Congenital dacryostenosis

Specialty: Ophthalmology.

• congenital obstruction of the nasolacrimal duct
• persistent neonatal tearing
• congenital nasolacrimal stenosis

Why it occurs

• Persistence of an imperforate membrane at the level of Hasner's valve at the distal end of the nasolacrimal duct (most common congenital cause of lacrimal duct obstruction in newborns)
• Congenital stenosis or atresia of the lacrimal puncta or lacrimal canaliculi
• Deviated nasal septum or pathological hypertrophy of the inferior turbinate that physically obstructs the inferior nasal meatus
• Congenital dacryocystocele (accumulation of amniotic fluid or mucus in the obstructed lacrimal sac that causes a distension of the sac visible at birth)

Initial workup

Sodium fluorescein clearance test (FDDT, instilling fluorescein into the conjunctival sac and assessing its persistence in the tear meniscus after 5 minutes, indicative of obstruction if it remains accumulated); Gentle digital pressure on the region of the lacrimal sac to assess the outflow or reflux of mucous or purulent material through the lacrimal puncta; Ophthalmological examination under pupil dilation to rule out congenital glaucoma (important differential diagnosis for epiphora and photophobia in neonates); Probing of the lacrimal duct (usually indicated from 10 to 12 months of age if there is no prior spontaneous resolution).

Standard management

• Tobramycin — 0.3% eye drops, 1 drop every 6 hours in the conjunctival sac for 5-7 days only in periods of active bacterial superinfection with abundant purulent secretion
• 0.9% physiological saline solution — apply abundantly in the conjunctival sac to wash mucopurulent debris before administering the eye drops.
• Crigler's hydrostatic massage (a fundamental non-pharmacological maneuver that consists of pressing the little finger firmly on the medial canthal tendon and sliding it downwards to increase the hydrostatic pressure inside the lacrimal sac and break Hasner's obstructive membrane; it is indicated to be performed 3 to 4 times a day, being the main therapeutic measure of first choice in children under one year of age).