Current management strategies of congenital nasolacrimal duct obstructions

ABSTRACT

Introduction: Congenital nasolacrimal duct obstruction (CNLDO) is characterized by epiphora starting in the first two weeks after birth, representing 90% of the causes of epiphora in childhood. The purpose of this article is to provide information about the main aspects of this important entity.

Method: This is an extensive database search, including articles about causes of epiphora in newborns, clinical diagnosis, types and treatments of CNLDO, exploring conservative (massage and antibiotics), or invasive treatment (probing, intubation, balloon catheter dilatation, dacryocystorhinostomy) as well the use of adjuvant treatment.

Results: Despite the many controversies related to the CNLDO treatment, the decisions must be based on the natural history of the affection, type of obstruction, and clinical manifestation. Recognizing the types of obstruction (simples or complex) can facilitate choosing the adequate treatment. Nasal endoscopy is the most important tool for CNLDO diagnosis and management, mainly in complex cases, highlighting the variants of CNLDO, optimizing management to achieve better success rates. Endoscopic dacryocystorhinostomy in children can also provide a very good outcome.

Conclusion: Simple CNLDO can have a spontaneous resolution or evolve to cure with a massage. However, complex CNLDO must have more attention. Endoscopy can document the efficacy of sondage and provide the opportunity to treat associated nasal alterations detected during the procedure, improving the outcome.

KEYWORDS:

• Nasolacrimal duct obstruction
• congenital obstruction
• diagnosis
• treatment
• review article

Article highlights

• CNLDO accounts for 90% of congenital lacrimal drainage system obstructions in newborns.

• Epiphora, ocular secretion and matted eyelashes in the first two weeks of life in a child with a ‘calm eye’ can be a sign of CNLDO.

• Clinical tests such as the positive dye disappearance test (Milder test) can indicate the diagnosis.

• CNLDO can be classified as simple or complex. About 70 to 80% of cases are simple, being unilateral and spontaneously resolving in 90% of cases.

• Bilateral CNLDO is more related to complex obstruction and the obstruction does not resolve spontaneously.

• Massage is the first-line treatment and should be used in cases occurring up to 12 months of life.

• Antibiotic eye drops to treat CNLDO are not indicated, unless there is concomitant conjunctivitis.

• Persistent epiphora after 12 months of life can be treated with ‘blind’ or endoscopic probing. Endoscopic assistance increases the chance of successful treatment.

• Probing failure can suggest complex obstructions. For these cases, endoscope- assisted intubation of the lacrimal system or even DCR can be the next steps. These next steps should be decided during the endoscopic exam, avoiding other procedures and improving outcome.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.