Journal of Pediatric Ophthalmology and Strabismus

Letter to the Editors Free

Lacrimal Sac Compression Not Massage

Ying Qian, MD; Elias I. Traboulsi, MD

Abstract

To the Editors:

Congenital nasolacrimal duct (NLD) obstruction is a common problem encountered in pediatrician offices and is one of the common reasons for referral to ophthalmologists. Symptoms include tearing and mucous or purulent matting of the eyelids and eyelashes. These can be irritating to the infant and alarming to the caregiver, and can lead to acute or chronic dacryocystitis. The duct of the lacrimal excretory system (Figure) is the last to canalize in development and can remain closed in up to 50% of infants at birth. The valve of Hasner is the fold of membranous mucosa at the distal end of the NLD, which drains into an ostium under the inferior turbinate in the nasal cavity. In most infants, the membrane spontaneously opens within several weeks of birth, before the onset of lacrimation. Of the remaining patients, symptoms resolve by 1 year of age in up to 90%. Conservative management includes the Crigler hydrostatic massage1 to encourage patency of the NLD.

Abstract

To the Editors:

Congenital nasolacrimal duct (NLD) obstruction is a common problem encountered in pediatrician offices and is one of the common reasons for referral to ophthalmologists. Symptoms include tearing and mucous or purulent matting of the eyelids and eyelashes. These can be irritating to the infant and alarming to the caregiver, and can lead to acute or chronic dacryocystitis. The duct of the lacrimal excretory system (Figure) is the last to canalize in development and can remain closed in up to 50% of infants at birth. The valve of Hasner is the fold of membranous mucosa at the distal end of the NLD, which drains into an ostium under the inferior turbinate in the nasal cavity. In most infants, the membrane spontaneously opens within several weeks of birth, before the onset of lacrimation. Of the remaining patients, symptoms resolve by 1 year of age in up to 90%. Conservative management includes the Crigler hydrostatic massage1 to encourage patency of the NLD.

To the Editors:

Congenital nasolacrimal duct (NLD) obstruction is a common problem encountered in pediatrician offices and is one of the common reasons for referral to ophthalmologists. Symptoms include tearing and mucous or purulent matting of the eyelids and eyelashes. These can be irritating to the infant and alarming to the caregiver, and can lead to acute or chronic dacryocystitis. The duct of the lacrimal excretory system (Figure) is the last to canalize in development and can remain closed in up to 50% of infants at birth. The valve of Hasner is the fold of membranous mucosa at the distal end of the NLD, which drains into an ostium under the inferior turbinate in the nasal cavity. In most infants, the membrane spontaneously opens within several weeks of birth, before the onset of lacrimation. Of the remaining patients, symptoms resolve by 1 year of age in up to 90%. Conservative management includes the Crigler hydrostatic massage1 to encourage patency of the NLD.


Figure. The infant faces the caregiver (insert). Note discharge from the right eye. The anatomy of the lacrimal system is shown with puncta, canaliculi, lacrimal sac, and valve of Hasner opening under the inferior turbinate. Proper support of the head (insert) and direct compression of the lacrimal sac toward the base of the nose and away from the eye using the tip of the index finger is performed. The obstruction at the distal end of the nasolacrimal duct is overcome and the mucus and fluid gushes into the nose. (Reprinted with permission from The Cleveland Clinic Foundation.) 

We find that parents and caregivers may not perform the “massage” correctly and are often frustrated with its lack of efficacy. They often report that they were instructed by primary healthcare professionals to repeatedly massage the area of the tear ducts in a circular motion or downward sweeping motion along the side of the nose, without attention to finger placement or technique.

We illustrate what we believe to be an effective method of NLD massage, which is more a motion of firm compression than gentle stroking. In a randomized prospective trial comparing different massage techniques, the “hydrostatic massage” group showed statistically significant improvement in resolution rates of NLD obstruction when compared to the “gentle massage” and control groups.2 The goal of the maneuver is to occlude and compress the lacrimal sac to transmit the increased hydraulic pressure to the valve of Hasner.

The infant faces the caregiver. The contralateral palm is used to support the head while the compression is performed. The pad of the tip of the index finger with trimmed fingernail is placed over the area of the lacrimal sac; this would also occlude the lacrimal puncta and prevents backflow of the contents of the lacrimal sac. The sac and surrounding lacrimal fossa and bone should be felt with the light initial touch; no pressure should be placed on the globe itself.

The area over the lacrimal sac is firmly and relatively briskly compressed while the infant’s head is supported on the opposite side (Figure). The purpose is to compress the distended lacrimal sac without reflux of material through the puncta and to directly transmit the pressure downward through the NLD to mechanically overcome the obstruction at the valve of Hasner area. If successful, a “pop” may be heard or a “giving way” of resistance may be felt.

We believe that this technique is effective in cases in which the obstruction is at the distal end of the NLD and can prevent unnecessary prolongation of symptoms, unnecessary visits to the ophthalmologist, and possibly unnecessary probings under anesthesia.

REFERENCES
    1.    Crigler LW. The treatment of congenital dacryocystitis. JAMA. 1923;81:23-24.

    2.    Kushner BJ. Congenital nasolacrimal system obstruction. Arch Ophthalmol. 1982;100:597-600.

Ying Qian, MD
Elias I. Traboulsi, MD
Cole Eye Institute
Cleveland Clinic Foundation
Cleveland, Ohio

10.3928/01913913-20090706-17

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