Blocked Tear Ducts
Blockage
of the nasolacrimal system, or a blocked tear duct, is a very common
disorder in children. About 2-3% of infants will develop symptoms of
a blocked tear duct in the first several weeks of life. Usually, the
main symptom is epiphora, or an overabundance of tears due to a blockage
of the outflow of tears from the eye. Many infants also have a yellow
discharge from the eyes due to secondary infection.
The blockage
of tear flow affects the drainage of tears from the eye. The tear film
is normally produced in almost all children. The normal tear film has
three main components. The first component is from the lacrimal gland,
which is gland that is present in the orbit or area around the eye.
This lacrimal gland sits on the upper, outer area of the orbit or bony
cavity in which is eye sits. The mucus layer of the tear film and the
oily layer are produced by other glands.
The tears
are almost always normally produced and flow normally onto the eye.
Normally, tears are made constantly throughout the day. Normally, the
tears flow off the eye through the nasolacrimal system that is
a series of drainage tubes located just inside (close to the nose) the
eye. The blockage of this drainage system can be anywhere from the eyelid
to the normal drainage outlet for tears in the nose. Most of the time,
the blockage consists of a thin membrane overlying the nasolacrimal
system as it enters the nose. Sometimes the end of the nasolacrimal
system is too narrow. Sometimes a piece of cartilage in the nose (the inferior turbinate) blocks the outflow of tears. In some cases,
a portion of the nasolacrimal system fails to develop normally.
Sometimes
the main complaint related to a blocked tear duct is not the abundance
of tears but rather a mucoid or yellow (purulent) discharge from the
eyes. The discharge may occur intermittently or may be constant. Most
of the time, even though the blockage is constant, the discharge is
intermittent. Just like water that sits in a sink and does not drain
tends to become cloudy, the tears that sit on the eye and do not drain
properly often become infected. The infection with bacteria produces
the mucoid or yellow discharge. Antibiotic eye drops are often helpful
in controlling the infection. These drops should be used on an "as
needed" basis: that is, used every 4-6 hours as needed to control
the discharge. The antibiotic eye drops do not relieve the nasolacrimal
obstruction but only help control secondary infection that occurs as
a result of the blockage of tear drainage.
It is very
important that the eye drops do not contain a steroid. Steroid
eye drops may cause glaucoma or increase in the pressure within the
eye (intraocular pressure) and may permanently damage the eye. Make
sure when you obtain the eye drops that they do not contain steroids.
Steroid eye drops can be useful in other eye conditions but should not
be used on a long-term basis in nasolacrimal obstruction.
Treatment
of Nasolacrimal Obstruction
For children
under age one year, the nasolacrimal obstruction can be expected to
subside spontaneously, or simply "go away" in about 90% of
cases. Therefore, the main treatment is to use antibiotic eye drops
as needed for any yellow or mucoid discharge. Also, pressure on the
upper portion of the nasolacrimal system, the lacrimal sac, can
be helpful in relieving the obstruction. Sometimes parents are told
to "massage" the area around the inner corner near the eye.
Unfortunately, "massage" is the incorrect word for what is
actually needed. Massage usually ends up with the parent pushing on
the bone near the eye and not getting pressure on the lacrimal sac that
sits just inside the bone near the eye. Pressure must be placed with
the soft part of the finger (sorry, Mom, you may need to cut one fingernail
if it is long) on the small area between the lower inner bone around
the eye (the orbital rim) and the eye itself. Your baby may cry because
your child feels some pressure. However, if you use the soft part of
the finger, the maneuver is not painful although your child may fuss
a bit, as the baby does not understand what is happening.
We recommend
that parents place gentle but firm pressure for 2-3 seconds on the lacrimal
sac once or twice daily.
If the
yellow discharge is difficult to control under age one year, a procedure
called a tear duct probe can be performed to relieve the nasolacrimal
obstruction (the "blocked tear duct"). In babies under 9-10
months old, the procedure can be performed under local anesthesia; that
is, general anesthesia is not usually necessary. It is important that
your child does not eat or drink anything for at least 3 hours before
the procedure (since your child will be held down for about a minute
on his or her back, we want the stomach to be empty).
The tear
duct probe itself consists of passing a smooth metal rod (a tear
duct probe) from the small opening in the eyelid down through the
nasolacrimal system into the nose. A second tear duct probe is momentarily
placed in the nose to be certain that an opening has been made in the
tear duct. Therefore, sometimes after the procedure a small amount of
blood may come out of the nose. If a nosebleed occurs, sit your child
up (laying down will put create more pressure in the blood vessels
in the nose and increase bleeding) and gently pinch the nostrils (the
nose) together for 1-2 minutes.
A tear
duct probe can also be done in a hospital or day surgery facility under
a short general anesthesia. There is a slightly greater risk from general
anesthesia as compared to local anesthesia. The risk is approximately
1 in 20,000 or even less for this type of procedure. I usually recommend
that a tear duct probe be done under local anesthesia if your child
is under age 6 months. Between ages 6-12 months the procedure can be
done with either local or general anesthesia. Over age 12 months, it
is usually easier to perform the procedure under a short general anesthesia.
A tear
duct probe is successful in over 90% of cases if performed under age
13 months. After age 13 months, the chance of success from a tear duct
probe decreases significantly.
There are
two other treatments for a blocked tear duct that can be used. Both
the other treatments must be done under general anesthesia.
A tear
duct probe with insertion of silicone tubes can be performed
if the initial tear duct probe is unsuccessful or if the child is over
13-15 months of age when first treated. With this procedure, small silicone
tubes are inserted into the tear duct and tied in the nose. It is usually
best to leave the tubes in place for at least six weeks. Parents can
see a small portion of the tube on the inner portion of the eyelid as
the tubing travels between the eyelids. It is best not to point to the
tubes or tell your child about the tube or it is very likely your child
will pull the tubes out. Usually the tubes cause no discomfort and your
child is usually not aware that the tubes are in place. This procedure
is often successful when a simple tear duct probe is not. If the tubing
comes loose, parents may see a large plastic loop of tubing coming out
of the inner eyelids. Although the tubing looks alarming, the child
is usually not bothered by this incident. Rather than go to an emergency
room, we advise that you wait until the office is open and the tubing
can be removed easily in the office with your child wide awake. Emergency
room personnel usually have no experience with this tubing.
In most
cases, excessive tearing and infection from a blocked tear duct can
be relieved even if surgery is necessary. Remember that no operation
is 100% successful but most tear ducts can be successful opened even
if more than one operation is required.
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