Question of the Week

A 3-month-old boy presented to a pediatric ophthalmology clinic for concern of eye watering and mattering. His parents report that these symptoms have been ongoing since his first month of life and have not improved. His parents deny attempting any maneuvers for his tearing. He was born at full term and reached all developmental milestones. His parents deny any illness or sick contacts. Physical examination is notable for increased tear lake and mucoid discharge in the right eye, which was exacerbated when the patient cried.

What is the most likely management at this time for this patient’s condition?

A. Nasolacrimal stents

B. Crigler massage

C. Dacryocystorhinostomy

D. Nasolacrimal duct probing and irrigation under general anesthesia

Answer

Answer: B

This infant was diagnosed with a right nasolacrimal duct obstruction (NLDO), which is a common cause of epiphora (excess tearing) in infants. The most notable anatomical landmark to know is the valve of Hasner, which is a mucosal fold located at the inferior nasal meatus that drains the nasolacrimal duct. In most patients with congenital NLDO, the valve of Hasner remains imperforate and results in obstruction. The literature estimates that 90% of children experience spontaneous resolution of NLDO in the first six months of life.

NLDO is diagnosed on physical exemption through palpation of the lacrimal sac that results in reflux of mutinous discharge. Fluorescein-stained saline can also be placed on the inferior cul-de-sac of each eye and observed for persistence after 5 minutes. In patients without NLDO, the fluorescein should disappear as it drains through the lacrimal system.

Crigler (lacrimal sac) massage is the preferred initial treatment in infants. The massage technique involved five consecutive strokes of moderate pressure applied to the lacrimal sac in a downward fashion. If unsuccessful, subsequent treatment may involve nasolacrimal duct probing and irrigation, balloon dacryoplasty (dilating the lacrimal drainage system with an inflated balloon), and nasolacrimal stents. Refractory cases may involve more invasive surgeries, such as dacryocystorhinostomy and conjunctivodacryocystorhinostomy.