Lacrimal Apparatus comprises of main Lacrimal gland, Accessory Lacrimal gland, and Lacrimal passages which include puncta, canaliculi, lacrimal sac and Nasolacrimal duct. The nasolacrimal duct drain into the inferior nasal meatus of the nasal cavity.
Congenital Nasolacrimal duct obstruction (CNLDO)
It occurs in approximately 30% of normal newborn infants. The blockage occurs most commonly at the valve of Hasner, at the distal end of the Nasolacrimal duct. Both male and female are equally affected. The blockage can be unilateral or bilateral.
The rate of spontaneous resolution is estimated to be 90% within the first year of life. Obstruction of the nasolacrimal duct leads to the excess overflow of tears called Epiphora. In our country Nepal, the use of mascara (Gajal) for beauty, pouring mothers milk or Mustard oil in the eye if the child has any ocular problem, has become the leading cause of blockage in the Nasolacrimal duct of newborn infants.
Nasolacrimal duct obstruction in adults and congenital NLDO causes and treatment modalities are different, here we are talking only about blockage of the lacrimal system in children. The International Classification of Diseases ICD-10-CM Code for Neonatal obstruction of the nasolacrimal duct is H04. 53.
- Presence of Epithelial debris.
- Membranous occlusion at its upper end near lacrimal sac.
- Membranous occlusion at “valve of Hasner”.
- nasolacrimal duct stenosis
- Maldevelopment of punctum and canaliculi.
Note: In our country Nepal, it is widely believed that frequent watering is due to cold weather too. Sometimes, watering does occur in winter but not all epiphora are due to cold weather.
Parents come with the complaint of watering (Tearing) in one or both eyes even when the child is not crying. Watering may be associated with discharge or without discharge.
- No conjunctival congestions.
- Most become symptomatic during the first month of life.
- Congenital NLDO presents as chronic tearing of one or both eyes may or not may not be associated with mucopurulent discharge.
- The involved side has an increased tear lake meniscus.
- The eyelashes are usually wet and matted.
- The skin of the lower eyelid may appear erythematous in more severe cases.
Diagnostic procedure for CNLDO
A fluorescein dye disappearance test can be helpful in confirming the diagnosis of nasolacrimal duct obstruction. A drop of fluorescein is instilled into the eyes and the disappearance of dye from the tear film after 5 minutes is observed. The retained dye in a thickened tear strip is diagnostic of an obstruction. The test is most useful if the disease is unilateral and the findings of the affected eye can be compared to those of the normal eye.
In most cases, the treatment is simple nasolacrimal duct massage may be enough because of the high rate of spontaneous resolution. Parents should be advised to apply gentle pressure with their finger over the common canaliculus, stroking downwards firmly to raise the pressure in the lacrimal sac causing the opening of the valve. Parents should perform this massage at least four times per day (10 counts each time). Parents should be advised to keep their child’s eye free of discharge.
Use topical antibiotics for any episodes of associated conjunctivitis (that is red conjunctiva as opposed to simple discharge).
In infants with NLD obstruction who are aged between 6 and 10 months, non-surgical management will resolve symptoms within six months, in over half of cases.
- Lacrimal syringing with normal saline and antibiotic solution.
- Nasolacrimal duct probing with Bowman’s probe.
- Intubations with silicone tube may be performed if repeated probings are failed.