Nasolacrimal Duct Obstruction (NLDO) in neonates
Summary
- NLDO is a common congenital cause of a sticky, watering eye in newborns caused by failure of distal canalization (valve of Hasner).
- Most cases are benign and resolve spontaneously; approximately 80-90% clear by 12 months.
- First‑line management in the ED is conservative care, parental education, safety‑netting and selective topical antibiotics only for suspected bacterial infection.
- Urgent ophthalmology/ENT review is required for red‑flag presentations (see below). (NIPE; NICE IPG113)
Pathophysiology and natural history
- The distal nasolacrimal duct normally canalizes late in fetal life; a persistent membranous obstruction at the valve of Hasner produces tear stasis, mucoid pooling and secondary mucopurulent discharge.
- Tear stagnation predisposes to superficial bacterial overgrowth and, rarely, to dacryocystitis or periorbital cellulitis if infection spreads.
Typical presentation
- Unilateral or bilateral persistent epiphora with sticky, mucopurulent discharge and eyelid crusting, often worse on waking.
- Infant usually well, feeding normally, and without fever or systemic toxicity.
- Examination typically shows a clear cornea, normal pupils and full eye movements; conjunctiva may be mildly injected but not markedly red or painful.