Lacrimal Ducts Surgery in Children

Each eye has a tear-producing gland, which are konwn as " Lacrimal Gland" . They are situated in the upper lateral region of each orbit, behind the upper eyelid edge and secrete the aqueous layer of the tear film. In the following, the ophthalmologists of Noor Eye Hospital provide you with useful information on lacrimal ducts.

 Tear film layers

1.The innermost layer of the tear film is mucous layer, produced and secreted by the conjunctival goblet cells.

2. The middle layer is the thickest layer of tear film and in fact it is like a solution of water and salt . This layer, produced by lacrimal glands in eyelids, keeps the eye hydrated, cleanses the eye and washes away foreign particles or irritants. Problem in the secretion of this watery layer of the tear film is the most common cause of dry eye, which is so- called "keratoconjunctivitis sicca".

3. The outermost layer of the tear film is the very thin oil layer، produced by the meibomian glands in the eyelids. Its main task is prevent the evaporation of the underlying watery layers of the tear film.

Tears pass over the eye surface to the lacrimal ducts, through the two small openings, punctum, located on the inner edges of the upper and lower eyelids and then pass into the lacrimal sac, which is next to the inner corner of the eyes (between the eyes and the nose). From the lacrimal sacs, tears move down through the nasolacrimal duct and drain into the back of the nose. That's why you usually get a runny nose when you cry. Therefore, the tear system consists of lacrimal glands, lacrimal ducts, the lacrimal sac and nasolacrimal duct.

The obstruction of the narrow nasolacrimal duct that naturally drains tears from the surface of the eye is called nasolacrimal duct obstruction, which may be either congenital or acquired.

Causes of congenital nasolacrimal duct obstruction

 Congenital lacrimal duct obstruction is common in children. 6 to 10 percent of infants are born before their lacerimal ducts begin to open and are fully developed. In some sources, the prevalence of this disorder in infants is 50%. The cause of this obstruction is a membranous obstruction at the distal end of the nasolacrimal duct.

Signs and symptoms of congenital lacrimal duct obstruction

 Usually infants with blocked lacrimal ducts have symptoms in the first 2 to 6 weeks after birth, the most common of them is excessive tearing. In the first month after the birth, there is no reflexive tear or shedding of tears when the infant is crying, unless it is most likely to be pathologic (caused by a disease). Other symptoms of congenital lacrimal duct obstruction include discharge from the eyelids and surface of the eye, recurrent eye infection or inflammation of the conjunctiva, swelling and infection in lacrimal sac so that eyelids and the area around the nose become red, inflamed, painful and sensitive to touch. Also this area may swell and mucus or pus discharge from the eyelids and in the inner corner of the eye may be seen. In one third of the cases, these symptoms are seen in both eyes. Usually the symptoms are aggravated by dust and wind, but there is no fear of light (photophobia).

 Note: Congenital glaucoma should be considered in children with tearing and photophobia.

With gentle pressure on the lacrimal sac, the fluid passes out of the lacrimal pores (puncta). Special substances such as fluorescein dye is instilled onto the eye and judgment can be made about the presence or absence of lacrimal duct obstruction, based on the time they disappear from the eye or when they are present in the oral pharyngeal cavity (which is measured by cobalt blue light). Performing this diagnostic method in newborns has its own problems. To do this diagnostic test, first drop 1% of fluorosine in the conjunctiva and then wait 2 to 5 minutes. In normal conditions, after 5 minutes, there should be almost no fluorescein in the eye. This treatment is done under the supervision of experienced specialists In Tehran-Iran Noor Eye Hospital.

 Congenital lacrimal duct obstruction often usually resolves spontaneously within the first few months of life so that most of them ( up to 95% ) open on their own by the time a baby is 1 year old. However, interventional therapies include non-surgical and surgical procedures.

1. Conservative (non-surgical) treatment

Conservative treatment involves monitoring, lacrimal sac massage, and the use of topical antibiotics. For lacrimal sac massage, you should wash your hands and place your index finger on the inner corner of the eye ( near the nose) and push downward. You may also be asked to use a warm compress. If you have an infection, use an ointment or topical antibiotic drops. Remember that antibiotics will not resolve the blockage.

If the obstruction of the lacrimal duct does not resolve with conservative treatments, or if a severe infection occurs or if your child has recurrent infections, probing should be done, which is successful in 95-85% of children under one year of age, but the sucsess rate decreases with incressing age of the child.

2. Probing surgery

Probing is a surgical procedure that takes about 10 minutes, and involves passing a thin, metallic probe through the blocked lacrimal duct to resolve the obstruction. Some doctors believe that the age of six months is the best age for probing, because in this age the surgical procedure can be performed without general anesthesia, but some also believe that probing should be delayed until one year of age, so that the maximum chance of spontaneous resolving of lacrimal duct obstruction could be given to the child.

Probing surgery for childern who are older than one year old is carried out in the operating room and under general anesthesia. If probing is unsuccessful or it shows that there is a duct stenosis (narrowing of the duct), there may be a need for more extensive surgical procedures such as silicone tube intubation, in which a silicone tube is left in the lacrimal duct for about 6 months so that it will extend the lacrimal duct and after six months it is removed by a short surgical procedure.

3. Balloon Dacryoplasty

A new surgical technique in which a balloon is inserted into the corner of the eye and the lacrimal duct. At first, the balloon is expanded by a sterilized fluid for 90 seconds, and then the liquid is removed, and the balloon expands again for 60 seconds, and at the end the fluid is again removed. The success rate of this technique has been reported between 100% and 80%.

 4. DCR

In rare cases when in spite of the above treatments children still suffer from excessive tearing, DCR or Dacryocystorhinostomy may be performed in children too (as it is performed in adults). This method, which is the main treatment for most patients with acquired lacrimal duct obstruction, should be used in people who suffer from recurrent dacryocystitis ( a collection of amniotic fluid or mucus secretion in the lacrimal sac), and painful inflammation of the lacrimal sac or bothersome excessive tearing.

Although there are several ways to treat this condition, the main technique in all of them is to open a pathway through the lacrimal sac to the nasal space. Our colleagues in Tehran-Iran Noor Eye Hospital are always ready to help you and are trying to keep your eyes healthy.

- How many layers is the tear film composed of ?

- When does lacrimal duct obstruction occur?

-What is the most common type of lacrimal duct obstruction in children?

- How many percentage of children suffer from lacrimal ducts obstraction?

-What are the symptoms of congenital lacrimal duct obstruction?

- what sign can it be if a child with congenital lacrimal duct obstruction suffers from photophobia too?

- How can congenital lacrimal duct obstruction be diagnosed?

-How is congenital lacrimal duct obstruction treated?

 

 

 

- How many layers is the tear film composed of ?

 1.The mucous layer, produced and secreted by the conjunctival goblet cells.

2. The middle layer is a solution of water and salt.

 3. The oil layer secreted produced by the meibomian glands in the eyelids.

- When does lacrimal duct obstruction occur?

This problem occurs when tears naturally can not drain from the surface of the eye and may occur as acquired or congenital.

- What is the most common type of lacrimal duct obstruction in children?

Congenital lacrimal duct obstruction is common in children.

- How many percentage of children suffer from lacrimal ducts obstraction?

 About 6% to 10% of newborns are born before their lacrimal ducts are fully developed . Some studies have reported that about 50% of infants suffer from this disorder.

- What are the symptoms of congenital lacrimal duct obstruction?

 The most common symptom is excessive tearing. In the first month after the birth, there is no reflexive tear or shedding of tears when the infant is crying, unless it is most likely to be pathologic (caused by a disease). Other symptoms of congenital lacrimal duct obstruction include discharge from the eye lids and surface of the eye, recurrent eye infection or inflammation of the conjunctiva, swelling and infection in lacrimal sac so that eyelids and the area around the nose become red, inflamed, painful and sensitive to touch.

- what sign can it be if a child with congenital lacrimal duct obstruction suffers from photophobia too?

 Congenital lacrimal duct obstruction with fear of light can be a sign of congenital glaucoma.

- How can congenital lacrimal duct obstruction be diagnosed?

1- Gentle pressure on the lacrimal sac

2-  Special substances such as fluorescein dye is instilled onto the eye.

- How is congenital lacrimal duct obstruction treated?

 According to studies conducted in 95% of cases, congenital lacrimal duct obstruction often usually resolves spontaneously within the first few months of life so that most of them open on their own by the time a baby is 1 year old. Otherwise, interventional treatments include non-surgical and surgical procedures, as following:

 1. Conservative: A non-surgical treatment, including observation, lacrimal sac massage, and topical antibiotics.

2. Probing: Probing is a surgical procedure that takes about 10 minutes, and involves passing a thin, metallic probe through the blocked lacrimal duct to resolve the obstruction.

3. Balloon Dacryoplasty: A new surgical technique in which a balloon is inserted into the corner of the eye and the lacrimal duct, and during specific procedure the lacrimal ducts obstruction resolves. The success rate of this technique has been reported between 100% and 80%.

4. DCR: It is a surgical procedure that is performed in rare cases in children like adults. This is the main treatment method for most patients with acquired lacrimal duct obstruction.