6 - Ant Seg Lacrimal

Question 1

Atresia of puncta or canaliculi

Answer 1

Failure of canalization during development of lacrimal structures

Pt presents with overflow of clear tears

No infection (bacteria cannot get to lac sac)

Possibly tx with sx (difficult)

Question 2

Congenital lacrimal fistula

Answer 2

An epithelium lined tract extending from lac sac to overlying skin surface

Small dimple (like another punctum), medially, difficult to detect w/o symptoms (e.g. crying from both puncta)

No tx if no symptoms
May use salve to cover area, may need excised if severe

Discharge could be present in presence of NLDA, could resolve after probing

Question 3

Dacryocele

• what
• dx
• symptoms

Answer 3

Congenital
Distal blockage -> firm/hard distention of lac sac
Kinking at canaliculus doesn’t allow back flow of secretion

Very common - imaging not required

Symptoms assoc w NLDO

Question 4

Dacryocele

• ddx
• prone to
• respiratory
• tx

Answer 4

Hemangioma (usually not at birth, vascular/red, less firm)
Dermoid cyst (above medial canthus)

Infections
-acute dacrocystitis = redness in area with possible reflux of purulent discharge with pressure

If large intranasal involvement

Early tx to prevent complications (preseptal infection)
Could resolve with careful digital massage/probing
If no resolution in 1-2 weeks or infected, surgery indicated

Question 5

NLDO

• prevalence
• cause

Answer 5

Most common lac disorder in peds
~5% of full term babies

Usually due to thin membrane at lower end of NLD
Can be due to stenosis (didn’t open up)

Question 6

NLDO

• presentation
• culture

Answer 6

1st mo of life

Epiphora and/or recurrent periorbital crusting

Intermittent or chronic, usually bilateral

Digital pressure can lead to mucopurulent discharge

Culture: multiple strains of bacterior, not necessary for management

Question 7

NLDO

• ddx (4)
• when to consider differentials

Answer 7

Infantile glaucoma (megalocornea, photophobia, K clouding, Haab)

Conjunctivitis (conj injection)

Epiblepharon (K irritation) or other K disorders

Eyelid abnormality

Consider with concerns of photophobia, cornea, conj

Question 8

NLDO

-management (not treatment)

Answer 8

Infants are not bothered

Clear K and conj

Perform full eval with cyclo

~90% will have spontaneous resolution by 12 mo

PCP tend to refer when there’s no resolution

Question 9

NLDO

-initial treatment

Answer 9

Lacrimal massage
-few times/day

Topical antibiotics

• for significant discharge, not to cure the obstruction
• any broad spec antibiotic (Dr O uses erythromycin - very safe, can use at home)
• dosing for a number of days, then PRN, no refills

Question 10

NLDO

-probing

Answer 10

Very common

Done after initial conservative tx give no resolution