Nasolacrimal-duct obstruction and dacryocystitis

Tears pass from the ocular surface through the puncta and canaliculi into the lacrimal sac, then down the nasolacrimal duct into the nose. Obstruction or narrowing at any level can cause overflow onto the cheek. A raised tear meniscus, chronic watering and intermittent sticky discharge support drainage dysfunction, but similar symptoms occur with reflex tearing from dry eye or lid malposition. Examine the surface and punctal position before assuming that every watery eye has an obstructed duct. The 2026 College guidance uses the broader term nasolacrimal drainage dysfunction to reflect these different sites and mechanisms.

Congenital obstruction often results from delayed opening of the distal drainage pathway. Symptoms begin early in life, with watering and crusting that may fluctuate during respiratory infections. In an otherwise comfortable infant with a clear, normally sized cornea and no significant inflammation, initial management is usually cleaning, demonstrated lacrimal-sac massage and observation. Many cases resolve before twelve months. Persistent symptoms beyond the first birthday commonly prompt routine referral under local pathways, while severe symptoms, suspected dacryocystocele or infection warrant earlier assessment.

The infant examination must actively distinguish obstruction from more serious disease. Photophobia, corneal haze or enlargement can indicate congenital glaucoma. Marked conjunctival redness or purulent discharge in a neonate needs assessment for neonatal infection. A bluish swelling beside the inner corner may represent a dacryocystocele, in which retained fluid distends the drainage system; associated intranasal cysts can interfere with breathing. An infant with respiratory difficulty, fever or a red tender sac needs urgent hospital care rather than repeated massage advice.

Acute dacryocystitis is bacterial infection within an obstructed lacrimal sac. The characteristic focal swelling is inferomedial to the eye, with tenderness and erythema; purulent reflux or discharge may occur. The patient may have preceding chronic watering, but a dramatic acute presentation can be the first recognised episode. Assess how far inflammation extends and whether ocular movement and vision remain normal. An abscess, systemic illness or inability to examine the eye changes management. Children should receive same-day hospital assessment because progression can be rapid.

A clinically stable adult with mild, localised disease may receive oral systemic antibiotics under an agreed pathway with close review. One UK local regimen is co-amoxiclav 500/125 mg orally every eight hours for seven days, adjusted for renal function and contraindications. It is an example from NHS Ayrshire and Arran guidance rather than a universal replacement for local antimicrobial policy. Severe infection may need admission, intravenous therapy and drainage. A penicillin allergy requires assessment of the reaction and selection of an appropriate alternative; a fluoroquinolone should not be chosen automatically without considering current restrictions and specialist advice.

Treating infection does not necessarily correct its cause. After recovery, persistent symptomatic obstruction or repeated infection warrants lacrimal assessment. A dacryocystorhinostomy creates a passage from the sac into the nose, bypassing a distal blockage; other procedures address punctal or canalicular disease. Surgical timing and technique depend on anatomy, inflammation and the specialist plan. Avoid routine syringing or probing through an acutely inflamed sac in first-contact care. Unexpected bleeding, a firm atypical mass or persistent unilateral symptoms may require imaging or tissue diagnosis before a benign obstructive label is accepted.