Paediatric ophthalmology: Case eight

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This 9 month old baby was referred by his family doctor because of right epiphora. The above picture was taken two minutes after the instillation of fluoresecein.

a. What does the picture show?

There is pooling of dye and a drop of green dye seen inferomedial to the medial canthus.

b.What is the diagnosis?

Right congenital nasolacrimal duct obstruction with fistula of the nasolacrimal system.
Fistula of the nasolacrimal system is a developmental abnormality. It is usually asymptomatic unless there is associated nasolacrimal duct obstruction. In which case, pus or tear can be seen leaking out of the fistula.

c. How would you manage this patient?

The treatment is aimed at the nasolacrimal duct obstruction which typically occurs at the distal end of the duct. The following measures can be used:

• in the first instance, try massaging the lacrimal duct in the inferior direction to increase the hydrostatic pressure which can help unblocking the obstruction. Antibiotic is given if there is associated conjunctivitis.
• if the above measure failed, probing of the system is performed when the patient is about one year old. The success rate is about 90%.

The fistula does not require treatment unless it causes problem through continuous leakage in the presence of a patent nasolacrimal duct. In which case, it can be excised.