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Summary Table

Feature	Description
Risk Factors	Newborns and infants (congenital form, most testable). In adults: midface trauma, chronic sinusitis, prior dacryocystitis, granulomatous disease, and involutional change with aging
Etiology	Failure of the distal nasolacrimal duct to canalize, with persistence of a membrane at the valve of Hasner
Patient Presentation	Persistent watery eye (epiphora) and mucoid discharge from one or both eyes since the first weeks of life
Classic Physical Exam	Tearing overflowing onto the cheek, matting of lashes, mucoid material expressed from the punctum on digital pressure over the lacrimal sac
Key Diagnostic Results	Clinical diagnosis. Fluorescein dye disappearance test shows delayed clearance. Probing and irrigation confirms obstruction
Management	Conservative: lacrimal sac massage (Crigler technique), warm compresses, topical antibiotic if mucopurulent. Probing if unresolved by 12 months
Keywords	"Tearing since birth", "wet eye in an infant", "matted eyelashes on waking", "mucoid material on sac compression", "epiphora", "valve of Hasner"

1. Pathophysiology

The nasolacrimal drainage apparatus carries tears from the ocular surface to the inferior meatus of the nose. Tears enter the upper and lower puncta, travel through the canaliculi into the lacrimal sac, and drain inferiorly through the nasolacrimal duct. The distal end of this duct opens into the nose at the valve of Hasner.

During fetal development, the nasolacrimal duct canalizes from above downward. The last segment to open is the membrane at the valve of Hasner. In roughly 5 to 20 percent of newborns, this membrane persists at birth. An imperforate membrane at the valve of Hasner is the testable cause of congenital dacryostenosis.

Because tears cannot drain into the nose, they overflow onto the cheek, producing the chief complaint of epiphora since the first month of life. Stagnant tears within the lacrimal sac become colonized by ocular surface and skin flora, producing the mucoid or mucopurulent discharge that parents notice each morning. Pressure on the sac forces this material back through the punctum, which is the basis of the classic bedside maneuver.

When the obstruction is incomplete, the duct opens as the infant grows. Approximately 90 percent of cases resolve by 12 months of age, which underpins the conservative-first management strategy.

In adults, acquired dacryostenosis follows scarring from chronic sinus disease, trauma, prior infection, granulomatous disease (sarcoidosis, granulomatosis with polyangiitis), or involutional fibrosis with aging. Adult cases are far more likely to require surgery.

2. Classification and Clinical Manifestation

Type	Onset	Mechanism	Typical Course
Congenital, simple	First weeks of life	Imperforate valve of Hasner	Resolves in ~90% by age 1 with massage
Congenital, complex	At or near birth	Bony obstruction, dacryocele, craniofacial anomaly	Often needs earlier surgical intervention
Acquired, primary	Middle-aged or older adults, female predominance	Idiopathic involutional fibrosis	Usually requires surgery
Acquired, secondary	Any age	Trauma, infection, tumor, sinus disease, systemic inflammatory disease	Treat the underlying cause; surgery often needed

Clinical progression follows a recognizable order:

Epiphora: the earliest and most consistent feature
Mucoid discharge with crusting of the lashes on waking
Recurrent low-grade conjunctival irritation
Acute dacryocystitis if the stagnant sac becomes infected, presenting as a tender, red, warm swelling at the medial canthus with fever

A simple obstruction has a quiet, non-tender lacrimal sac. An infected sac (dacryocystitis) is tender, erythematous, and warm. This single distinction drives most of the testable decisions.

3. Diagnostic Workup

Test	Purpose	Order
History and external eye exam	Identifies tearing, discharge, crusting, and any sac swelling	Always first
Digital sac compression	Expresses mucoid reflux from punctum, confirming an obstructed fluid-filled sac	Best initial bedside test
Fluorescein dye disappearance test	Detects functional obstruction (dye persists in tear lake at 5 minutes)	Best initial objective test
Probing and irrigation	Documents level of obstruction; therapeutic in young children	Confirmatory (gold standard)
Dacryocystography or nasolacrimal endoscopy	Localizes obstruction before surgery	Adult or recurrent cases
CT orbit and paranasal sinuses	Evaluates bone, tumor, sinus disease	Acquired adult or atypical cases

In an infant with classic findings, the diagnosis is clinical. The bedside maneuver to remember is digital pressure over the lacrimal sac at the medial canthus; mucoid reflux from the punctum confirms an obstructed, fluid-filled sac.

The fluorescein dye disappearance test is the best initial objective study. A drop of fluorescein is placed in the conjunctival sac. Under cobalt blue light, the dye should clear within 5 minutes. Persistence of dye in the tear lake at 5 minutes indicates impaired drainage and is the classic positive finding.

Probing and irrigation of the nasolacrimal system is the confirmatory test. Saline is flushed through the canaliculus into the sac; failure of fluid to reach the nose or pharynx confirms obstruction and localizes its level. In children older than 6 to 12 months who have failed conservative therapy, probing is also therapeutic.

For adults, imaging plays a larger role. Dacryocystography (contrast study of the lacrimal system) and nasolacrimal endoscopy localize the level of obstruction before surgery. CT of the orbits and sinuses is ordered when tumor, trauma, or sinus pathology is suspected.

4. Management and Treatment

Step	Intervention	Indication
1	Lacrimal sac massage (Crigler technique), 2 to 3 times daily	All infants under 12 months with simple obstruction
2	Warm compresses and lid hygiene	Adjunct in all cases
3	Topical antibiotic (erythromycin ointment, or polymyxin B with trimethoprim drops) for 5 to 7 days	Mucopurulent discharge or secondary conjunctivitis
4	Office probing of the nasolacrimal duct	Persistent obstruction beyond 12 months of age
5	Repeat probing with silicone intubation or balloon dacryoplasty	Failed simple probing
6	Dacryocystorhinostomy (DCR)	Adults, complex congenital cases, or repeated failures
7	Systemic antibiotic (amoxicillin-clavulanate orally, clindamycin if penicillin-allergic) plus warm compresses; IV antibiotics if severe; incision and drainage if fluctuant abscess	Acute dacryocystitis

The guiding principle in infants is observation with conservative care. Parents are taught the Crigler massage: place an index finger over the lacrimal sac at the medial canthus and apply firm downward pressure for 5 to 10 strokes, 2 to 3 times daily. The hydrostatic pressure helps rupture the membrane at the valve of Hasner. Approximately 90 percent of cases resolve by 12 months of age with massage alone.

If discharge becomes purulent, a topical antibiotic such as erythromycin ophthalmic ointment or polymyxin B with trimethoprim drops is added for 5 to 7 days. Topical drops do not treat the obstruction itself; they only treat the secondary conjunctivitis.

When obstruction persists beyond 12 months, the next best step is office probing of the nasolacrimal duct under topical or general anesthesia depending on local practice. First-attempt success exceeds 90 percent in this age group. Failure leads to a second probing with silicone tube intubation (left in place for 2 to 6 months), balloon dacryoplasty, and ultimately dacryocystorhinostomy (DCR), which creates a new drainage pathway from the lacrimal sac directly into the nasal cavity through a bony osteotomy.

For acute dacryocystitis, treatment shifts to systemic therapy. Oral amoxicillin-clavulanate (875/125 mg twice daily for 7 to 10 days in adults; 25 to 45 mg/kg/day divided twice daily in children) is first-line for outpatient management. Severe, febrile, or orbital cellulitis-suspect cases require admission and intravenous antibiotics covering Staphylococcus aureus and Streptococcus species. Incision and drainage is reserved for fluctuant abscesses. Definitive DCR is performed once the acute infection has settled.

Probing during active dacryocystitis is contraindicated because it can create a false passage and disseminate infection.

In pregnancy, elective DCR for adult acquired obstruction is deferred until after delivery; only acute infection is treated medically. In renal impairment, dose adjustment of beta-lactams is required.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why it is similar	Key Discriminator
Acute dacryocystitis	Tearing, discharge, medial canthal findings	Tender, erythematous, warm swelling at the medial canthus with fever; represents infection of an already obstructed sac
Bacterial or viral conjunctivitis	Discharge and red eye	Diffuse conjunctival injection, often bilateral, no chronic tearing pattern, no mucoid reflux on sac pressure
Congenital glaucoma	Tearing in a newborn	Photophobia, blepharospasm, corneal haziness, and buphthalmos; raised intraocular pressure
Foreign body or corneal abrasion	Tearing and irritation	Acute onset, unilateral, severe pain, fluorescein uptake on cornea
Allergic conjunctivitis	Watery eyes	Bilateral itching, chemosis, atopic history, no sac findings
Dacryocele (amniotocele)	Medial canthal swelling in a newborn	Bluish cystic mass present at birth at the medial canthus; can rapidly become infected and needs earlier intervention
Punctal or canalicular atresia	Epiphora without discharge	Absent or stenotic punctum on slit-lamp inspection; irrigation fails proximally
Trichiasis or entropion	Tearing and irritation	Eyelashes contact the cornea on lid examination

6. Traps and High-Yield Pearls

Students lose marks on this topic by failing to separate dacryostenosis (a quiet, persistent obstruction) from dacryocystitis (an acute infection layered on top of that obstruction). The vignette signals the difference with fever, tenderness, redness, and warmth at the medial canthus; their absence steers you toward simple obstruction and conservative care.

The second trap is acting too soon. In an infant younger than 12 months whose eye is otherwise quiet, the answer is almost always lacrimal sac massage, not probing, not antibiotics, not imaging. Choosing probing in a 4-month-old is the textbook wrong answer. Probing becomes correct only after age 12 months or after a documented failure of conservative therapy.

The third trap is forgetting congenital glaucoma as a competing cause of tearing in a newborn. The presence of photophobia, blepharospasm, or a cloudy or enlarged cornea changes the answer entirely; you are no longer treating a duct, you are referring urgently to ophthalmology to measure intraocular pressure.

The fourth trap is mismanaging acute dacryocystitis. Probing during active infection is contraindicated. The correct sequence is systemic antibiotics first, then definitive DCR after the inflammation has settled. Picking "probe and irrigate now" in a febrile child with a red, tender medial canthal mass is a high-yield wrong answer.

The fifth trap is conflating dacryocele with simple dacryostenosis. A bluish cystic medial canthal mass present at birth is a dacryocele. It deserves earlier intervention because it carries a high risk of rapidly becoming infected and may communicate with an intranasal cyst causing respiratory distress in obligate nasal breathers.

The core competency being tested is recognizing a benign, self-limited condition, resisting unnecessary escalation, and correctly sequencing observation, topical therapy, probing, and surgery by age and clinical state. A second layer tests your ability to discriminate a draining-system problem from an ocular-surface, globe, or orbital problem on subtle vignette cues.

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