Blocked Tear Duct (Nasolacrimal Duct Obstruction)

A blocked tear duct (nasolacrimal duct obstruction, or NLDO) occurs when the tear drainage pathway from the eye to the nose becomes partially or completely blocked. Tears cannot drain normally, leading to excessive tearing (epiphora), mucous discharge, and sometimes infection. It is extremely common in newborns and also affects adults, particularly older individuals.

Overview

Tears are produced by the lacrimal gland and drain through two small puncta (openings) in the inner corner of each eyelid, travel through the canaliculi into the lacrimal sac, and then through the nasolacrimal duct into the nose. A blockage at any point in this system causes tears to back up and overflow onto the cheek.

Symptoms

In Infants

• Watery eyes (tearing) — often noticed within the first few weeks of life
• Sticky discharge that crusts on the eyelashes, especially after sleeping
• Mattering — mucous accumulation in the inner corner of the eye
• Eyelids sticking together upon waking
• Usually one eye, though both can be affected
• The eye is typically white (not red) — this helps distinguish it from infection

In Adults

• Excessive tearing (epiphora) — tears running down the cheek
• Blurred vision from the tear film
• Mucous or mucopurulent discharge when pressing on the inner corner of the eye
• Recurrent eye infections or conjunctivitis
• Swelling at the inner corner of the eye (if the lacrimal sac is distended)

Dacryocystitis (Infected Tear Sac)

Causes

Congenital (Infants)

• Membranous obstruction at the valve of Hasner — the most common cause; a thin membrane at the lower end of the nasolacrimal duct fails to open at birth
• Affects up to 20% of newborns
• Most open spontaneously by age 6-12 months

Acquired (Adults)

• Age-related narrowing — the most common cause in older adults; gradual fibrosis of the nasolacrimal duct
• Chronic inflammation — from sinusitis, nasal disease, or allergies
• Previous nasal or sinus surgery
• Nasal or sinus tumors (rare but important to rule out)
• Trauma — facial fractures involving the lacrimal drainage pathway
• Medications — docetaxel (chemotherapy), certain eye drops with long-term use
• Dacryolith — a stone (calculus) in the lacrimal sac

Diagnosis

Clinical Evaluation

• History and symptoms — tearing pattern, discharge, recurrent infections
• Dye disappearance test — fluorescein dye placed in the eye; normally drains within 5 minutes
• Irrigation of the lacrimal system — saline flushed through the punctum; reflux confirms obstruction
• Pressing on the lacrimal sac — reflux of mucous or pus confirms obstruction

Imaging (When Needed)

• Dacryocystogram — contrast dye injected into the system with X-ray or CT to locate the blockage
• CT scan — if a tumor or bony cause is suspected
• Nasal endoscopy — to evaluate the nasal end of the drainage system

Treatment

Congenital NLDO (Infants)

Crigler massage (first-line):

• Keep the eye clean by wiping discharge with a warm, damp cloth
• Antibiotic drops may be used for bacterial discharge episodes but do not treat the obstruction itself

Probing:

• Recommended if obstruction persists beyond age 12 months
• A thin probe is passed through the drainage system to open the blockage
• Quick office or operating room procedure (under brief anesthesia in young children)
• Success rate: approximately 80-90%

Additional procedures if probing fails:

• Balloon dacryoplasty — a small balloon is inflated in the duct to widen it
• Nasolacrimal duct intubation — silicone stents are placed for several months
• DCR surgery — rarely needed in children

Adult NLDO

Dacryocystorhinostomy (DCR):

• The definitive treatment for adult nasolacrimal duct obstruction
• Creates a new pathway from the lacrimal sac directly into the nasal cavity, bypassing the blocked duct
• External DCR — incision on the side of the nose; very high success rate (>95%)
• Endoscopic (endonasal) DCR — performed through the nose with no external incision; success rate ~85-90%
• Silicone stents are typically left in place for several weeks

Temporary measures:

• Warm compresses to the lacrimal sac area
• Gentle massage
• Antibiotic drops for discharge episodes
• These do not resolve the obstruction but manage symptoms

Dacryocystitis Treatment

• Oral antibiotics (augmentin, or IV antibiotics for severe cases)
• Warm compresses
• Incision and drainage if an abscess forms
• DCR surgery once the acute infection resolves (to prevent recurrence)

When to See a Doctor

Frequently Asked Questions

Will my baby's blocked tear duct fix itself?

Most congenital blocked tear ducts resolve on their own by age 12 months. Consistent Crigler massage accelerates resolution. If it hasn't resolved by 12 months, a probing procedure is very effective.

Is the discharge from a blocked tear duct contagious?

The discharge itself is not contagious in the same way conjunctivitis is. It's caused by stagnant tears, not a transmissible infection. However, secondary bacterial infection of the stagnant fluid can occur.

How effective is DCR surgery?

External DCR has a success rate of over 95%, making it one of the most reliable procedures in ophthalmology. Endoscopic DCR success rates are slightly lower (85-90%) but avoid an external scar.

Is the probing procedure painful for my baby?

The procedure is very brief (minutes). It is done under topical or general anesthesia depending on the child's age. Babies may be fussy for a short time afterward but recover quickly.

Can a blocked tear duct cause permanent damage?

A blocked tear duct itself does not cause permanent eye damage. However, recurrent infections (dacryocystitis) can be serious if not treated, and chronic tearing significantly affects quality of life. Treatment resolves both issues.

References