A 6-month-old child is brought to the pediatrician with a history of tearing, drainage, crusting of the eyelashes and lids, perhaps of both eyes and most notably upon awakening. The tearing occurs without distress and is worse with outside air exposure, especially if it is cold and windy. There is no associated fever or discomfort. Despite the increase in tearing, there is no light sensitivity.¹ Most notable is the chronically increased tear film meniscus (Figure 14-1). The baby has a chronic problem since shortly after birth with constant tearing, mucoid debris and a couple of episodes of increased debris, suggestive of conjunctivitis.

Examination demonstrates no photophobia by penlight or indication of pain. There is mild erythema to the lower lids. Notable is the increased tear lake bilaterally, dried mucous on the skin and mucoid debris in the tear film. The eyes show no conjunctival injection or inflammation. There is a normal and symmetrical red reflex by ophthalmoscopy. Fluorescein dye disappearance test demonstrates prolonged retention of the dye in the tear film of each eye longer than 5 minutes.^2,3 Massage of the tear sac can result in expression of copious amount of mucopurulent material but did not in this case. The child was diagnosed with neonatal nasolacrimal duct obstruction (NLDO).

Neonatal nasolacrimal duct obstruction (NLDO) presents with the parents stating that the eye is always crying. The eye remains wet leading to debris and crusting. NLDO may look like infectious conjunctivitis and occasionally leads to the development of true conjunctivitis.

Dacrocystitis is when the NLDO is infected. Epiphora is the overflow of tears.

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  In a large cohort by Peterson and Robb published in 1978, 50 percent had resolution by the age of 4 months and 89 percent resolved without surgical therapy.⁴

  
  
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  There is no sex predilection and no genetic predisposition. The blockage can be unilateral or bilateral.

  
  
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  Range of spontaneous resolution (including the use of massage) is from 65 percent to 95 percent by the age of 10 months.^{5 – 7}

  
  
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  The natural history of resolution helps to determine the optimal age of surgical intervention (Table 14-1).

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  NLDO can result from Congenital Impatency of Nasolacrimal System. Canalization of the nasolacrimal duct (NLD) is usually complete by 8 months of gestation.⁸

  
  
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  Most frequent location for impatency is the distal end of NLD at the valve of Hasner beneath the inferior turbinate of the nose.

  
  
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  Both upper and lower system obstructions can occur.

  
  
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  May present as an amniocele or dacryocystocele and be associated with the infection Dacryocystitis (Figure 14-2).

  
  
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  May have fluid filled cyst within the nasal cavity.

  
  
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  NLDO can be acquired as a consequence of conjunctivitis.

  
  
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  Less common presentations include:

  
  
  
  
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    Generalized ductal stenosis.

    
    
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    Imperforate nasolacrimal puncta.

    
    
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    Canalicular abnormalities.

NLDO is associated with craniofacial abnormalities and syndromes such as:

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  Trisomy 21, Crouzon, Treacher-Collins, ectodermal dysplasia, Hay-Wells syndrome, Saethre-Chotzen syndrome, Kallmann syndrome, Nager syndrome, frontonasal dysplasia, branchio-oculofacial syndrome, CHARGE syndrome, and velocardiofacial syndrome (Figure 14-3).^{9 – 11}

History

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  Parents state that the eye is “always crying.”

  
  
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  The eye remains wet leading to debris and crusting.

Physical Examination

Presentation can range from simple tearing to an acute dacryocystitis. Key findings include:

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  Erythema of surrounding skin with the primary location of inflammation at the nasal and inferior lid.

  
  
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  An increased tear film meniscus with tears frequently resting on the skin temporally (Figure 14-4).

  
  
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  Occasionally a fluctuant or a cystic mass at the inner lower lid (Figure 14-5).

  
  
  
  
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    May also have a cystic lesion present upon nasal endoscopy (Figure 14-6).

  
  
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  Tenderness of the localized mass.

  
  
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  Expression of mucopurulent debris with compression of the sac.