Neonates do weird things. Some of these things are normal… and some are not. While it is true, that you should “never trust a neonate” (See ALTE / BRUE), there are sometimes when the odd is not cause for tremendous turmoil. One example is those pesky clogged tear ducts. Let’s take a moment to consider Nasolacrimal Duct Obstruction:

Nasolacrimal Duct Obstruction: Anatomy

Tear ducts are complicated (as is much of the human body).
- Lacrimal System consists of: [Orge, 2014]
  - Lacrimal Gland – an exocrine gland with 2 lobes nestled in the frontal bone
  - Lacrimal ducts – secrete the aqueous portion of tears
  - Accessory Lacrimal Glands of Krause and Wolfring – located within the conjunctival fornices
  - Puncta – located on the nasal corner of the upper and lower eyelids; serves as the exit point for tears
  - Ampulla – extend vertically from each puncta
  - Canaliculi – extend perpendicularly to the ampulla and meet to form the common canaliculus, which open into the lacrimal sac medially.
  - Lacrimal Sac – runs vertically
  - Nasolacrimal Duct – connects lacrimal sac to nasal cavity as it empties into the inferior nasal meatus (why your nose runs when you cry)
  - Valve of Hasner – a mucosal flap that separates nasal cavity from the nasolacrimal duct; one way valve.
- Tear Drainage is also complex: [Orge, 2014]
  - Tears do not simply drain by gravity.
  - Opening and closing the eyes (AKA, Blinking), literally, generates both negative and positive pressures within the system that pumps tears through it.

Lacrimal System: What Can Go Wrong

Congenital Nasolacrimal Duct Obstruction [Orge, 2014]
- Nasolacrimal Duct Obstruction (NLDO) is the most common lacrimal system problem.
- Occurs in ~6% of all newborns!
- Incomplete canalization of the nasolacrimal duct creating an imperforate Valve of Hasner is a common cause.
- Infants present after tear production matures (~6 weeks of life).
  - BONUS MORSEL:
  - Neonates may cry vigorously, but not produce tears!
- Presents as increased tearing, matted eyelashes, mucoid discharge from tear stasis.
- Distinguished from conjunctivitis as there is no light sensitivity and no bulbar conjunctiva redness (the eyes are still white).
- “Dye Disappearance Test” can help also:
  - Normally, fluorescein stained tears should disappear within 5 minutes as the tears eventually flow away.
  - With Nasolacrimal Duct Obstruction, the stained tears persist.
- Treated with:
  - Digital massage in a downward motion starting from the puncta toward the lacrimal sac and nasolacrimal duct. Increased pressure my open the obstructed valve.
  - Occasional topical antibiotic drops to help control the bacterial overgrowth in the stagnant tear pool (sounds like name of a 80’s grunge band).
  - Occasionally, surgery / procedure is required to open the obstruction and may done endoscopically or even be done in the office setting. [Galindo-Ferreiro, 2016; Miller, 2014; Lee, 2012]

Congenital Dacryocystocele [Orge, 2014]
- Present as a bluish mass overlying the area of the lacrimal sac or below the medial canthus.
- Noted soon after birth.
- Is an out-pouching of the lacrimal sac and duct.
- Associated with increased tearing, local inflammation, local infection, and cysts.
- May cause respiratory distress if it is bilateral (as neonates are obligatory nasal breathers).
- Often resistant to conservative therapy. Start with massage and topical antibiotics, but surgery may be needed.

Dacryocystitis [Orge, 2014]
- Infection of the Lacrimal Sac.
- Most commonly due to chronic tear stasis from Congenital Nasolacrimal Duct Obstruction
- Distinguished by erythema and swelling below the medial cantonal area.
- May be painful, but can also be painless.
- Treat with warm compresses and oral antibiotics (against Strep and Staph).
- Surgical drainage and repair is rarely needed.

Dacryoadenitis [Orge, 2014]
- Inflammation of the Lacrimal Gland.
- May be due to noninfectious reasons – malignancy
- May be due to infectious reasons – EBV, Tuberculosis, local trauma related infection

Canaliculitis [Orge, 2014]
- Infection of the canaliculus by viruses, bacteria, or fungi.
- Mucopurulent conjunctivitis and drainage are seen.
- Compression of the canaliculus can express more purulent material (gross).
- There is no lacrimal sac distention like in dacrocystitis.
- Treat with warm compresses, digital massage, and antibiotics (topical may be effective alone).
- Occasionally need punctual curettage to remove stone.

Acquired Punctal or Canalicular Stenosis [Orge, 2014]
- Acquired stenosis may result from viral infections (like varicella).
- Trauma and localized masses can also obstruct the delicate drainage system.

Moral of the Morsel

The human body is complex in almost every detail! Simple tear production and management isn’t all that simple really.
Not everyone cries. Especially Neonates… may take up to 6 weeks before they develop the ability to make tears!
Not all matted lashes are due to conjunctivitis! Think about clogged tear ducts and recommend gentle massage.