Congenital Nasolacrimal Duct Obstruction

Congenital obstruction of the lacrimal drainage system is usually caused by a membrane blocking the valve of Hasner at the nasal end of the NLD. Many newborns are born with imperforate NLDs, but most obstructions open spontaneously within the first few months of life. Such an obstruction becomes clinically evident in only 2%–6% of full-term infants at 3–4 weeks of age. Of these, one-third have bilateral involvement.

Management can be divided into conservative (nonsurgical) and surgical options. Conservative options include observation, digital compression over the lacrimal sac, and topical or even oral antibiotics. The long-term use of topical antibiotics may be necessary to suppress chronic mucoid discharge with mattering of the lashes.

When the obstruction fails to resolve with conservative measures, more invasive intervention may be required. Most often, this consists of probing of the NLD to rupture the membrane occluding the duct at the valve of Hasner (discussed in detail later in this chapter). Opinions differ regarding the optimal time to initiate probing, as approximately 90% of all symptomatic congenital NLD obstructions resolve in the first year of life. Prompt treatment may be required in cases with dacryocystitis or airway obstruction secondary to nasal occlusion by an enlarged lacrimal sac.

Most surgeons perform probing if symptoms persist at 1 year of age. Some advocate earlier probing for those with significant recurrent infections, and several reports have suggested that delaying probing past 13 months of age may be associated with a decreased success rate.

Children aged 1 year or older usually require general anesthesia during probing. Topical anesthesia is safe in well-trained hands, but it limits the acquisition of information about the nature of the obstruction and the physician’s intervention choices at the time of the procedure.

In some instances of congenital NLDO, dacryocystitis manifests as an acutely inflamed lacrimal sac with cellulitis of the overlying skin. Treatment with systemic antibiotics should be started promptly. Management of the pediatric patient is similar to that of the adult patient (discussed in detail later). Following resolution of the acute infectious process, elective probing is performed promptly to prevent recurrence of dacryocystitis.

• Miller AM, Chandler DL, Repka MX, et al. Office probing for treatment of nasolacrimal duct obstruction in infants. J AAPOS. 2014;18(1):26–30.

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.