Congenital Nasolacrimal Duct Obstruction: Massage, Probing and When to Refer
Last updated: November 2026
A watery, sticky eye from the first weeks of life is common and usually resolves without surgery. The job is to reassure, teach massage, recognise the few babies who need early treatment, and never miss congenital glaucoma.
Natural history
- Caused by a membrane at the lower end of the duct (valve of Hasner).
- Most cases resolve spontaneously in the first year; in a PEDIG study, two-thirds of infants aged 6–10 months resolved within 6 months of observation.
Look for
- Watering and mucous discharge, matted lashes, positive regurgitation on pressure over the sac, increased tear lake; the eye itself is white and quiet.
- Red flags: photophobia, a large or cloudy cornea, or a big eye (congenital glaucoma); a bluish swelling below the medial canthus at birth (dacryocystocele); a red, tender swelling (acute dacryocystitis).
Management
| Age or situation | Plan |
|---|---|
| Under 12 months | Reassure, teach Crigler massage (firm downward pressure over the sac several times a day), clean the lids; topical antibiotics only for frank infection |
| 12–18 months, still symptomatic | Probing (office-based or under general anaesthesia): high success, about 80–90% in this age group |
| Failed probing | Repeat probing with intubation (silicone tubes) or balloon dacryoplasty |
| Older children, multiple failures | Dacryocystorhinostomy (DCR) |
| Dacryocystocele | Early decompression or probing, as infection and breathing problems can occur |
| Acute dacryocystitis in infants | Systemic antibiotics (may need admission), then probing |
Where residents slip
- Labelling a watery eye with photophobia and a big cornea as NLDO: it may be congenital glaucoma.
- Long-term antibiotic drops for a mucous discharge.
- Probing too early in a baby likely to resolve.
Test yourself: flip cards
Related: Congenital NLD Obstruction: When to Wait, When to Act, Primary Congenital Glaucoma, Paediatric Ophthalmology.
Key sources
- Pediatric Eye Disease Investigator Group. Resolution of congenital nasolacrimal duct obstruction with nonsurgical management. Arch Ophthalmol. 2012;130:730-734
- American Academy of Ophthalmology. Office-based or facility-based probing for congenital NLDO: Ophthalmic Technology Assessment. Ophthalmology (current)
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