Patient will present as → a 6-week-old female is brought to your office by her parents with concerns of persistent tearing and discharge from her left eye since birth. The parents report that the eye often appears watery, and there is a yellowish discharge that collects near the inner corner of the eye, especially upon waking. They deny any redness of the sclera or changes in the baby’s feeding or behavior. On physical examination, there is tearing and mucopurulent discharge in the left eye. The conjunctiva appears normal without erythema, and there is no eyelid swelling. Gentle pressure over the lacrimal sac produces a small amount of purulent discharge. The patient is diagnosed with dacryostenosis, a common condition in infants caused by a blockage of the nasolacrimal duct, leading to impaired tear drainage. Initial management is conservative and includes lacrimal sac massage (Crigler massage) performed several times a day to encourage duct clearance. Parents are instructed to gently massage the area over the lacrimal sac with clean hands. If significant discharge is present, topical antibiotic ointment may be prescribed to prevent secondary infection. Most cases resolve spontaneously by 6 to 12 months of age. If symptoms persist beyond this period or if there are recurrent infections, referral to a pediatric ophthalmologist for nasolacrimal duct probing is recommended.
Dacryostenosis refers to congenital nasolacrimal duct (NLD) obstruction, the most common cause of persistent tearing and ocular discharge in infants
- Occurs in approximately 6% of newborns, often due to an imperforate membrane at the valve of Hasner
- In adults, it can result from infection, trauma, inflammation, or age-related narrowing of the duct
- Clinical features include persistent tearing (epiphora), mattering of the eyelashes, and reflux of tears or mucoid discharge upon palpation of the lacrimal sac
- Unilateral dacryostenosis is more common, but it can present in both eyes (bilateral), particularly in congenital cases
- Natural history: 80-90% of cases resolve spontaneously by the age of 6-10 months
- Complications include dacryocystitis (infection of the lacrimal sac) and, rarely, respiratory distress in cases of dacryocystocele
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| Feature | Dacryostenosis | Dacryoadenitis | Dacryocystitis |
| Definition | Obstruction of the nasolacrimal duct | Inflammation of the lacrimal gland | Infection/inflammation of the lacrimal sac |
| Cause | Congenital or acquired duct obstruction | Viral or bacterial infection; rarely autoimmune | Bacterial infection (e.g., Staphylococcus, Streptococcus) |
| Onset | Gradual | Acute | Acute (often sudden) |
| Symptoms | Excessive tearing (epiphora), discharge, mild crusting | Swelling and pain in the upper eyelid, erythema, tenderness | Pain, redness, and swelling over the lacrimal sac (medial canthus), purulent discharge |
| Location | Nasolacrimal duct (medial canthus) | Lacrimal gland (upper outer eyelid) | Lacrimal sac (medial canthus) |
| Laterality | Unilateral or bilateral | Usually unilateral | Typically unilateral |
| Age Group | More common in infants (congenital cases) | All ages; more common in young adults | All ages, often in adults |
| Complications | Chronic tearing, secondary infection | Orbital cellulitis (rare) | Orbital cellulitis, abscess formation |
| Diagnosis | Clinical; fluorescein dye disappearance test may help | Clinical, sometimes imaging (e.g., CT orbit) | Clinical, may require imaging for abscess |
| Treatment | Lacrimal sac massage, warm compresses; probing or surgery if persistent | Warm compresses, treat underlying cause (antibiotics for bacterial, supportive for viral) | Oral/IV antibiotics, incision and drainage if abscessed |
| Prognosis | Excellent with proper management | Good with appropriate treatment | Good if treated promptly |
Diagnosis of dacryostenosis is based on history and physical examination
- Clinical presentation includes a history of chronic tearing, debris on the eyelashes, and discharge exacerbated by colds or windy environments
- Palpation of the lacrimal sac may produce reflux of tears or discharge
- Dye disappearance test can confirm impaired drainage:
- Place fluorescein-stained saline in the conjunctival sac
- Persistence of dye after 5 minutes suggests obstruction
- Differential diagnosis includes conjunctivitis, infantile glaucoma, and foreign body in the eye
Management of dacryostenosis depends on age and symptom severity
- First-line treatment:
- Lacrimal sac massage (Crigler massage): Apply moderate pressure over the lacrimal sac in a downward motion 2-3 times daily to open the obstruction
- Demonstrate the technique to caregivers to ensure proper application
- Antibiotics may be used for mucopurulent discharge without other signs of infection:
- Common options include polymyxin B/trimethoprim or tobramycin eye drops, used for 3-5 days
- Persistent symptoms beyond 6-7 months of age:
- Refer to an ophthalmologist for lacrimal duct probing
- Probing has a 75-90% success rate and is performed under local or general anesthesia depending on age
- Refractory cases may require:
- Balloon dacryoplasty or nasolacrimal duct intubation
- Dacryocystorhinostomy in rare cases with bony obstruction
Question 1 |
A 4-week-old infant presents with excessive tearing from the right eye that has been present since birth. The mother reports occasional crusting on the eyelids but denies redness or significant swelling. On physical examination, the infant has normal conjunctiva and a small amount of discharge at the medial canthus. What is the most common etiology of this condition?
Viral conjunctivitis Hint: Typically presents with red, irritated eyes and watery discharge but does not cause chronic tearing from birth. | |
Nasolacrimal duct obstruction | |
Congenital glaucoma Hint: Features photophobia, cloudy cornea, and increased intraocular pressure, which are absent in this case. | |
Bacterial conjunctivitis Hint: Usually presents with conjunctival redness and significant purulent discharge, not chronic tearing. | |
Allergic conjunctivitis Hint: Rare in infants and associated with itching and bilateral involvement. |
Question 1 Explanation:
Nasolacrimal duct obstruction (dacryostenosis) is the most common cause of excessive tearing (epiphora) in infants, occurring in approximately 5-20% of newborns. This condition results from incomplete canalization of the nasolacrimal duct, leading to impaired drainage of tears into the nasal cavity. Symptoms include excessive tearing, crusting, and occasionally mild discharge without conjunctival injection or significant swelling. Risk factors include congenital anomalies, trauma, or infections affecting the duct. This condition typically resolves spontaneously within the first year of life with conservative management like lacrimal sac massage.
Question 2 |
A 3-month-old infant presents with persistent tearing and occasional yellowish discharge from the left eye since birth. Physical examination reveals mild crusting around the medial canthus and normal conjunctiva. What is the best next step in the diagnosis of this condition?
Fluorescein dye disappearance test | |
Culture and sensitivity of the discharge Hint: Used to diagnose bacterial infections but not helpful in diagnosing nasolacrimal duct obstruction. | |
Tonometry Hint: Measures intraocular pressure, relevant for glaucoma but unnecessary here. | |
Slit-lamp examination Hint: Evaluates anterior segment pathology but does not assess tear drainage. | |
MRI of the orbit Hint: Reserved for complex or atypical cases of orbital pathology, not routine for suspected dacryostenosis. |
Question 2 Explanation:
The fluorescein dye disappearance test is a non-invasive and simple diagnostic tool to confirm nasolacrimal duct obstruction. A small amount of fluorescein dye is instilled into the conjunctival sac, and the patency of the nasolacrimal system is assessed by observing the clearance of the dye from the eye into the nose. Persistent dye in the conjunctival sac after 5 minutes suggests obstruction. This test is particularly useful in infants to differentiate dacryostenosis from other causes of tearing.
Question 3 |
A 6-month-old infant presents with persistent tearing and mild discharge from both eyes since birth. The symptoms have not resolved despite conservative management with lacrimal sac massage. What is the next best step in management?
Oral antibiotics Hint: Indicated only if there is secondary infection, such as dacryocystitis. | |
Probing of the nasolacrimal duct | |
Topical antihistamines Hint: Not relevant for nasolacrimal duct obstruction. | |
Observation and continued massage Hint: Appropriate for infants under 6 months, but not after failed conservative treatment. | |
Surgical dacryocystorhinostomy Hint: Reserved for refractory cases in older children or adults, not the first-line treatment in infants. |
Question 3 Explanation:
Probing of the nasolacrimal duct is the next best step for infants with persistent dacryostenosis after 6-12 months of age or those unresponsive to conservative measures. This procedure involves mechanically opening the obstructed nasolacrimal duct to restore proper tear drainage. It has a high success rate, especially when performed before 1 year of age. If probing is unsuccessful, further interventions like stenting or surgical procedures may be considered.
There are 3 questions to complete.
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References: Merck Manual · UpToDate