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Tearing problems are common among newborn babies and infants. Approximately one-third of all babies have excessive tears and mucus formation during infancy.
Most excessive tearing problems in infants and very young children are due to a congenital obstruction of the nasolacrimal outflow pathway. The nasolacrimal duct (tear drainage system) carries tears from the medial eyelid (inner corner of eye) into the nose (Figure 1). In many infants a persistent membrane blocks the lower end of the tear duct just inside the nose preventing the proper drainage of tears. In 96% of children this congenital nasolacrimal duct obstruction opens spontaneously within the first 12 months of life. If the obstruction does not resolve by the child's first birthday, then intervention should be considered.
When the tear passageway remains blocked, stagnation of the tear flow occurs and tears may run down the cheek. With time, the delicate eyelid skin may become red and irritated. Chronic obstruction may also lead to discharge and even infection (dacryocystitis).
Very rarely, tearing in children may be caused by congenital glaucoma. There are other signs associated with this serious condition including enlarged eye (buphthalmos), a cloudy cornea, high intraocular pressure, light sensitivity and irritation. Tearing is occasionally due to misdirected eyelashes rubbing the cornea. This is more common in Oriental infants and is due to a fold of skin rolling the eyelashes toward the cornea. Tearing may also result from wind, pollen, smoke, or chemical exposure. Other rare congenital diseases exist which may lead to an overproduction of tears.
Initially, pressure and massage over the tear sac is recommended. If chronic discharge is a problem, antibiotic eye drops or ointment may be prescribed.
Place a finger under the inner corner of the infant's eye next to the nose and roll the finger over the bony ridge while pressing down and in. This increases pressure inside the tear sac and may also express mucus and tears from the sac. Following pressure on the sac area, an antibiotic drop or ointment may be recommended.
A thin, blunt metal probe is carefully passed through the punctum (tear duct opening) and lacrimal sac and down the nasolacrimal duct into the nose. A 'pop' is often appreciated as the membrane causing the obstruction is penetrated. Fluid is then irrigated through the tear duct system to ensure that the passageway is open. Probing is a relatively minor procedure, but in infants and children a brief general anesthetic is usually required. Infants do not experience pain after the probing but some blood stained tears or a bloody nose is common. Discharge from the eye may persist for up to a week. Antibiotic drops or ointment is used for 1 week following the probing. Complications from a simple probe are unusual.
Probing performed during the first 13 or so months of life have over a 95% success rate. The success rate may diminish some after 15 to 18 months of age, but an untreated tear duct obstruction may improve with simple probing up to 5 or 6 years of age.
If the tearing is not relieved after an initial probing, a second attempt may be tried. Silicone tubes are the next step in the management of children who have not improved after tear duct probing. A general anesthetic is required for silicone intubation of the nasolacrimal duct drainage system. A loop of the tubing will be seen in the inner corner of the eye. The silicone tube is secured in the nose and permits tears to drain into the nose by traveling around the tube and not actually through its lumen. The tube is left in place and removed in the office or with a brief inhaled anesthetic 6 to 12 months after placement.
The most common complication of silicone tubes is prolapse of the tube because the child has pulled the tube out. Parents should tape the prolapsed tube to the cheek or nose and contact the office. Typically, attempts to reposition the tube are unsuccessful and the tube is removed to prevent eye irritation. Often the tearing may still resolve, however if tearing continues after removal then a replacement tube may be needed.
In the infrequent case that tearing is not relieved with silicone tubes, a dacryocystorhinostomy (DCR) may be necessary to open the tear drainage system. This procedure involves a short skin incision in the medial canthal area (between the inner corner of the eye and the nose) with removal of bone and creation of a passageway into the nose. Silicone stents are put in to help keep the new tear duct system open during the healing phase. Dacryocystorhinostomy surgery is generally deferred until atleast 4 or 5 years of age when the nose is larger and permits a simpler surgical technique.
The scarring with the skin incision is usually not noticeable after several months of healing. However, prominent scarring may occur in some children requiring later revision. Scarring in the nose can re-obstruct the new opening requiring additional surgery if the tearing symptoms recur.
Canalicular agenesis (absence of the tear duct) is a rare congenital abnormality that results in poor tear drainage and chronic tearing problems. Conventional silicone stents can not be passed and a Jones tube (Pyrex glass tube) is used to direct the tears from the inside corner of the eye into the nose.
Figure 1
In children, the tear duct blockage often occurs where the duct
enters the nose just below the inferior turbinate.
Stephen R. Klapper, M.D., F.A.C.S. is a board certified Ophthalmologist and has completed extensive fellowship training in Ophthalmic Plastic and Reconstructive Surgery. In addition to his clinical practice Dr. Klapper has published numerous scientific articles in peer reviewed journals and presented several papers at regional, national, and international meetings on topics related to the field of eyelid and facial plastic surgery. Dr. Klapper's practice is limited to adult and pediatric cosmetic and reconstructive eyelid and facial surgery, tear duct surgery, orbital disease, thyroid eye disease and the anophthalmic patient. Dr. Klapper also has extensive experience performing facial Botox® injections and Restylane® lip and facial fold injections.
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