Congenital nasolacrimal duct obstruction — formative SAQs

SAQ 1 (10)

A ten-week-old is brought in because the right eye has been watering for a month and is sticky in the morning, the lashes glued by a yellow crust. The watering is worse during a cold and quieter between episodes. On examination the eye is white and quiet, there is reflux of mucopurulent material on firm pressure over the lacrimal sac, the red reflex is normal and the cornea is clear and of normal diameter. The infant is otherwise well and growing. [4]

a) State the most likely diagnosis and the single most important mimic to exclude, naming the bedside features that separate them. (3 marks) [4]

b) Outline the first-line management, naming the specific technique and its frequency, and explain why topical antibiotics are not routine. (3 marks) [4]

c) Explain the probing-timing controversy, drawing on the natural history and the procedural-success data, and state when you would offer probing. (2 marks) [2] [5]

d) Describe two safety-net features that would bring the family back urgently, and explain why each is not a simple duct obstruction. (2 marks) [4]

SAQ 2 (10)

A one-year-old with known left nasolacrimal duct obstruction returns with a one-day history of a tender, red, swollen mass at the inner canthus of the left eye, a fever and irritability. Separately, in the same clinic, a midwife refers a two-day-old with a blue-grey cystic swelling just below the medial canthus of the right eye who is feeding slowly and intermittently grunting. [4]

a) For the one-year-old, name the complication, the immediate management, and the reason massage is avoided at this stage. (3 marks) [4]

b) For the newborn, name the diagnosis, the immediate priority in assessment, and the reason it is an emergency rather than a watchful-waiting problem. (3 marks) [10]

c) Contrast the disposition of these two infants with the conservative management of the ten-week-old in SAQ 1, explaining what changes the threshold from reassurance to urgent referral. (2 marks) [4] [10]

d) Outline the stepwise procedural options for a child whose simple obstruction has not resolved by the planned review, naming each step and the indication that triggers escalation. (2 marks) [5] [2]