Nasolacrimal duct obstruction

first month alone. Conservative treatment consists of topical antibiotics and lacrimal sac massage. A topical antibiotic ointment may aid the inflammation at the lid margin [1,36]. Lacrimal sac massage, first described by Crigler [36], is the technique of placing one finger over the common canaliculus to block upward flow and then stroking downward along the lacrimal sac to increase hydrostatic pressure and attempt to break a membrane at the opening of the nasolacrimal duct into the nose (Fig. 6). Although studies quote varying degrees of success for lacrimal sac massage, it is not harmful.

Most investigators recommend probing and irrigation as the next intervention after conservative management. The procedure to probe and irrigate the nasolacrimal duct canal is performed under general anesthesia [1]. Early intervention occurs when the procedure is performed on a child younger than 1 year. Advantages to early probing are earlier relief of symptoms, the avoidance of complications of nasolacrimal obstruction (the development of acute dacryocystitis, conjunctivitis, and cellulitis), and decreasing the chance of fibrosis and scarring of the nasolacrimal system that would make further treatment di cult [30]. The main disadvantages to early probing are that it requires surgical intervention in patients who might have complete resolution of symptoms with conservative management and places the infant at risk for complications such as the creation of false passages and the morbidity from general anesthesia [30]. After the age 1 year, the success rate of probing decreases with increasing age. The addition of balloon catheter dilatation of the lacrimal sac (Lacri-Cath) at the time of probing may result in improved success rates. When probing is not successful, a silicone tube may be placed into the nasolacrimal canal.

Allergic conjunctivitis

Children are subject to the same ocular allergies as their adult counterparts. Allergic conjunctivitis can be divided into acute and chronic

Fig. 6. Mucous expressed from the lacrimal puncta with digital pressure over the lacrimal sac is diagnostic of congenital nasolacrimal duct obstruction.

Treatment with cold compresses, eyewashes with artificial tears, and avoidance of allergens (dust mite covers) are nonspecific measures to counsel the allergic patient. The use of topical therapy allows for direct and local application while avoiding the ocular drying e ects evident with the use of systemic oral antihistamines [38]. Combinations of antihistamines and topical vasoconstrictors provide relief from itch but are not recommended for long-term use because they may cause a reduction in body temperature, central nervous system depression, headache, cardiac arrhythmias, and papillary dilation [25]. Naphcon-A, which contains naphazoline hydrochloride and pheniramine maleate, is presently available over-the-counter for children older than 6 years (Table 2) [1].

H1 receptor antagonists such as levocabastine hydrochloride (Livostin 0.05%) are available for use in patients 12 years and older, with a suggested application regimen of four times daily to relieve ocular pruritus [1]. Azelastine (Optivar) is a second-generation H1 receptor antagonist with the added component of being an inhibitor of histamine–mast cell release. It can be prescribed in children older than 3 years and applied twice daily for relief. Comparisons of the two agents show a similar profile of tolerability and symptomatic relief [39].

Combination antihistamine–mast cell stabilizers have the advantage of rapid symptomatic relief given by immediate histamine receptor antagonism along with the long-term disease-modifying benefit of mast cell stabilizers. It should be noted that not all medications of this class are equivalent [37]. Olopatadine, ketotifen, and epinastine ophthalmic solutions have indications for the treatment of allergic conjunctivitis in patients age 3 years and older.

Another class of medications includes corticosteroids; however, caution is advised considering the potential side e ects (cataracts, increased intraocular pressure, and corneal melts). The use of corticosteroids is typically reserved for patients not responsive to the previously mentioned therapies or for severe forms of allergy; namely, vernal keratoconjunctivitis and atopic keratoconjunctivitis [37]. As mentioned previously, the use of topical corticosteroids in patients who have herpetic conjunctival disease can cause rapid proliferation of the virus and corneal scarring. If needed, rimexolone (Vexol), a derivative of prednisolone approved for the treatment of allergic conjunctivitis that becomes inactivated in the anterior chamber of the eye, may be an option [40] because it demonstrates e cacy while decreasing safety concerns (intraocular pressure) [41,42].

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are e ective for use in allergic conjunctivitis through their interruption of prostaglandin synthesis. Ketorolac (Acular) has been shown to diminish the ocular itching and conjunctival hyperemia associated with allergic conjunctivitis [43]. The advantage of this class of agents over corticosteroids is that NSAIDs do not increase intraocular pressure, induce cataract formation, or interfere with wound healing. Ocular irritation, however, is commonly associated