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Congenital Nasolacrimal Duct Obstruction

 


 

CONGENITAL DACRYOCYSTITIS (DACRYOCYSTITIS IN INFANTS)

 

Definition:-

 

Chronic inflammation of the lacrimal sac in infants.

 

 

Etiology:-

 

A. Predisposing factors (causes of congenital obstruction of NLD):-

 

Incomplete canalization of the NLD (it is normally completed one week before birth).

 

 

B. Precipitating factors (causes of infection):-

 

1. Pneumococcus in most of the cases.

 

 

2. Other bacteria as staph., strept.

 

 

Infection Usually descends from the conjunctiva, relay ascending from the nose or blood born.

 

 

Clinical picture:-

 

Symptoms (told by the mother):

 

- Chronic unilateral conjunctivitis.

 

 

- Watering of the eye and discharge dated shortly after birth.

 

 

- Swelling at the root of the nose.

 

 

Signs:

 

1. Epiphora (scanty, viscid and usually unilateral).

 

 

2. Swelling of the lacrimal sac (below the medial palpebral ligament) may be seen.

 

 

3. Regurgitation test: On pressure on the lacrimal sac (below MPL) the following may occur:

 

 

- Regurge of tears ---> stage of obstruction.

 

 

- Regurge of mucous, muco-pus or frank pus ---> stage of infection.

 

 

- Negative regurge ---> stage of cicatrization. It is a complication rather than a stage. Discharge becomes encysted inside the sac with negative regurge test. It occurs due obstruction of the common canaliculus, usually functional obstruction and rarely by stricture. It may be mucocele or pyocele.

 

 

Complications:-

 

I. Complications in the sac:

 

1. Acute dacryocystitis ---> lacrimal abscess ---> lacrimal fistula.

 

 

2. Mucocele of the lacrimal sac due to obstruction of the common canaliculus so that mucopurulent discharge becomes encysted within the sac. There will be sac swelling with negative regurge test.

 

 

3. Pyocele: Encysted pus within the sac with negative regurge test.

 

 

II. Epiphora ---> eczema and dermatitis ---> cicatricial ectropion ‑‑‑> more epiphora.

 

 

III. The inflamed sac acts as a source of infection:

 

1. Chronic conjunctivitis.

 

 

2. Hypopyon corneal ulcer.

 

 

3. Endophthalmitis after intraocular surgery.

 

 

Differential diagnosis:-

 

 From other causes of lacrimation or discharge in the early childhood:

 

 

1. Ophthalmia neonatorum: It is bilateral with red eyes, swollen lids and negative regurgitation test. It is acute with a short duration.

 

 

2. Buphthalmos: It is characterized by photophobia, lacrimation, high IOP and large cornea.

 

 

Treatment:-

 

A. Medical treatment:

 

It is done for 6 - 12 months aiming at spontaneous canalization which occurs in about 90 % of cases.

 

 

1. Local antibiotic eye drops 4 times daily.

 

 

2. Hydrostatic massage over the sac (below MPL) in a downward direction 10 strokes 4 times / day. Its values are:

 

 

- Regular evacuation of the sac to prevent stasis and infection.

 

 

- Pressure within the sac may help canalization.

 

 

B. Surgical treatment:

 

It is done if medical treatment fails.

 

 

1. Probing under general anaesthesia. The probe is introduced downwards till the nasal cavity. Then we irrigate with saline and penicillin. If fail it is repeated.

 

 

2. If probing fails it is repeated with a fixation of special silicon tube for few months.

 

 

3. If fails we wait few years then do DCR operation (mention).

 

4. If DCR is contraindicated we do dacryocystectomy (mention).