Pediatrician’s response: Babies present with blocked tear ducts from birth to 18 months. If the conjunctivae are clear I treat with gentle massage or “pumping” of the tear duct when changing the diaper as a routine, regardless of the colour or consistency of the “mucus” coming from the eye. If the eye is red (especially the eyelid) I add an antibacterial drop to the eye several times a day until it clears. I tell parents that if it doesn’t resolve by 18 months, we can then refer to an ophthalmologist for tear duct probing if possible.

Ophthalmologist’s response: Congenital nasolacrimal duct obstruction (NLDO) is an extremely common condition in infants, occurring in 2-4% of healthy newborns. The tear duct system is actually blocked in up to 50% of infants at birth, but since lacrimation doesn’t start until 6 weeks of age, the abnormality isn’t noticed until later. The condition is caused by the normal post-natal development of the nasolacrimal system. In the lower aspect of the nasolacrimal duct (NLD), a small membranous flap of tissue known as the valve of Hasner is present to prevent fluid reflux from the nasal cavity. This normal anatomical structure can cause partial or complete blockage of the NLD in the early months until the system is fully developed. This can be seen clinically as frequent mucopurulent discharge and matting of the eyelashes.

Congenital NLDO resolves spontaneously in over 90% of affected infants by one year of age. What differentiates it from a conjunctivitis is that the process is typically non-infectious. As such, the conjunctiva and episclera are the normal white in appearance, and not injected or hyperemic, as they are in conjunctivitis. Mild topical antibiotic drops or ointments can be used to minimize the amount of mucoid discharge production, but since the process is usually not infectious these medications may offer minimal benefit. A technique known as Crigler massage can also help. Gentle pressure is applied over the side of the nose just inside the medial canthus, and the finger is slid down the side of the nose. This works to “milk” fluid down the nasolacrimal system towards the nasal cavity, hopefully forcing the valve of Hasner open. If these obstructions don’t open spontaneously by 12-18 months, referral to an ophthalmologist may be necessary to perform a nasolacrimal duct probing, with or without placement of a silicone tube into the duct to stent it open.

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