Watering eyes (tearing children)

Condition

One of the most common causes of watering eye in children is congenital nasolacrimal duct obstruction (CNLDO), which signifies a delay in the maturing of the nose and lacrimal system. Other causes of epiphora include congenital atresias and some craniofacial disorders.

At birth, 50% of nasolacrimal ducts are still not patent. Spontaneous perforation occurs rapidly in the first three to four weeks, meaning that only a few infants have symptomatic epiphora and/or stickiness after birth. Up to 96% of these cases resolve in the first year without intervention, a further 60% resolving in the second year, after which organic resolution continues more slowly.

Sufferers can therefore present with watering eyes during the first days of life, which can cause chronic conjunctival infection, mucous discharge, eyelid dermatitis, or even acute infections in the lacrimal sac known as acute dacryocystitis

Examination

Watering eye in children requires a specialised examination by a paediatric lacrimal surgery specialist in order to exclude absent puncta or canaliculi, as well as to identify mucocele, dacryocele and craniofacial disorders.

 Specialised examinations can be carried out, so as to identify the tear meniscus and a test involving blue light and a special dye is done.

Treatment

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.

Failed 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 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.