Blocked tear duct (BTD) is a common condition seen in the very young. Conservative management is the mainstay of treatment. Massaging of the tear duct is an effective treatment, but parents are frequently confused about the technique of tear duct massage.
Most cases of BTD spontaneously resolve in the first year of life. Conservative treatments such as cleaning away the dried secretions and collections in the eyes and massaging of the tear duct are frequently employed. Antibiotics, in drops or systemic preparation, are reserved for conjunctival infection or peri-orbital cellulitis.
One general misconception is that a tear duct massage is deemed successful when copious amounts of tears and pus are expressed from the tear sac into the conjunctival sac. This is in fact not the reason for massaging. The purpose of the massage is to pump the content of the tear sac to ‘break open’ the blockage.
To understand how tear duct massage works and how to perform a proper massage, one needs to understand the anatomy of the tear duct. Referring to Figure 1, tears drain into the upper and lower lacrimal canaliculi through the two puncta in the upper and lower lids. The canaliculi join before entering the tear sac (outlined in red in Figure 1). Tears then flow downwards along the tear duct (drawn in blue dashes) and eventually drain into the inferior meatus under the cover of the inferior concha/ turbinate in the nose.
The most common location of obstruction of the tear duct is at the lower end where there is a membranous obstruction at the inferior meatus. The tear duct (blue dashes in Fig. 1) is enclosed totally by bony structure (maxilla and lacrimal bone), so it is not accessible to be massaged.
duct massage
In essence, the tear sac is the only soft part of the system not enclosed by bony structure. Parents frequently run their massaging finger along the lower lid, or along the nose when they perform the massage. There is no benefit in this as they are essentially massaging bony structure of the face and nose.
A simple but effective way of performing the massage is to ‘pinch’ the bridge of the nose adjacent to the inner canthus of the two eyes, where the tear sac is located, with the thumb and index finger across the nose and ‘squeeze’ the tear sac of both sides (Fig. 2). A few ‘pinch and squeeze’ motions will pump the content of the tear sac downwards to push open the obstruction downstream.
This technique will work for single eye or bilateral BTD. This is best done whenever the child is being fed. The child is distracted by food, the massage can be done with minimal complaint.
It is important to distinguished BTD from congenital glaucoma, which may also present with watery eyes. Glaucoma has the additional symptoms and signs of raised intraocular pressure, including hazy cornea from oedema, photophobia, and buphthalmos (enlarged eye).
Ophthalmological intervention is indicated only when surgical intervention is needed. This is usually for recalcitrant cases when BTD persists after the age of one. Infrequently early surgery is done when there is dacryocystitis, or if the child has severe and frequent episodes of infection, causing the lids to be stuck together, frequently risking amblyopia or causing peri-orbital cellulitis.
Probing of the tear duct is the surgery of choice. A metallic probe is passed down the tear duct through the punctum, to break the membranous obstruction at the inferior end of the tear duct.
The procedure has a success rate of over 90%. The reason for failure is either scarring after surgery, or anatomical abnormal tear duct system such as absence of the puncta, agenesis of canalicular or tear duct. These cases will require reconstructive surgeries such as dacryocystorhinostomy (DCR), or lacrimal bypass tube insertions (Lestor Jones tubes insertion).
Key messages
- BTD usually spontaneously resolves by the age of one
- The tear sac is the only accessible part for massaging
- A ‘pinch and squeeze’ technique is suggested.
Author competing interests – nil