List of Abbreviations
LDP - lacrimal drainage pathways
LPy - lacrimal punctum
LC - lacrimal canaliculus
LS - lacrimal sac
NLD - nasolacrimal duct
NLC - nasolacrimal canal
CT — computed tomography
DCR — dacryocystorhinostomy
DCT — dacryocystectomy
EDCR — endoscopic dacryocystorhinostomy
ODCR — open (external) dacryocystorhinostomy
Terms and Definitions
Tearing = epiphora — outflow of tear fluid outward beyond the palpebral fissure.
Lacrimal ducts — a complex of cavity structures of the lacrimal drainage system, including lacrimal puncta, lacrimal canaliculi, lacrimal sac, and nasolacrimal duct.
Atresia — a developmental anomaly, absence of an opening or channel.
Aplasia — a developmental anomaly, absence of an anatomical structure or organ.
Dacryocele — enlargement of the lacrimal duct resulting from tear stasis in the lacrimal sac (dacryocystocele) or nasolacrimal duct (dacryoductocele).
Dacryocystitis — inflammation of the lacrimal sac with suppuration of its contents due to impaired tear passage through the nasolacrimal duct.
Neonatal dacryocystitis (ND) — inflammation of the lacrimal sac based on congenital obstruction of the nasolacrimal duct.
Phlegmonous dacryocystitis — spread of the purulent-inflammatory process beyond the lacrimal sac into the surrounding cellular space.
Abscessing dacryocystitis — phlegmonous dacryocystitis with abscess formation in the soft tissues.
Positive / negative compression test — appearance / absence of mucopurulent discharge in the conjunctival cavity upon pressure on the projection area of the lacrimal sac, which allows the diagnosis of dacryocystitis to be established.
Nasolacrimal canal — a bony canal connecting the bony lacrimal fossa with the nasal cavity.
The nasolacrimal duct is a soft-tissue tubular formation within the lumen of the nasolacrimal canal.
Obstruction is a local barrier along the course of the canal or within the cavity of the lacrimal sac.
Dye test = Tear duct dye test = West test is a diagnostic test that allows evaluation of the lacrimal passage patency by instillation of a diagnostic dye (e.g., sodium fluorescein or collargol) into the conjunctival sac and its appearance in the inferior nasal meatus.
Double West test is a repetition of the dye test after instillation of vasoconstrictors into the nose to confirm or rule out a rhinogenic cause of epiphora.
Probing is a diagnostic procedure involving the passage of a probe through the lacrimal ducts.
Bougienage is a therapeutic and diagnostic procedure, which is a perforating probing of the lacrimal ducts.
The ** symbol after a drug name indicates that the medicinal product is included in the VLDNL list.
The # symbol before a drug name indicates that the drug is used off-label, contrary to the indications, contraindications, routes of administration, and dosages contained in the instructions for medical use of the medicinal product.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Congenital pathology of the lacrimal drainage system manifests primarily as impaired tear drainage.
Tear drainage insufficiency may be caused by developmental anomalies of the lacrimal ducts, abnormal position of the lacrimal punctum, narrowing of the lacrimal ducts, or delayed lysis of embryonic membranes in the lacrimal ducts.
Developmental anomalies in the form of a cutaneous fistula of the lacrimal canaliculus or lacrimal sac manifest as the discharge of a tear drop in the area of the fistula and, as a rule, are not accompanied by purulent complications.
Delayed tear drainage leads to the accumulation of mucus in the lacrimal ducts. Prolonged accumulation of contents can lead to the dilation of not only the soft-tissue structures of the lacrimal ducts but also the bony nasolacrimal canal.
The development of infection within the stagnant cavity leads to the development of purulent dacryocystitis.
When the lacrimal canaliculi are patent, pus is discharged from the lacrimal puncta, but in the absence of such an outlet, purulent dacryocystitis may progress to phlegmonous peridacryocystitis with subsequent subcutaneous abscess formation and the development of a cutaneous fistula.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The pathology is congenital and genetically determined.
The disease is associated with a congenital blockade of the nasolacrimal duct outlet by a gelatinous embryonic plug composed of mucus and dead embryonic cells, or by an embryonic persistent membrane that has failed to resorb by the time of the child's birth. About 35% of children are born with this membrane, and if it does not undergo regression, an obstruction to tear outflow occurs, causing tears to accumulate in the lacrimal sac cavity. At the same time, the contents of the lacrimal sac (mucus, embryonic cell detritus, epithelium, etc.) provide a favorable environment for the growth of microflora, followed by the development of purulent dacryocystitis—dacryocystitis of the newborn (DN).
1.3 Epidemiology of the Disease or Condition
Atresia of the nasolacrimal duct outlet occurs in nearly 10% of newborns, obstruction or stenosis of the nasolacrimal duct occurs in 4-6%, and in 2/3 of such children, it is complicated by dacryocystitis: 1-4% of newborns; 19% of premature infants; 6.5% of infants in the first year of life; 7-14% of all pediatric ophthalmopathology [1-5].
1.4 Features of Coding the Disease or Condition
Q10.4 Absence and agenesis of lacrimal apparatus
Q10.5 Congenital stenosis and stricture of lacrimal duct
Q10.6 Other congenital malformations of lacrimal apparatus
P39.1 Neonatal conjunctivitis and dacryocystitis
1.5 Classification of the disease or condition
Developmental anomalies:
Atresia of lacrimal punctum
Accessory lacrimal punctum
Atresia of lacrimal canaliculus
Atresia of lacrimal sac
Atresia of nasolacrimal duct
Aplasia of nasolacrimal canal
Fistula of lacrimal canaliculus
Fistula of lacrimal sac
Diverticulum of lacrimal canaliculus
Diverticulum of lacrimal sac
Hamartoma of the lacrimal drainage system
Dacryocystitis:
By time of onset:
Neonatal dacryocystitis
Acquired dacryocystitis
By clinical course:
Acute
Chronic
By clinical presentation:
Purulent dacryocystitis
Phlegmonous dacryocystitis
Abscessing dacryocystitis
1.6 Clinical presentation of the disease or condition
Developmental anomalies:
Atresias of the elements of the lacrimal drainage system and aplasia of the nasolacrimal canal clinically manifest as epiphora.
A fistula of the lacrimal canaliculus or lacrimal sac is visually identified by the presence of a point skin defect from which a drop of tear fluid periodically escapes. As a rule, purulent complications are not observed.
A diverticulum of the lacrimal canaliculus is usually small in size; the diverticulum cavity may be filled with tears, mucus, or pus. Upon compression, the contents may escape through the lacrimal punctum or through the nasolacrimal duct.
A diverticulum of the lacrimal sac can be significant in size; the formation may extend deep into the orbit and be filled with pus or mucus. The compression test is often questionable.
Dacryocele - an increase in the volume of the lacrimal duct resulting from the stagnation of contents in the lacrimal sac (dacryocystocele) or nasolacrimal duct (dacryoductorhinocystocele).
Dacryocystocele represents a progressive distension of the lacrimal sac resulting from the accumulation of mucosal secretions, without primary inflammatory changes. Visually, a firm-elastic formation is defined under the skin in the projection of the lacrimal sac, often with a bluish tint shining through the taut skin. Inflammatory changes are absent, and the general condition and behavior of the child are not disturbed.
Dacryoductorhinocystocele is a variant of dacryocele with predominantly accumulation of contents in the lower part of the nasolacrimal duct. At the same time, cystic bulging of the soft part of the nasolacrimal duct into the nasal cavity beneath the inferior nasal concha is observed. With substantial sizes of dacryoductorhinocystocele (especially with bilateral localization), impairment of the newborn's nasal breathing and the development of respiratory distress syndrome are possible.
Neonatal dacryocystitis.
The clinical presentation of neonatal dacryocystitis develops in the first days or weeks of life. In typical cases, mucous, mucopurulent, or purulent discharge appears in one or both eyes of the child. Tear pooling and epiphora may be detected, less frequently - conjunctival hyperemia. Very often, this process is mistakenly regarded as conjunctivitis. A distinguishing feature of neonatal dacryocystitis is the discharge of pus from the lacrimal puncta upon compression of the lacrimal sac and a relatively quiet state of the conjunctiva.
Usually, inflammation of the lacrimal sac develops in one eye, but bilateral neonatal dacryocystitis is also possible. In some newborns, the gelatinous plug subsequently resolves spontaneously, and the symptoms of dacryocystitis subside. If the outlet of the lacrimal sac is blocked at both the entrance and the exit, the activation of infection leads to the spread of purulent inflammation with the development of phlegmon of the surrounding soft tissues. In this case, the newborn's condition worsens: body temperature rises sharply, and symptoms of intoxication increase.
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis is established on the basis of:
- parents' complaints (epiphora, discharge of pus from the lacrimal puncta),
- medical history (appearance of pathological symptoms from birth),
- physical examination (prominence in the lacrimal sac area, skin hyperemia, discharge of pus from the lacrimal puncta, relatively quiet state of the conjunctiva, impairment of nasal breathing on the ipsilateral side, presence of general intoxication symptoms),
- palpation (sensation of cystic expansion of the lacrimal sac with fluctuation, possibility of emptying the lacrimal sac using finger compression).
It is recommended that all patients with suspected pathology of the lacrimal drainage system undergo an initial consultation (examination) by an ophthalmologist (B01.029.001) to establish a diagnosis and determine treatment tactics [1,3-6,17].
Level of Evidence CGrade of Recommendation 5Level of Evidence C (reliability of evidence – 5)
2.1 Complaints and Anamnesis
It is recommended to take the anamnesis and record complaints regarding eye pathology (A01.26.001) for all children with changes in the inner canthus area based on the words of parents or guardians - to determine the time of onset of clinical manifestations, changes in skin surface and color, presence of purulent discharge, and the dynamics of these manifestations over time [1–6,17,18].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.2 Physical Examination
It is recommended that all children with alterations in the inner canthus area undergo an external examination of the maxillofacial region (A01.07.005) and a visual examination of the eyes (A01.26.002). The external examination assesses the presence and position of the lacrimal puncta, tear lake height / epiphora, the presence of pus in the conjunctival cavity, bulging, and skin discoloration over the projection of the lacrimal sac [1-6,18].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: assess the presence of a tear lake or epiphora while the child is calm, as well as the position of the eyelids, the intermarginal strip of the eyelids, and eyelash growth. In newborns, especially those with chubby cheeks, a mongoloid facial appearance, a narrow palpebral fissure, or an epicanthus, a lower eyelid fold is frequently observed, which is accompanied by trichiasis (turning of the eyelashes toward the eyeball) and tear pooling due to corneal trauma.
It is necessary to assess the condition of the skin of the eyelids and over the lacrimal sac projection.
In infants with congenital dacryocystitis, skin changes in this area are typically absent; skin maceration may be observed only in cases of severe epiphora and profuse discharge.
The presence of skin hyperemia, tissue infiltration, fluctuation in the lacrimal sac area, and tenderness upon palpation indicate acute inflammation of the lacrimal sac. Edema, diffuse skin hyperemia, or swelling in the lacrimal sac area may indicate the spread of the inflammatory process beyond the lacrimal sac.
The presence of a prominent, non-pulsating mass in the lacrimal sac area with bluish-purple skin overlying it (tissue distension) is characteristic of dacryocystocele.
The presence and structural features of the lacrimal puncta are determined. Often, one or all lacrimal puncta are absent or covered by an embryonic membrane in children.
It is recommended to perform palpation of the maxillofacial region (A01.07.006) when pathology of the lacrimal ducts is suspected, specifically in the projection of the lacrimal sac — a compression test to assess discharge from the lacrimal puncta [1-6].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: the compression test is performed to assess the nature and amount of pathological discharge from the lacrimal puncta and lacrimal sac. Mucus or pus from one, more often both eyes of the infant in the first weeks or months of life and a positive compression test (mucus or pus from the lacrimal puncta upon pressing on the lacrimal sac area) allow for the diagnosis of neonatal dacryocystitis. At the same time, epiphora and tear pooling may be absent: tear production in newborns is insufficiently developed, especially in premature infants.
It is recommended for all children to assess nasal breathing (visual examination of the upper respiratory tract (A01.08.002)) to determine nasal cavity patency [1-6].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended in doubtful cases for postnatal and older children to perform the canalicular test (A02.26.019), (nasal dye test, lacrimonasal test) to confirm impaired tear outflow [1-6,18,20,21].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: various types of dye tests (West's dye test, canalicular test, dye lacrimal-nasal test) consist in instilling a dye, for example, #sodium fluorescein** solution (S01JA01) (instill 1 drop of the dye into the conjunctival cavity) [1,2,20] or #colloidal silver (silver compounds D08AL) 2% topical solution, 1 drop into the conjunctival cavity [3,21] and assessing its disappearance from the conjunctival cavity or appearance in the nasal cavity. There are many variations of test procedures and result interpretations. Performing the test and evaluating the result are difficult in infants due to anatomical and behavioral features.
To determine lacrimal outflow, a dye test can be used by instilling a dye into the conjunctival sac and evaluating the time of its disappearance from the conjunctival sac.
The "double West test" consists in instilling vasoconstrictor drops into the nose before instilling the dye into the conjunctival sac. Faster disappearance of the dye from the conjunctival sac compared to the primary dye test indicates a rhinogenic nature of epiphora.
2.3 Laboratory Diagnostics
It is recommended for children with purulent dacryocystitis with discharge of pus from the lacrimal puncta in the absence of effect from standard antibacterial treatment: microbiological (culture) examination of conjunctival discharge for aerobic and facultatively anaerobic opportunistic microorganisms (A26.26.004) to identify the infectious agent and determine the susceptibility of microorganisms to antimicrobial chemotherapeutic agents (A26.30.004) [4,7].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: in more than 95% of children with neonatal dacryocystitis, pathogenic staphylococci (epidermal, golden, hemolytic, etc.) are detected, less commonly streptococcus and even Pseudomonas aeruginosa, usually sensitive to broad-spectrum antibacterial drugs.
2.4 Instrumental Diagnostics
It is recommended for children with signs of lacrimal duct obstruction in the presence of lacrimal puncta to perform probing of the nasolacrimal duct (A11.26.005) to determine the patency of the lacrimal passages or to rupture embryonic membranes in the ducts. In the absence of a positive effect from the first procedure, repeated probing is performed in 1–4 weeks [5,18].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: primary probing of the lacrimal passages in children with congenital obstruction of the lacrimal outflow tract should preferably be performed without general anesthesia at the age of 1–9 months.
Probing of the canaliculi, especially the lower one as the most functionally significant, should be extremely delicate and atraumatic, since iatrogenic trauma to the lower lacrimal canaliculus often subsequently leads to intractable epiphora. A conical probe (RZN 2024/24284 probing instrument) is used to dilate the lacrimal punctum and, slightly rotating the probe along its axis, the distal part of the lacrimal canaliculus is probed. Then the conical probe is replaced with a cylindrical probe (Bowman probe), which is inserted through the canaliculus until it rests against the bone wall of the lacrimal fossa, and then rotated vertically into the nasolacrimal duct and, advancing the probe downwards, the stenotic area of the duct is bougied. The choice of probe thickness is important: with the thinnest probes No. 0 and No. 1, one can easily perforate the wall of the canaliculus or duct and create a false passage; with probe No. 2, unintentional perforation of the mucosa is possible only by applying significant force, therefore probe No. 2 is safer, although it requires prior dilation of the lacrimal punctum. As practice shows, in neonatal dacryocystitis, the obstruction is usually located at the exit of the nasolacrimal duct into the inferior nasal meatus, less commonly combined with secondary stenosis at the site of transition of the lacrimal sac into the nasolacrimal duct.
It should be borne in mind, however, that the lacrimal outflow pathways have a complex system of valves, similar to venous ones. The lacrimal canaliculus is an uneven tube of varying diameter: at the transition of the vertical part of the canaliculus to the horizontal one, there is a funnel-shaped narrowing and a pear-shaped dilation (ampulla), near the opening into the sac there is a protrusion (Rosenmüller's sinus) and a annular valve (inferiorly – the valve of Hasner, superiorly – the valve of Rosenmüller). The walls of the canaliculi often stick together during inflammation. With non-delicate probing, the complex system of folds-valves is damaged, and subsequent scarring of traumatized tissues leads to loss of elasticity of the canaliculus – atonic, often intractable epiphora. Therefore, during probing, one should strive to straighten the profile of the canaliculus by slightly pulling the skin of the lower eyelid, without forcing the advancement of the probe, which should move smoothly in the lumen of the canaliculus without injuring the fold-valves. If the movement of the probe is difficult, it is better to remove it and repeat the attempt.
Probing of the lacrimal outflow pathways is completed by their obligatory irrigation through the upper or lower lacrimal puncta using a syringe with a cannula (lacrimal pathway irrigation cannula RZN 2018/7824). Repeated irrigations, like probing, are best performed through the upper lacrimal canaliculus, protecting the functionally more significant lower canaliculus from excessive trauma and subsequent atonic tear pooling. When the patency of the lacrimal outflow pathways is restored, the irrigation fluid passes freely into the nasopharynx.
In newborns with dacryocystocele, it is advisable to perform probing of the lacrimal outflow pathways in stages: first, the lacrimal canaliculi with evacuation of mucus from the lacrimal sac, then (within the same procedure or after 24 hours) the nasolacrimal duct with restoration of its patency.
It is not recommended to perform nasolacrimal duct probing (bougienage) a third time if the first procedures are ineffective [5].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: in some cases, initial probing may not immediately yield a positive result. To minimize treatment trauma, a second identical procedure is performed after 1–4 weeks, during which anti-infective and anti-inflammatory treatment is administered. If the second procedure is also unsuccessful, the need for additional examinations, including computed tomography of the facial skeleton (A06.03.002), and the feasibility of more complex surgical treatment should be considered.
2.5 Other Procedures
It is recommended that children with dacryocystitis who show no response to repeated probing (bougieing) of the lacrimal ducts, or who have malformations of the facial skeleton and soft tissues of the middle third of the face regardless of age, undergo computed tomography of the facial skeleton (A06.03.002) and contrast dacryocystography (A06.26.007) to determine further differentiated treatment tactics [5,10,11,18].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: in case of lacrimal punctum atresia and absence of signs of dacryocystitis, computed tomography of the facial skeleton (A06.0.3002.) may be performed to detect malformations of the orbits, nasal cavity, and paranasal sinuses.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
Treatment is aimed at eliminating infectious inflammation, restoring the patency of the lacrimal outflow pathways, or forming bypass routes for tear outflow.
3.1 Conservative Treatment
It is recommended that children with symptoms of dacryocystitis undergo daily massage—compression of the lacrimal sac directed toward the nasolacrimal duct [3,5-7,18].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: lacrimal sac massage is a pressure massage in which the contents of the lacrimal sac are forced toward the lower end of the nasolacrimal duct. To do this, a finger is placed over the lacrimal sac area and pressed so that the contents of the lacrimal sac do not escape through the lacrimal punctum.
Massage of the lacrimal sac area is contraindicated in dacryocystocele, skin redness and maceration, and swelling in the lacrimal sac area. Lacrimal sac massage is combined with antimicrobial therapy. Therapeutic lacrimal sac massage is not performed in children with acquired dacryocystitis.
It is recommended to prescribe local therapy (instillations, ointments) with antimicrobial drugs (S01A)—broad-spectrum antiseptics/antibiotics—for children with purulent discharge in order to stop the infectious process and inflammation [1,3-5,6,7].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: antimicrobial agents (S01A) may be prescribed locally as instillations into the conjunctival sac: picloxydine (S01AX16) for children from birth; antibiotics (S01AA) — tobramycin (S01AA12 ) from the age of 2 months, netilmicin (S01AA23) from the age of 3 years; fluoroquinolones (S01AE) — ciprofloxacin** (S01AE03) for children from birth; ofloxacin**, levofloxacin** (S01AE05) from the age of 1 year.
All medications are instilled after toilet of the eyelids and removal of pus from the conjunctival sac.
It is advisable for children with exacerbation of chronic dacryocystitis, provided the lacrimal puncta are present and the patency of the lacrimal ducts is restored, to undergo a course of lacrimal pathway irrigation (A11.26.004) with systemic antibacterial drugs (J01) (1–3 sessions).
It is recommended for children with signs of acute purulent dacryocystitis and signs of abscessing/phlegmonous inflammation to use local antimicrobial drugs (S01A)—antibacterial/antiseptic agents in the form of instillations and eye ointments—in combination with systemic antibacterial drugs (J01) [3,5-7].
Level of Evidence CGrade of Recommendation 5Level of Evidence C (reliability of evidence – 5)
If conservative treatment fails within 2 weeks, surgical treatment is indicated [3,5-7].
3.2 Surgical Treatment
It is recommended that children with congenital nasolacrimal duct stenosis and dacryocystitis of the newborn undergo nasolacrimal duct probing (A11.26.005) / bougieing if conservative treatment is ineffective [2,4-8,11,12,18,19].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: it is recommended to perform lacrimal pathway probing in children with congenital obstruction of the lacrimal outflow pathways aged 1–9 months without general anesthesia, and at the age of over 9 months with general anesthesia.
It is recommended that children with recurrent narrowing of the nasolacrimal duct undergo nasolacrimal duct probing (A11.2.005) with lacrimal duct intubation (A16.26.007.002) using stents (including ophthalmic microdrains for correction of lacrimal outflow pathways — lacrimal duct tube - 186060; Lacrimal duct intubation set - 186120) to prevent scarring [2,4-8,11,12,14,15].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: various techniques of lacrimal outflow pathway intubation are possible.
Depending on the type, they are divided into monocanalicular and bicanalicular. Monocanalicular intubation involves passing a stent through one (lower or upper) lacrimal canaliculus, the nasolacrimal duct, and the nasal cavity. Part of the stent remains on the facial surface. Bicanalicular intubation involves passing a stent through both canaliculi, the nasolacrimal duct, and the nasal cavity. In this case, the stent does not remain on the facial surface.
Microdrains (stents) are made of silicone or polyurethane.
Various guides included in lacrimal intubation sets (including 186120 – Lacrimal Duct Intubation Set) are used to pass the stent through all segments of the lacrimal outflow pathways.
The duration of stent residence in the lacrimal ducts ranges from 1 week to 6 months.
It is recommended to perform dacryocystorhinostomy (A16.26.009) in children with recurrent dacryocystitis in the absence of a positive effect from conservative treatment and with anatomical preservation of the nasal cavity [2,4,5,6,7,8,11,12].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: if the necessary conditions are met, dacryocystorhinostomy can be performed via an endoscopic approach: dacryocystorhinostomy using endoscopic techniques (A16.26.009.001), dacryocystorhinostomy with intubation using endoscopic techniques A16.26.009.002.
Endoscopic dacryocystorhinostomy is performed provided there is sufficient technical equipment by an ophthalmic surgeon with appropriate skills.
External DCR is performed after the purulent-inflammatory process subsides. Endoscopic DCR may be performed during active purulent dacryocystitis [5,16].
In case of pronounced insufficiency of the horizontal and/or vertical parts of the lacrimal drainage system of congenital or acquired origin, conjunctivodacryocystostomy, conjunctivorhinostomy (A16.26.010), lacocystostomy with permanent intubation (A16.26.010.001), or lacorhinostomy with lacrimal prosthesis implantation (A16.26.010.002) may be performed [3].
Treatment timeline:
Possible treatment timeframes:
- massage: at any age upon detection of delayed tear outflow,
- antibacterial treatment: at any age in the presence of pus,
- probing under topical instillation anesthesia: at 1 - 9 months of age,
- probing under general anesthesia: over 9 months of age,
- probing with lacrimal drainage system intubation: under general anesthesia - over 3 months of age,
- DCR, DCT: under general anesthesia - over 3 years of age.
Medical nutrition therapy is not used.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended to conduct an appointment (examination, consultation) with an ophthalmologist (initial, follow-up) for all patients with congenital pathology of the lacrimal drainage system to assess the effectiveness of the ongoing treatment and determine further management tactics [1,2,5,6,18].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended for all patients after nasolacrimal duct probing or surgical intervention to locally prescribe antimicrobial agents (S01A) to prevent infectious complications [1,2,4,5,8,16].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: prior to obtaining laboratory test results, identification of the flora of the eyelid conjunctiva discharge and its sensitivity to antibiotics, it is recommended to start flushing the conjunctival sac (A21.26.019) of newborns and young children using minimally toxic, non-allergenic antimicrobial drugs (other antimicrobial drugs (S01AX; S03AA): picloxydine (S01AX16) – in children from 0 years of age, 1 drop 2–6 times a day, duration of treatment 10 days) [1,4].
5. Prevention and Dispensary Observation
There are no prevention methods.
6. Organization of Medical Care
The pediatrician or general practitioner (family physician) refers the patient, upon complaints of lacrimation or pus discharge, to an ophthalmologist at an ophthalmology office.
Initial diagnostics are performed by the ophthalmologist at the ophthalmology office.
The ophthalmologist at an ophthalmology consultation office, if necessary, refers the patient for a consultation with an ophthalmologist at an inpatient ophthalmology department.
Nasolacrimal duct probing under topical instillation anesthesia is performed by an ophthalmologist in a treatment room, outpatient operating room, on an outpatient basis, or in a day hospital.
Complex surgical interventions are performed by an ophthalmologist in an inpatient ophthalmology setting.
Indications for admission to an ophthalmological hospital: on an emergency basis for the treatment of phlegmonous or abscess-forming dacryocystitis, and on a planned basis for complex surgical intervention.
Indications for patient discharge from the ophthalmology inpatient department: absence of complications, absence of purulent inflammation.
7. Additional Information
No additional information.
Criteria for Evaluating the Quality of Medical Care
References
Show references
Brzhesky V.V. Pathology of the lacrimal apparatus in newborns // Neonatal Ophthalmology: A Guide for Physicians / Ed. by V.V. Brzhesky, D.O. Ivanov. - Moscow: GEOTAR-Media, 2021. P. 127-165.
Brzhesky V.V., Kalinina I.V., Chistyakova M.N., Obodov V.A. Epiphora in children (diagnosis and treatment principles) // Selected Chapters in Pediatric Clinical Ophthalmology / Ed. by E.E. Somov. - St. Petersburg: "Chelovek", 2016. - P. 103-128.
Cherkunov B.F. Diseases of the Lacrimal Organs. — Samara, 2001. — P. 34-36, 201–296.
Arestova N.N. Dacryocystitis of newborns. Selected Lectures on Pediatric Ophthalmology: Ed. by V.V. Neroev. M.: GEOTAR-Media, 2009; p. 9-26.
Shkolnik Sergey Filippovich. Minimally invasive technologies in the diagnosis and treatment of dacryostenosis and inflammatory diseases of the lacrimal drainage tract : Dis. ... Doctor of Medical Sciences : 14.01.07 ; 14.01.03 / Shkolnik Sergey Filippovich - Moscow, 2020. — 300 p.
Chinenov I.M. Pathology of the lacrimal organs / I.M. Chinenov // Ophthalmology: Textbook ed. by E.I. Sidorenko. – M.: GEOTAR-Media, 2005. – P. 143–153.
Galeeva G.Z., Samoylov A.N., Musina L.T. Differentiated approach to the treatment of various clinical forms of neonatal dacryocystitis. Russian Pediatric Ophthalmology. 2013; No. 2: p. 22-26.
Markova E.Yu., Valyavskaya M.E. Modern aspects of nasolacrimal duct probing in its congenital stenosis. Russian Pediatric Ophthalmology. 2017. No. 2. P. 20-26.
Valyavskaya M.E., Ovchinnikova A.V., Markova E.Yu., Rogatkin P.S. Computed tomography in choosing treatment tactics for children with lacrimal drainage disorders. Ophthalmology. 2014. Vol. 11. No. 3. P. 52-55.
Comparative diagnostic value of virtual endoscopy and textual descriptions of computed tomography of the lacrimal pathways in planning and performing endonasal endoscopic dacryocystorhinostomy. Ageev A.N., Dergilev A.P., Obodov V.A., Obodov A.V. Siberian Medical Bulletin. 2021. No. 3. P. 10-18.
Variant radiation anatomy of the lacrimal sac visualized by non-contrast computed tomography. Ageev A.N., Dergilev A.P., Obodov V.A. Journal of Radiology and Nuclear Medicine. 2016. Vol. 97. No. 1. P. 14-19.
Young JD, MacEwen CJ, Ogston SA. Congenital nasolacrimal duct obstruction in the second year of life: a multicentre trial of management. Eye (Lond). 1996;10:485–91.
Miller AM, Chandler DL, Repka MX, Hoover DL, Lee KA, Melia M, et al. Pediatric Eye Disease Investigator Group: office probing for treatment of nasolacrimal duct obstruction in infants. J AAPOS. 2014;18:26–30
Congenital nasolacrimal duct stenosis. Valyavskaya M.E., Ovchinnikova A.V., Markova E.Yu. Russian Pediatric Ophthalmology. 2014. Vol. 9. No. 1. P. 49-52.
Results of temporary nasolacrimal duct intubation in children. Valyavskaya M.E., Ovchinnikova A.V. Russian Pediatric Ophthalmology. 2013. No. 3. P. 48-50.
Shlyakhtov M.I., Naumov K.G., Krushinin A.V. Endonasal dacryocystorhinostomy as a method of treatment for acute abscess-forming dacryocystitis. // Otrazhenie No. 1-2 (10) 2020, p. 45-49
Taylor, D. Pediatric Ophthalmology / D. Taylor, C. Hoyt; transl. from English under the general editorship of E.V. Egorova. – M.: BINOM, 2007. – 246 p.
Shimko, Yu.N. Optimization of diagnostics and treatment of lacrimal drainage system pathology at the outpatient stage: Abstract of the diss. … cand. med. sci.: 14.01.07. M., 2011. – 23 p.
El-Mansoury, J. Results of late probing for congenital nasolacrimal duct obstruction / J. El-Mansoury, J.H. Calhoun, L.B. Nelson, R.D. Harley // Ophthalmology. – 1986. – Vol. 93, № 8. – P. 1052–1054.
Ophthalmology: National Guidelines / Ed. by S.E. Avetisov, E.A. Egorov, L.K. Moshetova, V.V. Neroev, H.P. Takhchidi. – 2nd ed. – M.: GEOTAR-Media, 2024. – 904 p. – (National Guidelines Series).
Shamshinova A.M., Volkov V.V. Functional research methods in ophthalmology: - M.: Meditsina, 1998. – P.
Appendix A1. Working Group Composition
Arestova N.N., MD, Leading Researcher, Ophthalmologist at the National Medical Research Center for Eye Diseases named after Helmholtz of the Russian Ministry of Health, member of the All-Russian Public Organization "Association of Ophthalmologists".
Brzhesky V.V., MD, Professor, Head of the Department of Ophthalmology at the Saint Petersburg State Pediatric Medical University, member of the All-Russian Public Organization "Ophthalmological Society of Russia", All-Russian Public Organization "Association of Ophthalmologists".
Kataev M.G., MD, Professor, Head of the Department of Reconstructive, Plastic and Restorative Surgery at the National Medical Research Center "S.N. Fyodorov Eye Microsurgery Complex" of the Russian Ministry of Health, member of the All-Russian Public Organization "Ophthalmological Society of Russia".
Prisich N.V., Ophthalmologist at the Saint Petersburg State Pediatric Medical University, member of the All-Russian Public Organization "Ophthalmological Society of Russia".
Starikova A.V., PhD in Medicine, Ophthalmologist, Head of the Ophthalmological Department of Pediatric Surgery at the National Medical Research Center for Eye Diseases named after Helmholtz of the Russian Ministry of Health, member of the All-Russian Public Organization "Association of Ophthalmologists".
Shkolnik G.S., PhD in Medicine, Ophthalmologist at the Cheboksary Branch of the National Medical Research Center "S.N. Fyodorov Eye Microsurgery Complex" of the Russian Ministry of Health, member of the All-Russian Public Organization "Ophthalmological Society of Russia".
There is no conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
1. Pediatricians.
2. General practitioners (family doctors).
2. Ophthalmologists.
3. Otorhinolaryngologists.
Methods used for evidence collection/selection: search in electronic databases, analysis of modern scientific developments on the problem of congenital pathology of the lacrimal pathways in Russia and abroad; generalization of practical experience of Russian and foreign specialists; library resources. Description of methods used for evidence collection/selection: the evidence base for the guidelines includes publications included in the Cochrane Library, EMBASE and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on this topic. The search depth was 10 years. Methods used to assess the quality and strength of evidence: expert consensus, significance assessment according to the rating scheme.
Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic review of randomized clinical trials using meta-analysis |
2 | Individual studies with reference standard control or individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials, using meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials using meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Current package leaflets for the drugs mentioned in these clinical guidelines can be found on the website http://grls.rosminzdrav.ru
International Classification of Diseases, Injuries and Causes of Death, 10th Revision (ICD-10). World Health Organization.
Nomenclature of medical services. Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017 "On approval of the nomenclature of medical services".
Federal Law No. 323-FZ of November 21, 2011, "On the Fundamentals of Health Protection of Citizens in the Russian Federation."
Procedure for providing medical care to children with diseases of the eye, its adnexa and orbit. Order of the Ministry of Health of the Russian Federation No. 442n dated October 25, 2012 "On approval of the Procedure for providing medical care to children with diseases of the eye, its adnexa and orbit".
List of Vital and Essential Medicines for Medical Use for 2025. Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019 (as amended on January 15, 2025) "On Approval of the List of Vital and Essential Medicines for 2025, as well as Lists of Medicines for Medical Use and the Minimum Assortment of Medicines Required for Medical Care".
Order of the Russian Ministry of Health No. 205n dated May 2, 2023 (as amended on December 4, 2023) "On approval of the Nomenclature of positions of medical workers and pharmaceutical workers".
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Parents are informed about the causes of lacrimal drainage delay and the appearance of purulent discharge, the sequence and conditions of therapeutic measures, the need to consult a doctor in case of activation of the inflammatory process, the likelihood of additional, more complex diagnostic and treatment methods, and are trained in lacrimal sac massage.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
None.