Congenital Nasolacrimal Duct Obstruction

Sasha Mansukhani
Congenital Nasolacrimal Duct Obstruction - Presentation
Most commonly, the parents complain of watering from the baby’s eye or eyes. Around 5-6% of infants are symptomatic for lacrimal obstruction(1). The condition is bilateral in one third of the babies1. Parents may also complain of discharge and stickiness, or a swelling in the region of the sac. Babies with dacryocystocoele may present with difficulty with breathing, and poor feeding due to the intranasal nasolacrimal cyst component(7).

The most important thing is to different epiphora from pseudoepiphora. The causes of psuedoepiphora include lid causes like entropion, ectropion, epiblepharon, trichiasis, conjunctival causes like allergy, conjunctivitis and corneal causes like foreign body. An important cause of pseudoepiphora is congenital glaucoma, which may simply present as a watering eye, so whenever there is doubt, the intraocular pressure should be checked and the optic disc evaluated. A delay in the diagnosis of glaucoma could lead to loss of vision.

The child is evaluated under good illumination using a magnifying loupe. The 10 D lens of the direct ophthalmoscope or the 20 D lens of the indirect ophthalmoscope can be used. Some children may require an examination under sedation or general anaesthesia.

The affected side shows an increased tear film height. There maybe periocular dermatitis due to the constant watering. The sac maybe swollen, resulting in a mass just below the medial canthal tendon. Mucoid or mucopurulent discharge can be expressed out of the puncta when the sac is compressed. This finding is commonly reported as ‘ROPLAS positive’ (Regurgitation on Pressure over the Lacrimal Sac). When a dacryocystocoele is formed however, the sac does not release its contents on compression due to the kinking of the common canaliculus.

The location of the sac swelling always occurring below the medial canthal tendon is important to differentiate it from an encephalocoele, another mass lesion that can occur in that region; which is found above the medial canthal tendon.

The stasis of the tears presents a warm and moist environment for the bacteria to proliferate, and this can lead to chronic or acute dacryocystitis. When there is acute dacryocystitis, the surrounding skin is warm and erythematous, and the swelling is tense and tender. The child maybe febrile. Chronic dacryocystitis present as intermittent or consistent mucopurulent discharge, with crusting of the lids and matting of the eyelashes.

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