The evaluation of a patient with congenital tearing is usually straightforward. The patient’s parents report a history of tearing, mucopurulent discharge, or both, beginning shortly after birth. In rare cases, visible distention of the lacrimal sac is present, suggesting a congenital dacryocystocele. Otherwise, distinction should be made among the following:
constant tearing with minimal mucopurulence, suggesting blockage of the upper system (puncta, canaliculi, and common canaliculus) caused by punctal or canalicular dysgenesis
constant tearing with frequent mucopurulence and mattering of the eyelashes, suggesting complete obstruction of the NLD
intermittent tearing with mucopurulence, suggesting intermittent obstruction of the NLD
Office examination includes inspection of the eyelid margins for proper apposition and patent puncta and evaluation for extrinsic causes of reflex hypersecretion, such as
Additional aspects of the examination include inspection of the medial canthal region to assess for a distended lacrimal sac (below the tendon), inflammation, or congenital defects such as an encephalocele (above the tendon). The single most important maneuver is application of digital pressure over the tear sac. If mucoid reflux is present, complete obstruction at the level of the NLD becomes the working diagnosis.
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.