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Nasolacrimal duct obstruction and dacryocystitis
Obstruction of the nasolacrimal duct causes watering and discharge; in infants it results from a membrane that has not opened at the end of the duct (valve of Hasner) and opens on its own in most cases by age one, while in adults it is acquired and treated with a bypass operation (DCR) — and acute inflammation of the lacrimal sac is treated with antibiotics first.
Why it matters in the exam
In infants: watering and mucoid discharge from a few weeks of age, with sticky lashes in the morning, a white eye and no photophobia. About 90% open on their own by age one, so treatment starts with lacrimal sac massage (Crigler) and cleaning. If the obstruction persists beyond 6–12 months of age — probing, with a high success rate. Dacryocystocele — a bluish swelling below the inner corner in a newborn — needs early treatment because of the risk of infection and airway obstruction when there is an intranasal cyst. Watering with photophobia and a large cornea is not duct obstruction — it is congenital glaucoma.
In adults, mainly older women: persistent watering. The dye disappearance test and irrigation of the system — when fluid refluxes from the other punctum and does not reach the nose, the block is in the duct. Other causes of watering must be excluded: dry eye with reflex watering, ectropion, a narrow punctum and canalicular obstruction. The standard operation is dacryocystorhinostomy (DCR) — a bypass from the sac into the nose, by an external or endoscopic approach. Unilateral obstruction with blood in the tears or a hard mass above the tendon — exclude a tumour.
Acute dacryocystitis: a red painful swelling below the medial canthal tendon, sometimes with pus expressed on pressure; treatment is systemic antibiotics, no irrigation or probing during acute inflammation, and DCR is planned after it settles. Canaliculitis — a swollen "pouting" punctum, discharge with "sulphur granules", usually Actinomyces; treatment is curettage of the canaliculus and antibiotics. Dacryoadenitis — swelling of the outer upper part of the lid in an S shape, usually viral (glandular fever, mumps) or inflammatory.
Key points
- Infants: about 90% open on their own by age one.
- Probing if it persists beyond 6–12 months.
- Adults: DCR.
- Acute dacryocystitis → antibiotics, no irrigation.
- Canaliculitis: Actinomyces and sulphur granules.
Summary table
| Condition | Finding | Treatment |
|---|---|---|
| Congenital obstruction | Watering and discharge, white eye | Massage; probing if it persists beyond 6–12 months |
| Dacryocystocele | Bluish swelling in a newborn | Early treatment, probing and nasal examination |
| Acquired obstruction | Watering, irrigation refluxes from the other punctum | DCR |
| Acute dacryocystitis | Red painful swelling below the inner corner | Systemic antibiotics, then DCR |
| Canaliculitis | Pouting punctum, sulphur granules | Canalicular curettage and antibiotics |
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Sources
- AAO Preferred Practice Pattern: Pediatric Eye Evaluations, 2022 — Nasolacrimal duct obstruction
- Pediatric Eye Disease Investigator Group (PEDIG): Resolution of congenital nasolacrimal duct obstruction, 2012 — Natural history and probing
- AAO Basic and Clinical Science Course, Section 7: Oculofacial Plastic and Orbital Surgery, 2024-2025 — Lacrimal drainage system
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.