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Blocked Tear Ducts

NLDO in Taj

Gunk…not exactly a medical term, but a descriptive one nonetheless. Any parents out there reading this are probably familiar with the following scenario.  After the trauma of childbirth (for mom, that is), you feel so blessed to hold your child close and the first thing you do is make sure everything on him/her is perfect.  Then, a day or two later, you may notice that there’s a lot of mucus in your infant’s eye, maybe even so much to cause it to stick shut.   The eye is constantly wet with tears.  Is it an infection?  Do you need antibiotics?

What I described is a blocked tear duct, or ophthalmologists refer to it as a neonatal lacrimal duct obstruction(NLDO).   Both of my sons suffer from this condition.  Nikhil is now 2.5 years old and his is much better, but Taj’s is actually pretty bad.  The good news is that it isn’t an infection and it isn’t contagious.  There are some things that parents can do to help improve matters and lessen the tearing.  I wanted to post on this topic since Taj currently has this and I have been treating him at home.  Just yesterday, my husband, Dr. Jeff Wong, turned to me and asked “How do you do the massage thing again?”  And I thought, if he (a well trained ophthalmologist) can’t remember how to do the massage, then, for sure my patients’ parents may be forgetting as well.

First, what is a blocked tear duct?

The tears are constantly manufactured by glands within the eyelids. After lubricating the eye, the tears normally drain into two small holes (“puncta”) located on the inner corner of the upper and lower eyelids. Look in the mirror and you can find these puncta on your own eyelids.  From there, the tears drain into the back of the nose via the tear duct (a.k.a. nasolacrimal duct). This is why we tend to have a runny nose when we cry! Infants with a nasolacrimal duct obstruction typically have a blockage at the most distant end of the duct immediately before it empties into the nose

Blockage at the end of lacrimal duct

 

Approximately six percent of all infants are born with a nasolacrimal duct obstruction (tear duct blockage) affecting one or both eyes. Fortunately, the good news is that at least 90% of these obstructions will clear without treatment within the first year of life.

What are the signs of a blocked tear duct?

As the tears have nowhere to drain, they will well up on the surface of the eye and often overflow onto the eyelashes, lids and cheek. Normally there are bacteria in the tears and now these have nowhere to drain when a blockage is present. These bacteria tend to grow within the tear duct and cause a pus-like discharge from the inner corner of the eye and on the lashes — frequently observed when the child awakens.

It is important that see your pediatrician or pediatric ophthalmologist for a correct diagnosis.  There are other serious and vision threatening conditions which can cause tearing in a newborn and those need to be ruled out.

Here’s picture of Taj.  See the yellow crusting mucous in the corner of his left eye and on his eyelashes causing them to stick together?  Even though it looks troubling, it doesn’t bother him one bit, which is very normal.

So, what can be done?

Since these obstructions resolve by the time the baby is 12 months old, I manage the condition very conservatively.  I typically recommend the following:

  • Crigler massage (see video down below).  This is basically massage of the tear duct to get it to open up and create a patent system for the tears to flow.  To perform the massage, use your index finger in the corner of the eye, right below the eye and roll the finger downwards over the bony ridge towards the nose.  This has been proven to work.  Success rates in published studies range anywhere from 30-90%.  Do this three times a day.  It’s easy, free and doesn’t harm the baby, isn’t that the best treatment?  You can see in the video, sometimes it’s tricky performing the massage in an infant (in my case, Taj always seems to think my finger is more food for him).  Usually I will use my other hand to stabilize his face, but for the video, it was getting in the way of the shot of Taj’s face, so that’s why he’s moving around so much.
  • Warm compresses
  • Antibiotic drops – these will need to be administered by your pediatric ophthalmologist if there is a lot of green-pus discharge.  I typically recommend erythromycin ointment  and it’s what I’ve been using intermittently on Taj
  • Breastmilk – This is not a medical recommendation, and I’m going to preface this. A lot of old folklore, Ayurvedic medicine and maybe even your Hawaiian auntie down the street has recommended breastmilk for everything.  Breastmilk has a lot of wonderful properties, one of which is that it contains IgA, a type of antibody.  The theory is that squirted into the eye, the breastmilk prevents the adhesion of bacteria to the eye and decreases the discharge.  I only found one published study as to the effectiveness of breastmilk and because the journal was a bit obscure (Journal of Pediatric Tropical Medicine), I wasn’t able to read the full article to evaluate it.  However, I will say that one of the pediatricians who routinely refers to me was always recommending this to her patients and I thought this weird.  Yes, I know my background is Indian and I should be down with the Indian home remedies, but I usually require hard published data before I change my practice style.  But, Taj’s eye was pretty bad.  The antibiotic ointment wasn’t doing too much, so I figured, why not give the breastmilk a try.  And, I have to admit, it really improved things for Taj.  The swelling and amount of discharge lessened considerably.
  • Probing and irrigation.  This is surgery.  I pass tiny smooth wire probes through the tear duct and into the nose, in order to open up the passageway.  For adults, we can do this procedure in the office, but obviously a baby is not going to stay still for you to insert long thin metal probes in the eyelids, so this must be done in the operating room under general anesthesia.  It only takes about 5 minutes and usually cures the condition.  I only do this surgery if the baby is older than 12 months because as I mentioned earlier, 90% of the time, the blockage will clear itself so why put your child through the risk of general anesthesia if not necessary?  That being said, this is probably one of the most common procedures that pediatric ophthalmologists perform.  It’s very safe and effective. There are no incisions or scarring from this operation and there is no significant post-operative discomfort.  Just see here for a post by a patient’s mother about the procedure.

Here is what the probes look like.  I start out using the tiniest diameter probe (on the left hand side) and then increase the size, confirming that I’ve opened up the passageway.  Sometimes, if the child is older (older than age 2), then I may also insert a silicone tube to keep the duct open.  I remove this 3-6 months later.  The tube is extremely small and pliable and children do not feel it at all.

So, if your child is like mine – a newborn diagnosed with a lacrimal duct obstruction, don’t worry, 9 times out of 10, this will get better all on its own.  It resolved with Nikhil,  but, if it doesn’t, the surgery is minimally invasive and painless and that’s a reason to jump with joy.

 

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2012 – Year in Review

It will definitely take me another month to get used to writing 2013 as I sign charts in the office.  Unbelievable how fast 2012 went by.  And, a lot was accomplished in 2012 at Honolulu Eye Clinic.  Here’s a little recap of our favorite moments/accomplishments of 2012!

1. Our office renovation was begun and completed (though almost wasn’t completed!).  Amidst a contractor who declared bankruptcy mid-way through our project and the fact that I was coordinating everything while on maternity leave, somehow our renovation was finished.  Click here to see our fist blog about demolition (I was so excited and naive to think things would be completed without a hitch!).  And, click here for the post about the progress.  If you haven’t been in yet for your annual eye exam, here’s a look at the finished office.

2.  Jeff and I made the Best Doctors in Hawaii list and were featured on the cover of Honolulu magazine.  Click here to read about the photoshoot.

3.  We had 2 glasses trunk shows (Gucci/Dior and Fendi/Valentino).  Below are pics from the latest trunk show.

 

4. We were featured in Midweek twice – in the Business Roundtable section and the Doctor in the House section.

5. Taj (my second son), turned one !

6.  We added some amazing staff members to our HEC ohana (Summer, Amalis, Amber, Michelle, Jocelyn, Lauren, and Sam join verteran HEC staff – Lia and Grace).  See how we’ve grown over the past 4 years!

[caption id="attachment_762" align="aligncenter" width="639" caption="September 2009 (one year)"][/caption] [caption id="attachment_761" align="aligncenter" width="640" caption="August 2010 (two years)"][/caption]

 

[caption id="attachment_760" align="aligncenter" width="695" caption="April 2011 (2.5 years)"][/caption] [caption id="attachment_759" align="aligncenter" width="695" caption="April 2012 (3.5 years)"][/caption]

 

[caption id="attachment_763" align="aligncenter" width="695" caption="November 2012 (4.25 years!)"][/caption]

 7.  I published my first textbook on strabismus surgery.

8.  We had 4 cosmetic open house events, including the very successful Mommy Makeover event.  Below are pics from our last one in December – Gold Medal Glam – Beauty for Athletes.

 

9.  421 likes on Facebook.

10.  Judged the Miss Chinatown competition this past fall and met some amazing young leaders in our community.

Thanks to all of our patients, friends and family for your support throughout the year!

The end is in sight

Our renovation is almost over – thankfully!  Thanks to all of our patients who have endured the chaos, mess and cramped temporary reception area as we have renovated over the past 2 months.  Our HEC patients are so great – they tolerated sitting on the ground, their charts being misplaced and all sorts of blunders as we tried to cope with seeing patients while renovating.

Of course, the reno was supposed to be done on Feb 1, by the time I returned from maternity leave.  And, of course, that didn’t happen.  Demolition only began on January 23, so there was no way that it was getting done in a week.  We have never renovated anything before and this was certainly a learning experience.  Lots of delays, items that we had to make sure were done properly.  But, we are getting very excited – the new space will certainly now be large enough to accommodate all of our patients.  Below is a sneak peek at the office.  We have started using the reception area even though we are still waiting for the granite to be installed and there’s a laundry list of items that still need to be completed.  The end is in sight!  Anyone out there survived a recent renovation of your home or office?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[caption id="attachment_391" align="alignright" width="695" caption="Even baby Taj is helping clean the new shelves!"][/caption]

The demolition has begun!

After many months of planning and delays, our renovation project is now officially underway.  For some time now, we have realized that we are outgrowing the current layout of our waiting room and optical shop.  Friday was our first day of demolition and it was amazing to see just how fast our entire waiting room, optical shop and reception area could be dismantled!  I made sure to emphasize the importance of proper eye protection to the demo crew (do you know how many nails in the eyes we see as ophthalmologists?  One is enough!)  Don’t worry, we are still open our regular hours.

Here is the way our waiting room/optical shop/reception used to look like. Say goodbye to the teal and mauve color scheme that was so characteristic of the late 80’s/ealy 90’s.

 

[caption id="attachment_263" align="aligncenter" width="640" caption="Our old optical shop"][/caption]

Gone is the pink laminate and pink wallpaper! And the stained (despite the fact that we steam cleaned it annually) grey-raspberry-teal carpet?  Ripped out!  Though in all fairness, everything has held up very well over the last 21 years.

 

 

 

 

 

 

 

 

So, you may be asking yourself how do you enter Honolulu Eye Clinic now for your eye exam?  We have erected a temporary reception and waiting room.  When you come to our usual office door, you’ll be greeted by this sign.

Follow the hallway all the way to the end and you’ll get to the back entrance of our office which leads to our temporary reception desk (this used to be the nursery and will return to Taj once renovations are complete).  

The pediatrics waiting room has been converted into the regular waiting room, along with the optical shop.

[caption id="attachment_272" align="aligncenter" width="640" caption="Our temporary optical shop"][/caption]

 

We still carry all of the 650+ frames that we used to, they’re just organized in cabinetry now in the smaller space, so don’t worry that you won’t find what you need.  Thanks in advance to everyone for their patience while we renovate our office.  The new waiting room/optical will have an expanded optical shop and more room at reception to decrease patient wait times to check in and check out.