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Congenital nasolacrimal duct obstruction
Background
Overview
Definition
CNDO is the failure of one or both nasolacrimal ducts to open properly at birth, leading to tear drainage issues. The obstruction typically occurs at the valve of Hasner, located at the distal end of the nasolacrimal duct.
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Pathophysiology
CNDO results from a persistent membrane at the valve of Hasner, which prevents normal tear drainage from the eye into the nasal cavity. This leads to tear stasis, which can cause secondary infections and inflammation of the lacrimal sac (dacryocystitis).
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Epidemiology
The reported incidence of CNDO ranges from 1.2% to 30%, depending on the diagnostic criteria used. It is estimated that 70% of all newborns are born with CNDO, but only 6-20% of them develop symptoms.
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Risk factors
Risk factors include a family history of the condition, craniofacial anomalies, and certain genetic syndromes. Prematurity, Down syndrome, and Caucasian race have also been associated with increased risk of CNDO.
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Disease course
The clinical course of CNDO often begins with symptoms such as excessive tearing (epiphora), recurrent eye discharge, and crusting of the eyelashes, typically presenting within the first weeks of life.
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Prognosis and risk of recurrence
Most cases resolve spontaneously within the first year of life. Persistent cases may require intervention, such as lacrimal sac massage, probing, or surgical procedures.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of congenital nasolacrimal duct obstruction are prepared by our editorial team based on guidelines from the College of Optometrists (CO 2024) and the Japanese Society of Lacrimal Passage and Tear Dynamics (JSLPTD 2024).
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Diagnostic investigations
Medical management
Nonpharmacologic interventions
Lacrimal sac massage: as per CO 2024 guidelines, instruct parents on performing lacrimal sac massage using the Crigler technique. Advise gentle pressure with index finger over lacrimal sac and massage downwards for infants under 6 months of age. Offer ten strokes BID. Advise regular cleaning of discharge from lids.
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Therapeutic procedures
Probing: as per CO 2024 guidelines, recognize that the rate of spontaneous resolution during the first 12 months of life is high (> 50% resolve within 6 months, > 70% by 12 months). Consider performing probing in patients with unilateral obstruction or where symptoms persist beyond 12 months.
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Lacrimal lavage
Specific circumstances
Patients with congenital dacryocystocele: as per JSLPTD 2024 guidelines, monitor congenital dacryocystocele carefully in the early postnatal period for serious complications, such as acute dacryocystitis, cellulitis, and respiratory and breastfeeding problems. Consider performing early surgical treatment (transnasal marsupialization, probing, or a combination) if serious complications occur.
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