Update on Congenital

Nasolacrimal Duct Obstruction

Scott E. Olitsky, MD

’ Introduction

Congenital nasolacrimal duct obstruction is the most common

disorder of the nasolacrimal duct system in children. Although this is a
common disorder, there is debate among ophthalmologists about the
best approach to treatment, regarding both treatment and timing of that
treatment. Recent studies have helped to shed some light on these
debates and provide the ophthalmologist with reliable data, which he/
she can use when considering their own practice patterns.

’ Presentation

The diagnosis of a nasolacrimal duct obstruction is generally

straightforward in the vast majority of cases. Most infants present with
tearing and/or mattering of the involved eye. If the obstruction involves
the distal portion of the nasolacrimal system (valve of Hasner) as it often
does, there may be significant mattering and mucopurulent discharge.
When the obstruction is proximal to the nasolacrimal sac (valve of
Rosenmuller or punctal atresia) there is generally little mucopurulence
and the excessive tearing tends to be more of a watery discharge. Digital
pressure over the nasolacrimal sac can often produce an increase in the
mucopurulent discharge. Most parents will note that the tearing is worse
in the cold, wind, or when the child has an upper respiratory infection.
Unless there is a concurrent infection, the conjunctiva usually shows
no sign of injection which helps to differentiate a nasolacrimal duct
obstruction from a viral or bacterial conjunctivitis. Although the
diagnosis of a nasolacrimal duct obstruction is usually not difficult, the
child may not demonstrate significant signs of the obstruction at the time
of an examination. In these cases, the history as noted above is often
sufficient to make the diagnosis. A dye disappearance test may also be
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helpful in some cases. It must be noted that not all tearing in infants is
secondary to a nasolacrimal duct obstruction. Other important causes of
epiphora in infants include infantile glaucoma, corneal abrasion or
foreign body, and keratitis.

’ Incidence and Natural History

Approximately 6% of all children will demonstrate signs and

symptoms of nasolacrimal duct obstruction at the time of birth or shortly
thereafter. Historically the natural history of congenital nasolacrimal
duct obstruction has been somewhat unclear due to a number of studies
reporting various rates of spontaneous resolution among a small
number of patients. The rate of spontaneous resolution in this disorder
is important to address the debate that often exists regarding both the
treatment and the timing of treatment of the tearing child. Petersen and
Robb1 evaluated the natural history of nasolacrimal duct obstruction in
50 patients and found that 44 (88%) resolved spontaneously using
conservative treatment. A recent study by the Pediatric Eye Disease
Investigator Group (PEDIG) found spontaneous resolution in 66%
of patients between the ages of 6 and 10 months over a 6-month time
period.

’ Treatment

Most ophthalmologists recommend conservative measures as the

first line of treatment for infants with nasolacrimal duct obstruction. This
usually consists of nasolacrimal massage which was first described by
Crigler.2 Massage of the nasolacrimal sac is performed to produce an
increase in hydrostatic pressure within the sac in an attempt to open the
imperforate membrane. The use of Crigler massage has been shown to
be more effective than observation alone in the conservative treatment of
these obstructions. It is important to demonstrate the correct technique
to parents to provide the benefit of massage.3 If conservative treatment
and time does not improve the tearing, a surgical procedure is generally
considered. There is some debate concerning the timing of surgery and
the procedure of choice.

’ Timing of Surgery

Debates over the timing of surgical intervention involve the use of a

probing procedure in the office in younger children versus a procedure
performed in the operating room in older patients. Proponents of office
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 Congenital Nasolacrimal Duct Obstruction ’ 3

probing cite the ability to treat the condition sooner and without the use
of general anesthesia. Those ophthalmologists who prefer waiting and
performing surgery in the operating room note that they end up having
to treat fewer patients as the spontaneous resolution rate for congenital
nasolacrimal duct obstruction is high. They also prefer the controlled
environment of the operating room and general anesthesia. Recently,
PEDIG has attempted to address this debate with several studies that
provide the ophthalmologist with data that could help them determine
their preferred practice pattern. In 1 study, 57 infants with bilateral
nasolacrimal duct obstruction between the ages of 6 and 10 months were
randomized to receive either immediate office-based probing within
2 weeks or 6 months of observation and nonsurgical management
followed by probing in an operating room for unresolved cases.
In the 26 patients who were initially observed, resolution occurred in
both eyes in 56%, in 1 eye in 5%, and in neither eye in 24%. In the 31
patients who underwent an immediate office probing, 66% were tear
free in both eyes with 4 patients requiring a later operating room–based
probing.4
Another concern regarding the choice between these approaches is
the cost involved when comparing a less expensive procedure (office-
based probing) that would be performed more frequently versus a more
expensive procedure (operating room–based probing) that would be
performed less often. A study utilizing Medicare fee data looked at this
issue. As would be expected, potential cost differences are related to the
spontaneous resolution rate and a comparison of the effectiveness of the
probing procedure between the 2 groups. On the basis of a 75%
spontaneous resolution, an in-office probing would be more expensive
($771 vs. $641) and slightly less effective (93.0% vs. 97.5%) than a
delayed probing in the operating room with the in-office probing costing
$44 per month of symptoms avoided. As spontaneous resolution
decreases <70%, in-office probings would cost less ($342 less at 50%).
By varying spontaneous resolution rates between 50% and 68%, it was
shown that immediate in-office probings would cost less than delayed
operating room probings (from $2 to $342 less) and remained slightly
less effective (2.0% to 3.8% less). Finally, based on a 90% spontaneous
resolution rate, in-office probing would lead to a cost of $169 per month
of symptoms avoided.5
Although these studies provide useful objective data for the
discussion regarding time of treatment of patients with congenital
nasolacrimal duct obstruction, they do not definitively answer the
question of which method is better for all patients. Obviously both
points of view have merit and these studies support the use of either
approach. Ultimately, the decision regarding where and when to
perform the procedure is based on surgeon preference, comfort with
each of the available options, and parental desires.
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’ Treatment

The traditional first-line surgical treatment for unresolved congenital

nasolacrimal duct obstruction has been a probing procedure. Although
historically there has been little debate over the use of a simple probing
procedure for routine nasolacrimal duct obstruction, there was consid-
erable discussion regarding the best surgical treatment for older children
and for those patients who failed an initial probing procedure.
Success rates for initial probings in younger children have been
reported to be high in most studies. These studies report on success rates
of different populations of patients with respect to age and use different
definitions of success. Not surprisingly, these studies report varying cure
rates. In addition, there have been conflicting reports regarding the
success rates of probing in older children which have prompted some
investigators to recommend alternative treatments for older children.
These proposed alternative treatments have included the use of silicone
tube intubation and balloon dacryoplasty. Most studies looking at the
advantage of probing versus these other treatments have been single
treatment, retrospective reports which have made direct comparison
between the suggested approaches difficult. Recent prospective studies
by PEDIG have been helpful in addressing this debate.
A study of primary treatment of nasolacrimal duct obstruction with
probing in children younger than 4 years of age looked at 955 eyes of
718 children between the ages of 6 and 48 months. The study was
prospective but not randomized. Treatment success was defined as no
epiphora, mucous discharge, or increased tear lake present at the
outcome visit 1 month after surgery. The overall success rate was 78%
with no difference in patients between the ages of 6 and 36 months.
There were too few patients in the 36 to 48 months age group to
adequately assess the success rate in that population.6 A separate study of
182 eyes of 139 children undergoing silicone tube intubation with
planned tube retention for 2 to 5 months demonstrated a success rate of
90% in patients between 6 and 48 months of age. A total of 74% of the
enrolled cases utilized monocanalicular tubes.7 These results differ
slightly from a large 3-surgeon retrospective study of 803 eyes, which
reported a success rate of 96% in patients under the age of 24 months
who had undergone monocanalicular silicone tube intubation with the
success rate dropping to 90% in children over 24 months of age.8
Moncocanalicular silicone tube intubation involves placement of a tube
through a probing introducer through either the upper or lower puncta
with retrieval of the tube from the nose (Fig. 1). The tube is secured by a
footplate in the puncta which eliminates the need for tying the tube in
the nose and allows for easy removal in the office. Recently, a pushed
monocanalicular nasolacrimal intubation device has been introduced
that eliminates the need to retrieve the silicone tube from the nose.9
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 Congenital Nasolacrimal Duct Obstruction ’ 5

Figure 1. Silicone intubate of the nasolacrimal system using a monocanalicular tube retrieved from
the nose. A, Suture is retrieved from the nose. B, Silicone tube is pulled into the nasolacrimal system.
C, Footplate is pulled into puncta.

Balloon dacryoplasty has been used by some surgeons in older

patients who have been thought to be at higher risk for failure. A recent
PEDIG study of balloon dacryoplasty as a primary procedure demon-
strated a success rate of 82% in the same patient age group.10
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6 ’ Olitsky

Because a small but significant number of children will fail an initial

probing, the ophthalmologist is often asked to suggest a second treatment
for these patients. Options include a second probing, silicone tube
intubation, and balloon dacryoplasty. PEDIG studies have shown the success
rates of these procedures to be 56%, 84%, and 77% respectively.11,12
Although these studies were all large, prospective studies that
provide useful data regarding the effectiveness of each of these surgical
treatments, it should be noted that they were not randomized and did
not compare the various treatments to each other which may or may not
be significant. These studies may help provide some direction for the
ophthalmologist when discussing treatment options with parents. Both
immediate in-office probing and observation with delayed treatment of
unresolved cases in the operating room are reasonable approaches for
congenital nasolacrimal duct obstruction. For children undergoing
surgery in an operating room, a simple probing of the nasolacrimal
duct system is an effective treatment strategy. However, given the slightly
higher cure rate and relative ease of placement and removal of
monocanalicular silicone tubes, primary silicone tube intubation is also
a good first-line treatment plan.

’ Conclusions

Congenital nasolacrimal duct obstruction is a common disorder in

children. There are many treatment options used to treat children with
tear duct obstructions. Historically there has been considerable debate
about the timing and the methods of treatment. A number of recent
studies have produced good clinical data regarding these discussions.
Although these data do not provide definitive answers to these
questions, they do offer valuable information to help guide and support
current practice patterns.

The author declares that there is no conflicts of interest to disclose.

’ References
1. Petersen RA, Robb RM. The natural course of congenital obstruction of the
nasolacrimal duct. J Pediatr Ophthalmol Strabismus. 1978;15:246–250.
2. Crigler LW. The treatment of congenital dacryocystitis. JAMA. 1923;81:23–24.
3. Kushner BJ. Congenital nasolacrimal system obstruction. Arch Ophthalmol. 1982;
100:597–600.

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 Congenital Nasolacrimal Duct Obstruction ’ 7

4. Lee KA, Chandler DL, Repka MX, et al. A comparison of treatment approaches
for bilateral congenital nasolacrimal duct obstruction. Am J Ophthalmol. 2013;156:
1045–1050.
5. Frick KD, Hariharan L, Repka MX, et al. Pediatric Eye Disease Investigator Group
(PEDIG. Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruc-
tion in infants: the importance of the spontaneous resolution rate. Arch Ophthalmol.
2011;129:603–609.
6. Pediatric Eye Disease Investigator Group, Repka MX, Chandler DL, Beck RW, et al.
Primary treatment of nasolacrimal duct obstruction with probing in children younger
than 4 years. Ophthalmology. 2008;115:577–584.
7. Pediatric Eye Disease Investigator Group, Repka MX, Melia BM, Beck RW, et al.
Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation
in children younger than 4 years of age. J AAPOS. 2008;12:445–450.
8. Engel JM, Hichie-Schmidt C, Khammar A, et al. Monocanalicular silastic intubation
for the initial correction of congenital nasolacrimal duct obstruction. J AAPOS.
2007;11:183–186.
9. Fayet B, Katowitz WR, Racy E, et al. Pushed monocanalicular intubation: an
alternative stenting system for the management of congenital nasolacrimal duct
obstructions. J AAPOS. 2012;16:468–472.
10. Pediatric Eye Disease Investigator Group, Repka MX, Melia BM, Beck RW, et al.
Primary treatment of nasolacrimal duct obstruction with balloon catheter dilation in
children younger than 4 years of age. J AAPOS. 2008;12:451–455.
11. Pediatric Eye Disease Investigator Group, Repka MX, Chandler DL, Bremer DL,
et al. Repeat probing for treatment of persistent nasolacrimal duct obstruction.
J AAPOS. 2009;13:306–307.
12. Repka MX, Chandler DL, Holmes JM, et al. Pediatric Eye Disease Investigator
Group. Balloon catheter dilation and nasolacrimal duct intubation for treatment of
nasolacrimal duct obstruction after failed probing. Arch Ophthalmol. 2009;127:
633–639.

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