**6. Lacrimal system disorders in children**

Unlike many insidious and asymptomatic ocular pathologies in children lacrimal system disorders alert parents immediately, because of an obvious watering eye with adherence of the lashes and with a mucoid discharge. Congenital nasolacrimal duct obstruction is the main etiology of epiphora in the pediatric age group.

#### **6.1 Congenital nasolacrimal duct obstruction**

The nasolacrimal duct is the continuation of the lacrimal sac. It opens into the nasal meatus. Its final end is partially covered by a mucosal fold called the valve of Hasner. This final

The ROP can be categorized as active and chronic disease. Active disease is the ROP diagnosed at the early months of infancy. Most of the cases regress spontaneously. The role of an ophthalmologist is to recognize the more severe cases with the risk of progression and to apply treatment in the indicated cases. Ridge formation in the periphery of the retina is a feature of early ROP. Ridge is a fibrovascular tissue, developed as a response to hypoxia. Retinal bleeding and/or tractional retinal detachment may occur, if the disease progresses. In 20% of the babies with active ROP, chronic sequels of the disease may evolve. Most of these are innocuous, but fibrovascular tissues leading to macular distortion or retinal detachment may also develop. These may result in visual loss or even total blindness.

Screening by an ophthalmologist is recommended for infants with a birth-weight of ≤1500 grams and/or ≤31 weeks of gestation. The time for screening is 4-7 weeks postnatally. There is inconsistency in the literature regarding the screening protocols. Protocols including more

Argon laser photocoagulation is performed in babies with threshold disease. Threshold disease is defined as 5 contiguous clock hours or 8 total clock hours of extraretinal neovascularisation located at or near the macula, which is the critical region of the retina for vision. Plus disease is also a feature of the threshold disease. It is defined as sausage like dilatations of the vessels around the optic disc, as a response to hypoxia. Posterior segment surgeries are indicated if retinal detachment occurs. The outcomes after laser therapy are successful in 85% of the cases, but they are not promising after surgery. Laser ablation of the avascular retina is applied to halt the progression of ROP. VEGF inhibitors alone or combined with laser therapy or surgery may be injected into the eyes to stop or slow the

Pediatricians must be aware of the association between refractive disorders, amblyopia and strabismus in early or late childhood period and ROP. The risk of developing these disorders is correlated with the severity of ROP, but it still exists in regressed ROP cases with no sequel according to some literature. Therefore all ROP cases must be routinely

Unlike many insidious and asymptomatic ocular pathologies in children lacrimal system disorders alert parents immediately, because of an obvious watering eye with adherence of the lashes and with a mucoid discharge. Congenital nasolacrimal duct obstruction is the

The nasolacrimal duct is the continuation of the lacrimal sac. It opens into the nasal meatus. Its final end is partially covered by a mucosal fold called the valve of Hasner. This final

mature babies may be designed for developing countries (Basmak, 2009).

referred to an ophthalmologist to screen for these possible associations.

**5.2 Clinical presentation** 

**5.3 Screening** 

**5.4 Management** 

progression of the disease (Erol, 2011).

**6. Lacrimal system disorders in children** 

main etiology of epiphora in the pediatric age group.

**6.1 Congenital nasolacrimal duct obstruction** 

lower part of the canal at the level of the valve of Hasner, is not completely developed in some of the neonates. This developmental delay present in one fifth of the neonates. Spontaneous resolution of epiphora occurs in more than 90% of the cases within a year, after completion of the lower end of the canal (Ballard, 2000).

#### **6.2 Differential diagnosis of epiphora in children**

Amniontocele (congenital dacryocele), punctual atresia or fistulae between the sac and the skin are other rare etiologies for epiphora. Amniotecele is characterized by a blue-green distention of the lacrimal sac, observed externally at the level of inner canthus. It is due to an imperforate valve of Hasner. Amniontocele is mostly self limiting within a few days of birth, especially if massage is applied (Rose, 2000).

Fig. 2. Left dacryocele

#### **6.3 Management of congenital nasolacrimal duct obstruction**

Spontaneous resolution is usual, so conservative treatments including antibiotic drops and massage of the lacrimal sac region is preferred within the first year of life. The index finger is put over the inner canthal region and the massage is applied firmly downwards. Three strokes of massage, 3-4 times per day are recommended. Early intervention is indicated if recurrent dacryocystitis occur before the first year of age.

Probing of the nasolacrimal canal under general anesthesia is performed if epiphora persists beyond the first year of age. Probing is performed to disrupt the obstructive membrane at the level of valve of Hasner mechanically. The success rate of probing is very high. If it fails, the probing can be repeated once more. If epiphora persists after 2 technically satisfactory probing, more invasive procedures, including silicon tubes implantation, balloon dilatation of the nasolacrimal duct or dacryocystorhinostomy should be considered (Rose, 2000).

Dacryocystorhinostomy is an invasive surgery, which involves anastomosing the lacrimal sac to the middle meatus by the removal of the lacrimal bone, is the gold standard treatment in adults, whereas it is usually the final treatment alternative in the pediatric age group.
