Congenital obstruction of the lacrimal system is present in 1- 6% of newborn children. Spontaneous resolution happens in 90-95% of cases during the first year of life. In the remaining 5-10% of children, 60% resolve spontaneously during the second year of life. After the fifth year, the probability of spontaneous resolution is minimal. The symptoms of obstructed flow of tears are: tearing (epiphora), stickyness of the eyelashes due to muco-purulent discharge, and irritation of the periocular skin.

 

Congenital obstruction of the left tear duct (nasolacrimal canal) in a 12 month old infant. The tears in both eyes have been dyed yellow (fluorescein).

 

Bearing in mind the statistical data, surgical intervention is thus deferred at least until the 10-th month of life. In the meantime, cleansing of the eyelids should be performed using cotton buds moistened with physiological saline. Massage of the tear sac (lacrimal sac) is done with the small finger. The cleansed eyelid skin should be protected by a thin layer of vaseline (petrolatum gel).

Infrequently, an acute inflammation of the lacrimal sac can develop, which necessitates the use of systemic antibiotics.          

 

Acute inflammation of the lacrimal sac in a newborn

 

The surgical intervention is performed with a short general anesthesia, allowing the surgeon 5-10 minutes to perform the procedure properly, under controlled conditions, with minimal trauma. The technique involves irrigating the tear duct (nasolacrimal duct) with saline solution under pressure from the syringe, in order to rupture the membrane at the nasal end of the canal. During the procedure, nasal endoscopy is used to see if there are any other obstructions to tear flow in the nose, such as an enlarged or impacted lower turbinate. If this is the case, the surgeon may need to push the turbinate slightly, away from the opening of the canal, otherwise the procedure may fail. In some cases with lacrimal pathway narrowing (stenosis), a silicone stent has to be inserted, and is subsequently removed after 3-6 months.

Performing this procedure without anesthesia (local anesthesia is not effective in infants) is not recommended due to psycho-physical trauma induced on the child, combined with an increased risk of operative complications due to damage of the delicate lacrimal structures during sudden movements of the head and / or squeezing of the eyelids. Beacuse of crying and irregular breathing, there is a risk of the irrigating fluid being aspirated (inhaled) by the child.

In a small percentage of children, the patency of the tear drainage pathways cannot be achieved with the previously described methods, which is why an alternative path for tears into the nose has to be created surgically by an operation called dacryocystorhinostomy or DCR.

Acquired obstruction of the lacrimal system is more frequent in women after middle age. The initial symptoms are only tearing, however, with time, an infection of the lacrimal sac usually develops. The only option is surgical treatment, the results of which are better in cases where an infection did not previously occur.

 

 
Chronic inflammation of the lacrimal sac, which is cystically dilated
 
Acquired obstruction of the tear duct (nasolacrimal canal). Irrigation of the tear duct (painless diagnostic procedure), causes the reflux of muco-purulent discharge accumulated in the tear sac.

 

The operation of the tear duct is performed via a skin incision approach – external DCR. The operation can be performed in either general or local anesthesia. The scar at the incision site on the side of the nose is barely visible after 2-3 months. During surgery, a silicone stent is inserted into the newly made opening into the nose, and it is usually removed, in the office, after 2 months. Proper rinsing of the nose at home, combined with endoscopic follow-ups after surgery, are very important in maintaining the patency of the new opening.

The operation of the tear duct can be performed without a skin incision, with the help of a laser, which is introduced through the small tear canals (canaliculi) into the tear sac. From here, the laser makes a new opening for the drainage of tears into the nose (trans-canalicular laser DCR). It is essential to monitor the effect of the laser, during surgery,  with an endoscope inside the nose.
The operation can also be performed  from inside the nose (endonasal DCR).

In situations where the small lacrimal canals (canalicular system) are completely obstructed, the only solution is to implant a special glass tube, which conducts the tear flow from the inner angle of the eye into the nose.

 

 




Eyelids and the periocular region | Lacrimal (tear) drainage pathways | The eye socket – orbit | Anesthesia for oculoplastic surgical procedures | Ocular prosthetics

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