Congenital nasolacrimal duct obstruction — branching viva

Branching viva on congenital nasolacrimal duct obstruction: recognising the white quiet watering eye with reflux on lacrimal-sac pressure, excluding congenital glaucoma, applying the conservative-first Crigler massage management, reasoning through the probing-timing controversy, and escalating the acute dacryocystitis and neonatal dacryocystocele.

branching clinical structured oral2 min readVerification in progress

Prompt

Outpatient clinic: a ten-week-old with a month of watering and a sticky right eye that is worse during colds, a white quiet eye with reflux of mucopurulent material on firm pressure over the lacrimal sac, a normal red reflex and a clear cornea of normal diameter. The examiner asks: what is the diagnosis, which mimic must you exclude, and what is the first-line management — then branches to the probing-timing controversy, to a second infant with photophobia and a large hazy cornea, and finally to a newborn with a blue-grey medial canthal mass and slow feeding.

Branch 1 — The diagnosis and the mimic

The candidate should identify congenital nasolacrimal duct obstruction from the white, quiet, watering eye with reflux on sac pressure and a normal red reflex and cornea, and immediately name congenital glaucoma as the must-not-miss mimic that also waters but adds photophobia, blepharospasm, a large or cloudy cornea and Haab striae. ^[4]

Probe the candidate on the mechanism: persistence of the membranous valve of Hasner at the distal duct opening, the last segment to canalise, backing up tears and mucus to overflow as epiphora. Ask why the eye stays white (the infection is confined to the drainage sac and tear film, not the conjunctiva) and why colds worsen it (nasal congestion swells the mucosa around the distal opening). ^[4]

References4Show

[4]Schnall BM Pediatric nasolacrimal duct obstruction. Curr Opin Ophthalmol, 2013.PMID 23846190
[2]Petris C; Liu D Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev, 2017.PMID 28700811
[5]Lekskul A; Preechaharn P; Jongkhajornpong P; et al Age-Specific Outcomes of Conservative Approach and Probing for Congenital Nasolacrimal Duct Obstruction. Clin Ophthalmol, 2022.PMID 35698598
[10]Harris GJ; DiClementi D Congenital dacryocystocele. Arch Ophthalmol, 1982.PMID 7138344

Congenital nasolacrimal duct obstruction — branching viva

branching clinical structured oral2 min readVerification in progress

Branch 1 — The diagnosis and the mimic

References4Show

[4]Schnall BM Pediatric nasolacrimal duct obstruction. Curr Opin Ophthalmol, 2013.PMID 23846190
[2]Petris C; Liu D Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev, 2017.PMID 28700811
[5]Lekskul A; Preechaharn P; Jongkhajornpong P; et al Age-Specific Outcomes of Conservative Approach and Probing for Congenital Nasolacrimal Duct Obstruction. Clin Ophthalmol, 2022.PMID 35698598
[10]Harris GJ; DiClementi D Congenital dacryocystocele. Arch Ophthalmol, 1982.PMID 7138344