and Matthew Hoppe, O.D

Nasolacrimal duct stenosis is a common etiology for epiphora and mattering in infants. Treatment options for congenital nasolacrimal duct stenosis, also known as dacry-ostenosis, include balloon catheter dacryocystoplasty, which is less invasive than dacryocystorhinostomy and is becoming increasingly popular among surgeons. This new and effective treatment for congenital nasolacrimal duct obstruction is especially effective for children older than 12 months of age who have not responded well to probing or silicone tube intubation.
Chronic epiphora is seen in up to 20% of American infants and 12.5% of Japanese newborns.1,2 Premature infants have an 11% incidence of epiphora.3
Most congenital blockages spontaneously resolve by 6-8 months of age, while about 5% remain blocked.4 Failure of the nasolacri-mal duct to open on its own is the most common cause of blockage. A membrane that consists of lacrimal or nasal epithelial cells at Hasners valve is most often the culprit at the distal end of the nasolacrimal duct.5 Mucus and other debris can cause impeded flow, leading to complete obstruction.

The blocked nasolacrimal duct is a cul-de-sac that, like other blind pouches throughout the body, is prone to recurrent infections.6 If the discharge is composed of only mucus, then no infection exists. Mucopurulent discharge, however, indicates infection.

Figure 1: Passage of Bowman probe through nasolacrimal duct.
The lining of the canaliculi, the lacrimal sac and the nasolacrimal duct consists of a pseudostratified columnar epithelium similar to that found in the upper respiratory system.6 Mucus-producing goblet cells can be found in this lining. Blockage of the system stimulates and irritates the goblet cells proximal to the obstruction. These cells then produce more mucus, resulting in the typical clinical presentation. If tearing alone is present, with no mucopurulent discharge, suspect stenosis of the punctum or canaliculi.7

In most cases, the conjunctiva remains uninflamed and white. This sign helps rule out conjunctivitis as a cause of the infants clinical signs. Persistent dacryostenosis may lead to purulent conjunctivitis and sometimes to acute dacryocystitis.8 Dacryocystitis is a stagnation, distention, inflammation and infection from pyogenic (pus-producing) bacteria of the lacrimal sac. Most of the underlying organisms are Gram -positive bacteria such as Staphylococcus, Streptococcus and pneumococcus.6,9 These microorganisms are commonly found in the respiratory tracts of children.

The surrounding eyelid skin may also become involved. Untreated or recurrent disease may go on to form an abscess, which can rupture through the skin and establish a draining fistula.6 Orbital cellulitis secondary to lacrimal sac infection, though rare, is also a possibility.10 The child at this point is usually restless and in pain, and may develop a fever. There is a predisposition to severe, chronic or recurrent dacryocystitis to induce permanent stenosis of the lacrimal passage.11,12 Scarring of the lacrimal sac with obliteration of the lacrimal passages is a troublesome consequence that should be avoided.

Simple observation and thorough history will help guide you in most cases of congenital dacryostenosis. Common presenting symptoms include persistent epiphora, chronic mucopurulent discharge, and mattering of the eyelids nasally. Purulent discharge from the puncta upon digital massage of the lacrimal sac and an increased tear meniscus are presenting signs as well.

A dye disappearance test can confirm the diagnosis of dacryostenosis. Instill a drop of 2% sodium fluorescein dye into the conjunctival sac of each eye. Then use a Burton lamp to grade the rate of dye disappearance after five minutes. Use the following scale: 0 (no dye remaining), 1 (less than 25% remaining), 2 (up to 50% remaining), 3 (up to 75% remaining) and 4 (up to 100% remaining). Asymmetry demonstrates a problem with the outflow of one eye.2

Treatment Options
Conservative treatment involves external nasolacrimal massage using the Creiger maneuver. Place one finger over the common canal-iculus to prevent regurgitation and use another finger to rub downwards. Ten strokes, four times a day is recommended along with warm compresses twice daily. The massage creates hydrostatic pressure to help open the nasolacrimal duct. Using this technique, an estimated 54% of cases resolve by 6 months of age, and another 17% of cases resolve by 12 months of age.13

Figure 2: Inflated balloon with fluorescein stained saline.
 If the infant has epiphora and mattering but no evidence of infection, prescribe warm compresses, topical broad-spectrum antibiotic drops and lacrimal sac massage.14 Avoid ointments because they are less likely to penetrate the nasolacrimal system, and tend to make the lids and lashes appear more heavily mattered. The purpose of the antibiotic is not to cure the blockage, but to minimize the risk of infection until there is spontaneous resolution or until a more definitive therapy used.15
If acute dacryocystitis occurs, the child needs to be hospitalized and treated with intravenous antibiotics. When the results of bacterial culture and sensitivity testing are available, you should modify accordingly and continue the course of treatment for 10-14 days. Aggressive and prompt therapy should help control inflammation, prevent the spread of infection and maintain nasolacrimal duct patency.14

Bowman probing is the standard primary surgical approach, al-though it has a significant decrease in effectiveness as a child ages. The success rate at age 12 months or less is 92%, whereas the success rate at age 18 months or older is only 50%, so it is generaly avoided after 12 months of age.12
Bicanalicular silicone tube intubation is 83-100% effective.19,20 The tubing acts as a stent to prevent recurrent obstruction caused by the natural healing response of the surrounding tissues.

Monocanalicular intubation is the next most common technique, in which only the upper or lower canaliculus is utilized. However, it has a lower success rate of 79%.21
There are some drawbacks to  intubation, however: Another procedure is needed to remove the tubes 6-8 weeks after insertion.22 Theres also a chance the child may pull the tubing out prematurely.

When Bowman probing and silicone intubation fail, dacryocystorhinostomy is the most common procedure. It has a success rate of 82-100% and is considered the gold standard.12 However, this surgery is the most invasive. Bleeding is a major concern during and after surgery. Noticeable scarring 10-12mm nasally to the medial canthus is very common. Wound infection and sinusitis are also associated with the surgery if there is a long recovery time. This surgery should be reserved for children over 5-6 years of age in whom more conservative measures have failed.13

A New Alternative
Balloon catheter dacryocystoplasty is a new alternative that has a 95% success rate in children ages 13-73 months.5 It is an effective treatment for congenital nasolacrimal dacryostenosis in cases that have not been successful with probing or silicone tube intubation. It can also be used as a primary procedure for children older than 12 months. There is little or no trauma and minimal postoperative discomfort from the procedure. No external scars are noticeable after surgery, and a second procedure is usually unneccessary.13,23

The treatment consists of Bowman probing and irrigation followed by the actual balloon catheter dacryocystoplasty. The surgeon probes both the proximal and distal portions of the nasolacrimal duct. This technique is an easy transition for the surgeon that has already been doing Bowman probing. General anesthesia is indicated for the surgery in children, but usually is not indicated in adults.

Figure 3: Fluorescein stained saline is injected through the upper punctum.
Here is how the procedure works: Using a pediatric dilator, the surgeon dilates both the upper and lower puncta. He then probes the upper canalicular system and lacrimal duct using gradually larger gauge probes. He continues probing until the probe comes to a hard stop on the floor of the nose (figure 1). Next, he maneuvers a second, larger-gauge Bowman probe along the floor of the nose until he achieves metal-on-metal touch. Then both probes are removed.

Next, the surgeon inserts the balloon catheter into the upper puncta and follows the nasolacrimal duct pathway until it comes to a stop on the floor of the nose. He positions the balloon halfway between the terminal end of the lacrimal duct and the nasal cavity. Using saline, he inflates the balloon to 8 atmospheres (atm) for 90 seconds (figure 2). He deflates the balloon, then reinflates it to 8atm for 60 seconds.

He deflates the balloon again, moves it to the proximal lacrimal duct using the black marking indicators on the probe as a positioning guide and repeats the same inflation-deflation process.

After the final deflation, he removes the balloon catheter. Rotation of the catheter facilitates removal and allows the balloon to fold over on itself like an umbrella.
Next, the surgeon injects fluorescein-stained saline through the upper puncta and suctions it through a soft gastric feeding tube positioned in the nose to ensure nasolacrimal duct patency (figure 3). Finally, he injects 2cc of Tobradex (tobramycin, Alcon) ophthalmic suspension and suctions it through the gastric feeding tube.24

The patient receives nasal spray decongestant and a combination of topical and systemic steroids and antibiotics, both pre- and postoperatively. These drugs help eliminate or suppress dacryocystitis. They are  important to ensure proper healing and prevent scarring secondary to the surgery or the disease.5

Most children with dacryostenosis spontaneously improve in the first few months of life. Conservative treatment is often the first choice for managing these patients.

Bowman probing is typically the first surgical procedure and is highly effective prior to 12 months of age. Silicone tube intubation and dacryocystorhinostomy are also options, but have higher complication rates.

Balloon catheter dacryocystoplasty is effective in treating children with persistent symptoms following Bowman probing procedures or as a primary procedure after 12 months of age. 

Dr. Skorin is the staff ophthalmologist at Albert Lea Eye ClinicMayo Health System, Albert Lea, Minn., and Dr. Hoppe is in private practice in Minocqua, Wis.

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Vol. No: 140:12Issue: 12/15/03