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Nasolacrimal Duct Obstruction
- 2. Patient case 18 months baby girl presented with her mother at outpatient clinic. Complaining of constant mucus discharge from the left eye since birth. She had two swabs both were normal. Medical history – Hereditary spherocytosis – Lexpec iron
- 3. Nasolacrimal Duct • Lacrimal drainage structure begin to form during the 5th week of gestation. • Canalization begin at 8th weeks of gestation. Tear drainage system: Lacrimal glands tears puncta canacliculi lacrimal sac nasolacrimal duct
- 4. Nasolacrimal Duct Obstruction Nasolacrimal duct obstruction is a blockage of the lacrimal drainage system. • occurs in approximately 5% of normal newborn infants. • commonly at the valve of Hasner • The blockage can be unilateral or bilateral • The rate of spontaneous resolution is estimated to be 90% within the first year of life
- 5. Etiology: • A membranous obstruction at the level of hasner. • Stenosis of the duct
- 6. signs • Excessive tearing • Redness of the white part of the eye • Recurrent eye infection or • Painful swelling near the inside corner of the eye • Crusting of the eyelids • Mucus or pus discharge from the lids and surface of the eye • Blurred vision
- 7. Differential diagnosis • Acute conjunctivitis • Glaucoma • Congenital anomalies of the upper lacrimal drainage system • Entropion • Triachiasis.
- 8. Diagnosis • Fluorescein dye disappearance test • Irrigation and probing • Eye imaging tests
- 9. Treatment Non surgical • Spontaneously improve during first several months of life • Digital massage of the lacrimal sac • Antibiotic Surgical • Probing • Balloon catheter dilation • Stenting or intubation
- 10. Recourses • https://www.aao.org/disease-review/nasolacrimal-duct- obstruction-4 • https://www.mayoclinic.org/diseases-conditions/blocked- tear-duct/symptoms-causes/syc-20351369 • http://eyewiki.aao.org/Nasolacrimal_Duct_Obstruction,_Cong enital
Editor's Notes
- Embryology and anatomy The lacrimal drainage structures begin to form during the fifth week of gestation as a crease between the frontonasal and maxillary processes, the nasolacrimal groove. A solid cord of ectodermal tissues separates from the surface and enters this groove. This tissue canalizes and forms the lacrimal sac and nasolacrimal duct. The lacrimal canaliculi form by a similar process. Canalization begins around the eighth week of gestation and continues until birth. Canalization occurs along the entire system at the same time. The opening between the nasolacrimal duct and the nares at the distal valve of Hasner is often not patent at birth. Tears are produced in the lacrimal gland. They cross the eye, enter the upper and lower eyelid punctum, and travel through the canaliculi to the lacrimal sac and then into the nares via the nasolacrimal duct. Contraction of the orbicularis muscles creates a pumping action that facilitates the flow of tears through the lacrimal system. --- The lacrimal glands produce most of your tears. These glands are located inside the upper lids above each eye. Normally, tears flow from the lacrimal glands over the surface of your eye. Tears drain into the puncta, located in the inside corners of your upper and lower eyelids. Your eyelids have small canals (canaliculi) that move tears to a sac where the lids are attached to the side of the nose (lacrimal sac). From there tears travel down a duct (the nasolacrimal duct) draining into your nose. Once in the nose, tears are reabsorbed. A blockage can occur at any point in the tear drainage system, from the puncta to your nose. When that happens, your tears don't drain properly, giving you watery eyes and increasing your risk of eye infections and inflammation.
- Disease Entity Nasolacrimal duct obstruction is a blockage of the lacrimal drainage system. In children the majority of nasolacrimal duct obstruction is congenital. Disease Congenital nasolacrimal duct obstruction occurs in approximately 5% of normal newborn infants. The blockage occurs most commonly at the valve of Hasner at the distal end of the duct. There is no sex predilection and no genetic predisposition. The blockage can be unilateral or bilateral. The rate of spontaneous resolution is estimated to be 90% within the first year of life.[1][2][3]
- Etiology The etiology of congenital nasolacrimal duct obstruction is most commonly a membranous obstruction at the valve of Hasner at the distal end of the nasolacrimal duct. General stenosis of the duct is the second most common cause of duct obstruction. Congenital proximal lacrimal outflow dysgenesis involves maldevelopment of the punctum and canaliculus. Proximal outflow dysgenesis can occur concurrently with distal obstruction. Congenital lacrimal sac mucocele or dacryocystocele occurs when there is a membranous cyst extending from the distal end of the duct into the nose. The nasolacrimal duct sac is filled at birth with clear amniotic fluid. The fluid becomes purulent within days of birth and neonatal dacryocystitis occurs . Acquired nasolacrimal duct or canalicular obstructions can occur following trauma, viral conjunctivitis, acute dacryocystitis, and use of topical antiviral medications. Risk Factors Children with Down syndrome, craniosynostosis, Goldenhar sequence, clefting syndromes, hemifacial microsomia, or any midline facial anomaly are at an increased risk for congenital nasolacrimal duct obstruction. Causes Blocked tear ducts can happen at any age. They may even be present at birth (congenital). Causes include: Congenital blockage. Many infants are born with a blocked tear duct. The tear drainage system may not be fully developed or there may be a duct abnormality. Often a thin tissue membrane remains over the opening that empties into the nose (nasolacrimal duct). Age-related changes. As you age, the tiny openings that drain tears (puncta) may get narrower, causing blockage. Infection or inflammation. Chronic infection or inflammation of your eyes, tear drainage system or nose can cause your tear ducts to become blocked. Injury or trauma. An injury to your face can cause bone damage or scarring near the drainage system, disrupting the normal flow of tears through the ducts. Even small particles of dirt or loose skin cells lodged in the duct can cause blockage. Tumor. A tumor in the nose or anywhere along the tear drainage system can cause blockage. Eyedrops. Rarely, long-term use of certain medications, such as eyedrops used to treat glaucoma, can cause a blocked tear duct. Cancer treatments. A blocked tear duct is a possible side effect of chemotherapy medication and radiation treatment for cancer.
- History A history of tearing, mucous discharge and epiphora of one or both eyes is typical. The periocular skin may be chapped from continual exposure to tears. Regurgitation of purulent material into the eye can cause conjunctivitis and a history of recurrent "pink eye" in an infant or young child should alert the investigator to the presence of nasolacrimal duct obstruction. The signs and symptoms are usually worse with a concurrent upper respiratory infection. An associated preseptal cellulitis is rare. The signs of nasolacrimal duct obstruction consist of an increased tear lake, mucous or mucopurulent discharge, and epiphora. The periocular skin is sometimes chapped. The globe is usually white. When pressure is applied over the lacrimal sac there is a reflux of mucoid or mucopurulent material from the punctum.
- acute conjunctivitis glaucoma, congenital anomalies of the upper lacrimal drainage system (punctal or canalicular atresia or agenesis) Entropion Triachiasis. Diagnosis/Differential Diagnosis NLDO is by far the most common cause of epiphora and periocular discharge in infants. The presence of enlarged tear lakes and periocular discharge helps confirm the diagnosis. The vast majority of infants with these findings will have NLDO. The most important entity in the differential diagnosis of NLDO is infantile glaucoma. NLDO may be confused with glaucoma by primary care physicians due to the presence of epiphora. Ophthalmologists easily establish the diagnosis by evaluating for associated findings seen in glaucoma: corneal enlargement, Haab striae, enlarged globe, increased cup:disc ratio, and elevated intraocular pressure. When educating primary care physicians about NLDO, it is important to stress the need for ophthalmic evaluation of infants who have photophobia and other signs of ocular irritation (eg, excessive eye rubbing) to rule out this possibility. Any disorder that causes corneal irritation in infants may also be confused with NLDO. Among these disorders are epiblepharon (which may cause irritation due to in-turned eyelashes), primary corneal disorders, and corneal infection. These entities can be identified by the presence of associated eyelid or corneal abnormalities. Conjunctivitis may also cause epiphora and ocular discharge but is easily differentiated from NLDO by conjunctival changes such as injection, chemosis, and follicles.
- A fluorescein dye disappearance test can be helpful in confirming the diagnosis of nasolacrimal duct obstruction.[4] A drop of fluorescein is instilled into the eyes or introduced on a moistened pledget. The disappearance of dye from the tear film after 5 minutes is observed. 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. Tests used to diagnose a blocked tear duct include: Tear drainage test. This test measures how quickly your tears are draining. One drop of a special dye is placed on the surface of each eye. You may have a blocked tear duct if after five minutes most of the dye is still on the surface of your eye. Irrigation and probing. Your doctor may flush a saline solution through your tear drainage system to check how well it's draining. Or he or she may insert a slender instrument (probe) through the tiny drainage holes at the corner of your lid (puncta) to check for blockages. In some cases this probing may even fix the problem. Eye imaging tests. For these procedures, a contrast dye is passed from the puncta in the corner of your lid through your tear drainage system. Then X-ray, computerized tomography (CT) or magnetic resonance imaging (MRI) images are taken to find the location and cause of the blockage.
- The majority of infants with NLDO spontaneously improve during the first several months of life. Therefore, most primary care physicians appropriately treat these patients initially with conservative measures. If infants have only mild symptoms, there may be no need for treatment. If significant epiphora or discharge is present, digital massage of the lacrimal sac is commonly recommended. The goal of massage is to force fluid through the distal NLD and cause the obstruction to open. If massage is used, it is important to demonstrate proper technique, which requires direct digital pressure over the lacrimal sac. The presence of mucopurulent reflux through the puncta indicates that pressure is being applied appropriately. It is not necessary to stroke the finger in a downward motion over the lacrimal sac as commonly taught; compression of the lacrimal sac is the only requirement to proper massage. Treatment with topical antibiotics is sometimes recommended if there is significant discharge. It is important that caregivers understand that the benefits of topical antibiotics are usually temporary, and symptoms often recur when they are discontinued. --- Clinic vs. operating room (OR) probing If children do not improve with time and conservative measures, surgical treatment is indicated. NLD probing has a fairly high success rate. There are two main approaches to surgery. Some ophthalmologists perform in-office probing in awake infants, typically at an early age (6 months or younger). The benefits of this approach are earlier resolution of NLDO and the avoidance of general anesthesia. The downside is increased discomfort and the treatment of infants who would spontaneously improve with additional time. Other ophthalmologists recommend waiting until infants are older and performing NLD probing in the operating room under anesthesia. The benefits of this approach are less discomfort, avoiding treatment of infants who spontaneously improve after the age at which in-office probing is performed, and the ability to perform additional procedures if other abnormalities are found while the child is anesthetized. The primary downside is the risk of general anesthesia. Cost is also a factor when comparing these two approaches. The cost of performing the procedure in the operating room is higher, but this is partially offset by avoiding treatment of many infants, postponing surgery instead until they are older.1 Routine NLD Probing The objective of NLD probing is to establish a connection between the NLD and the nares by removing the obstruction at the distal duct. Whether done in the office or the operating room, this is achieved by passing a probe through the punctum, along the canaliculus to the lacrimal sac, and down into the nares. The probe is first placed nearly perpendicular to the eyelid through the lacrimal punctum, then quickly turned to follow the course of the canaliculus parallel to the lid margin. Usually, bone is felt when the probe encounters the nasal wall on the medial side of the lacrimal sac. It may be helpful to apply tension to the lower eyelid at the lateral canthus to facilitate passage of the probe to the lacrimal sac. The probe is then turned approximately 90 degrees and passed into the distal duct, through the obstruction into the nares (Figure 2 ). In most infants a popping sensation is felt as the probe passes through the obstruction. Balloon catheter dilation. If other treatments haven't worked or the blockage returns, this procedure may be used. It's usually effective for infants and toddlers, and may also be used in adults with partial blockage. First the patient is given a general anesthetic. Then the doctor threads through the tear duct blockage in the nose a tube (catheter) with a deflated balloon on the tip. He or she inflates and deflates the balloon a few times to open the blockage. Stenting or intubation. This procedure is usually done using general anesthesia. A thin tube, made of silicone or polyurethane, is threaded through one or both puncta in the corner of your eyelid. These tubes then pass through the tear drainage system into your nose. A small loop of tubing will stay visible in the corner of your eye, and the tubes are generally left in for about three months before they're removed. Possible complications include inflammation from the presence of the tube. https://www.mayoclinic.org/diseases-conditions/blocked-tear-duct/diagnosis-treatment/drc-20351375