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What's the Diagnosis?

September 2019

Visual Diagnosis

Author: Katelyn McAnany, MD | Pediatrics, Clinical Assistant Professor of Pediatrics, UMKC School of Medicine; Clinical Assistant Professor of Pediatrics, Kansas University Medical Center
Column Editor: Angela Myers, MD | Director, Division of Infectious Diseases | Associate Director, Infectious Diseases Fellowship Program | Associate Professor of Pediatrics, UMKC School of Medicine      


A 2-month-old infant presents for a routine check-up. Mom reports he has been a healthy baby, born at 39 weeks with an uncomplicated vaginal delivery. He is breastfeeding well, meeting all milestones and growing appropriately. Today she is concerned about a blue bump that she noticed by the inside corner of his right eye. Over the course of the last month, it has gotten a little bigger. She notes that the eye has not been red, he has not had any fevers, and it does not seem to bother him.     


Visual Diagnosis.jpg

What is your next step in evaluation?

A. Watchful waiting: advise her that this typically resolves on its own
B. Referral to ophthalmology
C. Advise to massage with warm washcloth several times per day
D. Initiate antibiotic treatment

Correct answer: B

The infant pictured has a dacrocystocele. Congenital dacryocystoceles are produced when both the proximal and distal portions of the nasolacrimal system are obstructed. The obstruction blocks a valve so that tears may enter the cyst or lacrimal duct, but not leave. This results in distention of the lacrimal sac and duct, which appears as a bluish bulge below the medial canthus. Congenital dacryocystocele is less common than nasolacrimal duct obstruction, but is associated with potentially serious complications such as infection, and hence requires urgent referral to an ophthalmologist.

Clinical signs of dacrocystitis include erythema, swelling, tenderness and fever. Subtle early symptoms of infection include mild erythema over the lacrimal sac, poor feeding or altered behavior. Acute dacryocystitis is a medical emergency in a newborn infant, and it must be treated promptly with systemic antibiotics to prevent the development of secondary preseptal or orbital cellulitis, sepsis, meningitis or brain abscess.

Treatment of dacrocystocele may include lacrimal duct probing as the first-line surgical procedure, although some may wait for spontaneous resolution. This procedure is done in the office or operating room, if general anesthesia is required. A small probe is inserted into the punctum of the eye and it is pushed through the lacrimal drainage system. This procedure may take 2-3 minutes. If there is an intranasal component of the dacrocystocele, it must be opened to prevent recurrence of the obstruction by surgery under general anesthesia with aid of nasal endoscope.

Nasolacrimal duct obstruction is fairly common, occurring in about 6% of newborns. Most cases resolve spontaneously. However, symptoms may be minimized by advising parents to massage the eye near the canthus with a warm, wet towel.

References

1. Congenital Dacrocystocele: Diagnosis and Treatment. Cavazza S, Laffi GL, Lodi G, et al. Acta Otothinolaryngologica Italica. 2008;28:298-301.   

2. Presentation and Management of Congenital Dacrocystocele. Krishnamurthy WR, VandreVeen D. Pediatrics. 2008;122:e1108-e1112.