Success rates of nasolacrimal duct probing at time intervals after 1 year of age

[Outcome of Congenital Obstruction of the Nasolacrimal Duct]

BACKGROUND

Congenital nasolacrimal duct obstruction, a common condition in newborns, is characterised by narrowing of the tear drainage system, often at the nasolacrimal duct. In most cases, the tear duct opens spontaneously within the first year of life, assisted by massage. In cases where there is no improvement, surgical probing may be required. This study aimed to analyse the presentation and outcomes of surgically treated tear duct obstructions in children at our clinic.

PATIENTS AND METHODS

A retrospective analysis was conducted using electronic medical records of patients under 18 years of age who were treated for congenital nasolacrimal duct obstruction between 2011 and 2023. Data collected included demographic information, symptoms, stenosis location, surgical therapy, and outcomes. Additionally, parents of the patients were surveyed regarding the postoperative condition and symptomatology. The study was approved by the Cantonal Ethics Commission Zurich (BASEC2022-00830).

RESULTS

Of a total of 147 identified patients (39 female, 62 male), 69% could be analysed with available consent. The age at initial examination ranged from 8 months to 12 years (median 27 months). Unilateral stenosis was observed in 69% of cases and bilateral stenosis in 31%. The most common symptoms were epiphora (95%), matted eyelashes (68%), mucous discharge (23%), and redness of the eyelids/conjunctiva (19%). Malformations were identified intraoperatively in 11% of cases. A second probing was necessary in 10% of cases, with ages ranging from 18 to 69 months (median 38 months). Dacryocystorhinostomy was performed in 4% of cases (age 92 - 145 months, median 113 months). Postoperatively, 70.5% reported subjective and/or objective symptom resolution, 22.7% experienced persistent epiphora, and 6.8% had recurrent matted eyelashes. Of the 101 patients surveyed, 77 responded to the questionnaire. Among them, 92% reported that tearing was no longer present, 96% no longer required therapy, 97% reported uncomplicated surgery, 17% experienced recurrent tearing, and 6% required additional non-lacrimal treatments.

CONCLUSION

In most cases, probing and irrigation alone are sufficient for healing. Temporary stent placement is more frequently necessary in older children. An intervention after 18 months of age does not negatively impact healing.

Management and outcomes of congenital nasolacrimal duct obstruction in trisomy 21 patients vs. non-trisomy 21 patients within a paediatric population: a 5-year follow-up

PURPOSE

To assess the management of patients with congenital nasolacrimal duct obstruction (CNLDO) in a paediatric population and review the long-term outcomes over a 5-year interval, with particular emphasis on the difference between patients with trisomy 21 and those without trisomy 21.

METHODS

This single-centre, retrospective, cross-sectional, case review study included patients suffering from CNLDO at Alder Hey Children's Hospital NHS foundation Trust. Patients were divided into two groups: Non-trisomy 21 and trisomy 21. Patients were followed-up for a 60-month interval. Patients aged <12 months at the time of surgery, patients with <60 months of follow-up data and patients with acquired nasolacrimal duct obstruction were excluded. The main outcome measures were discharge rates in patients undertaking primary intervention with syringe and probe (S&P), number of patients requiring further treatment with lacrimal intubation or dacryocystorhinostomy (DCR) and overall symptom-free periods post-treatment.

RESULTS

Ninety-three patients (142 eyes) were included. The mean number of surgical interventions was 1.53 ± 0.65. The mean interval between the 1st and 2nd intervention was 15.54 ± 16.33 months. There was a trend towards greater success rates non-trisomy 21 patients versus patients with trisomy 21 (p = 0.1352). The average symptom-free period after the final intervention was 44.31 ± 20.68 months, significantly longer in the non-trisomy 21 group compared to the trisomy 21 group (p = 0.0074).

CONCLUSIONS

The overall success rate after primary S&P was 55.9%. Our results suggest that in trisomy 21 patients suffering from CNLDO, a one-stage intervention with primary monocanalicular intubation should be considered instead of sequential approach.

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.

Probing and nasolacrimal intubation outcomes in children over 18 Months of age with congenital nasolacrimal duct obstruction

Purpose

To evaluate how risk factors impact success rates of initial probing and nasolacrimal duct (NLD) tube intubation in children over 18 months of age with congenital nasolacrimal duct obstruction (CNLDO).

Methods

This cohort study included 98 CNLDO patients aged 18 months to 10 years who underwent NLD probing with stent insertion. We employed the multivariate frailty model as our final model to conceptually elaborate on our correlated eye data, with the primary outcome measure evaluating the success rates of probing and tube intubation. Factors such as age, probing complexity, tube type, prior surgeries, and passive smoking were considered in the evaluation.

Results

The study involved 98 patients (54 males, 44 females) with a mean age of 41.46 months and an average follow-up of 98.37 days (95 % CI 87.65-109.1). Out of the 110 eyes that underwent surgery, 13 (11.8 %) experienced failure while 97 (88.2 %) were censored. Kaplan-Meier analysis indicated significant differences in age category and probing (P-value = 0.03 and 0.006 respectively), but not tube type (P-value = 0.8). Multivariable analysis confirmed that older age and complex probing were associated with higher failure rates in CNLDO cases, with each monthly increase correlating to a two percent higher likelihood of intubation failure.

Conclusions

Patient age and probing complexity influence CNLDO treatment, impacting surgical techniques and outcomes. Tube type, prior surgery, and passive smoking have no significant impact on treatment success.

High incidence and recurrence of tympanostomy tube procedures in children who underwent nasolacrimal duct probe and intubation for congenital nasolacrimal duct obstruction

PURPOSE

To determine the incidence of tympanostomy tube (T-tube) insertion in children who required probing and intubation for congenital nasolacrimal duct obstruction (CNLDO) at a single academic institution and to analyze success rates.

METHODS

The medical records of 92 patients who underwent nasolacrimal probing and intubation for CNLDO over a 9-year period were reviewed retrospectively. A preoperative questionnaire was given to the patient's guardian concerning laterality of CNLDO, history of otitis media (OM) antibiotic therapy, history of T-tube placement and number placed. At least 12 months following the initial nasolacrimal duct P&I, a second questionnaire was administered regarding resolution of CNLDO symptoms, additional measures taken to relieve postoperative symptoms if present, and any further history regarding OM episodes or T-tube insertion.

RESULTS

Of the 92 children with CNLDO, 37 (40%) required T-tubes either prior to or following nasolacrimal duct probing and intubation, a rate higher than in the general population (P < 0.00001). 21 (56%) of CNLDO probing and intubation patients who required T-tubes required at least two sets, at different times, to relieve OM symptoms. Six of 37 patients (16%) with a history of T-tube placement and 1 of 55 (2%) with no history of T-tube placement had persistent epiphora after nasolacrimal probing and intubation (relative risk, 8.92; P = 0.0388).

CONCLUSIONS

In our study cohort, pediatric patients with CNLDO who required nasolacrimal probing and intubation were at higher risk of needing T-tubes for chronic OM than the general population, and those needing T-tubes were at increased risk of residual epiphora.

Nasal endoscopy-guided primary nasolacrimal duct intubation for congenital nasolacrimal duct obstruction in children older than 4 years

PURPOSE

To evaluate the clinical outcomes of endoscopic guided primary bicanalicular intubation (BCI) for congenital nasolacrimal duct obstruction (CNLDO) in children older than 4 years.

METHODS

A total of 40 eyes from 33 children (18 males, 15 females) with CNLDO who underwent bicanalicular intubation were evaluated. The type of CNLDO was determined by endonasal endoscopic visualisation. The mean silicone tube removal time was 4.3 ± 0.9 months (ranging from 3 to 6 months). The children were followed up for 6 months after the removal of tubes. Therapeutic success was defined as the normal result of the fluorescein dye disappearance test and complete resolution of previous lacrimal symptoms and signs.

RESULTS

The median age was 80 [48] (range 48-156) months. Treatment success was achieved in 32 of 40 eyes (80.0%). A statistically significant correlation was observed between the age and success rate (p = 0.006). The success rate was lower in older children. Membranous type of CNLDO was observed in 47.5% (19/40) of the cases. The median age of patients with a membranous and complex type of CNLDO were 60 [30] months and 96 [53] months, respectively. Surgical success was 100% in the membranous type of CNLDO and 61.9% in the complex CNLDO group.

CONCLUSIONS

Primary BCI using nasal endoscopic visualisation has a favourably high success rate for treating CNLDO in children aged 4 to 13 years. Treatment success was found to be related to both the type of CNLDO and age.

Age-Specific Outcomes of Conservative Approach and Probing for Congenital Nasolacrimal Duct Obstruction

Purpose

Patients and Methods

Results

Conclusion

Comparison of Endoscopically Assisted Primary Probing and Bicanalicular Silicone Intubation for Congenital Nasolacrimal Duct Obstruction in Children Aged 4 to 7 Years

PURPOSE

To compare the clinical outcomes of primary nasolacrimal duct probing and primary bicanalicular intubations with endoscopic assistance for congenital nasolacrimal duct obstruction (CNLDO) in children aged 4 to 7 years.

METHODS

Forty-three eyes of 43 children (25 boys and 18 girls) with congenital epiphora who underwent primary unilateral probing and bicanalicular intubation were evaluated retrospectively. The tubes were removed 3 to 4 months after their placement, and the children were followed up for another 6 months after their removal. Treatment success was defined as the normal result of the fluorescein dye disappearance test and complete resolution of the lacrimal symptoms and signs of patients. The success rates were compared between the two groups (bicanalicular intubation vs probing). Type of CNLDO (membranous, incomplete complex, and complete complex) was determined with an endonasal endoscope.

RESULTS

The mean age was 63.3 ± 11.1 months (range: 48 to 84 months) for the probing group and 64.4 ± 12.1 months (range: 48 to 84 months) for the bicanalicular intubation group (P = .915). The bicanalicular intubation group showed significantly greater treatment success (21 of 24, 87.5%) compared to the probing group (11 of 19, 57.9%; P = .038). Bicanalicular intubation provided higher treatment success among patients with complex CNLDO compared to probing (80.0% vs 11.1%, P = .002). There was no difference in mean age between the patients with successful and failed treatment in both groups (P = .631 and .137, respectively).

CONCLUSIONS

Bicanalicular intubation was associated with a higher success rate than probing under nasal endoscopic visualization for the treatment of CNLDO in children aged 4 to 7 years. The type of CNLDO might be the primary factor for the treatment success. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

Outcomes of Congenital Nasolacrimal Duct Obstruction Surgery Converted into Balloon Dilation and Silicone Intubation due to Probing Difficulty

Background. To report the outcomes of balloon catheter dilatation and silicone intubation as a sequential secondary surgery under the same anesthesia, a stepwise approach for congenital nasolacrimal duct obstruction (NLDO) when probing and irrigation as primary procedure fails. Methods. A retrospective study included children with NLDO who underwent probing and irrigation only, and those who underwent in the same surgery under anesthesia, adjunct balloon catheter dilation and silicone intubation due to difficulty of the probe passage or fluid regurgitation from the punctum. The primary outcome was surgical success defined as resolution of preoperative symptoms and signs at 1 month. Results. A total of 105 NLDO cases were included. Eighty-four cases underwent probing and irrigation only, whereas 21 cases required balloon dilation and silicone intubation consecutively after the first procedure. Patient age at surgery was higher for those requiring balloon dilatation and intubation (30.3 ± 8.0 months) when compared to those with probing and irrigation only (22.4 ± 10.3 months, $p<0.001$ ). The onset of symptoms, preoperative clinical findings regarding tearing and discharge and gender distribution of patients were comparable between the two groups. During the follow-up, the overall success rate for probing and irrigation only was 76.2% (64 out of 84 cases) and for balloon dilatation and silicone tube intubation was 90.5% (19 out of 21 cases). Conclusions. The surgical team may prepare to proceed with secondary surgery under the same anesthesia after the initial attempt of probing and irrigation. This stepwise two-stage approach in patients with congenital NLDO failing primary surgery resulted in a high success rate with minimal interventions, avoiding repeated general anesthesia.

The significance of primary monocanalicular silicone tube intubation in late surgical treatment in children

PURPOSE

To evaluate the effect of monocanalicular silicone tube intubation outcomes as an initial surgical treatment in children older than 1 year old with primary nasolacrimal obstruction.

METHODS

Probing or monocanalicular silicone tube intubation was performed as primary surgical treatment on 12-48 months old children with primary nasolacrimal obstruction. Probing was performed on 53 eyes of 43 patients and silicone tube intubation on 45 eyes of 39 patients. Treatment was considered successful after improvement in patient complaints, the presence of normal tear meniscus, and normal results of fluorescein disappearance time test. Retrospective treatment success was compared between two groups according to age groups.

RESULTS

Treatment success was 79.1% in the probing group and 92.3% in the silicone tube intubation group. The success of the treatment was evaluated separately in the groups of 12 to <24 months, 24 to <36 months, and 36 to <48 months, and although the success level of the silicone tube intubation group was consistently found to be higher, the difference was not statistically significant. Treatment success decreased statistically significantly in the probing group with increased age of the patients, especially after 24 months. There was no such statistically significant decrease in the silicone tube intubation group.

CONCLUSION

The choice of monocanalicular silicone tube intubation for primary surgical treatment in children with primary nasolacrimal obstruction provides success without the need for repetitive surgical interventions, especially in children older than 24 months.

Monocanalicular intubation in children with incomplete complex congenital nasolacrimal duct obstruction older than five years of age

Purpose:

To evaluate the role of monocanalicular intubation (MCI) in congenital nasolacrimal duct obstruction (CNLDO) in children older than 5 years of age.

Methods:

A retrospective case series study was done on children over 5 years of age diagnosed with CNLDO who underwent MCI. Success rates were evaluated subjectively by asking their parents about persistent symptoms and objectively using the dye disappearance test in clinical examination.

Results:

A total of 43 eyes of 37 patients with a mean age of 7.42 ± 2.33 (range, 5–15 years of age) were included. The success rate was 60.46%, and the rate of secondary surgical intervention was 25% of all cases (61.11% of failed cases).

Conclusion:

Primary MCI maintains a reasonable success rate in incomplete complicated CNLDO regardless of age.

Minimally-Invasive Surgical Approach to Congenital Dacryostenosis: Proposal for a New Protocol

Background: Congenital dacryostenosis is one of the most common ophthalmological disorders in infants, with a high spontaneous resolution rate. In patients unresponsive to conservative treatment, the first-line approach is lacrimal drainage system probing, thought there is no clear consensus on optimal timing of surgery. The optimal treatment of patients unresponsive to primary probing is also controversial. Objectives: The aim of this study is to assess the optimal timing of probing in children with congenital dacryostenosis. Other purposes are to evaluate the efficacy of repeated probing and dacryointubation in patients unresponsive to the initial surgery without evident lacrimal outflow dysgenesis, and to determine the epidemiology of these maldevelopments. Methods: A retrospective consecutive cohort study was conducted in 625 eyes of 457 patients aged 7-48 months who underwent surgery for dacryostenosis. Patients were divided into 4 cohorts according to the timing of surgery. Data were analyzed using Fisher's test. Results: The success rate of primary probing was high, without significant differences between cohorts. One-third of recurrences were related to maldevelopments, the other two-thirds were treated with a second probing or dacryointubation, with high success rates, that did not significantly differ between the procedures. All cases unresponsive to the second surgery were resolved with dacryointubation. Conclusions: Probing is highly effective and its outcome is not affected by timing of surgery. Nevertheless, we advocate for early intervention, in order to identify possible maldevelopments, which require more invasive management. In patients unresponsive to primary probing, without evident maldevelopments, repeated probing should still be considered as the first-line approach, since it's less invasive but similarly effective to dacryointubation.

Office- or Facility-Based Probing for Congenital Nasolacrimal Duct Obstruction: A Report by the American Academy of Ophthalmology

PURPOSE

To review the published literature assessing the efficacy and safety of in-office probing compared with facility-based probing to treat congenital nasolacrimal duct obstruction (NLDO).

METHODS

Literature searches were conducted in March 2020 in the PubMed database with no date restrictions and limited to studies published in English and in the Cochrane Library database with no restrictions. The combined searches yielded 281 citations. Of these, 21 articles were deemed appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. Four articles were rated level I, 2 articles were rated level II, and 15 articles were rated level III.

RESULTS

Treatments consisted of observation, in-office nasolacrimal probing, or facility-based nasolacrimal probing. Success rates and complications or recurrences were recorded from 1 week to 6 months after surgery. Complete resolution of symptoms after surgery ranged from 66% to 95.6% for office-based procedures versus 50% to 97.7% for facility-based procedures. Level I evidence indicated that 66% of cases spontaneously resolved after 6 months of observation in infants between 6 and 10 months of age. Success rates for in-office probing were lower for bilateral than for unilateral NLDO (67% vs. 82%), whereas success rates were high in both unilateral (83%) and bilateral (82%) patients who underwent facility-based probing after 6 months of observation. Cost data did not indicate a definitive cost savings of either treatment method ($562 for in-office vs. $701 for facility-based, depending on cost models predicting spontaneous resolution rates at different ages). No serious adverse events with treatment or anesthesia were reported for either treatment method.

CONCLUSIONS

Evidence supports the efficacy and safety of both in-office and facility-based surgery for congenital NLDO. However, treating bilateral NLDO in a facility setting may be better. Because a significant percentage of children achieved resolution spontaneously before 12 months of age, deferring treatment until 12 to 18 months of age is a reasonable option. Additional research may address symptom burden on families and the impact of anesthesia and emotional trauma of nonsedated office probings on patients and may explore further the cost of treatment for each treatment method.

[Congenital nasolacrimal duct obstruction : A real-life study from the first symptoms to the results of surgical treatment]

OBJECTIVE

The optimal timing for surgery of congenital nasolacrimal duct obstruction (CNLDO) is controversially discussed . An aspect that has not yet been studied in this context is the path from first symptoms to the initial diagnosis and surgical treatment with respect to social factors and burden of suffering. The aim of this study was a real-life analysis of the entire course of the disease.

METHODS

Monocentric, retrospective study evaluating children with CNLDO (n = 147) who underwent surgery. The minimum follow-up was 3 months (26 ± 14 months). The patient information was collected by telephone using a questionnaire especially created for this purpose. The famelial suffering was measured on a scale of 1-5.

RESULTS

Data were collected from 118 parents with a mean follow-up of 26 months. First symptoms occurred at a median age of 1 month. The diagnosis was confirmed through a pediatrician/ophthalmologist after a median of 6 months. An assignment to a referral center for surgical treatment was performed a median of 18 months after the first presentation. The average age of the patients at the time of surgery was 23 months. Surgery before the age of 13 months showed a 100% success rate. The average age of those who needed revision surgery was 27 months (±12 months). The familial suffering was measured as 4.1 points before surgery and 1.3 after surgery.

CONCLUSION

This study is the first real-life study, which illustrates the path of CNLDO from the first symptoms to rehabilitation, including influential social factors. Early surgery significantly shortens the suffering of both patients and parents. Considering the low operative risks and excellent success rate of operative treatment, an early consultation at a surgical department is recommended.

Comparison of Hasner valvulotomy outcomes in pediatric and adult patients: does age matter?

BACKGROUND

Hasner valve incision has been recently introduced as a new treatment for ophthalmic patients with epiphora symptoms. The aim of this study was to examine whether surgical outcomes of Hasner valve incision for inferior nasolacrimal duct obstruction were different between pediatric and adult patients.

METHODS

A total of 53 eyes of 52 patients who underwent Hasner valve incision in the Beijing Tongren Hospital from October 2016 to November 2019 were retrospectively observed. Patients were divided into two groups, including pediatric group (23 eyes of 22 patients, <18 years old) and adult group (30 eyes of 30 patients, ≥18 years old). Success rate of surgery was determined by both subjective measure (complete resolution of epiphora) and objective measure (lacrimal passage irrigation and tear meniscus height). Fisher exact test was conducted.

RESULTS

By conducting Fisher exact test and comparing complete resolution of epiphora (P = 0.627), lacrimal passage irrigation (P = 0.663), measurement of Tear Meniscus Height (P = 0.561), and appearance of complication (P = 0.339), there was no statistically significant difference of surgical outcomes between pediatric and adult patients (P > 0.05).

CONCLUSION

Hasner valve incision was effective for both adult and children with inferior nasolacrimal duct obstruction, with no difference in surgical outcomes between the two groups.

Management of congenital nasolacrimal duct obstruction: results of a national survey of paediatric and oculoplastic ophthalmologists

BACKGROUND

To survey variation in management of congenital nasolacrimal duct obstruction (CNLDO) by oculoplastic and paediatric ophthalmologists in the UK.

METHODS

A 14-question online survey was sent to all members of the British Oculoplastic Surgery Society (BOPSS) and the British and Irish Paediatric Ophthalmology and Strabismus Association (BIPOSA) in February 2020. The aim was to establish preferred primary, secondary and tertiary interventions for CNLDO treatment, with emphasis on the use of nasoendoscopy and ductal intubation. Results were compared with a national survey from 2007 to observe trends in management.

RESULTS

One hundred and three responses from single-speciality consultants were analysed. In total, 71.8% of CNLDO patients were assessed by paediatric ophthalmologists. Fluorescein dye disappearance test was the commonest investigation, and paediatric consultants were five times more likely to perform Jones test. No clinicians performed outpatient probing. Age of first intervention was most commonly 12 months, although more interventions are being conducted at younger ages than in 2007. Preferred primary procedure for both subspecialties was syringe and probe under general anaesthetic, with 43.9% of oculoplastic consultants using nasoendoscopy vs 12.9% of paediatric consultants. Most common re-do procedure for both subspecialties was nasoendoscopy-guided syringe and probe ± intubation. In contrast to 2007, dacryocystorhinostomy is now the commonest tertiary procedure, with endonasal approach twice as common as external.

CONCLUSION

Despite changes in approach since 2007, there is still considerable variation between oculoplastic and paediatric ophthalmologists regarding treatment preferences for CNLDO, particularly the use of nasoendoscopy. We propose a national audit of CNLDO treatment outcomes to potentially standardise treatment protocols.

Outcomes and comparison of nasolacrimal probing for patients older than 12 months

Objective:

In this study, we report the results of probing done in our clinic. We also want investigate role of late probing on outcome, especially in children older than 24 and 48 months.

Methods:

We retrospectively evaluated records of patients who underwent probing under general anaesthesia due to congenital nasolacrimal duct obstruction between 2013 and 2017 in Nigde Ömer Halisdemir University Faculty of Medicine in Nigde, Turkey. Success rates of probing for different age groups were compared.

Results:

143 eyes of 123 patients were included in the study. Overall success rate was 93.7% (134 eyes out of 143). We found the success rate as 95.5 in 12–18 months age group, 93.3% in 18–24 months age group, 93.8% in the 24–48 months age group, 86.6% in the 48 months and older age group. Overall success rate in 24 months and older age group was 91.5%. The second operation was performed on seven of the nine patients where the initial surgery failed, and successful results were achieved in six patients. Success rate was 100% after the second surgery in patients older than 48 months.

Conclusion:

The success rate of probing is high in patients with congenital nasolacrimal duct obstruction from 12 to 84 months. In patients with congenital nasolacrimal duct obstruction who are older than 48 months probing is effective and should be first-choice in this age group in management of congenital nasolacrimal duct obstruction. Probing may be used even in older patients who had previous unsuccessful probing.

The Role of Inferior Turbinate Fracture in the Management of Congenital Nasolacrimal Duct Obstruction

PURPOSE

To evaluate the effect of inferior turbinate fracture in the treatment of congenital nasolacrimal obstruction combined with first attempt probing in children younger than 36 months.

METHODS

This prospective case-control study was conducted on 230 eyes from 176 children aged 12 to 36 months with congenital nasolacrimal duct obstruction. All patients underwent simple probing under general anesthesia. Inferior turbinate fracture was performed in case group combined with first probing. Patients were followed up 1, 3, and 6 months after surgery.

RESULTS

Total success rate was 91.2% for patients with turbinate fracture and 86.4% for patients without turbinate fracture. The difference between success rates was not statistically significant (p = 0.269). The authors did not find significant difference between cases and controls in age subgroups. Success rate in combined case and control groups in patients younger than 24 months (success rate: 91.7%) was significantly higher than those older than 24 months (success rate: 71.9%; p = 0.001). In univariate logistic regression analysis, age ≥24 months showed a negative association with the success rate (odds ratio = 0.232; 95% confidence interval: 0.91-0.59; p = 0.002). Other factors like sex, bilaterality of nasolacrimal duct obstruction, method of probing were not significantly associated with response to treatment.

CONCLUSIONS

Inferior turbinate fracture does not improve the outcomes of simple probing and is not recommended during the first attempt in treatment of congenital nasolacrimal duct obstruction. Late probing (after 24 months of age) may have a higher failure rate, and increased age is the important factor that predicts failure in probing simple congenital nasolacrimal duct obstruction.

Outcome of Primary Probing for Simple Membraneous Congenital Nasolacrimal Duct Obstruction in Children Older Than 4 Years

PURPOSE

To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction.

METHODS

The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting.

RESULTS

Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement.

CONCLUSIONS

This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing. [J Pediatr Ophthalmol Strabismus. 2020;57(1):44-47.].

Congenital nasolacrimal duct obstruction continues trend for spontaneous resolution beyond first year of life

PURPOSE

To investigate spontaneous resolution of congenital nasolacrimal duct obstruction (CNLDO) beyond 12 months of age in Japanese infants.

METHODS

Retrospective, observational case series. We retrospectively reviewed the clinical records of patients diagnosed with CNLDO beyond 12 months of age at Kyoto Prefectural University Hospital, Kyoto, Japan. This study involved 155 cases of CNLDO in 133 Japanese infants diagnosed with CNLDO. All patients chose intervention with either dacryoendoscopic guided probing and stenting or conservative management. The proportion and age of patients who had spontaneous CLNDO resolution were analysed.

RESULTS

The patients were divided into two groups: (1) 62 patients with 70 obstructed nasolacrimal ducts (45%) in whom spontaneous resolution occurred and (2) 71 patients with 85 obstructed nasolacrimal ducts (55%) who underwent dacryoendoscopic guided probing and stenting. The mean age of spontaneous resolution was 17.8±5.3 months (range: 12.0-35.4 months). Dacryoendoscopic guided probing and stenting were successful in 83/85 (97.6%) of cases.

CONCLUSIONS

Spontaneous resolution of CNLDO can occur in 45% of infants over the age of 12 months. Dacryoendoscopic guided stenting also has high success rates in this patient group, and both treatment options can be proposed to caregivers.

Nasolacrimal Duct Probing for Young Children With Congenital Nasolacrimal Duct Obstructions in China: A 10-Year Systematic Review

PURPOSE

To investigate the success rate of probing for young children with nasolacrimal duct obstructions and the risk factors involved.

METHODS

The medical records of 3,143 patients (3,928 eyes) who received nasolacrimal duct probing in southwest China were collected. These included delivery method, age and gender, preoperative treatments, anesthesia methods, probing procedure, and follow-up clinical records. Then the relationship between the success rates of the probing and a few probable risk factors were analyzed.

RESULTS

Children delivered by eutocia were more likely than those delivered by cesarean section to have nasolacrimal duct obstruction. The total success rate of the probing was 85.2%. Patients older than 19 months had a lower completion rate compared with those younger than 1 year (P < .01). In the follow-up observations, the younger age groups were more likely to have higher success rates than the older ones (P < .05) using pairwise comparison. The success rates also had a significant relationship with the type of obstruction and older patients were more likely to have complex obstruction (odds ratio: 1.13, 95% confidence interval: 1.08 to 1.19, P < .001).

CONCLUSIONS

This large-scale study proved several factors affect the success rate of nasolacrimal duct probing, and confirmed children delivered by eutocia were more likely to have nasolacrimal duct obstruction. [J Pediatr Ophthalmol Strabismus. 2019;56(6):365-372.].

Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct obstruction

Purpose: To highlight the importance of dacryoendoscopy in recognizing the factors responsible for failure with successful recanalization obviating the need for dacryocystorhinostomy in a few selective cases.Method: A retrospective study of 13 children undergoing dacryoendoscopy for refractory congenital nasolacrimal duct obstruction (CNLDO) was carried out during a period of 3 years from 2016 to 2018. Children with single or multiple failed probings were included in the study.Results: Out of the total 13 cases included in the study there 9 males and 4 females. The age ranged from 9 months to 36 months with the involvement of the right side in 7 cases and the left side in 6 cases. Four cases had dysgenesis of bony nasolacrimal duct (NLD), 4 cases had dacryolith, 3 cases had an intact membrane at the lower end of NLD and 2 cases had fibrosis of the lower end of NLD and the surrounding area in the inferior meatus (IM) following multiple interventions, (Table 1). Dacryoendoscopic recanalization was done in 7 cases while the endoscopic dacryocystorhinostomy (DCR) was done in 6 cases. Asuccessful outcome was achieved in all the cases and at the end of 6 months, all the children remained asymptomatic.Conclusions: Dacryoendoscopy (DEN) facilitates direct examination of the nasolacrimal system and thus has an added advantage over nasal endoscopy assisted probing in the refractory cases of CNLDO.

Risk Factors for Poor Surgical Outcome of Pediatric Nasolacrimal Duct Obstruction

PURPOSE

To determine whether there are common factors that may help predict if a child is at a higher risk for surgical failure for nasolacrimal duct obstruction.

METHODS

This retrospective, observational case-control clinical study reviewed patient factors present prior to surgical intervention and their correlation with the necessity of multiple surgeries. A pediatric ophthalmologist identified patients who required surgical correction based on symptom history refractory to conservative management. Patients were grouped by the need for multiple surgical interventions versus single surgery. Patient factors hypothesized to predispose patients to an unsuccessful initial procedure were compared via odds ratio analysis. Patient success was based on symptom resolution 6 months postoperatively.

RESULTS

Patient factors with statistically significant increased odds ratios were trisomy 21, allergic rhinitis/seasonal allergies, history of an upper respiratory tract infection within 1 month, and obstructive sleep apnea.

CONCLUSIONS

This study suggests that patients with trisomy 21 or a history of recent upper respiratory tract infection may be correlated with a higher risk of failure with a probing and irrigation surgery only. Patients with trisomy 21 may benefit from an initial balloon dilation procedure rather than probing and irrigation, due to an increased risk profile. Patients with a recent upper respiratory tract infection may benefit from postponing surgery until symptom treatment or resolution. [J Pediatr Ophthalmol Strabismus. 2019;56(4):261-264.].

Effect of Probing in Congenital Nasolacrimal Duct Obstruction in Children Older Than 2 Years

PURPOSE

To determine the effect of probing for congenital nasolacrimal duct obstruction in children older than 2 years.

METHODS

A prospective interventional case series included 110 eyes of 94 patients with congenital nasolacrimal duct obstruction (CNLDO) aged 2 years or older, with no previous intervention. The diagnosis was based on clinical findings (epiphora, discharge, regurgitation test, and fluorescein dye disappearance test). The children were divided into two groups: 2 to 5 years and 6 to 8 years. Probing of the nasolacrimal duct under general anesthesia was done. Success was predefined as resolution of symptoms and signs that persisted 3 months postoperatively. Another probing was done at 4 to 6 weeks when necessary before considering the final outcome as a failure. The chi-square test was used to analyze the result.

RESULTS

Patients' ages ranged from 2 to 8 years (average age: 55 months). Twenty-six (28%) patients needed a second probing. The overall success rate was 80%: 85% in the 2 to 5 years group and 73% in the 6 to 8 years group. The success rate was significantly lower in patients with complex obstruction (33.3%). The outcome of probing was not affected by the age of the patients (P = .2305).

CONCLUSIONS

Probing is a viable primary surgical option in CNLDO in older children and hence should not be withheld in children who are referred late. [J Pediatr Ophthalmol Strabismus. 2019;56(3):141-145.].

Tobramycin/dexamethasone eye drops as a better choice for lacrimal duct probing in persistent congenital nasolacrimal duct obstruction: A consort study

BACKGROUND

Congenital nasolacrimal duct obstruction (CNLDO) is common and. lacrimal duct probing is the major treatment. But persistent CNLDO in older children makes the success rate rapidly decreased due to long-term chronic inflammation. To improve the success rate, probing combined with tobramycin/dexamethasone ointment is considered effective. But in practice, we found a lot of problems in using the ointment. So we tried tobramycin/dexamethasone eye drops as a replacement. The results is surprising, so we hope to do some further research in order to prove it is worth to clinical application.

OBJECTIVE

To evaluate the effect of lacrimal duct probing combined with tobramycin/dexamethasone eye drops or ointment on persistent CNLDO in children older than 1-year-old.

METHODS

This randomized controlled study included 409 subjects (496 eyes) older than 1-year-old with persistent CNLDO in southwest China, and classified into 3 groups: 96 cases (123 eyes) were the tobramycin/dexamethasone eye drops group (drops group), 88 cases (104 eyes) were the tobramycin/dexamethasone ointment group (ointment group), and 225 cases (269 eyes) were control group which probing with normal saline (NS group). The data of age, sex, and laterality were analyzed through pairwise comparison. Then the 3 groups were divided into 2 subgroups by age, 12 to 24 months and 25 to 36 months. The surgical findings and success rate in two subgroups were compared.

RESULTS

The success rates in the tobramycin/dexamethasone eye drops group in both 2 age subgroups were significantly higher than that in the ointment group and NS group (P < .05).

CONCLUSIONS

Probing combined with tobramycin/dexamethasone eye drops was effective and easy-to-perform in the clinic, and it may be a better choice for persistent CNLDO.

Perioperative use of intravenous dexamethasone in the management of congenital nasolacrimal duct obstruction with balloon dacryoplasty

PURPOSE

To evaluate the effect of perioperative dexamethasone, presumed to reduce edema, on the success rate of nasolacrimal duct obstruction (NLDO) treatment by balloon dacryoplasty.

METHODS

The medical records of patients treated for NLDO using balloon dacryoplasty were reviewed retrospectively. Infants with <6 months' follow-up, genetic diseases, prior NLDO surgery, or anomalous nasolacrimal duct system were excluded. Patients either received intravenous dexamethasone perioperatively at a dose of 0.50 mg/kg (steroid group) or no dexamethasone (control group). Surgery was considered successful if there was no tearing or mucus discharge 1 month after surgery.

RESULTS

A total of 74 patients were included. In 71 eyes of 61 patients, dexamethasone was used; in 18 eyes of 13 patients, no dexamethasone. The mean age at treatment was 23.3 ± 15.6 months for the steroid group and was 22.5 ± 14.9 for the control group, with no difference between groups (P = 0.84). In the steroid group, 6 eyes (8.5%) had residual symptoms after surgery; in the control group 5 eyes (27.8%). There was a statistically significant higher success rate in the steroid group compared with the control group (P = 0.045; RR = 0.31 [95% CI, 0.11-0.9]).

CONCLUSIONS

In our study cohort, use of perioperative dexamethasone was associated with a reduced rate of failure in children treated for NLDO using balloon dacryoplasty.

Spontaneous Resolution and Timing of Intervention in Congenital Nasolacrimal Duct Obstruction

Importance

Although the overall rate of spontaneous resolution in congenital nasolacrimal duct obstruction (CNLDO) and efficacy of probing have been documented in the literature, the optimal timing of intervention has not been established.

Objective

To report new findings regarding spontaneous resolution in a large cohort of children with CNLDO.

Design, Setting, and Participants

The medical records of 1998 consecutive infants diagnosed with CNLDO from January 1, 1995, through December 31, 2004, while residing in Olmsted County, Minnesota, were retrospectively reviewed. Data were analyzed between January 1, 2015, and January 2017.

Main Outcomes and Measures

Rate of spontaneous resolution over time and by sex.

Results

The cohort, diagnosed at a median age of 1.2 months (interquartile range, 0.4-3.6), was 48% girls (n = 959) and 89% white (n = 1626; 173 were unreported). Among the 1998 cases, 1669 (83.5%) spontaneously resolved, 289 (14.5%) underwent treatment, and the remaining 40 (2.0%) were lost to follow-up. Of the 1958 infants followed up, CNLDO in 925 (47.3%) spontaneously resolved by age 3 months, in 1300 (66.4%) by 6 months, in 1472 (75.7%) by 9 months, and in 1516 (78.4%) by 12 months. The rate of resolution was 35% faster (95% CI, 23%-47%; P < .001) at less than 1 month vs 3 months, 43% faster (95% CI, 27%-64%; P < .001) at 3 months vs 6 months, 39% faster (95% CI, 16%-64%; P < .001) at 6 months vs 9 months, and 1% slower at 9 months vs 12 months (hazard ratio, 0.99; 95% CI, 0.80-1.22; P = .78). Congenital nasolacrimal duct obstruction resolved in boys 0.5 months (95% CI, 0.2-0.8; P < .001) faster than girls (median, 2.9 vs 3.4 months), and unilateral obstructions resolved 0.2 months (95% CI, 0.1-0.4; P = .002) faster than bilateral (median, 3.1 vs 3.3 months) ones. Children probed at 15 months or older had decreased odds of resolution after probing (odds ratio, 0.11; 95% CI, 0.01-0.89; P = .04) compared with children probed at age 12 to 14 months.

Conclusions and Relevance

Based on this large cohort of children with CNLDO, probing between age 9 and 15 months may be reasonable given that the rate of spontaneous resolution plateaued after 9 months and initial probing success declined after 15 months. This time frame supports both an earlier and narrower range of ages for intervention compared with the current practice of probing after age 1 year.

Systematic, Combined Treatment Approach to Nasolacrimal Duct Obstruction in Different Age Groups

Purpose

To report the outcome of a step-by-step treatment approach for congenital nasolacrimal duct obstruction (CNDO).

Methods

Three-hundred and fifty eyes with CNDO were included in the study. A number of treatment methods were applied systematically until a successful outcome was achieved. Listed in order from simple to more complex, the following methods were used: conservative management (massage and topical antibiotics), high-pressure syringing, probing, and silicone intubation. Treatment efficacy was determined according to age (Group 1: 0–6 months, Group 2: 7–12 months, Group 3: 13–24 months, Group 4: 25–72 months) and success rates were compared.

Results

Conservative management was applied only in children less than 1 year of age, and was successful in 91.8% of Group 1 and 60% of Group 2 eyes. The difference between these two success rates was significant (p = 0.003). High-pressure syringing was performed in children under 24 months of age, with success rates of 41.7% in Group 1, 33.3% in Group 2, and 12.5% in Group 3. The overall success rate for first probing in all groups was 76.1%, with a range of 69.4% to 80.9%. After second probing, the overall cure rate for the entire cohort was 88.0%, with a range of 74.9% to 94.8%. There was no real difference in probing cure rates relative to age (p > 0.05). Silicone intubation was indicated and performed in two eyes of Group 2 children, three eyes of Group 3, and nine eyes of Group 4. Two ducts in Group 4 eyes remained obstructed after silicone intubation.

Conclusions

The systematic treatment approach to CNDO, including conservative management and minimally invasive procedures such as high-pressure syringing, probing, and silicone intubation, is highly successful. In this study, the cure rate for this combined approach was 100% in youngsters under 2 years of age and 94.5% in children 2 to 6 years old.

Clinical profile of the patients with pediatric epiphora in a tertiary eye care center

Purpose:

To study the clinical profile of children aged <10 years presenting with epiphora at a tertiary eye care center, to compare the clinical profile between the early onset (<3 years) and the late-onset (≥3 years) group, and to study the success of different treatment modalities.

Materials and Methods:

A prospective nonrandomized observational study was conducted in 209 eyes of 167 patients (42 bilateral cases). The main outcome measure was postoperative relief of presenting symptoms and signs at 3 months follow-up.

Results:

Fifty-five percent cases (92 of 167) were early-onset cases, and 45% (75 of 167) were late onset. The male:female ratio was 1.9:1. Seventy-five percent cases were unilateral. The etiological profile was –76% cases of congenital nasolacrimal duct obstruction (NLDO), 18% traumatic/surgical, 4% acquired NLDO, and 2% punctal causes. The overall success rate of all the treatment modalities in our study was 80% (167/208) –82% for sac massage, 77% for probing, 79% for intubation dacryocystorhinostomy, and 100% for punctal surgery. A significant association was noted between the treatment outcome and laterality (P = 0.04), presence of infection (P = 0.032), symptom severity (P = 0.027), history of previous treatment (P = 0.024), and age. No significant association was found between the treatment outcome and gender (P = 0.73), socioeconomic status (P = 0.43), etiology (P = 0.45), and treatment modality (P = 0.33).

Conclusion:

This study describes the complete range of causes and treatment modalities for pediatric epiphora and highlights the etiology, signs and symptoms, treatment, and the comparative outcome between the early versus the late-onset group and analyses the factors predictive of the outcome.

A Case Series of Dacryoendoscopy in Childhood: A Diagnostic and Therapeutic Alternative for Complex Congenital Nasolacrimal Duct Obstruction Even in the First Year of Life

INTRODUCTION

Congenital nasolacrimal duct obstruction (CNLDO) is the most common cause of epiphora in infancy. Spontaneous resolution occurs in the majority of the cases by 1 year of age. Nevertheless, obstruction has a negative impact on the outcome of conservative or surgical therapy, especially in cases of complex CNLDO. When the condition persists beyond several months, early intervention with dacryoendoscopy (DE) around the age of 1 year could yield good results. The objective of the study is to analyze the success rate and effectiveness of early DE for complex CNLDO in the first year of life.

METHODS

A retrospective, non-comparative case series is presented. DE was performed under general anesthesia in patients between the age of 1 and 12 months with severe recurrent acute or chronic dacryocystitis. The medical histories, intraoperative and postoperative results after 3 months as well as via parents' interviews were analyzed to investigate the success rate.

RESULTS

A total of 18 consecutive DE in 16 patients between the age of 1 and 12 months (mean 7.3 ± 3.4 months) were studied. Nine lacrimal ducts were diagnosed with persistent chronic dacryocystitis refractory to probing/syringing. The remaining 9 presented recurrent acute dacryocystitis. Diagnostic DE was performed in 18 cases. A therapeutic DE was conducted in 15 lacrimal ducts (83.3%) with simultaneous correction of the associated stenosiswith the tip of the endoscope. A visual controlled opening of the stenosis was impossible in 3 cases due to a too narrow presaccal anatomy (n = 1), an osseous duct stenosis (n = 1), and a bulging membrane of Hasner into the inferior nasal meatus (n = 1). Postoperative findings were classified into four categories: poor, fair, good and excellent. Good results were documented in 16.7% (n = 3) and excellent results in 77.7% (n = 14). The bony obstruction was treated with dacryocystorhinostomy. A minimum follow-up of 3 months was considered for final clinical analysis. Ten patients' parents (12 surgeries) were interviewed by telephone (mean follow-up 24.8 months). No recurrence of stenosis and no further postoperative complications were observed.

CONCLUSION

DE is a diagnostic and therapeutic option for complex CNLDO in patients before the age of 1 year. The outcome of DE in the 3 months follow-up is highly indicative of positive final results in terms of patency of the lacrimal duct.

[Minimally invasive diagnostics and therapy of congenital nasolacrimal duct obstruction]

BACKGROUND

One of the most frequent issues in pediatric ophthalmology concerns congenital nasolacrimal duct obstruction (CNLDO). Typically, irritation of the medial eyelid angle occurs during the first days of life and later increased epiphora appears as tear production is still reduced in young infants. In the case of intrasaccal or postsaccal nasolacrimal duct stenosis, a chronic dacryocystitis develops.

METHODS

Modern minimally invasive diagnostics and therapy of CNLDO are reviewed by means of a search of the recent literature and reflection of own experiences.

RESULTS

An early diagnosis of CNLDO is desirable. If conservative therapeutic approaches fail, invasive procedures have to be considered. Probing and high pressure syringing of the nasolacrimal ducts remains the therapy of choice. Further therapy options, such as balloon dacryoplasty and dacryoendoscopy are also available. Additionally, due to improvement of the surgical techniques a minimally invasive approach is possible even for dacryocystorhinostomy; nevertheless, this procedure should be considered only as a last resort.

CONCLUSION

Precise classification of CNLDO and knowledge about the possible treatment options are important. Lacrimal surgery in childhood is dominated by transcanalicular procedures. Advanced minimally invasive techniques, such as dacryoendoscopy or modern autostable intubation sets have to be emphasized. All therapeutic interventions can be summarized using a staged therapeutic concept, which should be used individually and patient-centered.

Factors Predictive of Success in Probing for Congenital Nasolacrimal Duct Obstruction

PURPOSE

To report the success rate of children undergoing probing for congenital nasolacrimal duct obstruction (CNLDO) and the factors relating to the failure of the procedure.

METHODS

This retrospective case series included 88 eyes of 62 patients, aged 1 to 138 months, who underwent probing between January 2008 and December 2014 in the Pediatric Ophthalmology Unit of Centro Hospitalar São João. The procedure was performed in the operating room under general anesthesia. Surgical success was defined as successful lacrimal irrigation in-traoperatively and resolution of epiphora at the follow-up visit 1 month after surgery.

RESULTS

The overall success rate after first probing was 77.3% (68 of 88 eyes). No differences were found regarding age (P = .546), gender (P = .740), surgical experience (P = .611), or laterality (P = .328) between children who were cured and not cured. The surgical success rate decreased in children older than 4 years, although not to a statistically significant degree (P = .190). Surgical success after second probing was 85.7% (12 of 14 eyes), and the median interval between the two procedures was 3 months (range: 2 to 54 months). In 30% (7 of 20 eyes, 4 of 13 patients) of children with persistent obstruction, otorhinolaryngology evaluation evinced an adenoid hypertrophy requiring surgical correction.

CONCLUSIONS

The success rate of nasolacrimal probing for CNLDO was not related to age, gender, laterality, or the surgeon's experience. Otorhinolaryngology evaluation is recommended for unresponsive patients. [J Pediatr Ophthalmol Strabismus. 2017;54(2):123-127.].

Pushed monocanalicular intubation versus probing as a primary management for congenital nasolacrimal obstruction

Purpose

Evaluation of efficiency, complications, and advantages of pushed monocanalicular intubation using Masterka^® tube versus simple probing in patients with congenital nasolacrimal duct obstruction (CNLDO).

Patients and methods

This is a case-controlled study that included 60 eyes (of 53 patients); 30 eyes underwent probing and 30 eyes intubation using the Masterka tube as a primary treatment for CNLDO. The children were aged between 6 months and 36 months at the time of surgery, with no previous nasolacrimal surgical procedure, and had one or more of the following clinical signs of nasolacrimal duct obstruction: epiphora, mucous discharge, and/or increased tear lake.

Results

We defined success by absence of epiphora, mucous discharge, or increased tear lake 1 month after tube removal. The overall success rate in the probing group was 80%, while it was 83.3% in the intubation group.

Conclusion

Pushed monocanalicular intubation is an effective method for treatment of CNLDO; it requires only mask inhalation anesthesia and could be considered as an appropriate alternative procedure with imperceptible complications.

Congenital Nasolacrimal Duct Obstruction: Comparison of Two Different Treatment Algorithms

PURPOSE

To clarify the most appropriate treatment regimen for congenital nasolacrimal duct obstruction (CNLDO).

METHODS

A retrospective observational analysis was performed of patients undergoing probing with or without intubation to treat CNLDO in a single institution (Royal Victoria Hospital, Belfast) from 2006 to 2011.

RESULTS

Based on exclusion criteria, 246 eyes of 177 patients (aged 0 to 9.8 years with a mean age of 2.1 years) were included in this study: 187 (76%) eyes had successful outcome at first intervention with primary probing, whereas 56 (23%) eyes underwent secondary intervention. There were no significant differences by gender, age, or obstruction complexity between the successful and unsuccessful patients with first intervention. For those patients requiring secondary intervention, 16 of 24 (67%) eyes had successful probing, whereas 22 of 24 (92%) had successful intubation. Patients with intubation as a secondary procedure were significantly more likely to have a successful outcome (P = .037). Statistical analysis was performed using the Fisher's exact test and Barnard's exact test.

CONCLUSIONS

Primary probing for CNLDO has a high success rate that is not adversely affected by increasing age. This study also indicates that if initial probing is unsuccessful, nasolacrimal intubation rather than repeat probing yields a significantly higher success rate. [J Pediatr Ophthalmol Strabismus. 2016;53(5):285-291.].

[Increased prevalence of congenital dacryostenosis following cesarean section]

BACKGROUND

Congenital nasolacrimal duct obstruction (dacryostenosis) with a persisting membrane at Hasner's valve is the most common cause of persistent tear and ocular discharge in infants.

PURPOSE

To evaluate whether there is an association between congenital dacryostenosis and delivery via cesarean section.

MATERIAL AND METHODS

In a prospective study we examined 107 children (mean age 9.2 ± 7.1 months) with congenital dacryostenosis. We evaluated data about the mode of delivery (vaginal delivery versus cesarean section) and gestational age at the time of birth. Within the first 8 months of life children were treated by probing using local anesthesia, whereas older children were treated using general anesthesia. After the age of 11 months treatment included nasolacrimal duct intubation with a bicanalicular stent. Statistical analyses were performed using binomial tests, Fisher's exact test and the t-test.

RESULTS

In this study 51 children delivered by cesarean section were compared with 56 children delivered by spontaneous vaginal delivery. A total of 44 age-matched pairs from both groups were evaluated in order to eliminate confounding factors due to gestational age at delivery. Based on the published rate of cesarean sections from the same region of the State of Hesse between 2002-2004 we observed a statistically significant association between congenital dacryostenosis and delivery by cesarean section among the 88 age-matched patients (P = 0.009). Moreover, subgroup analysis revealed a significant association between congenital dacryostenosis and delivery by primary cesarean section (P = 0.00004). The prevalence of surgical treatment was not statistically different between both groups based on the mode of delivery (P = 0.8).

CONCLUSION

Our results suggest that delivery via cesarean section is associated with a significantly higher prevalence of congenital dacryostenosis.

Clinical Effectiveness of Monocanalicular Silicone Intubation for Congenital Nasolacrimal Duct Obstruction Under Nasal Endoscopic Visualization of the Terminal End of the Obstructed Nasolacrimal Duct

PURPOSE

To evaluate the cause of nasolacrimal duct obstruction through confirmation by nasal endoscopic findings of Hasner's valve and to report the success rate of monocanalicular silicone intubation (MCI) for the management of congenital nasolacrimal duct obstruction (CNLDO).

METHODS

Seventy-seven eyes of 56 patients with CNLDO underwent MCI under nasal endoscopic visualization of the terminal end of the obstructed nasolacrimal duct at the Korea University Ansan Hospital and Guro Hospital from October 2008 to March 2013. The following demographic information was analyzed: age, sex, endoscopic findings of Hasner's valve during operation, complications, and outcomes. The main outcome measures were disappearance of epiphora symptoms beginning the first 2 months after removal of the silicone tube. The silicone tube was removed under topical anesthesia in the office between 2 and 3 months, postoperatively.

RESULTS

The mean (± SD) age of the study population was 29.8 (± 26.9) months (range: 6 months to 12 years). Under nasal endoscopic view, 45 ducts (58.4%) had a thin membranous obstruction or had a simple stenotic opening of Hasner's valve. Seven ducts (9.1%) had thick obstructing membranes with probe passage under the lateral nasal mucosa. Twenty-three ducts (29.9%) showed the probe tip protruding through balloon-like nasal mucosa. Two ducts (2.6%) appeared to have probe protrusion through a stretchable valve. The overall success rate was 89.6% (69/77). The incidence of tube prolapse and tube loss was 18.2% (14 eyes) and 13.0% (10 eyes), respectively. No other complications were observed.

CONCLUSIONS

Monocanalicular silicone intubation under nasal endoscopic visualization of the terminal end of the obstructed nasolacrimal duct can be an effective procedure for the management of CNLDO.

Nasolacrimal duct office probing in children under the age of 12 months: Cure rate and cost evaluation

INTRODUCTION

Controversy exists regarding the treatment of infants with symptomatic nasolacrimal duct obstruction. One philosophy advocates "early" nasolacrimal duct probing, generally in the office - a relatively common approach in France, while others prefer to wait until the age of 12 months to offer a procedure under general anesthesia. The goal of this study is to report results of immediate office probing for congenital nasolacrimal duct obstruction (CNLDO) under age 1 year in terms of efficacy and cost.

METHODS

A retrospective study was performed on 329 patients (443 eyes) treated by probing for CNLDO under the age of 12 months age. A single probing was performed at the first visit in the office under topical anesthesia without sedation. In order to determine the factors associated with failure of probing, univariate analysis was performed using the Student t-test, Pearson's, homogeneity Chi(2) or Fisher's exact tests. For cost evaluation, hypothetical estimates of spontaneous resolution month by month were used according to data in the literature, along with health insurance reimbursement data.

RESULTS

The ages of the patients ranged from 2 to 11 months (mean 7.0 ± SD 2.3). The overall success rate for cure by immediate office probing was 76.7%. Unilateral CNLDO had an 80.4% success rate whereas bilateral CNLDO had a 73.2% success rate for each eye (P=0.09). Discharge during probing was associated with failed probing (P=0.02). The cost for the spontaneous resolution strategy was 1.56 times higher than for the immediate probing strategy. A strategy which would apply the spontaneous resolution strategy for children ≤ 5 months and the probing strategy to children>5 months would be the most cost-effective.

CONCLUSIONS

Immediate office probing between the ages of 5 to 12 months is a safe, effective method to relieve CNLDO and is the most cost-effective.

Factors affecting treatment outcome in congenital nasolacrimal duct obstruction: A retrospective analysis from South India

PURPOSE

To investigate outcomes for different treatment modalities in congenital nasolacrimal duct obstruction (CNLDO) in an Indian population.

DESIGN

Retrospective, interventional, case series.

MATERIALS AND METHODS

In an institutional setting, case records of patients with CNLDO from January 2008 to 2012, were reviewed, and data on patient demographics, clinical presentation, and treatment details (sac massage, probing, and/or dacryocystorhinostomy) were recorded. Success of treatment was defined as complete resolution of symptoms and negative regurgitation on pressure over lacrimal sac (ROPLAS) area.

RESULTS

Two hundred and ninety-eight eyes of 240 patients with a mean age of 22.2 ± 26.14 months (median = 12 months, interquartile range = 17) were analyzed. Sac massage (n = 226) was successful in 67 eyes (30%). Multivariable logistic regression analyses showed that children with mucoid ROPLAS were almost 6 times more likely (odds ratio [OR] = 5.55 vs. clear ROPLAS, 95% confidence interval [CI] = 2.35-13.09, P < 0.001) to experience failure of sac massage. Overall probing (n = 193) was successful for 143 (74%) eyes. Multivariable logistic regression showed that older children were 25% more likely to experience probing failure (OR = 1.25 for every 6 months increment in age, 95%, CI = 1.09-1.42, P = 0.001).

CONCLUSION

Sac massage is successful in only a third of our patients and those with mucoid ROPLAS are more likely to experience failure. Probing is successful in three-quarter of our subjects, and its success declines with a progressive increase in age. Lower socioeconomic status, poor general health, and recurrent respiratory infections are unique to our population and may influence outcomes.

Nasolacrimal Duct Probing under Topical Anesthesia for Congenital Nasolacrimal Duct Obstruction in Taiwan

BACKGROUND

To report the success rates of office probing for congenital nasolacrimal duct obstruction (NLDO) among children of different age groups in Taiwan.

METHODS

In this single-center, retrospective study, 564 eyes of 477 patients under the age of 5 years diagnosed with congenital NLDO were treated in a stepwise manner between 2001 and 2013. For infants aged < 6 months, treatment with massage and observation was suggested, followed by deferred probing under topical anesthesia if symptoms persisted. However, in cases of severe infection, immediate probing was suggested. In children aged > 6 months, office probing was usually highly recommended. Those with probing failures received either a second probing or silicone intubation. Treatment success was defined as anatomic patency by immediate irrigation after probing and absence of epiphora or mucous discharge at the follow-up visit.

RESULTS

Primary probing was successful in 457 of 564 eyes (success rate: 81%). The success rate of primary probing was negatively correlated with increasing age: 90.1% (163/181), 79.6% (164/206), 76.8% (73/95), 73.5% (36/49), 75% (18/24), and 33% (3/9) for the age groups of 0 to <6 months, 6 to <12 months, 12 to <18 months, 18 to <24 months, 24 to <36 months, and 36-60 months, respectively (p < 0.001, Fisher's exact test). The second probing was successful in 52 of 81 eyes. In total, probing was successful in 509 of 564 eyes (success rate: 90.2%).

CONCLUSION

Office probing is safe and effective for treating congenital NLDO. The success rate of primary probing decreases significantly with age.

Nasolacrimal duct intubation in the treatment of congenital nasolacrimal duct obstruction in older children

PurposeThe purpose of this study was to investigate the outcomes of nasolacrimal duct intubation in the primary treatment of congenital nasolacrimal duct obstruction (CNLDO) in children aged 7 years and older.MethodsThirty children aged ≥7 years who underwent primary unilateral nasolacrimal duct intubation because of CNLDO were enrolled in this study. CNLDO diagnosis was based on signs and symptoms including typical epiphora, increased tear meniscus, recurrent or persistent mucopurulent discharge, and an abnormal dye disappearance test (DDT). Surgical success was defined as complete resolution of previous signs and symptoms and DDT grade 0-1.ResultsThe mean age was 10.7±2.5 years (ranging from 7 to 15 years). Of the 30 patients, 18 were male and 12 were female. The mean follow-up period was 8.8±3.4 months (ranging from 6 to 16 months). The mean silicone tube removal time was 4.6±1.1 months (ranging from 3 to 6 months). The complete resolution of signs and symptoms with DDT grade 0-1 was observed in 22 of 30 cases (73.3%) during the follow-up period. The mean age of the patients with unsuccessful outcomes was 12.7±1.4 years, whereas that of the patients with successful outcomes was 10.0±2.4 years, and the difference was statistically significant (P=0.006). No serious intra- and/or post-operative complication was observed.ConclusionsThe current study demonstrates that nasolacrimal duct silicone intubation with intranasal endoscopic visualization has favorable outcomes as a primary treatment of persistent CNLDO in children aged 7 years and older. It can be used to reduce the need for dacryocystorhinostomy which is a more invasive procedure.

The outcomes of endoscopic dacryocystorhinostomy in children: A systematic review

OBJECTIVES

To systematically review and discuss the published results about the application of endoscopic dacryocystorhinostomy in treating children with nasolacrimal duct obstruction.

METHODS

In October 2014 an appropriate string was run on PubMed to retrieve all relevant articles. A cross-check was performed by two of the authors on abstracts and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the procedures' rate of success and failure was performed.

RESULTS

Fourteen studies were identified comprising a total of 346 subjects affected by nasolacrimal duct obstruction (unilateral or bilateral). Overall there were 393 surgical procedures, all performed with an exclusive endoscopic approach. The average length of follow-up was reported in twelve studies resulting 15.2 months and ranging from 3 to 27.1 months. On the basis of our statistical analysis the mean (95% CI) rate of failure was 0.14 (0.09-0.21). The mean (95% CI) rate of success resulted 0.87 (0.80-0.91).

CONCLUSIONS

Although in young patients the nasal anatomy is more complex and narrow than in adults our review showed as the endoscopic dacryocystorhinostomy allows similar results in terms of success compared to the external approach.