Obstructions become clinically evident in only 2% to 6% of full-term infants at 3 to 4 weeks of age.

Conservative management options of congenital NLDO consist of observation, lacrimal sac massage, and topical/oral antibiotics. It is estimated that 90% of symptomatic congenital NLDO resolves in the first year of life with conservative management.

For the remaining 10% of these cases, probing of the NLD can be curative by creating an opening through the imperforate valve of Hasner.¹

At times, enough tear and mucous volume is accumulated within the lacrimal sac that there is a palpable or visible enlargement of the sac. Light pressure over the area of the lacrimal sac can often cause mucopurulent discharge to reflux through the lacrimal drainage system and out the puncta.

A history including duration since tearing onset, percentage of the day it occurs, how it interferes with activities of
daily living, and whether any particular activities provoke it (eg, cold, heat, wind, visual tasks such as computers or reading). Any history of facial trauma, prior episodes of dacryocystitis, radiation, or chemotherapy should be elicited. The patient should also be asked about bloody tears, which would be a concerning sign for underlying malignancy.

Prior to instilling any eye drops, the tear meniscus height should be noted, and the tear breakup time should be measured, as a cue to whether dry eye-related reflex tearing is contributing to the patient’s epiphora.

Eyelid structures and position in relation to the globe should be assessed for concurrent disease states such as ectropion, entropion, and trichiasis. The upper and lower puncta should be examined for patency and position relative to the globe. Lower lid tone should be evaluated for degree of laxity.

A dye disappearance test can be performed on patients of any age. A fluorescein eye drop is instilled in each eye. Normal nasolacrimal drainage will allow the dye to flow through the punctum, such that the yellow dye disappears from the ocular surface in a matter of minutes. Patients with nasolacrimal outflow obstruction show delayed clearance of fluorescein.

In adults, the lacrimal system should be probed and irrigated. Passage of saline into the nose and throat with ease and no reflux signifies a patent system. Reflux of irrigant signifies obstruction, and the pattern of reflux can reveal where the obstruction is located within the system. Reflux from the same punctum that is being irrigated indicated obstruction within the canaliculus. Reflux from the opposite punctum without mucous indicates obstruction at the common canaliculus. Reflux from the opposite punctum with mucus indicates obstruction in the nasolacrimal sac or duct.

Periocular skin may show erythema, edema, and breakdown of superficial tissues when the discharge or tearing is profuse and constant.

Finally, nasal evaluation should be performed. This may reveal deviated septum, polyposis, or tumors as a cause of obstruction. Nasal mucosa may also show erythema and edema indicating chronic sinus inflammation.

In contrast, dacryocystography, in which dye is injected into the punctum and CT or MRI imaging, is used to define the anatomic details of the lacrimal drainage system outlined by the contrast agent, allowing precise location of the obstructed site(s).

Dacryoscintigraphy uses radionucleotide eye drops to follow tear flow as a gamma camera takes multiple pictures of the outflow system.

Approximately 10% of children with congenital NLDO require probing of the duct. A small subset of those may require repeat probing with balloon dilation of the duct, infracture of the inferior turbinate, and/or placement of silicone stents within the nasolacrimal system to relieve their obstruction.

Because of the high success rate with these methods, dacryocystorhinostomy (DCR) is rarely needed in the pediatric population. It is reserved for children who have persistent tearing following intubation, recurrent dacryocystitis, or craniofacial abnormalities with bony obstruction of the duct.

Literature reports a slightly higher success rate with the external approach in certain studies. When appropriately placed, the incision heals with a very subtle and cosmetically acceptable scar.