Conservative management of watering eyes in children requires the parents to understand the natural history of epiphora. They also need to be aware that they should avoid frequent and unnecessary topical antibiotics, except in the case of conjunctivitis. They should also know to wipe sticky eyelids and lashes with cold boiled water.
Lacrimal sac massage
The parent can massage the sac below the medial canthal tendon with a little finger, provided the nail is short. This increases the pressure in the lacrimal system, helping to express fluid and mucous into the conjunctival fornix. Massage may also accelerate opening of the lower end of the nasolacrimal duct.
Syringing and Probing
Syringing and probing are both under general anaesthesia with a laryngeal mask, following a comprehensive examination of the eyelids and puncta. The procedure can be carried out in the children older than ten to twelve months, in which symptoms continue despite the conservative management, unless there is a congenital dacryocele or acute dacryocystitis.
The punctum is dilated, allowing for insertion of a lacrimal cannula and syringe. The nasolacrimal duct is then investigated using probes of a different size. After this point, the membrane is perforated to allow entrance into the nose. A ‘pop’ might be felt but there is usually minimal or no bleeding during this procedure. Clinica London favours endoscopic endonasal monitoring to assess the position of the probe.
Postoperatively, topical steroid-antibiotic drops are used for one to three weeks, depending on the severity of the CNLDO. The patient is then reviewed in clinic in six weeks.
Congenital dacryocele or congenital lacrimal sac mucocele management
Congenital dacryocele is an uncommon neonatal swelling of the lacrimal sac which can become inflamed with acute dacryocystitis leaving the child febrile and ill. It is typically a tense, bluish swelling present at birth or within one to four weeks. Approximately 25% of sufferers have bilateral dacryoceles.
In cases of a quiet dacryocele, massage and warm compresses can be tried first. Congenital dacryocele however is the exception to probing and syringing at one year old as, in these cases, probing is preferable at less than six weeks. In cases of acute dacryocystitis, intravenous antibiotics are administered five to seven days before probing.
If endoscopic endonasal monitoring of syringing and probing fails, the procedure is repeated with silicone intubation. If intubation fails or if the case is complex, a DCR is considered. A similar surgical technique is employed in both adults and child cases, the Dacryocystorhinostomy (DCR) being either external or endoscopic. It is however preferable to wait until the child is aged two to four years before performing this operation.