In most babies a blocked tear duct opens on its own during the first year. This page is about the ones that do not: how probing, silicone intubation, balloon dilation and duct surgery are planned in children still watering after the first birthday, and how follow-up runs. Infancy and sac massage are a separate subject, set out on the congenital nasolacrimal duct obstruction in babies page.
Congenital obstruction is caused by a thin membrane at the nasal end of the duct failing to open. In infancy that membrane is pliable, and pressure within the duct together with growth perforates it in most babies. As time passes it thickens, the surrounding mucosa changes permanently and adhesions can form inside the duct. What remains is no longer a temporary membrane but an established narrowing.
After the first year spontaneous opening becomes markedly less likely, and waiting invites recurrent infection, skin breakdown and an intervention in a more difficult picture. I therefore bring treatment onto the agenda when watering is still present at around one year, and bring the timing forward when there is recurrent infection of the sac or marked distension.
Probing usually comes up around one year of age. Where symptoms are mild and there is no infection, a few more months of observation are possible; once watering affects the ocular surface or infection recurs, there is little to gain from waiting. It is also performed in older children, with slightly different planning.
The punctum is gently dilated first. A fine, blunt-tipped probe is then passed through the canaliculus into the sac and along the nasolacrimal duct, opening the membrane at its nasal end. Syringing with saline confirms patency, with fluid seen passing into the nose. The procedure takes a few minutes, involves no incision and leaves no external mark.
Because the procedure requires the child to stay still, it is carried out under a short general anaesthetic; the child feels no pain and the duct can be assessed without force. Fasting time and pre-operative assessment follow the anaesthetist's instructions. Children usually go home the same day.
I usually see the child within the first week and again a few weeks later, looking at whether watering has decreased, at the tear meniscus height and, where needed, at a dye disappearance test.
Symptoms returning does not mean the procedure was done wrongly. The opened area can stick down again as it heals, narrowing may already exist along the duct, or the blockage may not have been at a single point. In children with repeated infection, scarring of the lining makes it harder still.
I consider a second probing where the duct passed easily at the first attempt and the blockage looked like a simple membrane. Where there was clear resistance, where narrowing was found along the duct, or where the child is older, moving straight to silicone intubation or balloon dilation makes more sense. The decision rests on the child's age, the findings of the earlier procedure and the examination.
A silicone tube is a fine, soft tube that keeps the duct open. I prefer it where the blockage has recurred after probing, where narrowing is found along the duct, and in older children. It is passed through the punctum along the duct and its ends are secured inside the nose; it is not visible from outside, though a fine loop may be noticed at the inner corner. It generally stays a few months and is removed in a short procedure, the period depending on the child's age and the state of the duct.
In balloon dacryoplasty a small balloon catheter is placed in the duct and inflated in a controlled way to widen the narrowed segment. It is used where probing has not sufficed or the narrowing extends along the duct; in some children a balloon and a silicone tube are used in the same session. These methods are also carried out under a short general anaesthetic and need no incision.
DCR is rarely needed in children. It comes up where the duct is structurally unusable, where infection of the sac keeps recurring, or where watering persists despite probing, balloon dilation and intubation, and in children whose duct has closed completely after trauma or surgery.
The operation creates a new passage between the lacrimal sac and the nose, bypassing the blocked duct. It can be performed through a skin incision or endoscopically through the nose. Children need a general anaesthetic and an overnight stay is usually planned, and a silicone tube may be left in place afterwards to support patency. For how this is done in adults see adult nasolacrimal duct obstruction, and for patients still watering after earlier surgery see revisional surgery for failed nasolacrimal duct obstruction treatment.
Not every blockage in a child is congenital. When watering starts in a child with no earlier symptoms, the cause is investigated separately.
Blows to the bridge of the nose, mid-facial fractures and lacerations can injure the canaliculus or the duct directly. In lid lacerations I keep in mind that the drainage system may have been cut as well, where early repair determines the result.
Recurrent infection of the sac, severe viral infections and prolonged conjunctivitis can leave scar tissue in the lining of the duct. Drops used over long periods can also narrow the entrance of the canaliculus.
Procedures inside the nose, sinus surgery and turbinate operations can affect the nasal end of the duct. A marked septal deviation, an enlarged turbinate or a mass inside the nose can likewise close the duct opening, which is why I do not skip nasal assessment in acquired obstruction.
A few reviews within the first year after the intervention are enough. Children with a silicone tube are seen at intervals until it is removed, then followed for some months. I also assess visual development in a watering eye, since prolonged irritation and recurrent infection can affect the ocular surface. For other childhood topics see pediatric eye diseases, and for the drainage system in general see lacrimal system disorders.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist, Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
Because spontaneous opening is likely during the first year, probing usually comes up at around one year of age. Where symptoms are mild and there is no infection a few more months of observation are possible; once watering affects the ocular surface or infection recurs, there is little to gain from waiting. It is also performed in older children, with different planning.
The procedure is performed under a short general anaesthetic, so the child feels no pain. It takes a few minutes, involves no incision and leaves no external mark, and same-day discharge is usually possible. Light blood-stained discharge from the nose or in the crusting for a few days afterwards is expected and settles on its own.
Light blood-stained discharge from the nose or in the crusting is usual for the first day or two. Temporary watering from swelling can last a few days and does not mean the procedure failed. The drops advised are used for the period given. The child returns to their usual routine the same day and is kept from rubbing the eye. I generally see them for review within the first week.
Symptoms returning does not mean the procedure was done wrongly; the opened area can stick down again as it heals, or narrowing may already exist along the duct. If the duct passed easily at the first attempt, a second probing is considered. Where there was clear resistance, where narrowing was found along the duct, or where the child is older, moving straight to silicone intubation or balloon dilation makes more sense.
A silicone tube generally stays for a few months and is removed in a short procedure, the period depending on the child's age and the state of the duct. It is not visible from outside, though a fine loop may be noticed at the inner corner. If the tube comes loose, hangs from the corner of the eye or catches on something, seek review without delay.
Dacryocystorhinostomy (DCR) is rarely needed in children. It comes up where the duct is structurally unusable, where infection of the sac keeps recurring, or where watering persists despite probing, balloon dilation and intubation, and in children whose duct has closed after trauma or nasal surgery. The operation creates a new passage between the sac and the nose.
Yes. When watering starts in a child with no earlier symptoms, the cause is investigated separately. Blows to the bridge of the nose, mid-facial fractures and lid lacerations can injure the duct directly. Recurrent infection of the sac can leave scar tissue, and procedures inside the nose, a septal deviation or an enlarged turbinate can affect the nasal end of the duct.
To get detailed information, send us your contact information and we will call you as soon as possible. Contact us now
English
