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Orbit/Oculoplastics Quiz 8
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Raymond Wee, MD | Massachusetts Eye and Ear Infirmary, Harvard Medical School
Aaron Fay, MD | Massachusetts Eye and Ear Infirmary, Harvard Medical School

January 20, 2005
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Figure 1

Case History
A 5 year old boy presented with tears overflowing from left eye since one month of age. This photo is five minutes after placing fluorescein into each eye.
Questions and Answers
1. What is the likely diagnosis?
Answer: This child has a left congenital nasolacrimal duct obstruction. The obstruction is an imperforate valve (Hasner) in the inferior nasal meatus.

2. How is the diagnosis confirmed?
Answer: Office examination should include observation for asymmetric tear lake, unilateral matting of lashes, digital massage of the tear sac with observation for mucoid reflux, and the dye disappearance test (shown in figure). The parents’ history is usually revealing with reported unilateral tearing, discharge, or eyelids stuck together on waking. Confirmation can be achieved with more invasive methods under general anesthesia.

3. What is the differential diagnosis of congenital tearing?
Answer: The differential includes glaucoma, epiblepharon, nasolacrimal duct obstruction, and other sites of obstruction such as the punctum, canaliculus, or turbinate. Dacryocele should also be considered, as dilation of the distal portion of the nasolacrimal duct may develop respiratory compromise.

4. How should this patient be treated?
Answer: Greater than 90% of congenital nasolacrimal duct obstruction resolves spontaneously before one year of age. If the child has not had spontaneous resolution, nasolacrimal duct probing may be berformed with a success rate of > 90%. The ideal timing of probing remains unkown. Most clinicians will consider probing at 1 year of age. However, good success rates have also been reported in older children. If tearing persists after probing, intubation of the lacrimal sytem is often performed although the benefit of this procedure is not clearly established.

Katowitz JA and Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94:698-705.

Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology 1998;105:1307-9.

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