Congenital nasolacrimal duct obstruction (dacryostenosis) and dacryocystocele

INTRODUCTION — Congenital nasolacrimal duct (NLD) obstruction (dacryostenosis) occurs in approximately 6 percent of newborns and is the most common cause of persistent tearing and ocular discharge in infants and young children. Most cases resolve spontaneously. Congenital dacryocystocele (or nasolacrimal duct cyst) occurs less commonly but is associated with potentially serious complications and, hence, requires timely referral to an ophthalmologist.

The clinical features, evaluation, and management of congenital NLD obstruction and dacryocystocele will be discussed below. The anatomy of the lacrimal system, other causes of persistent tearing, and the approach to the child with persistent tearing are discussed separately. (See "Approach to the child with persistent tearing".)

ANATOMY AND PATHOPHYSIOLOGY

●Normal tear production and drainage – Tears are produced by the main and accessory lacrimal glands. They drain medially into the puncta in the upper and lower eyelids, flowing through the canaliculi to the lacrimal sac and through the nasolacrimal duct (NLD) into the nose (figure 1). The NLD has a proximal valve (valve of Rosenmuller) and a distal valve (valve of Hasner) (figure 1), which are common sites of obstruction. (See "Approach to the child with persistent tearing", section on 'Anatomy and physiology of the lacrimal system'.)

During embryonic development, the nasolacrimal apparatus appears in the third to fifth week and gradually forms a cord of epithelium that extends from the eyelids to the nose. Canalization of the cord begins at the punctum in the eyelid during the third month of intrauterine life and extends distally toward the nose. Canalization is usually complete by birth.

●Common sites of obstruction – Obstruction at different locations in the nasolacrimal system causes different manifestations:

•Congenital NLD obstruction – The most common cause of congenital NLD obstruction is incomplete canalization at the distal end (ie, closest to the nose), leaving an imperforate membrane at the valve of Hasner (figure 1); however, NLD obstruction can also occur at other sites [1]. (See 'Nasolacrimal duct obstruction' below.)

•Congenital dacryocystocele – Congenital dacryocystoceles (also known as dacryoceles, amniotoceles, or NLD cysts) are produced when both the proximal and distal portions of the nasolacrimal system are obstructed. Like simple congenital NLD obstruction, the distal obstruction is usually at the level of the membrane of Hasner. The proximal obstruction typically occurs in the common canaliculus or at the valve of Rosenmuller (figure 1). The proximal obstruction is a one-way valve that permits tears to enter but not to reflux out of the canaliculi of the lacrimal drainage system. This results in distention of the lacrimal sac and duct, which appears as a bluish bulge below the medial canthus (picture 1). (See 'Dacryocystocele' below.)

NASOLACRIMAL DUCT OBSTRUCTION

Epidemiology — Congenital nasolacrimal duct (NLD) obstruction occurs in approximately 6 percent of newborns, usually as an isolated finding, and is the most common cause of persistent tearing and ocular discharge in infants and young children [1-3]. In one study, 20 percent of healthy infants demonstrated evidence of defective lacrimal drainage at some point during the first year of life [4].

Natural history — Approximately 80 to 90 percent of infants with congenital NLD obstruction have spontaneous resolution by the age of 6 to 10 months [4-6].

Among infants with persistent symptoms at age 9 to 10 months, approximately one-half have resolution within the next six months [6-8]. NLD obstructions that persist beyond the age of 12 months are unlikely to resolve spontaneously [4].

In a large retrospective study of nearly 2000 infants with congenital NLD obstruction, approximately 85 percent had spontaneous resolution and 15 percent underwent treatment [6]. The rate of spontaneous resolution decreased with age and plateaued after age nine months:

●47 percent of cases resolved by age three months

●66 percent resolved by age six months

●76 percent resolved by age nine months

●78 percent resolved by age 12 months

Spontaneous resolution occurred sooner in patients with unilateral compared with bilateral NLD obstruction and in male infants compared with females [6].

Clinical features — Infants with congenital NLD obstruction present with a history of chronic or intermittent tearing and debris on the eyelashes ("mattering") (picture 2).

Parents may note overflow of tears when the child is in an environment that stimulates a greater production of tears (eg, wind or cold) or when outflow of tears is reduced from swelling of nasal mucosa during an upper respiratory infection. Such "stress epiphora" may occur frequently enough that it becomes bothersome.

On physical examination, there is usually an increase in the size of the tear meniscus and there may be debris on the eyelashes ("mattering") (picture 2). Palpation of the lacrimal sac may cause reflux of tears and/or mucoid discharge onto the eye through the puncta. Conjunctival erythema is not typical, although irritation from overflow tearing and chronic rubbing of the eyes may cause mild redness of the lower eyelid (picture 3).

Evaluation and diagnosis — The diagnosis is typically made by history and physical examination alone. If symptoms are intermittent and there are no signs of abnormal tearing or mattering at the time of examination, the dye disappearance test (described below) can be performed to confirm the diagnosis.

●Assess for concerning symptoms – When evaluating an infant with abnormal tearing, the clinician should assess for other symptoms or findings that may raise concern for a more serious eye condition (see 'Differential diagnosis' below and "Approach to the child with persistent tearing"):

•Purulent discharge, erythema, or swelling, which may suggest infection (eg, ophthalmia neonatorum (picture 4) or acute dacryocystitis (picture 5)) (see 'Infection' below and "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum')

•Bluish swelling of the skin overlying the lacrimal sac, suggesting a dacryocystocele (picture 1) (see 'Dacryocystocele' below)

•Photophobia, corneal clouding, and/or large or asymmetric corneal diameters, suggesting glaucoma (see "Primary infantile glaucoma")

●Dye disappearance test – If the diagnosis is uncertain, the dye disappearance test can be performed to help confirm the diagnosis. The test is performed as follows:

•Place a drop of topical anesthetic into the eye (or use a fluorescein drop that contains a topical anesthetic).

•Place a drop of fluorescein-stained saline in the inferior cul-de-sac of each of the patient's eyes.

•Wipe away the excess tears from the eyelids.

•Observe the patient for five minutes. The eyes should not be rubbed; the tears that drain to the cheeks should not be wiped.

•After five minutes, inspect the eyes.

All of the fluorescein should drain into the nose within five minutes if the lacrimal drainage system has no obstruction. The test is normal if most of the dye is gone within five minutes and abnormal if a large amount of the dye persists or has drained over the lower eyelid and down the cheek.

Differential diagnosis — Causes of abnormal tearing in infants and children are summarized in the table (table 1) and discussed in greater detail separately. (See "Approach to the child with persistent tearing", section on 'Etiology of persistent tearing'.):

The absence of the following signs and symptoms distinguishes congenital NLD obstruction from other causes of persistent tearing:

●Eye redness and/or discomfort – Eye redness and discomfort are prominent features of conjunctivitis (infectious, allergic, or irritant induced), uveitis, and corneal abrasion or foreign body. Patients with NLD obstruction have little or no eye redness. (See "Conjunctivitis" and "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)

●Photophobia – Photophobia commonly occurs with corneal abrasions, uveitis, and infantile glaucoma. (See "Approach to the child with persistent tearing", section on 'Uveitis' and "Primary infantile glaucoma".)

●Signs of infection – In newborns, purulent eye discharge raises concern for ophthalmia neonatorum, which is usually caused by infection with Neisseria gonorrhoeae or Chlamydia trachomatis (or both organisms together). While infants with NLD obstruction can sometimes have purulent eye discharge due to bacterial overgrowth in the stagnant tear pool, the presence of copious purulent discharge in a newborn within the first two to three weeks after birth should prompt evaluation for ophthalmia neonatorum, particularly if other signs of infection are present (eg, redness and swelling of the eyelids) (picture 4). (See "Gonococcal infection in the newborn", section on 'Ophthalmia neonatorum' and "Chlamydia trachomatis infections in the newborn", section on 'Conjunctivitis'.)

Indications for referral — Most infants with congenital NLD obstruction can be diagnosed and managed by the primary care practitioner. Referral to an ophthalmologist is warranted if any of the following are present:

●Uncertain diagnosis, particularly if there is concern for infantile glaucoma (suggested by abnormal tearing associated with photophobia, blepharospasm, corneal clouding, and/or large or asymmetric corneal diameters). (See 'Differential diagnosis' above and "Primary infantile glaucoma".)

●Symptoms of NLD obstruction that persist beyond the age of six to seven months. (See 'Natural history' above.)

●Signs and symptoms of acute dacryocystitis (erythema, swelling, warmth, tenderness of the lacrimal sac, and/or purulent discharge) (picture 5). (See 'Infection' below.)

●Signs of anisometropia or amblyopia, detected by the Bruckner simultaneous red reflex test (figure 2). In one study, 10 percent of children with unilateral congenital NLD obstruction were found to have anisometropia (with or without amblyopia) [9]. (See "Refractive errors in children" and "Amblyopia in children: Classification, screening, and evaluation".)

●Clinical findings suggesting dacryocystocele (a bluish swelling of the skin overlying the lacrimal sac and superior displacement of the medial canthal tendon) (picture 1). (See 'Dacryocystocele' below.)

Management

General approach — Management of congenital NLD obstruction is summarized in the algorithm (algorithm 1) and described in the following sections:

●For most patients, management is nonsurgical and consists of lacrimal sac massage (often referred to as "Crigler" massage) and observation. (See 'Initial management' below.)

●For infants with NLD obstruction that persists beyond age 6 to 10 months, lacrimal duct probing can be performed. (See 'Persistent nasolacrimal duct obstruction beyond age 6 to 7 months' below.)

●For older children, who usually require general anesthesia for NLD intervention, NLD intubation is often performed rather than simple probing. (See 'Persistent nasolacrimal duct obstruction beyond age 6 to 7 months' below.)

●More invasive surgical interventions (which include balloon dacryoplasty, dacryocystorhinostomy, and conjunctivodacryocystorhinostomy) are reserved for patients with treatment failure after less invasive interventions. (See 'Treatment failure' below.)

Initial management

Lacrimal sac massage — External digital massage of the lacrimal sac is the first-line treatment for NLD obstruction [10]. Massage is believed to relieve the obstruction by increasing the hydrostatic pressure enough to force open the obstructed distal membrane. The term "massage" may not adequately convey the amount of pressure required, and some practitioners use the term "lacrimal sac compression" to more effectively communicate what the maneuver consists of [11].

Lacrimal sac massage is performed by applying moderate pressure over the lacrimal sac in a downward direction for two to three seconds (figure 3). It is important to demonstrate the technique to caregivers to ensure that it is performed correctly (ie, so they understand how much pressure to apply). Caregivers are instructed to perform this maneuver two to three times per day until symptoms resolve. Caregivers should be instructed to keep their fingernails trimmed and to wash their hands before and after performing lacrimal sac massage.

Treatment of bacterial overgrowth — Mucopurulent eye discharge occurs commonly in infants with NLD obstruction and, in the absence of other signs of infection, suggests bacterial overgrowth in the stagnant tear pool of the lacrimal sac. The organisms most commonly isolated include Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Streptococcus viridans [12].

●Mucopurulent discharge WITHOUT other signs of infection – Mucopurulent discharge without other signs of infection suggests bacterial overgrowth rather than infection. This often can be managed with nonpharmacological measures such as eye washes and nasolacrimal sac compression to reduce the mucus and bacteria. If these measures are not successful, treatment with topical antibiotics is a reasonable option. We typically use topical antibiotics only when the discharge is copious and present throughout the day. In addition, if a tear duct procedure is planned and the infants has mucopurulent drainage, topical antibiotic therapy should be provided before the procedure.

Commonly used agents include polymyxin B/trimethoprim or tobramycin sulfate 0.3%, one drop up to four times per day. Other appropriate agents include topical gentamicin, erythromycin, sulfacetamide, and if all these others are not effective, a fluoroquinolone can be considered (eg, ciprofloxacin, ofloxacin, norfloxacin, or moxifloxacin). To avoid chemical irritation, the duration of treatment should be short (three to five days).

●Purulent discharge WITH other signs of infection – Purulent eye discharge associated with other signs of infection such as erythema and/or swelling suggests acute dacryocystitis (picture 5), which requires systemic antibiotic therapy. This a rare complication of isolated congenital NLD obstruction. It occurs more commonly with dacryocystoceles. Management is discussed below. (See 'Management of acute dacryocystitis' below.)

Persistent nasolacrimal duct obstruction beyond age 6 to 7 months

●Referral – Infants with symptoms of NLD obstruction that have not resolved by age six to seven months should be referred to an ophthalmologist for further evaluation and management. Evaluation should include comprehensive eye examination, including cycloplegic refraction to look for anisometropia, which can occur in approximately 10 percent of patients with congenital NLD obstruction [9,13]. (See "Refractive errors in children", section on 'Anisometropia' and "Amblyopia in children: Classification, screening, and evaluation", section on 'Refractive amblyopia'.)

●Lacrimal duct probing – Lacrimal duct probing is the first-line intervention for young infants with symptoms of congenital NLD obstruction that persist beyond the age of six months (picture 6). The procedure is performed by an ophthalmologist in the office or the operating room, depending upon the experience and preference of the ophthalmologist and the age and size of the child (children ≥12 months old or weighing ≥9 kg usually require general anesthesia). In the office setting, the probing procedure usually takes only two to three minutes if the child's anatomy is normal [1]. (See 'Lacrimal duct probing' below.)

●Timing – The optimal timing of intervention for infants with congenital NLD obstruction is an area of controversy. Many ophthalmologists perform early probing in the office if symptoms have not resolved by the age of 6 to 10 months. However, a reasonable alternative is to wait until the infant is 12 months since many patients will have spontaneous resolution by this age. NLD obstructions that persist beyond the age of 12 months are unlikely to resolve spontaneously [4]. Parental preferences play an important role in the decision to perform early probing versus deferring intervention.

The advantages of early probing (ie, at age 6 to 10 months) compared with deferring the procedure until the child is ≥12 months of age are as follows [1,2,8,13]:

•The procedure can usually be performed in the office without general anesthesia.

•It results in earlier resolution of symptoms. Thus, early probing may be particularly helpful for infants with very bothersome symptoms.

•The risk of lacrimal duct scarring may be lower.

•The risk of infection may be lower (though is it fairly low even without intervention).

The advantages of deferring intervention (ie, waiting until the infant is ≥12 months old) are as follows:

•It allows more time for spontaneous resolution and thus avoids the need for intervention in some infants. (See 'Natural history' above.)

•It allows the ophthalmologist to perform a more definitive procedure. This is because most children require general anesthesia at this age in order to undergo a lacrimal duct procedure. The need for general anesthesia allows the ophthalmologist to perform a more complex procedure (eg, balloon dacryoplasty and/or NLD intubation) rather than a simple probing procedure. Both balloon dacryoplasty and NLD intubation generally have a higher success rate than simple probing, but they cannot be performed in the office setting without general anesthesia. These procedures are discussed in greater detail below. (See 'Balloon dacryocystoplasty' below and 'Nasolacrimal duct intubation' below.)

●Efficacy – The efficacy of NLD probing for treatment of congenital NLD obstruction is supported by two small randomized trials, case series, and clinical experience [14-19]. NLD probing is successful in relieving the obstruction in approximately 75 to 90 percent of cases [14-17].

Studies are inconsistent regarding the relationship between the age at which probing is performed and the success rate [3,6,15-18]. In a large multicenter prospective study, no association was observed between age and success rate in children <3 years old [18]. The probability of success was slightly lower when the procedure was performed in the office setting rather than a surgical facility (72 versus 80 percent). In another large retrospective study, success was more likely in patients who underwent initial probing at age <15 months compared with older age [6].

Outcomes with early versus deferred probing were evaluated in a multicenter randomized controlled trial of 163 infants with congenital NLD obstruction with unresolved symptoms at 6 to 10 months of age [8]. Patients were randomly assigned to immediate office-based probing (n = 82) or six months of nonsurgical management (n = 81) followed by surgical intervention (under general anesthesia) for those with persistent symptoms. Among patients in the deferred surgery group, 66 percent had resolution of symptoms without surgery and 27 percent underwent surgery (four of whom had early surgery because of worsening symptoms, parent request, or development of cellulitis within the observation period). Among patients in the early probing group, 9 percent required reoperation under general anesthesia for persistent NLD obstruction after the initial procedure. At age 18 months, more patients in the early probing group had complete resolution of symptoms compared with the deferred intervention group (92 versus 82 percent; absolute difference 10 percent, 95% CI -1 to 21 percent). The early probing group experienced three fewer months of symptoms (95% CI 1.8-4 fewer months).

Cost effectiveness studies have reached different conclusions about the relative costs of the two approaches, with some estimating lower costs for patients treated with early office probing, while other estimates yielded comparable costs with both approaches [8,20,21].

Treatment failure — Initial NLD probing is unsuccessful in 10 to 25 percent of cases [14,18]. Options for further management of these infants include:

●Repeat probing procedure – If the first probing procedure was uncomplicated and the infant is <12 months or <9 kg, repeat office probing may be attempted. Reported success rates for repeat probing range from 50 to 60 percent [19]. (See 'Lacrimal duct probing' below.)

●Alternative procedures – Procedures that are used for second-line treatment after unsuccessful probing include NLD intubation and balloon dilation. These procedures can also be used for primary treatment in patients whose first procedure is performed under general anesthesia and for those with a high likelihood of treatment failure with probing (those who have tight obstructions or anatomic abnormalities such as craniosynostosis or other craniofacial abnormalities). Both procedures require general anesthesia. (See 'Nasolacrimal duct intubation' below and 'Balloon dacryocystoplasty' below.)

Dacryocystorhinostomy and conjunctivodacryocystorhinostomy are more complex procedures that are reserved for patients with abnormal anatomy such as bony obstruction or punctal/canalicular aplasia and/or those with symptoms refractory to more standard treatments. (See 'Dacryocystorhinostomy' below and 'Conjunctivodacryocystorhinostomy' below.)

Specific procedures

Lacrimal duct probing — Lacrimal duct probing is the first-line procedure for young infants with symptoms of congenital NLD obstruction. The procedure can be performed in the office with local anesthesia or in the operating room under general anesthesia. Children ≥12 months usually require general anesthesia.

The procedure is performed by inserting a small blunt probe or irrigation cannula into the punctum and advancing it through the lacrimal drainage system until it abuts the obstruction (picture 6). The probe is then pushed gently through the obstruction into the nose. Irrigation with fluorescein-stained saline may be performed to ensure patency. NLD probing is successful in relieving the obstruction in approximately 75 to 90 percent of cases [14-17].

Nasolacrimal duct intubation — NLD intubation involves probing the NLD and placing a silicone stent within it. Stents usually are removed in the office after two to six months. NLD intubation is commonly used for patients who fail initial NLD probing. It is also used for primary treatment in infants and children whose first procedure is performed under general anesthesia. Reported success rates with this procedure are 90 to 96 percent when used for primary treatment and 84 percent when performed after failed probing [22-24]. It is not known whether early stent removal results in lower success rates.

Balloon dacryocystoplasty — Balloon dilation of the NLD can be used to increase the likelihood of successful treatment. Reported success rates of this procedure are 82 percent when used for primary treatment and 77 percent when performed after failed probing [22,25].

Dacryocystorhinostomy — Dacryocystorhinostomy is reserved for patients with bony obstruction and/or those with symptoms refractory to more standard treatments. The procedure involves the creation of a window between the lacrimal sac and nasal cavity. This procedure preserves the active drainage mechanism.

Conjunctivodacryocystorhinostomy — Conjunctivodacryocystorhinostomy is reserved for patients with significant anatomic abnormalities proximal to the lacrimal sac (eg, punctal or canalicular aplasia) that cannot be addressed with the procedures described above. In this procedure, a Pyrex glass tube is placed between the caruncle and the nasal cavity. This procedure relies solely on gravity for drainage.

DACRYOCYSTOCELE

Clinical features — Dacryocystoceles usually are noted at or shortly after birth. A bluish swelling of the skin overlying the lacrimal sac and superior displacement of the medial canthal tendon are the typical findings (picture 1). The diagnosis is made clinically, and further work-up generally is not necessary, although neuroimaging (image 1) can confirm the diagnosis.

Complications — Children with dacryocystoceles should be promptly referred to an ophthalmologist. They may require early intervention because of two potential complications: infection and breathing difficulties from nasal obstruction [26,27].

Infection — If left untreated, dacryocystoceles may become infected (picture 5) [26,28,29]. Acute dacryocystitis requires prompt treatment with systemic antibiotics to prevent the development of secondary preseptal or orbital cellulitis, sepsis, meningitis, or brain abscess. (See 'Management of acute dacryocystitis' below.)

The risk of acute dacryocystitis is considerably higher in infants with dacryocystoceles compared with those with simple nasolacrimal duct (NLD) obstruction because of the greater degree of tear pool stasis. Clinical signs include erythema, swelling, tenderness, purulent discharge, and fever (picture 5). Subtle early symptoms of infection include mild erythema over the lacrimal sac, poor feeding, or altered behavior.

Breathing difficulties — Distension of the mucosal lining of the NLD from entrapment of tears can create mucoceles that extend into the nose and cause obstruction. Because infants are obligate nose breathers, nasal obstruction from mucoceles can cause respiratory distress [30-33].

Management — Children with dacryocystoceles should be seen promptly by an ophthalmologist.

Decompression — Decompression of a dacryocystocele into the fornices can usually be achieved with digital massage and/or probing of the common canaliculus in the office setting. Some ophthalmologists may observe for a short period of time to look for spontaneous resolution. Probing of the NLD, if required, is performed in a similar manner as in older infants with NLD obstruction. (See 'Lacrimal duct probing' above.)

In addition, if an intranasal mucocele is present (diagnosed by examining the nasal cavity using a headlight and nasal speculum), it must be opened to prevent recurrence of the obstruction. The intranasal component can be opened in the office, but more complex cases are best managed in the operating room under general anesthesia, sometimes with the aid of a nasal endoscope. Marsupialization is required.

Management of acute dacryocystitis — Acute dacryocystitis (picture 5) requires prompt treatment with systemic antibiotics to prevent the development of secondary complications (eg, preseptal or orbital cellulitis, sepsis, meningitis, or brain abscess). (See "Preseptal cellulitis" and "Orbital cellulitis" and "Bacterial meningitis in children older than one month: Clinical features and diagnosis".)

Infants and children with acute dacryocystitis should be managed in consultation with an ophthalmologist. If NLD probing is to be performed, systemic antibiotics should be administered preoperatively [34]. Blood cultures and cultures of material obtained during drainage should be sent for culture to guide definitive antimicrobial therapy [35]. The most common causative organisms include alpha-hemolytic streptococci, Staphylococcus epidermidis, and Staphylococcus aureus [28].

Empiric systemic antibiotic therapy should be provided to patients with suspected acute dacryocystitis pending culture results. The choice of antibiotic depends upon the severity of the infection. For severe infections, empiric therapy typically consists of intravenous vancomycin plus an extended-spectrum cephalosporin to provide broad coverage. Mild infections can be treated with oral clindamycin.

Empiric antimicrobial therapy should be altered as warranted when culture results are available. The duration of antimicrobial therapy varies depending on clinical response but is usually 7 to 10 days.

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Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)

●Basics topic (see "Patient education: Blocked tear ducts in babies (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Congenital nasolacrimal duct (NLD) obstruction – Simple congenital NLD obstruction (dacryostenosis) occurs in approximately 6 percent of newborns and is the most common cause of persistent tearing and eye discharge in infants and young children. Spontaneous resolution occurs in approximately 80 to 90 percent of infants with congenital NLD obstruction. (See 'Epidemiology' above and 'Natural history' above.)

•Clinical features – Infants with congenital NLD obstruction present with a history of chronic or intermittent tearing and debris on the eyelashes ("mattering") (picture 3 and picture 2). On physical examination, there is often an increase in the size of the tear meniscus. Palpation of the lacrimal sac may cause reflux of tears and/or mucoid discharge onto the eye through the puncta. Conjunctival erythema is not typical. (See 'Clinical features' above.)

•Diagnosis – The diagnosis of congenital NLD obstruction is typically made by history and physical examination alone. If symptoms are intermittent and signs of abnormal tearing or "mattering" are not present at the time of examination, the dye disappearance test can be performed to help confirm the diagnosis. (See 'Evaluation and diagnosis' above.)

The differential diagnosis includes other causes of persistent tearing, which are summarized in the table (table 1). The absence of associated signs and symptoms distinguishes congenital NLD obstruction from other causes. (See 'Differential diagnosis' above and "Approach to the child with persistent tearing", section on 'Etiology of persistent tearing'.)

•Referral – Most infants with congenital NLD obstruction can be managed by the primary care practitioner. Referral to an ophthalmologist is warranted if any of the following are present (see 'Indications for referral' above):

-Uncertain diagnosis, particularly if there is concern for infantile glaucoma (see "Primary infantile glaucoma")

-Symptoms of NLD obstruction that persist beyond the age of six to seven months (see 'Epidemiology' above)

-Signs and symptoms of acute dacryocystitis (see 'Infection' above)

-Signs of anisometropia or amblyopia (see "Refractive errors in children" and "Amblyopia in children: Classification, screening, and evaluation")

-Clinical findings suggesting dacryocystocele (picture 1) (see 'Dacryocystocele' above)

•Initial management – Initial management of congenital NLD obstruction is usually nonsurgical and consists of lacrimal sac massage (figure 3) and observation (algorithm 1). (See 'Lacrimal sac massage' above.)

Mucopurulent eye discharge occurs commonly in infants with NLD obstruction and, in the absence of other signs of infection, suggests bacterial overgrowth in the stagnant tear pool of the lacrimal sac. This can usually be managed with nonpharmacological measures such as eye washes and nasolacrimal sac compression. If these measures are not successful and copious mucopurulent discharge is present throughout the day, we suggest treatment with topical antibiotics (Grade 2C). Commonly used agents include tobramycin sulfate 0.3%, polymyxin/trimethoprim, gentamicin, or moxifloxacin 0.5%, one drop up to four times per day for three to five days. (See 'Treatment of bacterial overgrowth' above.)

•Persistent symptoms – For infants with symptoms of congenital NLD obstruction that persist beyond age 6 to 10 months, we suggest office-based lacrimal duct probing (picture 6) (Grade 2B). The procedure is performed by the ophthalmologist in the office with local anesthesia. Deferring intervention until the child is older (ie, >12 months) is a reasonable alternative since NLD obstruction resolves spontaneously in many patients; however, general anesthesia is usually needed when the procedure is performed at this age. When the procedure is performed under general anesthesia, we suggest NLD intubation rather than simple probing (Grade 2C). (See 'Persistent nasolacrimal duct obstruction beyond age 6 to 7 months' above.)

If the initial NLD probing procedure is unsuccessful, options for further management include a second probing procedure or an alternative procedure (eg, NLD intubation or balloon dacryocystoplasty). (See 'Treatment failure' above.)

●Congenital dacryocystocele – Congenital dacryocystoceles (or NLD cysts (picture 1)) are less common than simple NLD obstruction. They are associated with potentially serious complications and thus require timely referral to an ophthalmologist. (See 'Dacryocystocele' above.)

Dacryocystoceles usually are noted at or shortly after birth. They appear as a bluish swelling of the skin overlying the lacrimal sac and superior displacement of the medial canthal tendon (picture 1). (See 'Clinical features' above.)

Infants with dacryocystoceles should be seen urgently by an ophthalmologist because of the risk of infection (acute dacryocystitis (picture 5) and other secondary infections) and/or respiratory difficulties from nasal obstruction. (See 'Complications' above and 'Management' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Michael Cassidy, COT, who contributed to an earlier version of this topic review.