A constantly watery eye is not just an inconvenience. In babies it is almost always treatable without surgery. In adults it deserves proper investigation. Either way, the solution exists.

The nasolacrimal duct is the channel that drains tears from the eye into the nose, which is why your nose runs when you cry. When this channel is blocked or narrowed, tears can’t drain properly and overflow onto the cheek. This is nasolacrimal duct obstruction (NLDO). It is one of the most common eye conditions in newborns, affecting around 6 percent of infants. It also occurs in adults, usually from ageing, chronic inflammation, or anatomical narrowing. Management differs considerably between the two age groups, but in both cases the condition is very treatable.

What You Need to Know About NLDO

In newborns, NLDO is almost always caused by a thin membrane that hasn’t yet opened at the lower end of the duct. Around 90 percent resolve without surgery in the first year of life
In adults, NLDO is usually caused by gradual narrowing from chronic inflammation, infection, or age-related changes
The main symptom in both groups is a constantly watery or sticky eye, often worse in cold or windy weather
In infants, gentle massage of the lacrimal sac (Crigler massage) is the first-line treatment and is effective in many cases
Probing and syringing under general anaesthetic resolves the obstruction in the majority of infants who don’t improve spontaneously
In adults, dacryocystorhinostomy (DCR) surgery creates a new drainage channel and has a very high success rate

Infant prevalence ~6% Of newborns have nasolacrimal duct obstruction at birth

Resolution rate 90% Of congenital cases resolve without surgery by age 12 months

DCR success rate 90-95% Of adult patients achieve lasting resolution after surgery

How the Tear Drainage System Works

Tears are produced by the lacrimal gland and spread across the eye surface with each blink. They drain away through two tiny openings called puncta, one on each eyelid at the inner corner. From there, tears flow through narrow channels called canaliculi into the lacrimal sac, which sits in a small bony hollow at the inner corner of the orbit. The lacrimal sac connects to the nasolacrimal duct, which runs down through the bone of the face and opens into the nose beneath the inferior turbinate.

Vector illustration of the tear drainage (see the <a href= — Tears drain from the puncta through the canaliculi, into the lacrimal sac, and down the nasolacrimal duct into the nose. A blockage anywhere along this path causes overflow tearing.

When any part of this system is blocked, tears overflow onto the lower eyelid. The lacrimal sac can also become a reservoir for bacteria, leading to recurrent infections and a sticky mucous discharge. In some cases the lacrimal sac becomes acutely infected (dacryocystitis), causing a painful red swelling at the inner corner that needs antibiotic treatment.

Congenital NLDO: In Babies and Infants

Why it happens

In the developing fetus, the nasolacrimal duct forms as a solid cord of cells that gradually hollows out. At the lower end, a thin membrane called the valve of Hasner normally opens just before or shortly after birth. In around 6 percent of newborns, this membrane remains intact, blocking the lower end of the duct. The baby’s eye looks normal but produces a persistent watery discharge, often with mucous crusting at the inner corner, particularly after sleep.

Most cases resolve on their own

The majority of congenital NLDO resolves spontaneously as the membrane naturally opens during the first year of life. Around 90 percent of affected infants clear up by 12 months without any surgical intervention. That figure is worth repeating, because a lot of parents arrive expecting to hear the word surgery. The parents’ role during this period is to keep the eye clean and to perform Crigler massage, which helps accelerate resolution and reduces the frequency of discharge and infection.

Crigler massage

Crigler massage applies pressure to the lacrimal sac to increase hydrostatic pressure within the duct and encourage the obstructing membrane to open. It is performed several times a day and takes only a few seconds.

When probing is needed

If the obstruction hasn’t resolved by 12 months, or earlier if recurrent infections are causing significant problems, probing and syringing under general anaesthetic is recommended. A fine metal probe is passed through the punctum and canaliculus into the lacrimal sac and down the nasolacrimal duct, opening the obstructing membrane. The duct is then syringed with saline to confirm it is patent. The procedure takes a few minutes and is successful in around 90 percent of cases after a single treatment. A small proportion of children require a second procedure or placement of a temporary silicone stent.

If you would like to learn more, the American Association for Pediatric Ophthalmology and Strabismus page on nasolacrimal duct obstruction offers a clear overview of symptoms, causes, diagnosis, and treatment.

Acquired NLDO: In Adults

Why it happens in adults

In adults, NLDO is usually acquired rather than congenital. The most common cause is idiopathic fibrosis and narrowing of the duct, a gradual process associated with ageing and chronic low-grade inflammation. Other causes include chronic sinusitis, previous nasal or facial surgery, inflammatory conditions such as uveitis or sarcoidosis, certain medications (particularly long-term eye drops), and less commonly tumours of the lacrimal drainage system.

Symptoms in adults

Persistent epiphora: tears running down the cheek. Worse in cold or windy conditions, when reading, and when driving. Some patients develop recurrent episodes of acute dacryocystitis, presenting as a red, swollen, tender lump at the inner corner. Chronic low-grade dacryocystitis causes a persistent mucous discharge that can be expressed from the punctum by pressing over the lacrimal sac. Untreated, this can occasionally progress to a mucocele or a fistula.

Investigation

The ophthalmologist first examines the eyelids and puncta to exclude other causes of watering such as dry eye disease, eyelid malposition (ectropion), or punctal stenosis. Syringing of the lacrimal system in the clinic, where saline is gently injected through the punctum, confirms the presence and level of obstruction. Imaging studies may be used to characterise the obstruction further before planning surgery.

Treatment in Adults

Dacryocystorhinostomy (DCR)

DCR is the standard surgical treatment for acquired NLDO in adults. The procedure creates a new opening directly between the lacrimal sac and the nasal cavity, bypassing the blocked nasolacrimal duct entirely. It can be performed externally, through a small skin incision at the side of the nose, or endoscopically, through the nose without any external incision. Both approaches have success rates of 90 to 95 percent. A thin silicone tube is usually placed through the new opening during surgery and removed in the clinic a few months later once the new channel has healed.

External DCR leaves a small scar at the side of the nose that typically fades to barely visible within a few months. Endonasal DCR avoids any external incision and allows simultaneous treatment of nasal pathology contributing to the obstruction.

Balloon dacryoplasty and syringing

For partial obstructions, balloon dacryoplasty (a tiny inflatable balloon catheter passed through the duct to dilate it) and simple syringing under local anaesthetic can provide relief in selected cases. These approaches are less definitive than DCR and have lower long-term success rates, but they are useful in patients who are not surgical candidates or who prefer a less invasive first step.

Watery Eyes in Adults: It Is Not Always NLDO

A watery eye in an adult is not automatically a blocked nasolacrimal duct. Worth knowing before anyone proposes surgery.

Dry eye disease is one of the most common causes of a watery eye. When the tear film is unstable, the ocular surface becomes irritated and the lacrimal gland produces reflex tears that overflow. Treating the dry eye resolves the watering. No drainage surgery needed.

Eyelid malposition is another common cause. Ectropion, the outward turning of the lower lid, prevents the punctum from making proper contact with the tear lake. Entropion, punctal stenosis, and canalicular obstruction from previous infections or topical medications are other possibilities that each require different management from NLDO.

Operating on the lacrimal drainage system when the problem is actually dry eye or eyelid malposition doesn’t help and may cause unnecessary complications. A thorough assessment by an oculoplastic ophthalmologist before any surgery is important.

Seek Prompt Assessment If You or Your Child Has

A painful, red, swollen lump at the inner corner of the eye (possible acute dacryocystitis)
Fever alongside a swollen inner corner of the eye
A newborn whose eye is constantly discharging from the first days of life, particularly if the white of the eye is also red
A visible swelling at the inner corner of a newborn’s eye that enlarges when they cry (possible congenital dacryocele)

A simple blocked duct with watering and discharge alone doesn’t require emergency care, but acute dacryocystitis does. It presents with pain, redness, and swelling at the inner corner and usually requires oral or intravenous antibiotics. In severe cases it can spread to surrounding tissues and requires urgent hospital assessment.

Frequently Asked Questions About NLDO

My baby’s eye has been watering since birth. Do they need surgery?
Almost certainly not, not yet. Around 90 percent of congenital NLDO resolves within the first 12 months without surgery. The approach during this period is to keep the eye clean, perform Crigler massage as instructed, and treat episodes of conjunctivitis with antibiotic drops if needed. If the obstruction hasn’t resolved by 12 months, probing under general anaesthetic is then recommended. Many ophthalmologists are comfortable waiting until 12 to 18 months before intervening, particularly if symptoms are mild.
How do I perform the massage correctly?
Place the tip of a clean index finger over the lacrimal sac at the inner corner of the eye, in the small hollow just below the inner canthus. Apply firm downward pressure toward the nose for a few seconds, then release. Repeat five to ten times per session. The key is firm, directed pressure downward toward the nose — not just rubbing the skin around the eye. The two feel very different once a nurse or orthoptist shows you the correct technique in person. Your ophthalmologist or orthoptist will demonstrate the technique and correct your positioning if needed.
Will my baby need general anaesthetic for probing?
Yes. The child needs to be completely still for the instrument to pass safely, which means general anaesthetic. Brief and safe in healthy infants, but still anaesthetic — your anaesthetist will discuss the risks. The anaesthetic is brief and the procedure takes only a few minutes. Modern paediatric anaesthesia in experienced hands carries very low risk for healthy infants, and the risks of leaving a persistently blocked duct untreated are considered to outweigh the anaesthetic risk in children over 12 months.
What is the scar like after external DCR?
The incision is placed in the skin crease at the side of the nose, approximately 1 to 1.5 cm long. In the first few weeks it’s visible as a pink linear scar. Over three to six months it typically fades to barely noticeable in normal lighting. Most patients find it much less visible than they expected. If scar appearance is a significant concern, endonasal DCR avoids any external incision entirely.
What is the silicone tube for after DCR?
A fine silicone stent is placed through the new opening during surgery and sits in place for two to three months while the new channel heals and matures. It’s thin, soft, and usually not visible or felt by the patient. Removing it is a quick clinic procedure without anaesthetic. The tube prevents the new opening from scarring closed during early healing and is used routinely in most DCR procedures.
Can NLDO come back after DCR?
DCR has a long-term success rate of 90 to 95 percent, but a small proportion of patients do experience recurrence, usually from scarring of the new opening over time. This is more likely in patients with previous nasal surgery or significant nasal inflammatory disease. If symptoms return after a successful DCR, revision surgery is possible and carries a reasonable success rate, though outcomes from revision procedures are generally somewhat lower than from primary surgery.

Nasolacrimal duct obstruction (NLDO) is a disruption of tear drainage through the nasolacrimal duct , the bony canal that runs from the lacrimal sac inferiorly to open under the inferior turbinate in the nasal cavity. Epiphora (watery eye) is the principal symptom, and NLDO is its most common structural cause in both infants and adults. In congenital NLDO, the obstruction is typically a membranous valve at the valve of Hasner (the distal duct opening) that fails to canalize at or shortly after birth; over 90% resolve spontaneously within the first year of life. In adults, acquired NLDO is most commonly idiopathic (primary acquired NLDO, PANDO), caused by fibrosis within the duct lumen, often without identifiable precipitant. Dacryocystorhinostomy (DCR) , creating a bypass from the lacrimal sac directly into the nasal cavity , is the definitive surgical treatment for adults with symptomatic NLDO that has failed conservative management.

Clinical Overview: NLDO

Anatomy: Tear drainage: puncta (upper and lower) → canaliculi (2 mm vertical + 8 mm horizontal components) → common canaliculus → lacrimal sac → nasolacrimal duct (12 mm bony canal) → inferior meatus of nasal cavity (valve of Hasner). Obstruction at any level produces epiphora. Canalicular obstruction (post-herpetic, cicatricial) requires different management from NLD obstruction.
Congenital NLDO: Incidence 2-6% of newborns; membranous occlusion at valve of Hasner. Presents with watery/sticky eye from birth or first weeks. Massage (Crigler technique) 5-10 times daily to the lacrimal sac. 90%+ resolve by 12 months. Probing under GA at 12-18 months if not resolved; bicanalicular intubation if probing fails; DCR in refractory cases.
Adult NLDO diagnosis: Syringing and probing: cannulate the lower punctum with a lacrimal cannula; irrigate with saline. Soft stop (probe rests in soft tissue) = canalicular stenosis. Hard stop (probe hits the medial wall of the lacrimal sac) = NLD obstruction (common canaliculus is patent). Reflux from the ipsilateral punctum = canalicular block; reflux from the opposite punctum = common canaliculus or NLD block.
DCR (dacryocystorhinostomy): Creates an osteotomy through the lacrimal bone from the lacrimal sac into the nasal cavity, bypassing the obstructed NLD. External DCR (cutaneous scar, high success >90%) vs endonasal DCR (no external scar, endoscopic approach, success approximately 85-90%). Bicanalicular silicone intubation for 4-6 weeks post-operatively to stent the new anastomosis.
Dacryocystitis: Infection of the lacrimal sac secondary to obstruction. Acute: tender, red, fluctuant swelling below the medial canthus (below the medial canthal tendon). Oral or IV antibiotics. Incision and drainage if pointing. DCR once acute infection resolved. Chronic: mucocele, mucoid discharge on sac pressure, no acute inflammation. DCR is the definitive treatment.
Differential for epiphora: NLDO, punctal stenosis, canalicular stenosis, functional (lacrimal pump failure from lower lid laxity), reflex tearing from dry eye, conjunctivochalasis, entropion, trichiasis. Syringing differentiates structural obstruction from functional causes.

Congenital NLDO 2-6% Of newborns; over 90% resolve spontaneously by 12 months

External DCR success >90% Long-term patency rate for external DCR with intubation

Endonasal DCR success ~85-90% No external scar; slightly lower success than external approach

Pathophysiology and Classification

Primary acquired NLDO (PANDO): The most common cause of adult NLDO. Idiopathic fibrosis and inflammation within the NLD lumen, leading to progressive luminal narrowing and eventual obstruction. Postmenopausal women are disproportionately affected , hormonal influences on mucosal and connective tissue health in the duct are the proposed mechanism. PANDO is a diagnosis of exclusion after ruling out the secondary causes below.

Secondary acquired NLDO: Dacryolithiasis (lacrimal sac stones , calcium phosphate concretions, often associated with Actinomyces israelii infection of the sac); post-infectious scarring (especially trachoma, herpes zoster ophthalmicus); post-traumatic (nasal fractures, orbital floor fractures, sinus surgery, DCR failure); inflammatory (Wegener’s granulomatosis, sarcoidosis); neoplastic (lacrimal sac tumors, rare but must be excluded in any NLDO with a palpable lacrimal sac mass above the medial canthal tendon , this is a red flag); iatrogenic (chemotherapy agents , topical 5-fluorouracil, docetaxel; nasal packing).

Vector illustration of the tear drainage anatomy showing the pathway from the puncta through the canaliculi into the lacrimal sac and down through the nasolacrimal duct into the nasal cavity — Tear drainage anatomy: puncta, canaliculi, common canaliculus, lacrimal sac, and NLD to the inferior meatus. Obstruction level determines the surgical approach.

Investigation

Clinical assessment: Document the level of the medial canthal tendon , lacrimal sac swelling below it is a mucocele (NLD obstruction); a mass above it is presumed lacrimal sac neoplasm until proven otherwise and warrants CT/MRI and biopsy. Regurgitation test: gentle pressure over the lacrimal sac , mucoid or purulent material from the punctum indicates a mucocele. Fluorescein dye disappearance test (FDDT): instil fluorescein, assess residual fluorescence at 5 minutes. Retained fluorescein = impaired drainage.

Slit-lamp and syringing and probing: The most informative office test for lacrimal drainage. Interpret by the location of resistance: soft stop = canalicular stenosis/obstruction (at or before the medial wall of the sac); hard stop with reflux from same punctum = incomplete canalicular obstruction; hard stop with nasal passage = patent system (functional epiphora); no passage and reflux from opposite punctum = NLD obstruction. Document exactly: “hard stop, reflux from upper punctum, no passage to nose.”

Dacryoscintillography and Anterior segment OCT and CT dacryocystography: Dacryoscintillography (99mTc pertechnetate instillation, gamma camera imaging) identifies functional drainage delay versus obstruction without instrumentation , useful for functional epiphora assessment. Anterior segment OCT and CT dacryocystography: contrast injected into the lacrimal system with CT imaging; delineates the level and nature of obstruction, identifies lacrimal sac abnormalities, and guides DCR planning in complex or revision cases.

Management

Congenital NLDO management: Conservative first year: Crigler massage (index finger placed over the common canaliculus inferior to the medial canthal tendon, applying downward pressure along the lacrimal sac and duct to express obstructing mucus and generate hydrostatic pressure). Topical antibiotic drops for conjunctivitis episodes (chloramphenicol 0.5%). Probing under GA at 12-18 months for persistent cases: 90-95% success with a single probing. Bicanalicular silicone intubation if probing fails. Balloon dacryoplasty or DCR for refractory congenital NLDO.

Vector illustration demonstrating Crigler massage technique showing a fingertip positioned at the inner corner of an infant eye applying downward pressure — Crigler massage: fingertip compresses the lacrimal sac inferiorly, generating hydrostatic pressure along the NLD to displace the valve of Hasner membrane.

Adult NLDO , surgical management: External DCR is the gold standard: medial canthal skin incision, expose the lacrimal fossa, create an osteotomy through the lacrimal bone (approximately 10 x 10 mm) into the nasal cavity, incise the lacrimal sac and nasal mucosa, anastomose the posterior flaps and then the anterior flaps, intubate with bicanalicular silicone tube. Tubes removed at 4-6 weeks. Success above 90% in experienced hands. External scar is typically inconspicuous within 3-6 months.

Endonasal (endoscopic) DCR avoids an external scar. A nasal endoscope and bone-removing instruments create the osteotomy from inside the nose. Slightly lower success (85-90%) compared to external DCR , the osteotomy tends to be smaller and the anastomosis less controlled. Preferred in: patients for whom scar is a significant concern, revision after failed external DCR (different approach avoids scar tissue), and patients with concurrent nasal pathology benefiting from endoscopic management.

Punctal and canalicular stenosis: Punctal stenosis: three-snip punctoplasty enlarges the punctal opening. Canalicular stenosis: more challenging , Mini-Monoka (monocanalicular) or bicanalicular intubation for incomplete stenosis; canaliculodacryocystorhinostomy (CDCR) with Jones tube for complete canalicular obstruction (Jones tube provides a permanent glass tube bypass from the conjunctival fornix to the nasal cavity).

Clinical Decision Points

Palpable mass above the medial canthal tendon in an NLDO patient: Lacrimal sac neoplasm until proven otherwise. CT orbit and lacrimal system. Refer for biopsy before DCR , incising a lacrimal sac tumor without tissue diagnosis risks seeding. Lacrimal sac neoplasms are rare but carry significant morbidity if missed.
Acute dacryocystitis: Start oral antibiotics (co-amoxiclav or cefalexin). If pointing or fluctuant, incise and drain from the skin surface, not the conjunctival surface. Do NOT perform DCR in the acute phase , operate 4-6 weeks after the infection has fully resolved. Acute DCR risks spreading infection and has poor outcomes.
Epiphora in an elderly patient with lax lower lid: Test lid laxity (snap-back test, lid distraction test). Functional epiphora from lower lid laxity and lacrimal pump failure is common and does not require DCR. Treat with lower lid tightening (lateral tarsal strip) if symptomatic. Syringing will show a patent system.
Child with sticky eye, age 3 months, Crigler massage started: Continue massage twice daily. If no improvement by 9-10 months: consider probing at 12 months rather than waiting. Earlier probing (6-9 months) has equivalent success rates with easier nasal anatomy and less GA risk.
Bilateral NLDO in a 45-year-old man: Bilateral PANDO in a man under 55 is unusual. Exclude: Wegener’s granulomatosis (pANCA), sarcoidosis (ACE, chest X-ray), previous chemotherapy (5-FU, docetaxel), midface trauma history, nasal polyps.

When to Escalate

Acute dacryocystitis with fever, periorbital cellulitis, or reduced vision , consider post-septal spread; IV antibiotics and CT orbit
Palpable lacrimal sac mass extending above the medial canthal tendon , urgent imaging and biopsy to exclude neoplasm
NLDO with bloody regurgitation on sac compression , lacrimal sac tumor until proven otherwise; urgent referral

Lacrimal sac squamous cell carcinoma and transitional cell carcinoma present identically to benign NLDO , with epiphora and a lacrimal sac mucocele , except that the mass extends above the medial canthal tendon and may produce bloody discharge. These tumors are rare but carry a poor prognosis when diagnosed late. Any adult NLDO presentation with these features requires imaging and biopsy as first steps, not empirical DCR.

Clinical Pearls: NLDO

A mass above the medial canthal tendon is not a mucocele. It is a tumor until biopsy proves otherwise.
The medial canthal tendon marks the junction between the lacrimal sac (below) and the common canaliculus (above). Benign mucoceles from NLD obstruction expand the lacrimal sac below this tendon. A palpable, visible mass that extends above the tendon , particularly if firm, irregular, or associated with bloody reflux , cannot be a simple mucocele. Multiple case reports document lacrimal sac carcinoma incidentally found and inadequately managed as NLDO. Before any DCR in a patient with a mass above the tendon, obtain imaging and biopsy tissue. Incising a lacrimal sac malignancy without tissue diagnosis and oncological staging is a preventable error.
Functional epiphora is common in the elderly and does not need DCR. Examine the lower lid before referring for surgery.
Horizontal lower lid laxity from disinsertion of the lateral canthal tendon allows the lower lid to fall away from the globe, disrupting the lacrimal pump mechanism (the orbicularis oculi’s pumping action moves tear fluid into the canaliculi with each blink). In a lax lid, this pump fails even with a fully patent lacrimal drainage system. The snap-back test (pull the lower lid down and release , it should return immediately to the globe without blinking; a slow return indicates laxity) identifies this in 5 seconds. Syringing will show a patent system. These patients need a lid-tightening procedure, not DCR.
Probing a congenital NLDO after 18 months has a lower success rate. Intervene at the right time.
The success rate of simple probing for congenital NLDO is approximately 90-95% when performed between 12-18 months. After 24 months, the rate drops to approximately 75-80%, and the nasal anatomy becomes more difficult to navigate. The argument for observation until 18+ months is legitimate given the high spontaneous resolution rate, but once the decision to probe is made, it should not be delayed further. Families who have been waiting for 2 or 3 years before probing are placing their child at an unnecessary disadvantage.

Further reading: RCOphth Oculoplastics Guidelines. Related conditions: dry eye disease (differential for epiphora), orbital cellulitis (complication of dacryocystitis). Subspecialty context: oculoplastics and orbit subspecialty page.