Nasolacrimal duct obstruction

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Discussed the need for emergency evaluation today. Caregiver expressed understanding and agreement with plan. Answered all questions.

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Nasolacrimal duct obstruction
• Constant tearing with mucus, consistent with a blocked tear duct
• No signs of infection of the eye or tear sac
• No light sensitivity or cloudy or enlarged cornea
• Recommended gentle massage over the tear sac at the inner corner of the eye
• Ophthalmology referral if not resolved by 12 months of age
• Follow up as needed

A blocked tear duct is common in babies and causes a watery eye with some mucus, often worse with colds. Most open on their own by the first birthday. Gentle massage over the inner corner of the eye can be done once a day if desired, and crusting can be wiped away with warm water and a clean cotton ball. Return precautions given including redness or swelling of the eyelid, a red or swollen lump at the inner corner of the eye, a cloudy eye, sensitivity to light, fever, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Laterality, bilateral in 30%
Constant tearing with mucus, eye not red, lid not swollen
Secondary conjunctivitis (pus)
Dacryocystitis (red lump at inner corner); dacryocystocele in a newborn
Glaucoma signs: light sensitivity, cloudy or enlarged cornea
Gentle massage
Observation without massage
Referral if persisting past 12 months (PVS) or repeated infections
Ophthalmology referral at six months if not improved
Erythromycin or Polytrim for secondary infection

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Massage technique, once a day, cotton swab
Natural history and reassurance
Probing or surgery if persistent
Fever in an infant younger than 12 weeks

Return precautions in the template

redness or swelling of the eyelida red or swollen lump at the inner corner of the eyea cloudy eyesensitivity to lightfever

Sources

AAP Clinical Report, Procedures for the Evaluation of the Visual System by Pediatricians. Donahue SP, Baker CN. Pediatrics 2016;137(1):e20153597. Reaffirmed February…

Few formal guidelines cover this topic, so the template also leans on expert opinion.