Nasolacrimal duct obstruction

Background

Right eye lacrimal system consisting of: of lacrimal gland (a), punctums (b,e), canalicules (c,f), lacrimal sac (g,d).

• Also known as dacryostenosis
• Most common cause of tearing in children
• Occurring in up to 20% of all normal newborns and up to 6% of all children during the first year of life

Clinical Features

• Chronic or intermittent tearing
• Debris on the eyelashes (mattering)
• Occasionally redness of the conjunctiva

Differential Diagnosis

Neonatal eye problems

• Nasolacrimal duct obstruction
• Dacrocystitis
• Conjunctivitis
  • Chemical
  • Gonococcal
  • Chlamydia
  • Herpetic
  • Streptococcus/S. Aureus
• Early onset glaucoma
• Uveitis
• Ocular foreign body
• Corneal abrasion
• Ocular trauma
• Ingrown eyelash

Periorbital swelling

Proptosis

• Normal IOP
  • Orbital cellulitis
  • Orbital pseudotumor
  • Orbital tumor
• Increased IOP
  • Retrobulbar abscess
  • Retrobulbar emphysema
  • Retrobulbar hemorrhage
  • Ocular compartment syndrome
  • Orbital tumor

No proptosis

• Periorbital cellulitis/erysipelas
• Dacryocystitis (lacrimal duct)
• Dacryocele/Dacryocystocele
• Dacryostenosis
• Dacryoadenitis (lacrimal gland)
• Allergic reaction
• Nephrotic Syndrome (pediatrics)

Lid Complications

• Blepharitis (crusts)
• Chalazion (meibomian gland)
• Stye (hordeolum) (eyelash folicle)

Other

• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Conjunctivitis
• Contact dermatitis
• Herpes zoster
• Herpes simplex
• Sarcoidosis
• Granulomatosis with polyangiitis

Evaluation

• Clinical diagnosis
  • Generally clear discharge without underlying conjunctivitis and lacrimal flow obstruction

Dye disappearance test

Not always necessary, but used to test if tears are draining at proper rate (particularly for intermittent symptoms)

1. Place a drop of fluorescein-stained saline in the inferior cul-de-sac of each of eye
2. Wipe away the excess tears
3. Observe for five minutes (do not rub eyes or wipe tears)
4. After five minutes, examine eyes
   • Normal (no obstruction): all fluorescein drained into the nose
   • Abnormal (obstructed): dye remains in eye (visible as a bright green tear meniscus) or escapes over eyelid to drain down cheek

Management

• Initial observation vs. duct massage

Disposition

• Follow up with primary care provider
  • If persistent, follow up with ophthalmology