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.