Congenital Nasolacrimal Duct Obstruction – Early Diagnosis and Graded Therapeutic Approach as Key Points for Successful Management

Figures & data

Figure 1. Factors affecting the therapeutic decision in children with congenital nasolacrimal duct obstruction.

Figure 2. Mucopurulent discharge upon lacrimal sac compression.

Table 1. Selection of possible differential diagnoses of epiphora due to congenital dacryostenosis (modified from [9]).

Disorder	Pathology	Clinical signs
Eyelid disorders	Congenital entropion, trichiasis, epiblepharon	Abnormally placed eyelashes irritate the ocular surface (conjunctival redness, conjunctival and corneal dye staining)
	Blepharitis	Redness and desquamation of the eyelids
	Euryblepharon	Functional lacrimal stenosis caused by broadening of the palpebral fissure with a temporal depression of the eyelid axis
	Lagophthalmos/ectropion	Insufficient closure of the eyelids; eversion of the lid margin causing inflammation of the tarsal conjunctiva
Inflammation of the ocular surface	Conjunctivitis	Redness caused by conjunctival injection, secretion, photophobia
	Keratitis	Pain, photophobia, corneal staining, and vascularization
	Foreign bodies	Corneal/conjunctival (subtarsal) foreign body, pain, photophobia, blepharospasm, corneal staining
Intraocular inflammation	Uveitis	Pain, photophobia, redness due to conjunctival and ciliar injection, cells/Tyndall of the anterior chamber, synechia
Opacities	Corneal scars	Photophobia, stromal corneal opacities
	Congenital cataract	Photophobia, leukocoria
	Vitreal opacities	Photophobia, leukocoria
Elevated intraocular pressure	Juvenile glaucoma	Buphthalmus, photophobia, enlarged corneal diameter, and corneal edema/opacities

Table 2. Classification of lacrimal stenosis.

Criterion			Evaluation
Degree of stenosis			Absolute
			Relative
Type of stenosis			Mechanical
			Functional
Localization of stenosis			Presaccal
			Intrasaccal
			Postsaccal
Time of manifestation			Congenital
			Acquired
			Primary (PANDO)
			Secondary (SALDO)
PANDO - primary acquired nasolacrimal duct obstruction
SALDO - secondary acquired lacrimal drainage obstruction

Figure 3. Localization of stenosis in regard to the lacrimal sac.

Figure 4. Lacrimal fistula and its surgical treatment.

a) Fistula duct (arrow) in projection to the canaliculus lacrimalis communis

b) Fistula excision after prior preparation of the lacrimal intubation

c) Fistula closure by suture

d) Skin suture and monocanaliculonasal lacrimal intubation inserted in the superior lacrimal punctum.

Figure 5. Lacrimal probing and syringing under local anesthesia (upper row) and general anesthesia (lower row).

From left to right: dilating the superior lacrimal punctum; inserting Bangerter’s cannula vertically into the lacrimal ampulla; probing the canaliculus until hard stop; further probing until reaching Hasner’s membrane after bringing the cannula in an upright position.

Figure 6. Instruments and materials for lacrimal syringing (glucose 40% solution, sponges, local anesthetic eye drops, probe for dilatation, syringe with Bangerter’s cannula and saline solution).

Figure 7. Monocanaliculonasal intubation in an 18-month-old child (left eye).

a) Insertion of the Ritleng’s probe into the nasolacrimal duct after opening the Hasner’s membrane

b) Black thread inside the Ritleng-Probe

c) Pulling the thread out of the nose using a special hook

d) Pulling the silicone tube into the lacrimal ducts

e) Positioning of the plug of the lacrimal intubation into the lacrimal punctum.

Figure 8. Dacryoendoscopy in a 14-month-old child (left eye).

a) Positioning of the adstringent nose tamponades into the inferior and middle turbinate

b) Insertion of the dacryoendoscope into the canaliculus lacrimalis superior

c) Dacryoendoscopy of the lacrimal sac

d) Opening Hasner’s membrane under visual control by dacryoendoscopic guided probing

e) Dacryoendoscopic findings (from left to right): regular appearance of the canaliculus; polypous mucose (stars) as a sign of inflammation; view to the bottom of the lacrimal sac after Hasner’s membrane was opened; mucosa of the nose (hard palate).

Figure 9. Transcutaneous dacryocystorhinostomy.

a) Skin incision over the anterior lacrimal crest

b) Preparation of the osteotomy

c) Suturing mucosal flaps of the lacrimal sac and the nose (sacconasal mucosal anastomosis)

d) Findings after skin closure.

Table 3. Staged therapeutic concept for Congenital Dacryostenosis [12].

Stage	Age	Technique	Procedure	Comment
1	0 to 6 months (1st year of life)	Conservative therapy using lacrimal sac massage; topical antibiotics only in case of (sub)-acute signs of infection; if necessary, astringent nose drops	Compression of the canaliculi and the entrance of the lacrimal sac (horizontal sequence); squeezing the lacrimal sac from superior to inferior (vertical sequence)	Especially in the first 6 months of life effectively, in individual cases up to the age of 2 years; parents have to be introduced to that procedure
2	0 to 12 months	Lacrimal duct probing and pressurized irrigation under local anesthesia	Fixing the child by wrapping in a cloth, topical anesthesia with eye drops, oral glucose 40% drops, opening of Hasner’s membrane with irrigation or probe pressure	Age-dependent even in the first year of life; use an atraumatic lacrimal cannula; follow postoperative conservative therapy (stage 1) for 2 weeks
3	Possible from birth	Lacrimal duct probing and pressurized irrigation under general anesthesia; if necessary supplemented with lacrimal intubation	Probing and syringing as performed under local anesthesia; mono- or bicanaliculonasal lacrimal intubation (different techniques, e.g. according to Jünemann or Ritleng)	Lacrimal intubation is recommended from 24 (possibly 18) months of age; tube removal after 3 months; ensure bridging the level of Hasner’s membrane with lacrimal intubationCave: avoid intrasaccal retraction of U-intubations, care for complications in the area of lacrimal puncta (cheese wiring)
4	During the 1st year of life	Dacryoendoscopy or balloon dacryoplasty under general anesthesia; if necessary supplemented with lacrimal intubation	Dacryoendoscopically (visually) controlled rupture of Hasner’s membrane; opening Hasner’s membrane (catheter) and expansion of Hasner’s valve by insufflation of a balloon	Postinterventional lacrimal intubation to increase treatment success
5	During the 1st year of life (endoscopic/endonasal DCR) After reaching the age of 12 months (external DCR)	Sacconasal anastomosis to the middle turbinate	Endoscopic/endonasal DCR: if required, partial ethmoidectomy via endonasal approach, the opening of the lacrimal sac followed by lacrimal intubation External DCR: small arcuate skin incision, preparation towards the lacrimal fossa, lateralization of the lacrimal sac, osteotomy, preparation of mucosal flaps from the nose and the lacrimal sac, suturing sacconsal mucosal anastomosis; if necessary lacrimal intubation	Ultima ratio after alternative treatments have failed Therapy of choice in case of bony atresia of the nasolacrimal duct
DCR	Dacryocystorhinostomy