The management of nasolacrimal duct obstruction in children between 18 months and 4 years old

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.

Assessing the success rate of treatment in simple and complex congenital nasolacrimal duct obstruction: a systematic review and meta-analysis

PURPOSE

To assess and compare the success rate (SR) of probing and intubation in patients with congenital nasolacrimal duct obstruction (CNLDO).

METHODS

We conducted a literature search for identifying relevant studies published in English using PubMed, Google Scholar, Scopus, and Web of Science databases from the date of inception to Feb 2023. After extracting data, the SR was compared between the study groups: simple and complex CNLDO. To compare the treatment outcome, the mean difference of the SR was considered as the effect size. Random effects model or fixed effects model were performed for statistical inferences.

RESULTS

A total of 21 studies were eligible to be analyzed. The pooled SR of treatment was 88% in simple, and 57% in complex CNLDO. Exerting intubation in increased the SR from 87% (SR of probing) to 92% in simple CNLDO which was not significant. However, compared to probing, intubation has a significantly higher SR in complex CNLDO (46 to 82%). While the SR of probing was significantly lower in complex CNLDO, the difference between the SR of intubation was not significant between groups. Although increasing the age does not have an adverse effect on the SR in simple CNDLO, it causes a significant decrease in the SR of complex group.

CONCLUSION

This study revealed that even though the addition of NLD intubation does not provide significant benefits beyond probing alone for patients with simple CNLDO, in children with complex CNLDO, NLD intubation should be considered as a primary treatment due to its substantial increase in surgical success rates. Delaying the treatment would increase its success in patients with complex but not the simple CNLDO.

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.

[Congenital anomalies in lacrimal drainage]

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Factors Associated With Nasolacrimal Duct Probing Failure Among Children in the Intelligent Research in Sight Registry

Importance

Understanding the factors associated with nasolacrimal duct probing failure in young children may help inform practice patterns.

Objective

To identify factors associated with repeated nasolacrimal duct probing in young children.

Design, Setting, and Participants

This retrospective cohort study analyzed data from the Intelligent Research in Sight (IRIS) Registry for all children who underwent nasolacrimal duct probing before 4 years of age between January 1, 2013, and December 31, 2020.

Main Outcomes and Measures

The Kaplan-Meier estimator was used to assess the cumulative incidence of a repeated procedure within 2 years of the initial procedure. Hazard ratios (HRs) derived from multivariable Cox proportional hazards regression models were used to evaluate the association between repeated probing and patient age, sex, race and ethnicity, geographic region, operative side, laterality of obstruction, type of initial procedure, and surgeon volume.

Results

This study included 19 357 children (9823 [50.7%] male; mean [SD] age, 1.40 [0.74] years) undergoing nasolacrimal duct probing. The cumulative incidence of repeated nasolacrimal duct probing was 7.2% (95% CI, 6.8%-7.5%) within 2 years of the initial procedure. Among 1333 repeated procedures, the second procedure involved silicone intubation in 669 (50.2%) and balloon catheter dilation in 256 (19.2%). Among 12 008 children aged 1 year or younger, office-based simple probing was associated with a slightly higher probability of reoperation compared with facility-based simple probing (9.5% [95% CI, 8.2%-10.8%] vs 7.1% [95% CI, 6.5%-7.7%]; P < .001). In the multivariable model, a greater risk of repeated probing was associated with bilateral obstruction (HR, 1.48; 95% CI, 1.32-1.65; P < .001) and office-based simple probing (HR, 1.33; 95% CI, 1.13-1.55; P < .001), and a lower risk was associated with primary balloon catheter dilation (HR, 0.69; 95% CI, 0.56-0.85; P < .001) and procedures performed by high-volume surgeons (HR, 0.84; 95% CI, 0.73-0.97; P = .02). Age, sex, race and ethnicity, geographic region, and operative side were not associated with reoperation risk in the multivariable model.

Conclusions and Relevance

In this cohort study, most children in the IRIS Registry undergoing nasolacrimal duct probing before 4 years of age did not require any additional intervention. Factors associated with lower risk of reoperation include surgeon experience, probing performed under anesthesia, and primary balloon catheter dilation.

Management of congenital nasolacrimal duct obstruction in down syndrome

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Primary Monocanalicular Stent Intubation for Children With Congenital Nasolacrimal Duct Obstruction: Surgical Outcome and Risk Factors

PURPOSE

To determine the risk factors impacting the surgical success of primary monocanalicular stent intubation for congenital nasolacrimal duct obstruction (CNLDO).

METHODS

This is a retrospective interventional case series of patients 18 years and younger treated more than a 12-year period with monocanalicular stent intubation with inferior turbinate fracture for CNLDO by a single surgeon. Patients with dacryocystoceles, dacryocystitis, Down syndrome and previous tear duct surgery were excluded. An intraoperative grading scale of tear duct stenosis, date of stent removal, stent length, and postoperative symptoms were recorded. Surgical success was defined as the complete resolution of symptoms.

RESULTS

One thousand four hundred sixty-nine stents were placed in 1,001 pediatric participants (533 unilateral, 468 bilateral). The mean age at surgery was 1.86 years (0.1-18.07). The mean follow up was 34.99 months (0.43-134.3) with mean in-office stent removal at 3.41 months (0.63-36.9). Early stent loss occurred in 14.8% intubations (217/1,469). The overall success rate was 92.4% (1,357/1,469 eyes). Subjects less than the age of 4 years had a success rate of 92.8% (1,296/1,397) compared with 84.7% (61/72) in children more than 4. In multivariable analysis, bilateral surgery, severe tear duct stenosis, and early stent loss were significantly associated with higher risk of surgical failure.

CONCLUSIONS

Severe tear duct stenosis, early stent loss, and bilateral surgery were significant risk factors for surgical failure. While the success rate stratified by age at surgery suggested a lower success after the age of 4. Primary monocanalicular stent intubation is an effective and safe treatment for CNLDO sparing a child the need for multiple staged surgeries.

Retrospective analysis of congenital nasolacrimal duct obstruction outcomes in a tertiary referral center

Background

The aim of this study was to profile patients with simple and complex congenital nasolacrimal duct obstruction (CNLDO) and to determine the success rates of interventions at a third-level referral center.

Methods

In this retrospective and comparative study, medical records of patients with CNLDO were reviewed. Demographic data, types of CNLDO, surgical approach, type of silicone intubation, as well as outcome were recorded up to 3 months after the intervention. Obstruction location was identified by probing and irrigation following the American Academy of Ophthalmology (AAO) approach. Success rates were calculated for treatment approach and age group.

Results

Based on the outcome of 130 eyes with CNLDO, the overall success rate was 96%. The mean age of patients was 2.5 ± 2.2 months; 73% of cases were simple and 27% were complex CNLDO. Five children had to undergo reoperation; consequently, there was a lower success rate in the complex CNLDO (91%) than in the simple CNLDO subgroup (97%). There was a male predominance (61.5%), which was also present in the simple and complex CNLDO subgroups. The most frequent type of CNLDO was complete nasolacrimal duct obstruction (NLDO, 55.4%), followed by partial (17.7%) and bony NLDO (11.5%). In 87% of eyes, initial probing was performed followed by dacryocystorhinostomy (10%). Mono- or bi-canalicular lacrimal drainage system intubation was used in 86% of eyes.

Conclusion

The AAO-based diagnostic approach followed by an individualized treatment regimen yielded excellent success rates of 96% in unselected patients with CNLDO. These success rates were independent of patient age or gender.

Congenital Anomalies in Lacrimal Drainage

Congenital dacryostenosis is the most common reason for ophthalmic consultation in childhood. It is most often caused by persisting of Hasner's membrane. However, congenital malformations of the lacrimal drainage system can also occur in rare cases. In the area of the proximal lacrimal drainage system, supernumerary lacrimal puncta and canaliculi can arise as well as diverticula, fistula, and atresia. The distal lacrimal drainage system can be affected by fistulas, amniotoceles, and cysts. Association of lacrimal malformations with congenital systemic diseases is reported in about 10% of cases. Depending on the severity of the symptoms, surgical rehabilitation can be performed, and endoscopic procedures and modern lacrimal drainage intubation systems may be employed.

Congenital Nasolacrimal Duct Obstruction Update Study (CUP Study): Report III. Analysis of Earlier Failed Probing without Endoscopy Guidance

AIM

The purpose of this study was to report the profile and outcomes of children with an earlier failed probing that was performed without endoscopy guidance.

METHODS

Retrospective interventional case study was performed on all the patients who were referred with a diagnosis of a single or multiple failed probing from Jan 2016 to June 2019 to a tertiary care Dacryology center. All the patients had a blind probing without an endoscopy assistance before referral. The parameters evaluated were patient demographics, number of earlier probings, prior operative notes, clinical presentation, findings of endoscopy guidance during the repeat procedure, simple vs complex CNLDO, types of complex CNLDO, management, complications and outcomes.

RESULTS

One hundred eyes of 82 children had a failed probing experience without endoscopic guidance elsewhere. The mean age of the children was 55.7 months (range: 9-168 months). Of these, 63 eyes underwent repeat probing under endoscopic guidance, 35 eyes being simple CNLDO (35/63, 55.5%), and 28 eyes (28/63, 44.5%) being complex CNLDO. Among the complex subset, balloon dacryoplasty was performed for five cases and monoka-Crawford stents for eight cases under direct endoscopy visualization. Buried probes were managed successfully by standard protocols of probe exteriorization. The two cases of misdirected probes were re-directed under endoscopy guidance for appropriate recanalization and the single case of granuloma at the NLD opening was excised followed by intubation without any recurrence.

CONCLUSION

Endoscopy guidance plays a crucial role in the management of CNLDO with an earlier failed probing.

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.

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.

Congenital nasolacrimal duct obstruction update study (CUP study): Paper II - Profile and outcomes of complex CNLDO and masquerades

OBJECTIVE

To assess the profiles and outcomes of complex congenital nasolacrimal duct obstruction (C-CNLDO).

METHODS

Retrospective interventional case-series was performed on patients diagnosed with C-CNLDO and managed at a tertiary care Dacryology Institute from Jan 2016 to June 2019. Complex CNLDO was diagnosed based on intraoperative findings during probing and are defined as entities where CNLDO is secondary to, or associated with complex embryonic entities like buried probe, mal-development or non-development of bony NLD, additional proximal lacrimal dysgenesis, atonic sac, or associated craniofacial syndromes and craniofacial dysostosis. The parameters studied include patient demographics, clinical presentation, types of C-CNLDO, management modalities, and outcomes. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test. For patients who underwent a dacryocystorhinostomy (DCR), a minimum follow-up of 1-year post-DCR was considered for outcome analysis.

RESULTS

Of the 2714 cases of CNLDO managed during this period, 482 (17.75%) were diagnosed as complex CNLDO. C-CNLDO showed predilection to the male gender (60.3%, 291/482). A significant number of patients (40.2%, 194/482) presented beyond 36 months of age. The common subtypes of C-CNLDO were atonic sacs (33.8%, 163/482), buried probes (19.7%, 95/482), and associated proximal lacrimal drainage anomalies (11.2%, 54/482). Since C-CNLDO is usually confirmed during the initial endoscopy-guided probing, the managements varied based on the type of C-CNLDO. Silicone intubation and/or balloon dacryoplasty (BDCP), and/or additional minimally invasive procedures were added to the initial endoscopy-guided irrigation and probing based on the nature of C-CNLDO. The overall resolution rate with these non-bypass modalities was 72.6% (350/482). Although the success rates start dropping in C-CNLDO patients beyond 3-years of age, significant success rates with multi-modal (non-bypass) management were noted in age-groups 3-5 years (71.8%, 79/110) and encouraging results (38.5%, 27/70) in 5-10 years age group. The anatomical and functional outcomes in those who underwent endoscopic or external dacryocystorhinostomy with a follow-up beyond 1-year was 96.4% (55/57).

CONCLUSION

The age at presentation is delayed in patients with C-CNLDO. Multi-modal endoscopy-guided management facilitates the identification of several sub-types of C-CNLDO, and achieves significantly high favourable outcomes in older children. C-CNLDO refractory to probing, intubation and BDCP demonstrates high success with external or endoscopic dacryocystorhinostomy.

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.

Lacrimal drainage system involvement in Peters anomaly: clinical features and outcomes

PURPOSE

To present first of its kind series on the clinical features and outcomes of lacrimal drainage disorders in Peters anomaly and Peters plus syndrome.

METHODS

A retrospective chart review was performed of all consecutive patients who were known cases of Peters anomaly or Peters plus anomaly and were diagnosed with associated congenital lacrimal drainage disorders. The study period was from June 2016 to Dec 2020. All these patients underwent examination under anaesthesia for a detailed assessment of lacrimal drainage anomalies. Where indicated, they were treated with probing, intubation, or in refractory patients with a dacryocystorhinostomy. The anatomical and functional outcomes were assessed.

RESULTS

Of the 282 patients with Peters anomaly, 4 (1.4%) patients had associated lacrimal drainage system anomalies while of the 16 Peters plus anomaly children, 3 (18.75%) had associated lacrimal drainage system anomalies. A total of 12 lacrimal drainage systems of 12 eyes of 7 patients of Peters anomaly were found to be involved. Upper or lower punctal agenesis were noted in 3 eyes. Three eyes had complex congenital nasolacrimal duct obstruction (CNLDO), two of which had a bony NLD block and one had a misdirected nasolacrimal duct through the inferior turbinate. One eye had a diffuse NLD stenosis without a CNLDO. Following appropriate management, at a mean follow-up of 25.7 months (range: 3-48 months), all the eyes except one (91%, 10/11) demonstrated anatomical and functional success.

CONCLUSION

Lacrimal drainage involvement was more common in Peters plus syndrome. Multiple proximal and distal lacrimal drainage segment anomalies were noted in all the variants of Peters anomaly; however, Peters plus syndrome was noted to usually involve both the segments.

The Use of Stents in Children with Nasolacrimal Duct Obstruction Requiring Surgical Intervention: A Systematic Review

Nasolacrimal duct obstruction (NLDO) is the most common cause of childhood epiphora. It is managed conservatively in the first year of life, after which surgical treatment is classically based on a stepwise paradigm of probing, intubation, and dacryocystorhinostomy. This systematic review aims to present the current role of intubation in the management of children with NLDO requiring surgical intervention. A search for English-language articles from the electronic databases PubMed, SCOPUS, and the COCHRANE library was conducted over a period of five months in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook. The following keywords were used to aid retrieval: stents, children, lacrimal intubation, endoscopic dacryocystorhinostomy, external dacryocystorhinostomy, NLDO, dacryocystitis, congenital, acquired. The primary outcome was defined as the success of the intervention, determined by resolution of symptoms and patency of the lacrimal anatomy confirmed by the fluorescein dye disappearance test or syringing. Secondary outcomes included the presence of complications. A total of 144 articles were identified; of these, 35 fulfilled the study criteria. The majority of the included studies involved lacrimal intubation alone, followed by intubation as an adjunctive procedure to balloon dacryoplasty and dacryocystorhinostomy. The overall success rate of these procedures ranged from 41.1% to 100%. Post-operative complications were reported in 65.7% of the included studies. Lacrimal intubation was most commonly performed as a primary procedure in children with NLDO, with high success rates. The main complication was stent dislodgement. There is lack of evidence regarding the benefit of intubation over probing as primary treatment of congenital NLDO. In the absence of high-quality evidence, the decision of whether to perform lacrimal intubation in children with NLDO requiring surgical intervention depends on clinical judgement and other&nbsp;low-level evidence, such as observational non-randomised trials.

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.

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.].

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.].

Nasal endoscopic features and outcomes of nasal endoscopy guided bicanalicular intubation for complex persistent congenital nasolacrimal duct obstructions

Purpose:

To study the clinical presentation, nasal endoscopic features, and outcomes of nasal endoscopy guided (NEG) bicanalicular intubation (BCI) in children with complex persistent congenital nasolacrimal duct obstruction (pCNLDO).

Methods:

A prospective, interventional study including eligible children (age ≤ 12 years) having complex pCNLDO. The demographics, number of previous probings, nasal endoscopy findings, and outcomes; were noted in all children who underwent NEG-BCI with Crawford's stents. Matting of eyelashes (MoE, upper, and lower eyelid), tear-film height (TFH), and fluorescein dye disappearance test (FDDT) was assessed pre and postoperatively. The minimum stent in-situ period was 12 weeks, and the minimum follow-up was 6 months (after stent removal).

Results:

Total 32 children (36 eyes) including 18 females (56.25%) were studied. At a mean age of 4.9 years, all children had epiphora and discharge with MoE (both upper and lower), raised TFH and positive FDDT. Previously, all children underwent conventional probing (s)- once in 12 (33.3%), twice in 18 (50%) and thrice in 6 (16.7%) eyes. The general ophthalmologists performed the majority (n = 21, 58.33%) of those. The BCI was performed under GA in all eyes, and at a mean follow-up of 8.5 months, the “complete” success was noted in 29 eyes (80.5%), ‘partial’ success in 4 (11.1%) and failure in 3 (8.3%). The stent prolapse was seen in three.

Conclusion:

NEG-BCI may provide a satisfactory resolution to complex pCNLDO after single or multiple failed probings. NEG provides confident and efficient management of coexistent intranasal complexities related to the inferior turbinate and meatus.

Surgical management of congenital nasolacrimal duct obstruction; one procedure for all versus all procedures for one

PURPOSE OF REVIEW

After failed conservative management, most clinicians treat congenital nasolacrimal duct obstruction (CNLDO) in a conventional stepwise fashion: starting with probing, then repeat probing, next silicone intubation and/or balloon dilatation, and finally dacryocystorhinostomy. This approach is based on the patient's age and previously failed procedures and recruits 'one procedure for all' CNLDO. A newly introduced approach is based on the type of obstruction and recruits 'all procedures for one' CNLDO. The aim of this review is to examine the best available evidence regarding CNLDO management.

RECENT FINDINGS

Recent articles support the concept that through intraoperative evaluation of obstruction in CNLDO, clinicians may predict probing failure and instantaneously employ more appropriate treatment modalities. This review addresses whether an age-based approach should be changed into a one-stage obstruction-based approach.

SUMMARY

An age-based approach treats CNLDO as a homogeneous disease and thus treats all patients with one predetermined procedure. A one-stage obstruction-based approach, however, considers CNLDO to be a heterogeneous disease, and therefore allows recruitment of all procedures simultaneously and selects the best intraoperatively. It may allow replacement of the conventional stepwise approach to CNLDO treatment provided that randomized trials verify its efficacy, safety, and cost-effectiveness.Video abstract http://links.lww.com/COOP/A30.

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.

Prevalence of buried probe in complex congenital nasolacrimal duct obstruction and evaluation of its success rate post 'probing and irrigation': a single-centre retrospective study

INTRODUCTION

The aim of this study was to determine the prevalence of buried probe variant of complex congenital nasolacrimal duct obstruction (CNLDO) and to evaluate the outcome of probing and irrigation in such cases. Institutional review board approval was taken.

MATERIAL & METHODS

A total of 309 eyes (258 patients) were diagnosed with CNLDO during the study period of January 2014-March 2017. A retrospective file review of 25 lacrimal systems of 20 patients diagnosed as buried probe variant of complex CNLDO was carried out during the study period.

RESULT

Buried probe variant of complex CNLDO was found to be 8% of the total CNLDO cases during the study period. Mean age at presentation was 1.7 years (range 8-48 months). Discharge and matting of eyelashes were the presenting symptoms in 22 out of 25 (88%) cases, whereas the only epiphora was the presenting symptom in three (12%) cases. Regurgitation of mucopurulent discharge on pressure over lacrimal sac area was positive in 16 out of 25 (64%) eyes. Associated lacrimal and nasal pathologies were seen in six out of 25 cases (24%). Success rate in buried probe variant cases of CNLDO in our study at 3-month follow-up was 88% (22 of 25 cases).

CONCLUSION

A high period prevalence of 8% out of all CNLDO cases in our study suggests that the buried probe should be considered in selective cases of CNLDO and earlier unsuccessful probing.

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.

A comparison of the success rates of endoscopic-assisted probing in the treatment of membranous congenital nasolacrimal duct obstruction between younger and older children and its correlation with the thickness of the membrane at the Valve of Hasner

Congenital nasolacrimal duct obstruction (CNLDO) remains the most common cause of epiphora in infants. This retrospective study compares the success rate of nasal endoscopic-assisted probing between younger (3 years and below) and older (above 3 years) children with membranous CNLDO and its correlation with the thickness of the membrane at the valve of Hasner. Case records of a total of 38 eyes in 34 children with membranous CNLDO who underwent endoscopic nasolacrimal duct probing and irrigation under general anesthesia were analyzed. The cases were divided into two groups, Group Y (20 cases of children 3 years and below) and Group O (18 cases of children above 3 years). The success of the procedure was defined as complete remission of symptoms and a clinical examination of eye to rule out the presence for discharge or watering after three months of the procedure. Overall, 35 cases (92.1%) were successfully treated with a success rate of 95% in Group Y and 88.9% in Group O. The mid-P exact test p value for the success rate between the two cohorts was not statistically significant (p = 0.59). The thick membrane was observed in 50% cases in Group Y and 33.33% cases in Group O (p = 0.34). There is no age related decline in the overall success rate for nasal endoscopic-assisted probing and irrigation in cases of membranous CNLDO. The thickness of the membrane may be a factor for failed blind probing, but it has no correlation with the success rate if probing is done under endoscopic guidance.

Congenital Nasolacrimal Duct Obstruction and Its Association With the Mode of Birth

PURPOSE

To assess the association of congenital nasolacrimal duct obstruction (CNLDO) with mode of birth (vaginal or cesarean).

METHODS

This study was a prospective interventional case series of 200 consecutive cases of CNLDO presenting at a tertiary care center. Data collected include demographics, mode of delivery, elective or emergency cesarean section, primary or secondary cesarean sections, type of CNLDO (simple or complex), management, and outcomes. Statistical significance was set at a P value of less than .05.

RESULTS

Of the 200 consecutive patients, 97 (48.5%) were vaginal deliveries and 103 (51.5%) were cesarean sections. Of the 103 cesarean section patients, 57 (55.3%) were primary cesarean sections and the remaining were secondary cesarean sections. Based on the type of CNLDO, 172 (86%) were simple CNLDO. In general, the current study did not find any significant association between the incidence of CNLDO and mode of delivery. Among the complex CNLDO cohort (n = 28), a significant association was found with cesarean section delivery (P = .016); however, no such association was noted when the patients were analyzed with regard to their age at presentation.

CONCLUSIONS

The current study did not find an overall significant association between CNLDO and the mode of delivery; however, the subset of patients with complex CNLDO showed a significant association with cesarean section. [J Pediatr Ophthalmol Strabismus. 2018;55(4):266-268.].

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.

A Novel One-Stage Obstruction-Based Endoscopic Approach to Congenital Nasolacrimal Duct Obstruction

PURPOSE

To report 10-year results of a 1-stage, obstruction-based, endoscopic approach in children with congenital nasolacrimal duct obstruction (CNLDO) with and without prior failed probing/intubation.

METHODS

In a retrospective study, children with primary CNLDO of >6 months old previously failed probing/intubation, acute dacryocystitis or dacryocele at any age, and at least 6 months follow up. Diagnosis was based on history of tearing and dye disappearance test. Excluded were patients with complete puncto-canalicular obstruction and craniofacial anomaly. Type of CNLDO was confirmed using endonasal endoscopic guided probing. An endoscopic probing was performed for membranous, intubation for incomplete complex, and dacryocystorhinostomy for complete complex CNLDO. They were followed at 1 week, 1, 3, and 6 months, and then after. Success was defined as no or occasional tearing related to noxious stimulus at least 6 months after the procedure.

RESULTS

There were 226 eyes (200 patients). Mean age was 26.72 months. Previous failed probing/intubation was in 34.1%. Inferior turbinate impaction in 73.5% and septal deviation in 2.7% were noted. Membranous CNLDO was found in 38.9%, incomplete complex in 57.9%, and complete complex in 3.1%. Mean time of tube removal was 11.9 weeks and last follow-up time was 24.3 months. There was no significant effect of any variables on the final success rates (probing: 96.5%, intubation: 95.4%, dacryocystorhinostomy: 100%).

CONCLUSIONS

One-stage, obstruction-based endoscopic approach to CNLDO resulted in a high success rate for different types of CNLDO (membranous, incomplete complex, and complete complex). No variable significantly affected the success rates.

A survey of management of congenital nasolacrimal duct obstruction by pediatric primary health care providers in Spain

PURPOSE

To survey the management of congenital nasolacrimal duct obstruction (CNLDO) by pediatric primary health care providers in Spain.

METHODS

This was a descriptive study using a web-based questionnaire to evaluate the perceptions of the members of the Pediatric Primary Care Society in Castilla-León, Spain (APAPCYL), regarding management of CNLDO. The questionnaire contained 14 direct questions and was sent by e-mail to all the pediatricians. All the responses were analyzed by the frequency of occurrence and percentages.

RESULTS

Ninety physicians responded to the questionnaire. Massage 2 or 3 times a day was the initial treatment advised by 60.47% of pediatricians. Nearly half of the pediatricians recommended continuing massage until symptoms resolved. Fewer than 50% of children required referral to an ophthalmologist. Reasons for an ophthalmic consult included persistence of symptoms among 87.21% of pediatricians and parental/guardian request among 10.5% of pediatricians. According to 45.6% of pediatricians, their knowledge about CNLDO is limited, and 92.2% would like to receive further training on CNLDO.

CONCLUSIONS

Massage was the main initial treatment for managing CNLDO among pediatricians. The outcomes of this survey indicated that massage fails in fewer than 50% of patients and an ophthalmic referral is required for these cases.

Buried Probe in Complex Congenital Nasolacrimal Duct Obstructions: Clinical Profiles and Outcomes

PURPOSE

To report the clinical profiles and outcomes of buried probe variant of complex congenital nasolacrimal duct obstruction (CNLDO).

METHODS

Retrospective chart review of all patients endoscopically diagnosed as a buried probe variant of complex CNLDO, over a 3.5 year period from a single surgeon's (MJA) database were included in the study. A detailed lacrimal system evaluation was performed and intraoperative findings including nasal endoscopy were documented. A minimum follow up of 3 months following the final intervention was considered for analysis. Anatomical and functional success of the interventions was assessed at the final follow up.

RESULTS

Twenty-two eyes of 21 patients with buried probes were studied. The mean age at presentations was 41.2 months. Epiphora and discharge were the commonest presenting symptoms noted in 77.2% (17/22). Associated lacrimal anomalies include punctal agenesis, incomplete punctal canalization and atonic lacrimal sac. All patients underwent irrigation and probing under nasal endoscopic guidance. Further, 3 patients underwent endoscopic dacryocystorhinostomy for persistent CNLDO. At a mean follow up of 4.9 months, the final anatomical and functional successes were noted in 90.9% and 81.8%, respectively.

CONCLUSIONS

Buried probe is a variant of complex CNLDO, noted more commonly in older children. Endoscopic guidance is crucial for its diagnosis and satisfactory 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.

Simple vs complex congenital nasolacrimal duct obstructions: etiology, management and outcomes

BACKGROUND

The aim of this study was to report the comparative clinical profiles and outcomes of simple and complex congenital nasolacrimal duct obstruction (CNLDO).

METHODS

The study was a retrospective chart review of all patients presenting with CNLDO from a single surgeon's (M.J.A.) database. All patients underwent irrigation and probing under nasal endoscopic guidance. A detailed lacrimal system evaluation was performed, intraoperative findings including nasal endoscopy were documented, and etiologies of complex CNLDO were noted. Outcome measures were comparative profiles, and anatomical success and functional success of the interventions. Statistical analyses were performed using the Shapiro-Wilk test, Fisher's exact test, and Wilcoxon rank sum test.

RESULTS

Ninety-five eyes of 81 patients with simple CNLDO and 100 eyes of 83 patients with complex CNLDO were compared. The mean age at presentation was 17.6 months in simple CNLDO and 45.6 months in complex cases (p < 0.001). Epiphora and discharge were the most common symptoms; 89.4% among simple cases and 92% in the complex group. The most common causes of complex CNLDO were bony obstructions (23%), craniofacial syndromes (12%), and buried probe (10%). At a mean follow-up of 5.85 months for simple CNLDO and 4.68 months for complex CNLDO, anatomical success and functional success was noted in 97.8% and 94.7%, respectively, in simple CNLDO, and in 58% and 51%, respectively, in complex CNDLO (p < 0.001).

CONCLUSION

Bony obstruction, craniofacial syndrome, and buried probe were the most common reasons for a complex CNLDO, noted commonly in older children, with irrigation and probing having much poorer outcomes when compared with simpler obstructions.

Effects of medication methods after simple and effective probing of lacrimal passage

AIM

To evaluate the effect of reducing the use of antibiotics in the treatment of infant bacterial dacryocystitis after probing of the lacrimal duct.

METHODS

A total of 542 cases of children under one year old and accepting nasolacrimal duct probing treatment were divided into two groups, which were treated with topical and oral antibiotics, respectively. Conjunctival sac secretions were used as a control index of bacterial infection, whereas the disappearance of epiphora symptoms and lacrimal passage patency were used as cure indexes. The χ (2) test was used to compare enumeration and measurement data, and a statistical significance was set at P<0.05. The therapeutic effect on the two groups of postoperative patients was investigated.

RESULTS

In the two study groups, no significant differences in gender, age and postoperative control of lacrimal sac infection were observed. The cure rates after three probing operations also showed no significant difference.

CONCLUSION

After probing of the lacrimal passage, results of this study confirmed that postoperative medication without oral antibiotics but an ophthalmic dosage of antibiotics was a simple and effective treatment method.

Probing for congenital nasolacrimal duct obstruction in older children

Purpose:

The purpose of this study was to evaluate the role of probing in congenital nasolacrimal duct obstruction in children age 2 years and older and to establish factors predictive of the outcome.

Materials and Methods:

A prospective study was conducted on consecutive patients older than 24 months with congenital nasolacrimal duct obstruction. All patients were treated with a simple nasolacrimal duct probing as primary treatment. Outcome measures included an ophthalmologic examination plus a parental history of residual symptoms at one and 6 months after surgery.

Results:

A total of 82 children with a mean age of 34.5 months (range, 24 months to 60 months) underwent nasolacrimal duct probing. The complete response rate was 54%. Partial response and failure were observed in 25% and 20.8% of the eyes, respectively. Bilateral obstruction was associated with failure of probing (P = 0.007, Odds Ratio: 5.76). However, age older than 36 months was not associated with the failure rate.

Conclusion:

Primary probing maintains a high success rate without any age related decline in congenital nasolacrimal duct obstruction.

Nasal endoscopy in the management of congenital nasolacrimal duct obstruction

Probing is a reliable surgical intervention for the management of congenital nasolacrimal duct obstruction (CNLDO). However, it is a blind procedure that carries the risk of false passage formation. Moreover, its success rate is variable, with unexplained causes of failure. Recent literature suggests the use of nasal endoscopic-assisted probing to minimize nasal mucosal trauma, decreases the chance of creating a false passage and provides the optimum management option of different congenital variants of nasolacrimal duct obstruction. Nasal endoscopic-assisted probing has more or less consistent success rates varied between 85% and 98% compared with probing success rates, which vary between 55% and 95% despite having almost the same age range.

Evaluation of treatment modalities and prognostic factors in children with congenital nasolacrimal duct obstruction

PURPOSE

To evaluate the success rates of probing and silicone intubation and risk factors for failure of these procedures.

METHODS

This retrospective cohort study included patients who were diagnosed with congenital nasolacrimal duct obstruction (NLDO) and underwent probing or intubation as the primary procedure. Demographic data, clinical features, intraoperative, and postoperative data were evaluated. The patients were divided into four subgroups based on age: 12-24 months, 25-36 months, 37-48 months, and >48 months. The procedure was considered successful when all preoperative signs disappeared with normal dye disappearance test and a positive Jones primary dye test. Statistical analysis was performed to determine the risk factors for failure, and P < 0.05 was statistically significant.

RESULTS

The cohort comprised 350 subjects (162 males [46%]) who underwent a total of 454 nasolacrimal duct surgeries. The mean chronological age at time of surgery was 32.6 ± 22.1 months (range, 12-132 months). The overall success rate was 84.8%. Probing was performed 188 times, with a success rate of 80.3%; intubation was performed 266 times, with a success rate of 88%.

CONCLUSIONS

Intubation was more successful than probing in patients with bilateral congenital nasolacrimal duct obstruction, Down syndrome, history of acute dacryocystitis, lack of preoperative massage, or intraoperative observation of either a "tight" obstruction or obstruction at sites other than at the level of Hasner's valve. Primary nasolacrimal duct intubation should be considered in these higher risk patients.

Clinical outcomes of initial and repeated nasolacrimal duct office-based probing for congenital nasolacrimal duct obstruction

Purpose

To characterize the outcomes of initial and repeated office-based probing as a primary treatment for congenital nasolacrimal duct obstruction (CNLDO) in children.

Methods

The medical records of patients who underwent nasolacrimal duct office-based probing for CNLDO between March 2004 and January 2008 were reviewed retrospectively. Nasolacrimal duct probing was performed on 244 eyes from 229 consecutive patients with CNLDO. Patients who were refractory to the first probing underwent a second probing 4 to 8 weeks later.

Results

Based on exclusion criteria, 244 eyes from 229 patients (117 males and 112 females), aged 6 to 71 months (mean, 12.4 ± 8.36) were included. The success rate of the initial probing was 80% (196 of 244) for all patients, 82% (111 of 136) in the 6 to 12 month age group, 79% (64 of 81) in the 13 to 18 months age group, and 78% (21 of 27) among individuals older than 19 months (p = 0.868, Pearson chi-square test). The success rate of the second probing was 61% (25 of 41) for all patients, 74% (17 of 23) in the 6 to 12 months age group, 58% (7 of 12) in the 13 to 18 months age group, and 17% (1 of 6) among individuals older than 19 months (p = 0.043, Fisher's exact test).

Conclusions

While the success rate of initial nasolacrimal duct probing is not affected by age, the rate of success rate with a second probing was significantly lower in patients older than 19 months. Based on the results, authors recommend further surgical interventions, such as silicone tube intubation or balloon dacryocystoplasty, instead of repeated office probing for patients older than 19 months, if an initial office probing has failed.

Age-based comparison of successful probing in Nepalese children with nasolacrimal duct obstruction

PURPOSE

To compare the success rates of probing in Nepalese children younger than 2 years versus children older than 2 years with nasolacrimal duct obstruction (NLDO), and to identify factors associated with successful probing.

MATERIALS AND METHODS

Data was collected and analyzed retrospectively on children who underwent probing under general anesthesia for NLDO at Tilganga Eye Centre, Nepal, from May 2004 to October 2008. We compared successful probing rates in children less than or equal to 2 years old (group 1) versus children greater than 2 years old (group 2), and analyzed whether various clinical factors were associated with successful probing. Successful probing was defined as complete resolution of all clinical signs (discharge, epiphora or increased tear lake) at the outcome visit one month following surgery.

RESULTS

Data on 84 children (109 eyes) was reviewed. The mean age of children in group 1 and group 2 was 15.3 months and 37.3 months, respectively. The success rate of probing for the overall sample was 82.6% (90/109 eyes). The success rate in group 1 was 90.2% (55/61 eyes), and 72.9% (35/48 eyes) in group 2 (p=0.018). Increased age at time of probing (p=0.031) and duration of symptoms (p=0.027) were associated with decreased probing success.

CONCLUSION

Early treatment of NLDO with probing, ideally prior to 2 years, is associated with better outcomes. Age appropriate intervention may reduce the incidence of complications from NLDO, which is highly prevalent in the low-lying areas of Nepal, including Kathmandu.

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.