Clogged tear duct: Is surgery necessary?

I have a one-year-old son who has a clogged tear duct in one eye. Recently a specialist informed us that since it has not cleared up, he should have an operation to open the clogged duct before he is 14 months old. I have spoken to other mothers who say plugged tear ducts have cleared by themselves. Is this true?

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

Clogged tear ducts in infants, or congenital nasolacrimal duct obstruction, is quite common. It is thought to exist in about 75 percent of all babies. However, symptoms from this condition occur in only about six percent of cases.

Tears enter the duct at the puncta, which is the opening on the side of the eye closest to the nose. They then travel through the duct that opens inside the nose. This is one of the reasons why you get a runny nose when you cry. These tear ducts have a couple of valves in them so that tears flow in the correct direction but don't allow mucous and other nasal contents to flow the other way. Infants with tear duct obstruction usually have this condition because one of these valves, which is deep in the duct, is closed off. Thus, to correct the problem, the valve needs to open. This most often occurs spontaneously, but some infants require surgical intervention to open this up. The time to consider intervention is controversial.

One of the symptoms of tear duct obstruction is excessive tearing. The tears run down the face because they cannot go down the tear duct. Mucous, normally secreted by the eye, also does not go down the duct like it should, so it dries about the eye giving it a crusty appearance, or it collects in the eyelashes, often matting the eyelid shut. Occasionally, bacteria build up in the clogged duct causing an infection requiring antibiotic drops.

Treatment begins with the use of antibiotic eye drops. I would also recommend gently applying a clean, warm washcloth to the affected eye and massaging in the following manner: With the little finger (fingernail cut short), stroke the inside of the eye from the top to the bottom. Do this two to six times per day. I usually recommend doing this with each diaper change. In theory, this downward pressure on the duct will increase the pressure on the blockage and force it open.

When treated in this manner, about 90 percent of those with obstruction will correct within the first year of life. Those that fail this treatment are then referred to an ophthalmologist, who then tries to open the duct. This is most often done by using a wire passed through the duct to clear the obstruction. This is usually done under general anesthesia.

Both your specialist and your friends are correct. There are certainly children with clogged ducts that don't spontaneously open until after one year of age. However, these children are in the minority. Your specialist's concern probably stems from the fact that the success rate of wire probing drops dramatically after one year of age. About 90 percent of children under one year of age treated with probing will successfully have the ducts opened. This drops to about 70 percent before 18 months and then to 50 percent after 18 months. When probing fails, more invasive surgical intervention must be undertaken. Thus, it is certainly not unreasonable for you to wait and continue trying the massage technique, but if it fails, it may be more difficult for the ophthalmologist to successfully probe the duct open. I suggest you discuss these concerns with your specialist so that together you can devise a plan with which you are comfortable.

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