day. This is the only location where application of external pressure on the lacrimal sac can be effective. Passing the finger along the nares, which is often recommended by primary care providers, is not effective because the NLD is covered by bone at this site.
Figure 19-5 Bilateral NLDO. Note epiphora and periocular crusting without evidence of inflammation.
(Reproduced with permission from Lueder GT. Pediatric Practice Ophthalmology. New York: McGraw-Hill Professional; 2011:55.)
Topical antibiotics are often recommended if patients have significant periocular discharge. There are 3 important points with regard to topical antibiotic use in this disorder. First, the antibiotics do not cure the obstruction but may reduce the amount of mucopurulent discharge. Second, the infection in CNLDO is due to stasis of fluid within the lacrimal sac; therefore, almost any bacteria, including normal flora, may cause infection. Most broad-spectrum antibiotics are effective in reducing the associated symptoms, so culturing the mucoid or mucopurulent material is usually not necessary. Third, antibiotic use for a few days often produces improvement, and prolonged use may not be necessary. Parents may be instructed to administer the antibiotics as needed when the amount of discharge increases.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.