A 2-week-old boy is brought to the office due to eye tearing and discharge. For the past few days, the patient's left eyelid has crusted over and become matted shut during sleep. The discharge is easily cleaned with a washcloth, but his mother is now cleaning the eye every 2 hours. The boy has also had mild nasal congestion but continues to breastfeed well. The patient was born at term via vaginal delivery and was discharged after 1 day of routine newborn care. Temperature is 37.2 C (99 F). Physical examination shows a few shallow, linear abrasions across the left cheek and lower eyelid. The eyes were cleaned prior to the visit, and examination shows increased tears on the left side. The conjunctivae are clear bilaterally. Fluorescein dye testing on the left eye shows equal distribution on the cornea and conjunctiva. After 5 minutes, a large amount of dye persists and drains over the lower eyelid and down the cheek. Which of the following is the most likely diagnosis in this patient?

Question

A 2-week-old boy is brought to the office due to eye tearing and discharge.  For the past few days, the patient's left eyelid has crusted over and become matted shut during sleep.  The discharge is easily cleaned with a washcloth, but his mother is now cleaning the eye every 2 hours.  The boy has also had mild nasal congestion but continues to breastfeed well.  The patient was born at term via vaginal delivery and was discharged after 1 day of routine newborn care.  Temperature is 37.2 C (99 F).  Physical examination shows a few shallow, linear abrasions across the left cheek and lower eyelid.  The eyes were cleaned prior to the visit, and examination shows increased tears on the left side.  The conjunctivae are clear bilaterally.  Fluorescein dye testing on the left eye shows equal distribution on the cornea and conjunctiva.  After 5 minutes, a large amount of dye persists and drains over the lower eyelid and down the cheek.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d603_e8e1_bc81_a9c21fedf6d6_MD0003_00 This neonate has congenital nasolacrimal duct (NLD) obstruction (dacryostenosis), the most common cause of eye discharge in infants. The lacrimal system normally arises in early embryologic development and canalizes by birth. NLD obstruction occurs when the distal duct fails to canalize completely, resulting in a persistent membrane that blocks tear flow from the NLD to the nose. Tears flow out of the lacrimal sac (ie, increased tearing) and cause matting and crusting of the eyelashes. The conjunctivae remain clear. NLD obstruction NLD obstruction is typically diagnosed clinically. Fluorescein dye testing may be indicated for patients with tearing and additional findings concerning for a corneal abrasion (eg, facial scratches, photophobia, pain). However, abrasion would cause a discrete area of fluorescein staining, not present in this patient (Choice A). Dye that persists and flows down the cheek, rather than draining through the NLD, supports the diagnosis of dacryostenosis, as seen in this patient. Management of NLD obstruction is with lacrimal sac massage with downward pressure performed several times daily to open the duct. Although spontaneous resolution is common in the first few months of life, obstruction that persists after age 6 months is less likely to self-resolve and should be evaluated by an ophthalmologist for surgical treatment (eg, NLD probing). (Choice B) Dacryocystitis (NLD infection) is a rare complication of NLD obstruction that presents with purulent eye drainage and an area of erythema, warmth, tenderness, and swelling over the lacrimal sac, findings not seen in this patient. (Choice C) Gonococcal eye infection most commonly presents on day 2-5 of life in newborns who did not receive prophylactic erythromycin eye ointment, making it less likely in this 2-week-old boy who received routine prenatal care. In addition, patients typically have profuse, purulent eye drainage, conjunctival injection, and eyelid swelling. (Choice E) Viral conjunctivitis presents with clear or mucoid eye discharge and erythematous conjunctivae, often associated with a viral prodrome (eg, fever, congestion). Although this patient has congestion, which is often normal in neonates due to small nasal passages, his clear conjunctivae make conjunctivitis unlikely. Educational objective: Congenital nasolacrimal duct obstruction is typically due to incomplete canalization of the distal duct, resulting in blockage of normal tear flow. Infants have increased tearing and crusting of the eyelashes but clear conjunctivae. Initial management involves lacrimal sac massage several times daily to open the duct. References: Insights in the treatment of congenital nasolacrimal duct obstruction. (http://www.ncbi.nlm.nih.gov/pubmed/29450381)

A 2-Week-Old Boy Is Brought to the Office Due to Eye