Question of the Week

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A 6-month-old boy is brought to the clinic for persistent tearing and mucopurulent discharge from his left eye since birth. His parents have been performing regular Crigler massage as instructed, but there has been no improvement. He has had two episodes of dacryocystitis requiring oral antibiotics. On exam, the cornea and red reflex are normal, but pressure over the lacrimal sac produces reflux of purulent material from the punctum.

Which of the following is the most appropriate next step in management?

A. Continue Crigler massage until 12 months of age before intervening
B. Begin long-term topical antibiotic prophylaxis
C. Probing of the nasolacrimal duct under anesthesia
D. Dacryocystorhinostomy (DCR)
E. Enucleation of the globe

Correct Answer: C. Probing of the nasolacrimal duct under anesthesia

Explanation:

Most cases of congenital nasolacrimal duct obstruction resolve spontaneously by 6–12 months with massage. At 6 months, if symptoms persist despite conservative measures, probing is appropriate, especially with recurrent dacryocystitis.

A. Observation is reasonable if mild and improving, but recurrent infection is an indication for earlier probing.

B. Antibiotics may treat acute infection but are not definitive therapy.

D. DCR is reserved for older children/adults with failed probing or chronic dacryocystitis.

E. Enucleation is not indicated — the eye itself is healthy.