Congenital lacrimal fistula associated with Down syndrome

The effect of age on congenital nasolacrimal duct obstruction probing and stent intubation outcomes in pediatric Down syndrome patients

PURPOSE

To examine the effect of age at time of congenital nasolacrimal duct obstruction (CNLDO) intervention on symptom resolution and reoperation rates in patients with Down syndrome (DS).

METHODS

The medical records of patients with DS and CNLDO between 2012 and 2021 were reviewed retrospectively. Age at the time of first stent placement was utilized to categorize patients into age groups <3 and >3 years of age. Epiphora resolution at last office visit and restenting rate were used as outcome measures.

RESULTS

A total of 49 patients with DS and CLNDO were identified between 2012 and 2021; of these, 17 had received surgical stent placement with appropriate follow-up. Epiphora resolution (X21= 0.78, P = 0.33), restenting rate (X21 = 2.84, P = 0.09), cumulative stent duration (P = 0.33) and number of stent placement operations (P = 0.98) were not significantly different between the age groups. There was no significant difference between stent duration <1 year or >1 year with regard to epiphora resolution (X21 = 0.91, P = 0.34).

CONCLUSIONS

Success of stent placement and reoperation rates among patients with DS and CNLDO were not associated with age and duration of stent intubation. Intervention at later ages may still be beneficial for symptom resolution in patients with DS.

Management of congenital nasolacrimal duct obstruction in down syndrome

BACKGROUND

Congenital nasolacrimal duct obstruction (CNLDO) is common in Down Syndrome (DS), and more difficult to treat. Our purpose was to describe the management of CNLDO in paediatric patients with DS.

METHODS

Retrospective cohort study. Medical chart review of all DS patients diagnosed with CNLDO at the Division of Ophthalmology at the Children's Hospital of Philadelphia during a 12-year period (2009-2020). Main outcome measures included: Surgical interventions, primary probing outcome, rate of dacryocystorhinostomy (DCR) and/or conjunctivodacryocystorhinostomy (CDCR), and overall success.

RESULTS

126 patients (236 eyes) were included, mean age of 1.8 ± 2.1 years (range 0.1-11.3 y), 110 (87%) had bilateral CNLDO. Mean follow-up time was 41 months. 84 patients (67%) underwent at least one surgical intervention; the mean number of surgical interventions in this group was 1.8 ± 1.4 per patient (range, 1-6). The most common primary intervention was probing (n = 74, 88%), mostly (n = 57, 68%) with monocanalicular silicone intubation. Probing with silicone intubation had a higher success rate compared to probing alone (P = 0.002). Twenty (24% of 84) patients underwent DCR/CDCR during the follow-up period. Complete resolution was achieved in 123 patients (98%).

CONCLUSIONS

CNLDO in Down syndrome is associated with high rates of bilateral obstructions and with less favourable surgical outcomes. Many patients ultimately require a more robust surgical intervention such as DCR or CDCR. The use of monocanalicular stent in initial probing was associated with a higher success rate, and would appear to be appropriate in all CNLDO-DS cases.

The effect of lacrimal drainage abnormality on the surgical outcomes of congenital lacrimal fistula and vice versa

PURPOSE

To evaluate the various surgical modalities of congenital lacrimal fistula and assess the mutual effect of lacrimal fistula and lacrimal drainage abnormality on the individual surgical outcomes.

METHODS

In this retrospective cohort and case-control study, 74 eyes from 63 patients with lacrimal fistula who underwent surgical management between 2000 and 2015 at three medical centers were enrolled. The data collected included sex, age, preoperative symptoms, presence of concurrent lacrimal drainage abnormality, surgical methods, and surgical outcomes. The main outcome measures were treatment outcomes based on lacrimal drainage patency and symptom improvement, surgical outcome of fistulectomy according to the presence of lacrimal drainage abnormality, and surgical outcome of lacrimal drainage abnormality according to the presence of fistula.

RESULTS

The mean age at the time of surgery was 9.2 (SD, ±8.8) years and the mean follow-up duration was 14.4 (SD, ±19.5) months. All eyes (37/37) with fistula without lacrimal drainage abnormality demonstrated surgical success after simple fistulectomy. Patients with concurrent lacrimal drainage abnormalities showed more frequent surgical failure than those with fistula alone (p = 0.009). However, the presence of fistula did not affect the outcomes of surgery for lacrimal drainage abnormality (p = 0.179).

CONCLUSION

Simple fistulectomy is sufficient for sole asymptomatic or pauci-symptomatic lacrimal fistula. Symptomatic fistula as well as those accompanied with lacrimal drainage abnormality underwent fistulectomy and lacrimal drainage system surgery. Patients with accompanying lacrimal drainage system abnormalities showed less favorable outcomes. Meticulous preoperative examination of the lacrimal drainage system is critical for surgical planning and prognosis prediction.

Prevalence and Treatment Outcome of Nasolacrimal Duct Obstruction in Saudi Children with Down Syndrome

Introduction

Congenital nasolacrimal duct obstruction (CNLDO) is one of the most common congenital abnormalities encountered by pediatric ophthalmologists, occurring in 20-30% of all neonates (range: 6-84%). The majority of the cases (up to 90%) resolve within the first year of birth. Many syndromes, such as Down syndrome, are associated with congenital lacrimal anomalies. The prevalence of nasolacrimal anomalies in Down syndrome has been reported to be 22%.

Methods

This was a retrospective study of all children diagnosed with Down syndrome at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia between 2010 and 2015.

Result

The total sample size was 175 patients; 15 patients were diagnosed with CNLDO with a prevalence of 8.57%. The prevalence among the gender was 53.3% male and 46.7% female, with a median age of eight years. Regarding ocular disorders, 20.0% cases were diagnosed with refractive error, 13.3% with nystagmus, and 13.3% with blepharitis. Myopia, strabismus, conjunctivitis, and cataract were observed in four different patients, and the remaining four cases reported no other ocular disorders. Tearing, alone or associated with other symptoms, was the main presentation of CNLDO (86.7%). Bilateral CNLDO was the most commonly observed abnormality, alone or associated with others. The median age at diagnosis was one year. Of the cases, 53.3% were treated medically, 26.7% by surgical correction, and 13.3% required both.

Conclusion

Bilateral CNLDO is the most observed disease pattern among children with Down syndrome. In our study, tearing was the most common clinical presentation and most cases were treated medically. Down syndrome patients should be carefully examined for nasolacrimal duct obstructions and treated medically.

Surgical outcome and unusual complications of paediatric external dacryocystorhinostomy

Purpose: To report the surgical outcome of external dacryocystorhinostomy (DCR) in children treated for congenital nasolacrimal duct obstruction (CNLDO) at a single tertiary eye hospital. Materials and Methods: The medical records of 44 consecutive paediatric patients who underwent external DCR with silicon tube intubation from January 2002 to December 2015 were retrospectively reviewed. Age at the time of surgery ranged from 2 to 12 years. Surgical success was defined as resolution of symptoms, normal tear film height, and negative fluorescein dye disappearance test. This study adheres to the principles outlined in the Declaration of Helsinki. Results: Four patients had simultaneous bilateral surgery (9.1%). Four patients had redo surgery following previous unsuccessful DCR. The patients' follow-up ranged between 2 and 10 years. There were no cases of serious immediate post-operative complications, but four children developed subcutaneous emphysema, and in two children operated before the age of 2.5 years agenesis of the ipsilateral upper canine was observed. Of the 42 patients who completed follow-up (46 eyes), 39 (43 eyes, 93.5%) had a successful result with complete cure of symptoms. Conclusions: Paediatric external DCR can successfully treat CNLDO with a low rate of complications. As the bud of the upper canine may be very close to the site of the rhinostomy when this is performed before the age of 3, it cannot be excluded that the agenesis of the ipsilateral upper canine, an unusual finding in Caucasian populations, might be related to the size and the site of the rhinostomy.

Syndromic and Nonsyndromic Systemic Associations of Congenital Lacrimal Drainage Anomalies: A Major Review

PURPOSE

To review and summarize the syndromic, nonsyndromic, and systemic associations of congenital lacrimal drainage anomalies.

METHODS

The authors performed a PubMed search of all articles published in English on congenital lacrimal anomalies (1933-2016). Patients of these articles were reviewed along with the literature of direct references to syndromes and other systemic associations. Data reviewed included syndromic descriptions, systemic details, demographics, lacrimal presentations, management, and outcomes.

RESULTS

Syndromic and systemic associations with congenital lacrimal drainage disorders are not known to be common. Although familial presentations have been reported, the inheritance patterns are unclear for most anomalies. There is an increasingly growing evidence of a genetic basis to many lacrimal anomalies. However, few syndromes have either widespread or are frequently associated with lacrimal anomalies. Few sequences of distinct lacrimal presentations and intraoperative findings are seen. Surgical challenges in these patients are distinct and a thorough pre and intraoperative anatomical assessment, detailed imaging when indicated, and assessment and correction of associated periocular and facial abnormalities may facilitate good outcomes.

CONCLUSIONS

Lacrimal drainage anomalies associated with syndromic and nonsyndromic systemic conditions have certain unique features of their own and their surgical and anesthesia challenges are distinct. Diagnosis of congenital lacrimal drainage anomalies should prompt consideration of the possible presence of associated systemic abnormalities.

Congenital lacrimal fistula: A major review

The purpose of this article is to review and summarize the etiopathogenesis, symptomatology, systemic associations, management, complications and clinical outcomes of congenital lacrimal fistulae. The authors performed an electronic database (PubMed, MEDLINE, EMBASE and Cochrane Library) search of all articles published in English on congenital lacrimal fistulae. Congenital subsets of patients from series of mixed lacrimal fistulae were included in the review. These articles were reviewed along with their relevant cross-references. Data reviewed included demographics, presentations, investigations, management, complications and outcomes. The prevalence of congenital lacrimal fistulae is reported to be around 1 in 2000 live births. They are frequently unilateral, although familial cases tend to be bilateral. Lacrimal and systemic anomalies have been associated with lacrimal fistulae. Exact etiopathogenesis is unknown but mostly believed to be an accessory out budding from the lacrimal drainage system during embryogenesis. Treatment is indicated when significant epiphora or discharge is present and is mostly achieved by various fistulectomy techniques with or without a dacryocystorhinostomy. Congenital lacrimal fistulae are a distinct clinical entity with unique features. Surgical management can be challenging and successful outcomes are usually achieved with widely accepted protocols.

Unilateral Congenital Lacrimal Fistula with Renal Agenesis and Pelvic Kidney: A Case Report and Review of the Literature

A 12-year-old boy presented to the clinic of ophthalmology because of watering and discharge from his left lower eyelid. The inspection examination revealed an orifice that was associated with congenital lacrimal fistula (CLF). He underwent a complete ophthalmologic and systemic evaluation to explore possible associated findings. Systemic evaluation revealed multiple renal anomalies: right renal agenesis and left ectopic pelvic kidney. This case is unique because this is the first reported case of CLF accompanied with ectopic pelvic kidney in the literature.