Congenital nasolacrimal duct obstruction (CNLDO) is defined as the failure of drainage of tears down the nasolacrimal system in the neonatal age group. It results in tearing, which is termed "epiphora." The prevalence of CNLDO is between 5% and 20%. A comprehensive study of 4792 infants in Great Britain showed that the prevalence of epiphora in the first year of life was 20%, with 95% of these showing symptoms at one month of age. There is a higher prevalence of CNLDO in premature infants. CNLDO presents bilaterally in 14% to 34% of cases. It has also been shown that anisometropic amblyopia may occur in 10% to 12% of children with CLNDO, so a proper ophthalmic eye examination and cycloplegic refraction are performed in all cases with a careful subsequent follow-up for three to four years.
Of interest is the finding of Cassidy in 1952, who noted that there was obstruction of the nasolacrimal duct in 13 of 15 stillborn infants. His postulation that patency of the nasolacrimal duct occurs within the first few days to weeks after birth is a reasonable one.
Children most often present within a few months of birth with epiphora and sometimes mucoid discharge from one or both sides. However, even with symptoms present since birth, patients may present when several years old. Other causes of epiphora in children like epiblepharon, congenital glaucoma, foreign body, corneal infections, and corneal dystrophies need to be excluded. Wheres the Jones 1 test where insertion of fluorescein dye into the eye is followed by the presence of dye in the nose after 5 minutes may be used, it is rarely used now since the clinical history and observation of the tearing, and mucoid discharge generally confirms the diagnosis. Similarly, the dye disappearance test over 5 minutes may also be used, but there may be significant false positive and negative results in infants.
The excretory lacrimal system consists of the puncta, canaliculi, common canaliculi, lacrimal sac, and nasolacrimal duct, which opens at the inferior meatus over a mucosal flap, termed the Hasner valve.(Figure 1 & 2) The commonest causes of congenital nasolacrimal duct obstruction are:
Although it has been suggested that obstruction at the Hasner valve is more likely to present with mucoid discharge and obstruction closer to the lacrimal sac causes a watery discharge, this has not been our experience.
Natural History of CNLDO
Management of CNLDO
It is widely accepted that unless there is a mucocele or dacryocystitis, CNLDO is managed conservatively in children for the first 12 months of life in one of two ways:
The Crigler technique seems to have been forgotten in clinical practice, as we observe many surgeons simply observing these patients with no manipulation of the lacrimal sac with the different ways of massaging the sac. Indeed, some studies have stated that the massage technique is of questionable benefit. The advantage of using Crigler's technique has been shown by a number of studies:
Antibiotics for CNLDO
Antibiotics should only be used to treat active infection and in children with a mucopurulent discharge. The use of prophylactic antibiotics has not shown any improvement in the outcome of patients with CNLDO.
The above studies confirm that in children up to the age of 12 months, a conservative approach with proper lacrimal sac massage should be the first-line treatment of CNLDO. Crigler first described massage of the lacrimal sac for congenital nasolacrimal duct obstruction in 1923 (Crigler LW. The treatment of congenital dacryocystitis JAMA1923; 81: 23-24). Kushner later performed a randomized prospective study and showed the efficacy of the Crigler technique when compared to no massage application. He acknowledged in his presentation that the technique had been used by others in the past, but he noted that nobody had formally presented the technique at a medical meeting. He does note that "the late Dr. Kipp, however, was a strong advocate of it." He goes on to note that Dr. Kipp discussed the massage of the lacrimal sac in the discussion of a paper in 1908. There is mention of massage by others like Fuchs, Roemer, Crawford, Fage, Norris, and Oliver. So the originator of the technique may never be identified. As the best way to apply the massage is not widely known or practiced, we present the different ways that this technique may be applied.
The massage technique, as we have illustrated, is indicated in:
The massage technique is contraindicated in:
No specialized equipment is needed for this technique, which is illustrated in the video.
One of the parents needs to administer this technique to the nasolacrimal sac and duct.
It is best to perform the technique after the child is fed and asleep in the parent's arms.
It is worth reading the original description of the maneuver as described by Mr. Crigler as read before the Section on Ophthalmology at the New York Academy of Medicin on February 19, 1923, and subsequently published in the JAMA in the same year:
"The infant's head is held between the surgeon's knees in a manner similar to the method in vogue of inspecting the eyeball. Assuming that it is the right sac that is affected, he places his right thumb over the sac in a way to shut off the return flow through the puncta. This is done by holding the thumb sidewise, with the thumbnail outward and forming an acute angle with the plane of the iris. The edge of the thumb is now pressed down over the puncta, compress¬ ing it against the rim of the orbit; with this point of pressure maintained, the thumb is rotated to the right, at the same time pressing downward, abruptly, over the sac. The fluid, now being compressed by the thumb, transmits the pressure to the walls of the sac, which must give way at its weakest point, which happens to be the site of the nasal opening. Repeated cures after one manipulation of this sort, and no failures so far, extending over a period of seven years, convince me that the probe should never be resorted to except as a last resort. The salient points to be remembered are : (1) Pressure must be made over the sac only when it is distended; (2) care should be taken that the thumb is applied in such a way as to prevent régurgitation into the conjunctival sac, and (3) sudden pressure over the sac causes the retained fluid to burst through the persistent fetal membrane which separates the mucous lining of the nose from that of the nasal duct."
Kushner describes the hydrostatic massage technique as follows, "The technique consists of placing the index finger over the common canaliculus to block the exit of material through the lacrimal punctum and of stroking downward firmly to increase hydrostatic pressure within the nasolacrimal sac." Figure 1 He asked the parents to perform this with four to five strokes and four times a day. He treated his patients with this massage up to the time when the patient was six months old.
Our modification of the technique: We have found it best to massage both sides even if the tearing is only on one side as it makes it convenient to massage both lacrimal sacs with a pressure exerted downward by using the thumb on one side and the forefinger on the other side of the nose, over the respective lacrimal sacs. This is best performed with a fed child sitting on mum or dad's lap. We ask the parents to perform five to ten "strokes" four times a day. Although there is no agreement in the literature as to how long it should be done, we institute it at the first appointment and review the children every three to four months. (Video)
Excessive discharge and force applied to the medial canthal region can result in maceration of the skin. If so, the frequency of application is reduced, and topical moisturizers may be necessary.
This is a very useful technique that has been shown to allow resolution of the problem of CNLDO in children without surgical intervention. As it does not require any special instrumentation or medications, it should be used in all children seen with CNLDO.
We are presenting details of this technique so that not only physicians but other clinic staff like technicians, physician assistants, and nurses may be familiar with it and can show the parents how to perform it. We ensure that everyone in our pediatric clinic is familiar with the technique, and each person is able to teach it to the parents. [Level 3]
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