Success of balloon catheter dilatation as a primary or secondary procedure for congenital nasolacrimal duct obstruction

Management of adult focal nasolacrimal duct stenosis: long-term outcomes of 3D CT-DCG-assisted and endoscopically guided coronary catheter balloon dacryoplasty

The purpose was to evaluate the use of 3D CT-DCG-assisted and endoscopically guided coronary catheter balloon dacryoplasty (CC-BDCP) in adults with focal stenosis of the nasolacrimal duct (NLD) and report their long-term outcomes. A prospective, non-randomized, single-center clinical study was performed, and the patients underwent endoscopy-guided CC-BDCP using percutaneous transluminal coronary angioplasty (PTCA) balloon catheters. 25 patients were enrolled in the study. The CC-BDCP procedure was performed in 21 of 25 (84%) patients, and the remaining 4 (16%) patients had significant procedural difficulties due to unfavorable anatomical conditions. Of the 21 patients, 10 (47.6%) were procedurally assessed as "easy" (eCC-BDCP) and in 11 (52.4%) as procedurally "difficult" (dCC-BDCP). Values on Munk's epiphora intensity scale changed overall from 4.0 preoperatively to 1.4 ± 1.6 (p = 0.00001) postoperatively overall. FDDT changed overall from 2.9 ± 0.3 to 1.1 ± 1.2 after treatment (p = 0.00008) (from 2.8 ± 0.4 to 0.3 ± 0.6 in the eCC-BDCP group and from 2.9 ± 0.3 to 1.4 ± 1.2 in the dCC-BDCP group (p = 0.01352). The anatomical and functional success rate was 77% overall, 90% in the eCC-BDCP group, and 64% in the dCC-BDCP group. The CC-BDCP led to a statistically significant decrease in epiphora in a particular group of adult patients with demonstrable focal stenosis of the NLD.

Comparative efficacy of probing with or without intubation, and/or inferior turbinate fracture in simple congenital nasolacrimal duct obstruction: a randomized clinical trial

To compare the success rates of probing with or without monocanalicular intubation, and/or inferior turbinate fracture in resolving simple congenital nasolacrimal duct obstruction (CNLDO). A randomized, double-blind clinical trial was conducted on children aged 12-36 months exhibiting symptoms of epiphora and/or mucous discharge along with a positive fluorescein dye disappearance test (DDT). Patients were randomly assigned to one of the following interventions: (1) probing; (2) probing and monocanalicular intubation; (3) probing and inferior turbinate fracture; (4) probing, inferior turbinate fracture, and monocanalicular intubation. Participants were categorized into two age groups (12-24 months and 24-36 months) and assessed for resolution of CNLDO three months post-surgery. Success was defined as the absence of epiphora or mucopurulent discharge and a negative DDT. Among the 201 participants, 51 underwent probing alone, 53 underwent probing with intubation, 47 underwent probing with turbinate fracture, and 50 underwent probing with turbinate fracture and intubation. No significant differences were observed in age, gender, or laterality of the disease between the groups (Ps > 0.05). While there was no significant difference in success rates among interventions in both age groups (Ps > 0.05), patients aged 24-36 months who underwent interventions involving intubation exhibited a significantly higher success rate compared to those without intubation (93.0% vs. 76.2%; P = 0.018). However, this difference was not observed in patients aged 12-24 months (95.7% vs. 92.9%; P = 0.551). Incorporating interventions such as intubation and/or turbinate fracture alongside conventional probing does not significantly alter the success rate of simple CNLDO resolution in children aged 12-24 months. However, older patients (24-36 months) may derive greater benefits from interventions involving intubation.

Balloon dacryoplasty: A boon for dacryologists in managing persistent congenital nasolacrimal duct obstructions

PURPOSE

To study the outcomes of balloon dacryoplasty (BD) or (BDCP) in children with persistent congenital nasolacrimal duct obstruction (pCNLDO) by using new and reused balloon catheters.

METHODS

Our retrospective analysis focused on managing pCNLDO by using the BD or BDCP technique. The study included children aged >1 year to <12 years who underwent single or multiple probings before. Our specific lacrimal workup included a detailed history and examination, as published earlier. We used conventional, straight, 2 mm × 13 mm/3 mm × 15 mm lacrimal balloons (FCI, Ophthacath). We have described a technique to use the same catheter for three BD procedures (1 new + 2 reuse). The outcomes were categorized as complete success, partial success, and failure. The minimum follow-up of each child was 6 months.

RESULTS

We analyzed 64 children (89 eyes) with a mean age of 58 months (15-132 months). All children (100%) had epiphora with discharge and positive FDDT. All children underwent BD under general anesthesia - new balloons in 59 eyes and reused balloons in 30 eyes. The balloons were plasma sterilized akin to vitrectomy cutters and tubings of phaco machines. We noted three leaks from reused balloons (2 from the balloon tip and 1 from the plastic hub). At a mean follow-up of 14.5 months, complete success was noted in 77 eyes (86.5%) (52 new and 25 reuse), while 8 eyes had partial success (8.9%) (4 new and 4 reuse). Failure of BD was noted in four eyes (4.5%) (3 new and 1 reuse). None had significant complications with new or reused balloons.

CONCLUSION

BD or BDCP is a quick, safe, easy, and effective procedure that resolves pCNLDO symptoms satisfactorily. Carefully reusing a conventional balloon catheter is possible with comparable efficacy and no additional complications in pCNLDO.

Comparative Analysis of Silicone Tube Intubation Versus Probing and Balloon Dilation for Congenital Nasolacrimal Duct Obstruction: A Systematic Review and Meta-Analysis

OBJECTIVE

Congenital nasolacrimal duct obstruction (CNLDO) is a pediatric disorder with a wide range of pathology. If untreated, the condition may end up with serious complications. Multiple treatment options for CNLDO exist throughout the literature, and there is an ongoing debate on the best intervention for each disease subgroup and the best timing of such interventions. This study compares the success and failure rates of silicone tube intubation (STI) against probing and balloon dilation (BD).

METHODS

The authors searched the literature for relevant articles using PubMed, Scopus, web of Science, and Cochrane Library until January 2024. Using RevMan 5.4, the authors compared STI's success and failure rates to probing and BD using risk ratios (RRs) and a random-effect model. In addition, the complication rate of monocanalicular intubation (MCI) versus bicanalicular intubation (BCI) was investigated. The authors used the leave-one-out method to check for influential studies and to resolve heterogeneity.

RESULTS

The screening process resulted in 23 eligible articles for inclusion in the authors' review. Silicone tube intubation had a higher chance of resolving the symptoms of CNLDO than probing (RR = 1.11; 95% CI: 1.04, 1.20; P = 0.004) while having less risk of surgical failure (RR = 0.48; 95% CI: 0.30, 0.76; P = 0.002]. Monocanalicular intubation showed no statistically significant difference when compared with BCI in terms of surgical success and failure; however, MCI had a lower risk of complications (RR = 0.68; 95% CI: 0.48, 0.97; P = 0.04). In addition, STI did not demonstrate any significant difference from BD.

CONCLUSION

There was no significant difference in success/failure between MCI and BCI; monocanalicular had fewer complications. Silicone tube intubation did better in terms of surgical success than probing, especially in children over 12 months, suggesting that it is the preferred intervention for older patients with CNLDO.

The Use of Anterograde Percutaneous Transluminal Coronary Angioplasty Balloons in Congenital Nasolacrimal Duct Obstruction: A Cost-Effective Alternative to the Traditional Dacryoplasty Balloons

PURPOSE

To assess the efficacy of commonly available coronary angioplasty balloon catheters as a low-cost alternative to the traditional dacryoplasty catheters in select patients of congenital nasolacrimal duct obstruction.

METHODS

A prospective, interventional study was performed between July 2018 and December 2018 in children with congenital nasolacrimal duct obstruction, who underwent balloon dacryoplasty using the coronary angioplasty balloon catheters (2.75 × 10 mm, SPALNO, Cardiomac, Haryana, India). The inclusion criteria were children ≥4 years of age, and/or previously failed probing and/or previous failed intubation. Parameters documented were demographics, techniques, costs, complications, and postoperative outcomes.

RESULTS

Twenty-three eyes of 22 children underwent balloon dacryoplasty using coronary angioplasty balloon catheters. The mean age of the patients was 4.33 years (range 1.5-10 years). The procedure was performed in 8 patients (8 eyes, 35%) as the primary procedure. The remaining 14 patients (15 eyes, 65%) had a history of probing, of which 4 eyes had it twice earlier. All eyes underwent balloon dacryoplasty as per standard protocols. The insertion profile and trackability of the coronary catheters were good. At a mean follow up of 6.17 months (range 1.5-9 months), anatomical and functional success was obtained in 87% cases (n = 20/23). No lacrimal passage trauma or injuries were noted during the procedure. The cost of coronary balloon catheter was approximately $60.

CONCLUSIONS

The present pilot study has shown that outcomes of balloon dacryoplasty in patients with congenital nasolacrimal duct obstruction with coronary balloon catheters is comparable to that of traditional balloons and offers significant economic advantage for developing nations.

Incision of Hasner's valve under endoscopic intranasal surgery for the treatment of nasolacrimal duct obstruction in children

OBJECTIVE

To evaluate the effectiveness and safety of a Hasner's valve incision performed under endoscopic intranasal surgery for the management of congenital nasolacrimal duct obstruction.

METHODS

This retrospective study comprised 484 patients with congenital nasolacrimal duct obstruction who underwent incision of Hasner's valve under endoscopic intranasal surgery between April 2000 and October 2016. The primary endpoint was the procedure's functional success rate. The secondary endpoints were Hasner's valve and inferior turbinate anatomical findings, demographic data, complication rate and surgical duration.

RESULTS

In patients with no medical history of nasolacrimal duct probing, 91 per cent had a successful result, 5 per cent had a partially successful result, 3.9 per cent showed no change and 0.1 per cent had a worse result following the procedure. Concerning the secondary endpoints, outcomes were more frequently successful in children younger than three years. Only one patient had a post-operative infection. All patients underwent general anaesthesia; no complications related to general anaesthesia were observed. Mean surgical duration was 13.1 ± 5.7 minutes.

CONCLUSION

Incising Hasner's valve after medially displacing the inferior turbinate under nasal endoscopy seems to be an adequate primary surgical treatment for congenital nasolacrimal duct obstruction.

Balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction

PURPOSE

The aim of this study is to report the outcome of balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction in children of all ages.

METHODS

A 10-year retrospective study of 148 children (270 eyes), aged 9 to 159 months (mean age: 29.6 ± 17.7 months), who previously had not undergone a nasolacrimal surgical procedure and who presented with clinical signs of nasolacrimal duct obstruction, was conducted. All children underwent balloon catheter dilation of the nasolacrimal duct.

RESULTS

Treatment success, defined as complete resolution of nasolacrimal duct obstruction symptoms present at follow-up visits at 1 week and up to 6 months after surgery, was 87% (234 of 270 eyes). Partial success was defined as occasional tearing which was acceptable to parents and present in 3% (nine eyes). Only 10% of the children underwent a second procedure due to complete failure. In a sub-analysis by age groups-under 18 months, between 18 and 36 months, and above 36 months-complete resolution rates were 85%, 93%, and 77%, and partial success rates were 3%, 3%, and 4%, respectively. There was a statistically significant difference between the age groups (p = .007).

CONCLUSION

In this large cohort of patients with nasolacrimal duct obstruction, balloon catheter dilation was successful as a primary treatment for congenital nasolacrimal duct obstruction, particularly under the age of 36 months.

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.].

Congenital Nasolacrimal Duct Obstruction (CNLDO): A Review

Congenital nasolacrimal duct obstruction (CNLDO) is a common condition causing excessive tearing or mucoid discharge from the eyes, due to blockage of the nasolacrimal duct system. Nasolacrimal duct obstruction affects as many as 20% children aged <1 year worldwide and is often resolved without surgery. Available treatment options are conservative therapy, including observation, lacrimal sac massage and antibiotics, and invasive therapy. Observation, combined with conservative options, seems to be the best option in infants aged <1 year. Meanwhile, in children aged >1 year, nasolacrimal probing successfully addresses most obstructions. However, the most favorable timing for probing remains controversial. To alleviate persistent epiphora and mucous drainage that is refractory to probing, repeat probing, silicone tube intubation, balloon catheter dilation or dacryocystorhinostomy can be considered as available treatment options. Our review aims to provide an update to CNDO management protocols.

[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.

Endoscopic intranasal surgery for congenital nasolacrimal duct obstruction--a new approach

OBJECTIVE

Congenital nasolacrimal duct obstruction can be treated with a spectrum of techniques, starting with conservative massage to more invasive dacryocystorhinostomy. There has been controversy regarding the optimal treatment procedure. We introduced a unique technique to treat congenital nasolacrimal duct obstruction and analyzed its success rate and complications.

METHODS

In a retrospective study, we introduced the results of our technique. This technique consisted of endoscope guided inspection of the Hasner valve area, trial of irrigation, incision of the imperforate Hasner valve and irrigation again. If these maneuvers were not effective, more invasive procedure, probing under endoscopic control was done.

RESULTS

48 children (55 eyes) were included in the study. Complete improvement was achieved in 51/55 eyes (92.72% success rate). We did not encounter any early or late complication.

CONCLUSIONS

The great majority of the congenital nasolacrimal duct obstruction stem from Hasner valve area pathologies. The endoscopic intervention of this area is very effective and safe way of treatment. This technique should be added to the armamentarium of the congenital nasolacrimal duct obstruction treatment.

Dacryocystorhinostomy: History, evolution and future directions

Dacryocystorhinostomy (DCR) is a procedure of choice for nasolacrimal duct obstruction and chronic dacryostenosis in the setting of patent canaliculi and a functional lacrimal pump. Two major approaches are utilized: external, via a transcutaneous incision and endonasal endoscopically guided. The surgery has a high success rate via both approaches. We review the history, evolution, current techniques, complications and future directions of DCR.

Management of congenital nasolacrimal duct obstruction

Our review aims to provide an update of management protocols for congenital nasolacrimal duct obstruction (CNDO). Although early probing performed before the age of 1 year was traditionally recommended, many reports have since confirmed high frequencies of spontaneous resolution during the first year of life. Accordingly, a 'wait-and-see' approach, combined with conservative therapies, is judged to be the best option in infants aged<1 year. By contrast, persistent obstruction beyond 1 year of age warrants probing as a first-line interventional therapy. However, the optimal timing for probing remains controversial. Although there remains a high possibility of spontaneous resolution after the first year of age, this must be balanced against the decrease in success rates for probing that accompanies advancing age. If conservative management fails, persistent CNDO beyond 1 year of age should be managed either by further observation or by primary probing according to the severity of symptoms. In patients in whom probing fails, advanced treatment such as balloon catheter dilation, silicone tube intubation or dacryocystorhinostomy may be considered.

A national survey of the management of congenital nasolacrimal duct obstruction in the United kingdom

PURPOSE

To survey national variation in the management of congenital nasolacrimal duct obstruction, particularly the timing of intervention and the use of nasolacrimal intubation, nasal endoscopy, and assistance from an ear, nose, and throat surgeon at different stages of management.

METHODS

A telephone survey was conducted of 100 ophthalmologists in the United Kingdom who were involved in the management of congenital nasolacrimal duct obstruction. A sequential management protocol was established for each, including the nature of procedures, their timing, and the use of nasal endoscopy and ear, nose, and throat surgeons.

RESULTS

Of those surveyed, 49% use the dye disappearance test for diagnosis. Eighty-four percent suggest lacrimal sac massage to parents. No surveyed ophthalmologists perform "office" probing or balloon dilation. Seventy-four percent perform initial probing after 1 year, with 25% using nasal endoscopy. If symptoms persist, 64.5% (60 of 93) repeat the probing, whereas 35.5% (33 of 93) intubate the lacrimal system. The use of nasal endoscopy increases to 50.5% (47 of 93). By the third intervention, 77.6% (45 of 58) perform lacrimal intubation, with 72.4% (42 of 58) using nasal endoscopy. All opt for dacryocystorhinostomy as the fourth intervention and 28.3% (13 of 46) perform this procedure themselves, whereas 71.7% (33 of 46) refer the patient to another practitioner. In total, 65% (65 of 100) use tubes at some stage of management, 58% (58 of 100) make some use of nasal endoscopy, and 33% (33 of 100) involve ear, nose, and throat surgeons.

CONCLUSION

Based on the results of this survey, huge variation exists in the management of congenital nasolacrimal duct obstruction in the United Kingdom. Most ophthalmologists intervene soon after patients reach 1 year of age. The rate of nasal endoscopy increases with successive interventions, especially to aid with nasal intubation, either alone or with the assistance of ear, nose, and throat surgeons.

[Treatment of the congenital obstruction of the lachrymal duct, by means of balloon catheter, monocanalicular intubation, and endoscopic control]

INTRODUCTION AND GOALS

Congenital lachrymal obstruction is a frequent motive of consultation. Endoscopic control in the inferior meatus of the nostril allows to realize surgical controlled procedures. The aim of the study is to analyze the result obtained in the treatment of congenital obstruction of the lachrymal duct by monocanalicular intubation with Monoka and endoscopic control in children who had failed two lachrymal system probings.

METHODS

Between October 2004 and September 2008 this technique was performed in a prospective study on 36 patients with congenital nasolacrimal obstruction who had failed two lachrymal system probings. The mean age was 36.2 months (range 12-66 months). Patients were followed at 6 weeks, 3 months and 6 months, with clinical evaluation by Munk's score and ophthalmologic exam using dye disappearance test. Success was defined as complete resolution of signs and symptoms (Munk 0) and no fluorescein remaining in dye disappearance test (grade 0).

RESULTS

The procedure was successful in 91.66% of the cases and acceptable in 8.33%. We have not found any complication or side effects, and not further procedures have been needed on any patient.

CONCLUSIONS

Balloon dachryoplasty with monocanalicular intubation under endoscopic control is a safe, easy to perform and effective surgical technique for the treatment of congenital lachrymal obstruction with two previous failed lachrymal system probings.

Balloon catheter dilation for complex congenital nasolacrimal duct obstruction in older children

PURPOSE

To evaluate the effectiveness of lacrimal balloon catheter dilation in the treatment of complex congenital nasolacrimal duct obstruction in older children.

METHODS

In a retrospective study, the case records of 65 eyes of 59 children 2 to 6 years (mean: 37 months) who underwent probing for congenital nasolacrimal duct obstruction were evaluated. Complex obstruction was noted in 21 (32.3%) of the 65 children older than 2 years who underwent probing. Secondary balloon dacryoplasty was performed in 8 (38.09%) of these 21 lacrimal systems. Patient age ranged from 3 to 6 years (mean: 47 months). Balloon catheter dilation was performed according to a standard protocol. Clinical patency of the nasolacrimal system was the main outcome measure and was defined as complete resolution of signs and symptoms (crusting, discharge, and watering) on follow-up. The procedures were performed under general anesthesia. All dilations were performed by the same lacrimal surgeon.

RESULTS

Secondary balloon dacryoplasty was successful in seven of the eight lacrimal systems (87.5%). Complex obstruction at the distal end of the nasolacrimal duct was noted in all children. All children were older than 3 years (mean: 37 months), and all underwent secondary procedures because previous probing was unsuccessful.

CONCLUSION

Balloon catheter dilation is an effective procedure for complex nasolacrimal duct obstruction in older children. It can be an alternative to silicone intubation and dacryocystorhinostomy in children after unsuccessful probing.

Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing

OBJECTIVE

To compare the outcomes of balloon catheter dilation and nasolacrimal intubation as treatment for congenital nasolacrimal duct obstruction after failed probing in children younger than 4 years.

METHODS

We conducted a prospective, nonrandomized, multicenter study that enrolled 159 children aged 6 months to younger than 48 months who had a history of a single failed nasolacrimal duct probing and at least 1 of the following clinical signs of nasolacrimal duct obstruction: epiphora, mucous discharge, or increased tear lake. One hundred ninety-nine eyes underwent either balloon catheter nasolacrimal duct dilation or nasolacrimal duct intubation. Treatment success was defined as absence of epiphora, mucous discharge, or increased tear lake at the outcome visit 6 months after surgery.

RESULTS

Treatment success was reported in 65 of 84 eyes (77%; 95% confidence interval, 65%-85%) in the balloon catheter dilation group compared with 72 of 88 eyes (84% after adjustment for intereye correlation; 74%-91%) in the nasolacrimal intubation group (risk ratio for success for intubation vs balloon dilation, 1.08; 0.95-1.22).

CONCLUSION

Both balloon catheter dilation and nasolacrimal duct intubation alleviate the clinical signs of persistent nasolacrimal duct obstruction in a similar percentage of patients.

Balloon dacryocystoplasty and monocanalicular intubation with Monoka tubes in the treatment of congenital nasolacrimal duct obstruction

PURPOSE

To report our experience with combined use of balloon dacryocystoplasty and monocanalicular intubation with Monoka tubes for treating congenital nasolacrimal duct obstruction.

DESIGN

Retrospective consecutive interventional case series.

MATERIALS AND METHODS

This retrospective study consisted of 25 consecutive pediatric patients with congenital nasolacrimal duct obstruction who underwent balloon dacryocystoplasty and monocanalicular intubation with Monoka tubes between November 2003 and November 2006. Outcome evaluations included an ophthalmologic examination and a dye appearance test postoperatively. Age, history of a prior probing and complications related to the main outcome were also analyzed.

RESULTS

Thirty-three eyes of 25 patients aged 8 months to 9 years (3.5 +/- 2.4 years old) were included. Of the obstructed ducts treated, 97% (32/33) showed complete resolution of epiphoria. When analyzed by age groups, patients more than 1 year of age had higher success rate (30 successes in 30 patients) than patients less than 1 year of age (two successes in three patients). Statistical analysis revealed no statistically significant difference in success rate between both age groups (p = 0.09). The mean duration of intubation was 5.7 +/- 2.2 months. No significant complication was noted, except that early tube dislodgements occurred in six out of 31 Monoka intubations (19%).

CONCLUSIONS

The combined use of balloon dacryocystoplasty and monocanalicular intubation with Monoka tubes is an effective procedure for children with congenital nasolacrimal duct obstruction after failure of conservative treatment or probing.

Balloon catheter dilatation for frontal sinus ostium stenosis in the office setting

BACKGROUND

Frontal sinus ostium stenosis (FSOS) is problematic even for expert surgeons. Balloon catheter (BC) technology has been recently introduced to rhinology. The aim of this study is to assess technical feasibility and effectiveness of BC dilatation of FSOS in the office setting.

METHODS

This retrospective, multi-institutional case series describes all patients who underwent BC dilatation of FSOS in the office setting in the year ending December 31, 2007.

RESULTS

Six adult patients underwent a total of seven BC dilatations of FSOS in the clinical setting. The pretreatment ostium size was 1-2 mm. Four of the dilatations were performed with a 5-mm lacrimal BC (LacriCATH, Quest Medical, Allen, TX) and three dilatations were executed with a 7-mm sinus BC (SinuCATH, Quest Medical). All procedures were performed using topical anesthesia only. No complications occurred. Five of the six dilated FSOS dilatations were deemed successful after one BC dilatation. One ostium contracted >50% and required repeat BC dilatation. All ostia have remained patent with a follow-up range of 4-9 months. No subject has required formal surgical revision.

CONCLUSION

This preliminary report describes BC of FSOS in the office setting. The technique may serve as a safe and feasible alternative, potentially avoiding formal revision sinus surgery in select patients.

Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age

PURPOSE

To report the outcome of nasolacrimal duct intubation as the primary treatment of congenital nasolacrimal duct obstruction (NLDO) in children younger than 4 years of age.

METHODS

A total of 182 eyes of 139 children receiving intubation with planned tube retention for 2 to 5 months were enrolled in a prospective, nonrandomized observational multicenter study (19 sites). Children were ages 6 months to <45 months at the time of surgery, with no previous nasolacrimal surgical procedures and had at least one of the following clinical signs of NLDO: epiphora, mucous discharge, and/or increased tear lake.

RESULTS

Treatment success was defined as absence of epiphora, mucous discharge, and increased tear lake at the outcome visit, 1 month after tube removal. The surgical outcome was assessed in 150 eyes (82% of cohort). The proportion of eyes treated successfully was 91% (95% CI: 86%-95%). The outcome dye disappearance test was normal in 125 (86%) eyes, indeterminate in 13 (9%), and abnormal in 7 (5%) of the 145 eyes tested. Monocanalicular tubes were used in 74% of cases. The tube was removed before the planned minimum retention time of 2 months in 61 eyes (41%). For 23 eyes, the early removal was attributed to inadvertent displacement by the patient.

CONCLUSIONS

In children 6 months to <45 months of age, nasolacrimal duct intubation in a nonrandomized and noncomparative trial was a successful primary treatment of NLDO in about 90% of cases not lost to follow-up.

Primary treatment of nasolacrimal duct obstruction with balloon catheter dilation in children younger than 4 years of age

PURPOSE

To report the outcome of nasolacrimal duct balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction (NLDO) in children younger than 4 years of age.

METHODS

One hundred two children (151 eyes) ages 12 to <48 months (mean, 23 months) at the time of surgery, who previously had not undergone a nasolacrimal surgical procedure and who presented with at least one of the following clinical signs of NLDO--epiphora, increased tear lake, and/or mucous discharge--were enrolled in a prospective, nonrandomized observational multicenter study (20 sites). All children received balloon catheter dilation of the nasolacrimal system of the affected eye(s).

RESULTS

Treatment success was defined as no epiphora, increased tear lake, and/or mucous discharge present at the outcome visit at 1 month after surgery. The proportion of eyes treated successfully was 82% (95% CI: 74%-88%). The dye disappearance test at outcome was normal in 105 (73%), indeterminate in 15 (10%), and abnormal in 23 (16%) of the 143 eyes tested.

CONCLUSIONS

In children 12 to <48 months of age, balloon catheter dilation as a primary treatment of NLDO was successful in approximately 80% of cases. Because we did not perform a randomized trial with a comparison group, we were unable to determine how this procedure's success rate compares with that of simple probing or nasolacrimal intubation in this age group.

Effect of short-duration silicone intubation in congenital nasolacrimal duct obstruction

PURPOSE

To determine the incidence of premature dislocation of silicone tubes used in the treatment of congenital nasolacrimal duct obstruction and investigate the effect of early dislocation on treatment outcome.

METHODS

This retrospective review of 227 cases of silicone intubation in the treatment of 151 patients with congenital nasolacrimal duct obstruction. Specific attention was given to premature tube displacement, persistent epiphora, and the need for reoperation. The effect of the duration of silicone intubation and patient age on surgical outcome was assessed. Significance was determined using a Mantel-Haenszel chi-square test.

RESULTS

Tube displacement and removal prior to postoperative day 31 occurred in 93 of 227 (41%) of eyes. Four of 24 eyes (17%) in children younger than 12 months who had premature dislocation of silicone tubes compared with 7 of 40 eyes (18%) that maintained silicone tubes for 31 days or greater had persistent epiphora (p = 0.932); in eyes of children from age 12 months to 23 months, 5 of 46 (11%) had persistent epiphora compared with 6 of 78 (8%) (p = 0.549); and in children age 24 months or older, 9 of 23 (39%) eyes had tearing compared with 3 of 16 (19%) (p = 0.181). Reoperation rates were 1 of 24 (4%) compared with 0 of 40 (0%) (p = 0.23) of eyes in children younger than 12 months; no difference between groups (0%) in children from age 12 months to 23 months; and 5 of 23 (22%) versus 0 of 16 (0%) (p = 0.049) of eyes in children age 24 months or older for early tube removal versus standard tube removal, respectively.

CONCLUSION

Premature tube displacement and tube removal prior to day 31 does not increase the risk of persistent epiphora or reoperation in children younger than 24 months. Children older than 24 months who have early tube removal have poorer outcomes with a significantly higher reoperation rate.

A cadaveric model for balloon-assisted endoscopic paranasal sinus dissection without fluoroscopy

BACKGROUND

Recently, balloon catheter (BC) dilatation of paranasal sinus ostia has been introduced. In this procedure, a balloon-tipped catheter is placed across a sinus ostium over a flexible wire under fluoroscopic guidance, and inflation of the balloon enlarges the ostium. Some rhinologists have criticized this procedure for its failure to remove tissue and bone, especially in the setting of sinonasal polyposis. This project seeks to develop strategies for incorporating BC technology into standard functional endoscopic sinus surgery procedures.

METHODS

Endoscopic sinus dissection of three human cadaveric heads was performed with conventional instruments supplemented by lacrimal duct BCs (LacriCATH; Quest Medical, Allen, TX). No fluoroscopy was used. Each dissection was videotaped for later review.

RESULTS

For frontal recess dissection, these steps were performed under endoscopic visualization: (1) passage of the BC between frontal recess partitions, (2) BC inflation, and (3) removal of fractured frontal recess partitions with conventional instruments. This approach was used successfully in each frontal recess. Under endoscopic visualization, a BC was passed into the sphenoid ostium and inflated; this maneuver successfully dilated each sphenoid ostium. It was not feasible to reliably pass the BC through the natural maxillary ostium. Each BC was inflated to 8 atm for 30 seconds. No evidence of orbital or skull base injury was noted. No fluoroscopy was used.

CONCLUSION

BCs may be used as adjunctive instrumentation for endoscopic sinus dissection without fluoroscopy. This strategy warrants additional technical and clinical development.

Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction

BACKGROUND

Treatment of persistent nasolacrimal duct (nasolacrimal duct obstruction) obstruction traditionally has consisted of simple probing. The most common complication with this approach has been recurrent obstruction, requiring another probing, often with the use of bicanalicular silastic intubation. Monocanalicular silastic tubing offers the possibility of increased success rates over simple probing while theoretically minimizing the insertion and removal difficulaties posed by bicanalicular techniques. We report, to our knowledge, the largest series to date of patients undergoing monocanalicular silastic intubation, as well as the first report evaluating this technique as the primary treatment for congenital nasolacrimal duct obstruction obstruction.

METHODS

This was a retrospective chart review of 635 children treated by 3 pediatric ophthalmologists via probing with monocanalicular silastic intubation as the initial procedure for congenital nasolacrimal duct obstruction obstruction. Success was defined as good clearance of fluorescein dye and/or the absence of symptomatic tearing. Failure was defined as recurrent symptomatic tearing or inadequate clearance of fluorescein dye, leading to the performance of a second tear duct operation.

RESULTS

We identified 635 children who underwent probing with monocanalicular intubation as the primary treatment for congenital nasolacrimal duct obstruction obstruction (mean age at time of probing 18 months). The overall success rate for the 803 eyes undergoing surgery was 96%. The success rate for treatment performed in infants younger than 24 months of age (684 eyes) was 97%, declining to 90% when surgery was performed in infants older than 24 months of age (119 eyes; p < 0.001). These success rates compare favorably to previous reports of primary probing without silastic intubation, especially in children older than 12 months at the time of the probing. The only complication in the current study was conjunctival-corneal abrasion, occurring in 2% of cases.

CONCLUSIONS

Probing with monocanalicular silastic intubation as the initial surgical procedure for patients with congenital nasolacrimal duct obstruction obstruction is associated with a very high success rate and low complication rate, especially when performed by the age of 24 months.

Comparison of two endoscopically assisted procedures in primary surgical treatment of congenital nasolacrimal duct obstruction in children older than 3 years: balloon dilatation and bicanalicular silicone tube intubation

OBJECTIVES

To determine the success of two transnasally endoscopic assisted procedures as balloon dilatation and bicanalicular silicone tube intubation for the primary surgical treatment of congenital nasolacrimal duct obstruction in children older than 3 years.

STUDY DESIGN

Prospective randomized clinical trial.

METHODS

An interventional case series of consecutive primary endoscopic assisted balloon dilatation (BD) and bicanalicular silicone tube intubation (STI) for congenital nasolacrimal duct obstruction in children older than 3 years was reviewed. BD was performed in 20 eyes of 17 patients and STI was performed 24 eyes of 20 patients. Clinical success was defined as a complete remission of epiphora at the end of follow-up period of 12 months and a continuation of the remission at least for 4 months.

RESULTS

Eighteen out of 20 eyes (90%) nasolacrimal ducts responded to BD whereas the rate was 15 out of 24 eyes (62.5%) in STI group. No significant complications occured in BD group while the complication rate in STI group was 8 out of 24 eyes (33.3%). chi(2)-Statistical analysis showed significantly better results for BD in clinical success and complication rates than those of STI.

CONCLUSIONS

BD should be the first choice therapy instead of invasive approaches with high rate of complications and lower success rates such as silicone intubation, in patients who are older than 3 years.

Evaluation and management of congenital nasolacrimal duct obstruction

Congenital nasolacrimal obstruction is a common disorder in infants that results in persistent tearing and may lead to infections, such as dacryocystitis, orbital cellulitis, and bacterial conjunctivitis. The true incidence of this disorder in healthy newborns remains controversial. The most frequently quoted number of 6% comes from a study of 200 consecutive live births in the 1940s in which nasolacrimal patency was assessed by the presence or absence of discharge on compression of the lacrimal sac. Estimates from other studies, which often use different criteria for diagnosis, vary considerably from 1.2% to 30%. The incidence of the disorder is higher in children who have craniofacial disorders and Down's syndrome. This article reviews the causes and treatment of congenital nasolacrimal obstruction.

Stepwise treatment paradigm for congenital nasolacrimal duct obstruction

PURPOSE

To compare the outcomes achieved by a series of patients treated in a stepwise fashion who presented with congenital nasolacrimal duct obstruction.

METHODS

In this retrospective interventional case series, 127 patients, ranging in age from 1 month to 81 months, with 173 lacrimal systems diagnosed with congenital nasolacrimal duct obstruction, were treated in a stepwise fashion. A treatment paradigm was evaluated that prescribed probing as an initial procedure regardless of age. Those who failed probing received balloon catheter dilation. Those who failed probing and balloon catheterization received silicone intubation. Dacryocystorhinostomy was reserved for patients failing the above treatments. Clinical success was defined as complete resolution of symptoms. Success rates at each step were evaluated, and a cost analysis was performed.

RESULTS

Lacrimal probing was successful in 134 of 173 (76.9%) cases. Of the 39 probing failures, 32 (82.1%) were cured with balloon catheterization. All 7 cases (100%) that failed probing and balloon catheterization were cured with silicone intubation. No patient in this series required dacryocystorhinostomy.

CONCLUSIONS

A stepwise approach to the treatment of congenital nasolacrimal duct obstruction is a clinically and financially effective model for treatment.

A symptom survey and quality of life questionnaire for nasolacrimal duct obstruction in children

PURPOSE

To develop and validate a new parental questionnaire addressing symptoms and health-related quality of life (HRQL) in childhood nasolacrimal duct obstruction (NLDO).

DESIGN

Cross-sectional study.

PARTICIPANTS

Children ages 6 to younger than 48 months with and without clinical signs of NLDO.

METHODS

A new questionnaire was developed using semistructured interviews with parents of children with NLDO and through discussions with expert clinicians. Questionnaires were completed by parents of children with and without NLDO. Cronbach's alpha was calculated as a measure of internal-consistency reliability. Factor analysis was used to evaluate a priori subscales: symptoms and HRQL. Discriminant construct validity was assessed by comparing questionnaire scores between children with and without NLDO and between affected and unaffected eyes of children with unilateral NLDO. Instrument responsiveness was determined by comparing presurgical and postsurgical intervention scores in a subset of NLDO patients who underwent surgical treatment.

MAIN OUTCOME MEASURE

The NLDO questionnaire score.

RESULTS

Eighty-seven children were enrolled, 56 with and 31 without NLDO. All but 2 questions on the questionnaire showed a good distribution of responses, a high correlation with the rest of the questionnaire, and excellent discrimination between patients with and without NLDO. Cronbach's alpha values were good for the overall questionnaire (0.95), and for 2 predetermined subscales: symptoms (0.95) and HRQL (0.85). On a 0 to 4 scale, NLDO patients had worse scores compared with non-NLDO patients for both symptoms (mean difference, 2.1; 95% confidence interval [CI], 1.9-2.3) and HRQL (mean difference, 1.2; 95% CI, 0.9-1.5) subscales. The NLDO patients had worse scores before intervention compared with after intervention for both the symptoms (mean difference, 2.2; 95% CI, 1.6-2.9) and HRQL (mean difference, 1.4; 95% CI, 0.8-2.1) subscales. Finally, NLDO patients had worse symptom scores for affected eyes compared with unaffected eyes (mean difference, 2.3; 95% CI, 1.9-2.6).

CONCLUSIONS

This novel NLDO questionnaire is useful in quantifying parental perception of symptoms and HRQL in childhood NLDO. The questionnaire may have a role in future clinical studies of NLDO.

Treatment of congenital nasolacrimal duct obstruction with high-pressure irrigation under topical anesthesia

PURPOSE

To evaluate the effectiveness, safety, and success rate of high-pressure irrigation (HPI) applied under topical anesthesia in outpatient treatment of congenital nasolacrimal duct obstruction.

METHODS

HPI was applied under topical anesthesia to 39 eyes of 32 consecutive patients with congenital nasolacrimal duct obstruction. If obstructive symptoms persisted after the first attempt, treatment was repeated within 1 month. Patients were divided in two age groups: 7 to 12 months and 12 to 18 months. The two groups were compared in terms of the number of attempts needed to resolve the obstruction.

RESULTS

Thirty-nine eyes that had failed conservative treatment underwent high-pressure irrigation. The overall success rate was 31 of 39 (79.48%) at the first attempt; complete success (8/8, 100%) was achieved at the second attempt. The success rate in the younger group was 18 of 22 (81.8%) at the first attempt and 4 of 4 (100%) at the second attempt. The success rate in the older group was 13 of 17 (76.5%) at the first attempt and 4 of 4 (100%) at the second attempt. There was no statistically significant difference between the two groups regarding the number of attempts needed to relieve the symptoms (p > 0.05). There was no statistically significant difference in massage times and age between cases resolved at the first and second attempts (p > 0.05).

CONCLUSIONS

HPI can be attempted as an alternative second-step treatment or as a transition procedure between conservative and invasive methods. HPI has the advantage of being less invasive than other secondary methods, and its application under topical anesthesia seems to be safe and effective.

Balloon dilation of the nasolacrimal duct

PURPOSE

Our purpose is to report our experience with balloon catheter dilation of the nasolacrimal duct after failed probing for congenital nasolacrimal duct obstruction.

METHODS

We undertook a retrospective chart review. Patients who were enrolled had symptoms of persistent nasolacrimal duct obstruction after simple probing and irrigation. Balloon nasolacrimal ductoplasty was performed using the LacriCATH system (Quest Medical, Inc. An Atrion Company, Allen, TX). Outcomes were determined by postoperative examination and telephone follow-up.

RESULTS

Thirty-nine lacrimal systems of 26 patients (age range, 10 months to 84 months) were treated. Of the obstructed ducts treated, 82% (32/39) showed resolution of epiphora. There were 9 children older than the age of 2, with 15 nasolacrimal systems studied. These had 11 of 15 successes for a success rate of 73%. There were 17 children between the ages of 10 months and 2 years with 24 nasolacrimal systems studied. These had 21 of 24 successes for a success rate of approximately 88%. The difference was not statistically significant (P = 0.28).

CONCLUSION

Balloon dilation of the nasolacrimal duct is an alternative to silicone intubation in the treatment of congenital nasolacrimal duct obstruction after failed simple probing. Although our success rate was slightly lower than some published reports of nasolacrimal system intubation, this simple and atraumatic procedure was successful in 82% of cases for this specific situation.

Balloon dilatation for treatment of congenital nasolacrimal duct obstruction

PURPOSE

To evaluate the safety and effectiveness of balloon dacryocystoplasty in the treatment of congenital nasolacrimal duct obstructions.

METHODS

Balloon dacryocystoplasty was attempted in 25 eyes of 21 patients. The procedure was performed successfully in 24 eyes of 20 patients, age range 21-72 months. Nineteen eyes had no previous procedure. The mean age of this group was 43.9 months (range 36-72 months). Five eyes had failed probing of lacrimal system. The mean age of this group was 22.2 months (range 21-24 months). The authors performed balloon dacryocystoplasty under endoscopic guidance. Clinical success was defined as complete remission of epiphora within follow-up period of 7-34 months (mean 25.2 months).

RESULTS

The authors performed balloon dacryocystoplasty in 24 eyes. The first procedure was successful in 20 of them and the clinic success rate was 83.3%. The technique was repeated in the one eye that recurred and as it ended successfully, the clinic success rate increased to 87.5%. In 17 of the 19 eyes (89.4%) in which balloon dacryocystoplasty was performed primarily, and in 4 of 5 eyes (80%) in which balloon dacryocystoplasty was performed secondarily after unsuccessful probing, the procedure was clinically successful. There was intermittent epiphora in 3 eyes (15%) and these were considered as recurrence.

CONCLUSIONS

This experience shows that balloon dilatation is a safe and effective treatment of congenital nasolacrimal duct obstruction as a primary procedure in children over 36 months of age and as a secondary procedure after failure of lacrimal system probing. As a result, balloon dacryocystoplasty can be an alternative treatment in older children and can be preferred to silicone intubation and dacryocystorhinostomy performed after unsuccessful probing.

Comparison of Monocanalicular Stenting and Balloon Dacryoplasty in Secondary Treatment of Congenital Nasolacrimal Duct Obstruction After Failed Primary Probing

PURPOSE

To determine the success of monocanalicular stenting and balloon dacryoplasty as secondary treatment options for congenital nasolacrimal duct obstruction after failed probing surgery.

METHODS

An interventional case series of consecutive secondary balloon dacryoplasty and monocanalicular stenting for congenital nasolacrimal duct obstruction was reviewed. These secondary treatments were used in cases in which a bicanalicular stent would have been used in the past. Seventy-seven nasolacrimal systems in children with epiphora after probing and irrigation surgery were treated with a monocanalicular stent or balloon dacryoplasty. The patients were then evaluated at least 3 months after surgery or after stent removal by using a dye disappearance test. Cases in which there was no significant dye at 5 minutes were considered a success. Cases with residual dye or history of persistent tearing were considered failures.

RESULTS

The monocanalicular stent was used in 35 nasolacrimal systems, whereas balloon dacryoplasty was used in 42 nasolacrimal ducts. The mean age of treatment was 25.2 months for the monocanalicular stent group and 25.8 months for the balloon group. Overall, 32 of 35 (91%) nasolacrimal ducts responded to monocanalicular stenting, whereas 36 of 42 (86%) responded to balloon treatment. When the patient group was further stratified by age, the monocanalicular stenting was 94% successful in children younger than age 2 years and 89% successful for children older than 2 years. The balloon treatment had a success rate of 91% in the younger group and 79% in the older group. Chi-square statistical analysis showed no significant difference between the two treatments or on the basis of age stratification within each treatment group.

CONCLUSIONS

Monocanalicular stenting and balloon dacryoplasty are excellent secondary therapies for congenital nasolacrimal duct obstruction after initial probing and irrigation surgery has failed. These two treatment options are now our procedures of choice for secondary surgery.

Repeated probing results in the treatment of congenital nasolacrimal duct obstruction

PURPOSE

To assess the results of our protocol of repeated probing for the treatment of congenital nasolacrimal duct obstruction in various presentations.

METHODS

A total of 1600 patients (1748 eyes) with congenital dacryocystitis (850 boys, 750 girls; age range, 1 month to 48 months [mean 16.54 +/- 12.21 months]) were included. Diagnosis was confirmed by history of tearing, crusting of lids, and a boggy swelling over inner canthal region, which on pressure ejected mucopurulent discharge through punctum. Antibiotic eye drops were instilled five times a day for a week in affected eyes after the mother pressed the sac area and cleaned the discharge. The cases that were not relieved were subjected to sequential probing dilating with an increasing diameter probe repeated in failed cases second and third times at 1-week interval.

RESULTS

Medical treatment was effective in only 60 eyes (3.43%). Probing and syringing achieved successful results in 790 eyes (100%) aged 1 month to 12 months; 330 eyes (99.40%) aged 12 months to 18 months; 200 eyes (98%) aged 18 months to 24 months; 150 eyes (95.24%) aged 24 months to 36 months; and 158 eyes (89.87%) aged 36 months to 48 months. The cure rate with first probing was 98.10%, second probing was 99.64%, and third probing was 100%.

CONCLUSIONS

Our protocol of medical regime and early probing repeated two to three times was very effective in the treatment of nasolacrimal duct obstruction at all ages. A second and third probing was recommended after 1 week of the first probing with successful results if first probing failed.