Endoscopic dacryocystorhinostomy in children

Congenital Nasolacrimal Duct Obstruction - Early Diagnosis and Graded Therapeutic Approach as Key Points for Successful Management

PURPOSE

Epiphora in childhood is a frequent symptom that is typically associated with Congenital nasolacrimal duct obstruction (CNLDO). Nevertheless, inflammatory pathologies of the ocular surface as well as inside the eye, or even congenital glaucoma, must be considered in the differential diagnosis.

METHODS

A comprehensive literature review concerning CNLDO was conducted. Different therapeutic steps are categorized and summarized in order to reflect the existing staged therapeutic concept.

RESULTS

For CNLDO, a staged therapeutic concept is applicable, resulting in a cure rate of approximately 95% with only conservative or minimally invasive intervention. This concept includes five steps that encompass therapeutic interventions with increasing complexity. It includes conservative techniques, followed by probing and syringing, transcanalicular approaches without or with lacrimal intubation, and dacryocystorhinostomy which is the ultima ratio.

CONCLUSION

To preserve the topographic anatomy as much as possible, therapeutic recommendations enable stepwise and individualized management of children with CNLDO.

Pädiatrische Rhinologie

The following review article highlights key topics in pediatric rhinology that are currently the focus in research and at conferences as well as in the interdisciplinary discussion between otorhinolaryngologists and pediatricians. In particular, congenital malformations such as choanal atresia or nasal dermoid cysts are discussed, followed by statements on the current procedures for sinogenic orbital complications as well as on the diagnosis and therapy of chronic rhinosinusitis in children. Furthermore, updates on the role of the ENT specialist in the care for children with cystic fibrosis and primary ciliary dyskinesia are provided.

[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.

A Prospective Longitudinal Study to Evaluate the Outcomes of Success of Endoscopic DCR in Pediatric Age Group

Children with nasolacrimal duct obstruction (NLDO) have different therapeutic approach from that used in adults. Dacryocystorhinostomy (DCR) is the most common procedure in adults but it is less frequently carried out in children, indicated in children which are refractory to probing. The objective of the study is to report a series of 30 cases of paediatric epiphora who underwent endoscopic endonasal dacryocystorhinostomy surgery, for primary obstruction of nasolacrimal duct and results, outcomes of success are evaluated. This is a prospective and non-comparative review of 30 cases of epiphora aged between 3 and 9 years from April 2018 to March 2019. The main outcome measures assessed were determined by the resolution of symptoms and the patency of the lacrimal anatomy confirmed by syringing or irrigating the nasolacrimal duct. Secondary outcomes included the presence of such complications as bleeding, scarring, and/or persistent epiphora and infection. In our study 30 patients underwent unilateral DCR surgery in NLDO. Out of 30 patients males were 17 and females were 13. The overall success rate of endoscopic DCR was 90%, and failed cases were mainly due to pre-saccal obstruction. No major complications were reported, minor complications occurred in about 60% of cases. Analysis of the results indicated that EDCR was safe and an effective therapeutic approach for treating nasolacrimal duct obstruction in pediatric age group patients having NLDO. It's considered as an alternative procedure to external dacryocystorhinostomy after a failed conservative treatment.

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.

Surgical Site Reassessment: An Important Step in Improving Clinical Outcomes Following Pediatric Endoscopic Dacryocystorhinostomy

PURPOSE

To report the authors' experience with endoscopic unpowered dacryocystorhinostomy in the treatment of pediatric nasolacrimal duct obstruction, and to evaluate whether surgical site reassessment (after the appropriate healing period) affects clinical outcomes.

METHODS

This retrospective study included 47 children aged between 1.5 and 17.0 years (mean age: 6.9 years) who underwent endoscopic unpowered dacryocystorhinostomy between 2014 and 2019 at one tertiary care hospital. Twenty-six patients required unilateral and 21 required bilateral endoscopic dacryocystorhinostomy. The main outcome measures were duct patency on lacrimal irrigation ("anatomical success") and resolution of symptoms ("clinical success") over 6 months of postoperative follow-up.

RESULTS

Sixty-eight dacryocystorhinostomy procedures were performed. Surgical site reassessment during tube removal was performed in 52 of 68 cases. Five cases (9.6%) required treatment of local pathologies, only after which was symptomatic relief achieved. Overall anatomical success was observed in 49 (94.2%) of the 52 cases in which nasal endoscopy was performed, including the 5 cases treated during reevaluation. Clinical success was observed in 63 (92.6%) cases.

CONCLUSIONS

Pediatric endoscopic dacryocystorhinostomy is an effective surgical procedure used to correct nasolacrimal system obstruction resistant to conservative measures. The unpowered endoscopic dacryocystorhinostomy technique is practical and safe in the pediatric population. Surgical site reassessment allows treating local pathologies threatening ostium patency and increases clinical success rates. [J Pediatr Ophthalmol Strabismus. 2021;58(3):168-173.].

Pediatric endonasal dacryocystorhinostomy and operative standardization

OBJECTIVE

The objective of this study was to confirm that the standardized endonasal dacryocystorhinostomy (DCR) technique routinely performed in adults can be used in children.

MATERIALS AND METHODS

A consecutive series of children undergoing endonasal DCR between 2003 and 2017 was analysed. The surgical procedure consisted of: preoperative CT scan, anatomical localization of the ideal surgical zone, access to the nasal cavity via an optional planned enlargement, creation of a mucoperiosteal flap, osteotomy with rongeurs and equatorial resection of the medial wall of the lacrimal sac. This pediatric series was compared to a series of adult patients operated according to the same standardized technique.

RESULTS

A total of 20 DCRs (17 patients, with a mean age of 8 years (range: 4-16)) were included. Anatomical localization was effective in 100% of cases without the need for transillumination. With a mean follow-up of 4 years, the success rate was 95%, and no major complications were observed. Comparison with the same surgical technique in adults revealed similar results.

DISCUSSION

Our experience suggests that standardized endonasal DCR can be adapted to the nasal cavities of children. Anatomical localization is effective. The physiologically narrow nasal cavity does not constitute a major obstacle with the use of slightly smaller instruments. The results and complications are similar to those observed in adults.

CONCLUSION

The same standardized endoscopic endonasal DCR surgical technique can be used in adults and children with a similar good success rate.

[Diagnostics and treatment of lacrimal duct diseases : A structured patient-centred care concept]

BACKGROUND

The cardinal symptom of lacrimal stenosis is epiphora and a subjective high level of discomfort due to continuous dacryorrhea.

OBJECTIVE

The aim of the current paper is to present a structured review of common diagnostic and therapeutic strategies for lacrimal stenosis.

MATERIALS AND METHODS

The most important diagnostic and therapeutic approaches are analysed using the existing literature and by reporting the authors' own experiences.

RESULTS

A detailed patient history is crucial for diagnosis of lacrimal disorders. Precise inspection and palpation of the lacrimal and lid region may confirm lacrimal stenosis. Examinations of tear production, tear quality and the properties of the ocular surface are helpful. The most important diagnostic tool is lacrimal duct probing and syringing. Therapy is guided by underlying pathologies. Treatment of congenital lacrimal stenosis follows a staged concept. Epiphora in adults without signs of dacryocystitis should be treated with dacryoendoscopy. Dacryoendoscopy is also a therapeutic option for chronic dacryocystitis, but dacryocystorhinostomy may also be required. Lacrimal trauma should be reconstructed rapidly after the incident by lacrimal intubation. Neoplasia of the lacrimal excretory system requires histological classification to enable multidisciplinary management.

CONCLUSION

Basic ophthalmologic diagnostics are complemented by special symptom-based examinations. Due to ongoing improvement of available diagnostic and therapeutic options, patients' care is becoming increasingly individualised.

Limited Approach in Endoscopic Dacryocystorhinostomy of Pediatrics

Background:

Limited spatial nasal cavity in children, make pediatric dacryocystorhinostomy (DCR) a difficult surgical procedure. We apply a limited approach to pediatric DCR and follow them for their consequences.

Materials and Methods:

An experimental study was done in pediatric DCR with limited approach (age < 14-year-old). After written consent, with general anesthesia, with nasal endoscopic surgery, lacrimal bone is exposed and extruded. In contrast with routine procedure, ascending process of maxillary sinus reserve; and marsupialization and wide exposure to lacrimal sac was done only by lacrimal bone defect; and cannulation preserve with temporary silicone tube.

Results:

Between 2006 and 2012, 16 pediatric DCR was done by a unique surgeon in 2 otorhinolaryngologic centers. Before surgery 14 (87.5%) had epiphora, 3 (18.8%) had eye discharge, and 3 (18.8%) had eye sticky eye. Two (12.5%) had history of facial trauma, and 10 (62.5%) had congenital nasolacrimal duct insufficiency. Five (31.3%) had history of dacryocystitis. Patients were followed for 17 ± 9 months. Silicone tube stayed for 4 ± 2.5 months. We could follow 7 patients and minimal improvement or need to revision surgery considered as technical failure. After surgery, 3 patients had no epiphora with complete improvement; 2 had very good improvement with confidence of the patients and parents; 2 cases had unsuccessful surgery in our patients, who needs to another surgery. One of them had several probing and surgery before our endoscopic DCR.

Conclusions:

Limited approach in endoscopic DCR of pediatrics can be done in noncomplicated patients, with minimal manipulation, more confidence, and acceptable results.

Primary endoscopic endonasal dacryocystorhinostomy for pediatric nasolacrimal duct obstruction: A systematic review

BACKGROUND

Epiphora secondary to nasolacrimal duct obstruction is common in the pediatric age group. The mainstay treatment among these young patients has been conservative. Once epiphora becomes recalcitrant, however, an external or an endonasal approach is considered.

OBJECTIVE

Endoscopic dacryocystorhinostomy (EDCR) entails creating an opening from the lacrimal sac directly into the nasal cavity to counteract nasolacrimal duct obstruction. We reviewed the literature to determine the effectiveness and the safety of primary EDCR to treat pediatric nasolacrimal duct obstruction.

METHOD

A literature search was conducted by using a number of medical literature data bases for the period from 1995 to 2016. The following search words were used either individually or in combination: epiphora, nasolacrimal duct obstruction, endoscopic dacryocystorhinostomy, powered endoscopic dacryocystorhinostomy, laser-assisted endoscopic dacryocystorhinostomy, children, congenital, acquired, presaccal obstruction, and postsaccal obstruction. In addition, a few articles were identified based on the experience and information provided by the senior authors (B.A., S.H., D.Y.W.). The search was conducted over a 1-month period (January 2017). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were followed when possible.

RESULTS

Only 10 original clinical research articles were selected based on our objectives and selection criteria. All the studies were at level of evidence III: nonrandomized and noncomparative prospective or retrospective case series. Altogether, 313 patients with ages that ranged from 4 months to 18 years were enrolled. A total of 352 EDCRs were performed that were either single sided (n = 313) or bilateral (n = 39). The most common causes of the obstruction were classified as congenital, followed by idiopathic, and then acquired. A meta-analysis was not performed because of the heterogeneity of the patient groups and variability of the methods used to measure outcomes.

CONCLUSION

Analysis of the results indicated that EDCR was an effective, safe therapeutic approach to treating nasolacrimal duct obstruction in pediatric patients. It should be considered as an alternative procedure to external dacryocystorhinostomy after a failed conservative treatment.

Comparing outcomes of pediatric and adult external dacryocystorhinostomy in Nepal: Is age a prognostic factor?

We determine whether age is a prognostic factor for surgical outcomes of external dacryocystorhinostomy (Ex-DCR). This retrospective cohort study conducted at Tilganga Institute of Ophthalmology (Kathmandu, Nepal) compared pediatric Ex-DCR procedures (age ≤ 15 years) to adult Ex-DCR procedures (age > 15 years) and was performed between January 2013 and December 2013, with a minimum follow-up period of 6 months. Primary outcome measure was rate of success, defined as complete resolution of subjective symptom(s) of epiphora (subjective success), combined with patent lacrimal passage on syringing (anatomical success) at last follow-up visit. Other outcome measures included clinical presentation, diagnosis, intraoperative complications and post-operative complications. In total, 154 Ex-DCR procedures were included, with an age range of 8 months to 81 years (mean age 36.4 ± 21.0 years). In all, 38 pediatric Ex-DCR procedures were compared to 116 adult procedures. Success rates were 97% in the pediatric group and 95% in the adult group, with no clinically or statistically significant difference in success rate or complication rate between groups (p > 0.05). Our study yielded high success rates of Ex-DCR in both pediatric and adult age groups suggesting that Ex-DCR remains an optimal treatment choice for all age groups. With no difference in surgical outcomes between pediatric and adult patients, including complication rate, we conclude that age is not a prognostic factor for Ex-DCR failure. We do not recommend adjuvant therapy for pediatric patients.

[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 dacryocystorhinostomy: long-term experience and outcomes

PURPOSE

To report our experience in endoscopic dacryocystorhinostomy in treating nasolacrimal duct obstruction over a 14-year period.

METHODS

Retrospective case series carried out over a 14-year period from 1999 to 2014. A total of 624 endoscopic dacryocystorhinostomy procedures were performed in 442 patients who were diagnosed with persistent epiphora.

PARTICIPANTS

In total, 624 procedures in a total of 442 patients (<18 yo: 36 and >18 yo: 406) were included. Patients' records were assessed for demographics, intra- and postoperative complications, outcome and follow-up.

RESULTS

In total, 442 patients underwent an endoscopic dacryocystorhinostomy. There were 342 females (77.3%) and 100 males with a mean age of 50.2 years. All patients presented with epiphora: 33 congenital (7.5%), 357 acquired (80.7%) and 52 functional cases (11.8%). The adult dacryocystorhinostomy (n = 577) had an anatomical success of 90.1%. Children's group (<18 yo) n = 36 with a total of 47 procedures and an anatomical success of 91.5%. Functional cases (all adults - n = 52) showed a 91% benefit after operation. In 624 DCRs, we found a complication rate of 3.2%.

CONCLUSION

Endoscopic dacryocystorhinostomy offers good success rates with a safety profile and efficacy equivalent to the traditional external approach is an effective treatment with good outcome results in adults and children with persistent or functional epiphora.

Pediatric Acute Dacryocystitis

PURPOSE

To review and summarize the symptomatology, microbiology, special clinical entities, management, complications, and outcomes of pediatric acute dacryocystitis.

METHODS

The author performed a PubMed search of all articles published in English on acute dacryocystitis. Pediatric subpopulations of these articles were reviewed along with the scant literature of direct references to neonatal and pediatric acute dacryocystitis. Data reviewed included demographics, presentations, microbiological work up, management, complications, and outcomes.

RESULTS

Acute dacryocystitis is not very common in the pediatric age groups and occurs mostly as a complication of congenital nasolacrimal duct obstruction. The age of onset is usually in the neonatal period with a female preponderance. The clinical spectrum ranges from classic pediatric acute dacryocystitis to meningitis. Staphylococcus aureus is the commonest isolate. Occasionally acquired etiologies and rare organisms like Pantoea sp., Epstein-Barr Virus, and Sporothrix are implicated in the etiopathogenesis. The diagnosis is usually clinical aided by laboratory investigations. Better antibiotics, well-established laboratory techniques and surgical modalities, and improved patient care logistics have contributed to good outcomes; however, complications are still being noted although infrequently.

CONCLUSIONS

Pediatric acute dacryocystitis is a distinct entity with unique features of its own. It is a serious infection that warrants careful evaluation and immediate management. In the era of antibiotic resistance, microbiological work up of Pediatric acute dacryocystitis is very useful for subsequent treatment. Surgical challenges in the pediatric age group are distinct and the outcomes are good if standard protocols are followed.

The outcomes of endoscopic dacryocystorhinostomy in children: A systematic review

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term outcomes of powered endoscopic dacryocystorhinostomy in acute dacryocystitis

OBJECTIVES/HYPOTHESIS

Endoscopic dacryocystorhinostomy (DCR) is rapidly gaining recognition as a primary modality of management in acute dacryocystitis and lacrimal abscess. The purpose of the present study is to report long-term outcomes of powered endoscopic DCR in cases of acute dacryocystitis.

STUDY DESIGN

Prospective interventional case series.

METHODS

Twenty-one powered endoscopic DCRs were performed in 21 patients presenting with acute dacryocystitis. All cases were operated by a single surgeon (m.j.a.) using earlier published techniques. All lacrimal systems were intubated for 6 weeks. A minimum follow-up of 1 year after stent removal was considered for final analysis. Main outcome measures were the anatomical and functional success of the surgical procedure.

RESULTS

The mean age of patients at presentation was 31.8 years. A total of 14.3% (3/21) were pediatric patients with known history of persistent congenital nasolacrimal duct obstruction (CNLDO), and 9.5% (2/21) had a history of external DCR in the past. All patients received postoperative antibiotics. Additional procedures included distal canalicular trephination, septoplasty, and middle turbinoplasty in one patient each. All cases showed resolution of pain and swelling at 1 week follow-up. At the mean follow-up of 15.4 months, anatomical success was achieved in 85.7% of the patients (18/21), and functional success was achieved in 80.9% (17/21).

CONCLUSION

Powered endoscopic DCR is a useful modality in the management acute dacryocystitis, with good outcomes that are maintained over a long duration of time.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:551-553, 2016.

Pediatric Endoscopic DCR: The Outcome in 50 Patients

Congenital nasolacrimal duct obstruction is a very common condition affecting 20 % of infants. Pediatric DCR is indicated when there is no response to previous therapy like probing, or is associated with recurrent dacryocystitis. This is a retrospective case series study of 50 pediatric patients who underwent endoscopic DCR in two centers, Jordan University Hospital/Jordan, and Mosul teaching and private hospitals/Iraq. The age ranged from 3 to 12 years with a mean of 6.2 years. The overall success rate of endoscopic DCR was 90 %, and failed cases were mainly due to presaccal obstruction. No major complications were reported, but minor complications occurred in about 60 % of cases. As a conclusion, endoscopic DCR is a safe and effective procedure in pediatric age group.

Combined transcranial-orbital approach for resection of optic nerve gliomas: a clinical and anatomical study

PURPOSE

To describe a combined transcranial-orbital approach for en bloc resection of optic nerve gliomas with preservation of the annulus of Zinn that minimizes recurrence and prevents postoperative paralytic ptosis.

METHODS

DESIGN

A retrospective, noncomparative, interventional case series.

STUDY POPULATION

All patients who underwent optic nerve glioma resections using this technique with the authors between 1994 and 2010.

PROCEDURE

A transcranial-orbital approach is used to resect the intracranial segment of the optic nerve glioma from 2 mm anterior to the chiasm to the posterior extent of annulus of Zinn. The proximal transected edge of the nerve is examined intraoperatively for tumor margin clearance. Through a superior orbitotomy exposure, the entire retrobulbar segment of the tumor is transected from the globe to the annulus of Zinn. A simulation of the procedure in a cadaver and en bloc resection of the orbital apex are performed to demonstrate the subdural plane of dissection within the annulus of Zinn.

MAIN OUTCOME MEASURES

Postoperative outcome measures include: health of the ipsilateral globe, paralytic ptosis, postoperative complications, and tumor recurrence.

RESULTS

Eleven patients underwent resection of optic nerve gliomas using this technique. No patients had tumor recurrence or developed postoperative paralytic ptosis.

CONCLUSIONS

The combined transcranial-orbital approach with preservation of the annulus of Zinn is a safe and effective way to remove optic nerve gliomas and ensure tumor clearance while avoiding paralytic ptosis.

Paediatric powered endonasal dacryocystorhinostomy

Dacryocystorhinostomy (DCR) is indicated in children with persistent nasolacrimal duct obstruction (NLDO). Endoscopic endonasal DCR has been successfully performed in both adults and children, with success rates similar to that of external DCR. This paper aims to evaluate the outcomes of paediatric patients undergoing endonasal endoscopic DCR at a district general hospital. A retrospective review of all patients attending a joint lacrimal clinic undergoing endonasal endoscopic DCR between October 2001 and December 2008 was performed. Sixteen children (17 eyes) aged between 2 and 14 were analysed. The main outcome measure was resolution of symptoms. Fourteen cases (82%) presented with epiphora with or without stickiness. Three cases had recurrent dacryocystitis. Three patients had Down syndrome. There were no operative complications. During a mean post-operative period of 12 months, all but one case showed an improvement of symptoms. While 60% of the patients had a complete resolution of symptoms, the remaining were minimally symptomatic. Of those with residual symptoms, two had Down syndrome. Endonasal DCR is a safe and effective intervention for children with persistent NLDO. Success is higher in children with no craniofacial abnormality. Joint care under a consultant Oculoplastic and ENT surgeon provides optimum care for these patients.

Pediatric endocanalicular diode laser dacryocystorhinostomy: results of a minimally invasive surgical technique

The purpose of this study was to evaluate the effectiveness of endocanalicular diode laser dacryocystorhinostomy (DCR), which is a minimally invasive surgical technique, in pediatric patients with congenital nasolacrimal duct obstruction (NLDO). A retrospective study was carried out on patients treated between October 2008 and August 2009 for nasolacrimal duct obstruction with an endocanalicular diode laser procedure. Patients diagnosed as having nasolacrimal duct obstruction were included in this study and an endocanalicular diode laser procedure was performed. The main outcome measures were patients' previous treatments, clinical presentation, operative and postoperative complications, postoperative follow-up and resolution of epiphora. Eighteen children (10 girls, 8 boys) with a mean age of 6.11 ± 2.08 years (range, 4-10) underwent 20 endocanalicular laser DCR operations for congenital NLDO. In all eyes (100%), there was a history of epiphora and chronic dacryocystitis; two (10%) presented with acute dacryocystitis. Previous procedures included probing and irrigation of all eyes (100%) and silicone tube intubation in nine eyes (45%). None of the patients underwent any previous DCR operations. During a mean postoperative follow-up period of 20.50 ± 3.24 months (range, 14-24 months), the anatomical success rate (patency of ostium on nasal endoscopy) was 100%, and the clinical success rate (resolution of epiphora) was 85%. Endocanalicular diode laser DCR is an effective treatment modality for pediatric patients with congenital NLDO that compares favorably with the reported success rates of external and endoscopic endonasal DCR. Moreover, it has an added advantage of shorter operative time, less morbidity and avoidance of overnight admission.

Use of endocanalicular dacryocystorhinostomy with multidiode laser in children

OBJECTIVE

To evaluate the clinical outcome and efficacy of endocanalicular laser dacryocystorhinostomy using a multidiode laser in cases unresponsive to medical therapy, probing or intubation of pediatric nasolacrimal duct obstruction.

METHODS

Eight children with nasolacrimal duct obstruction were treated with a multidiode laser. The study was prospective, non-randomized, and noncomparative. The patients, 2 (25%) males and 6 (75%) females, ranged in age from 8 to 13 years (mean 11.25±2.43). Surgery was performed under general anesthesia. All procedures were performed using a multidiode laser. The nasal passage was visualized with a 30° nasal video endoscope. In all cases, silicone stents were inserted. The main outcome measure was resolution or improvement of the epiphora and no major laser damage intranasally. Patients were followed for at least 6 months.

RESULTS

The endocanalicular laser dacryocystorhinostomy failed in one of the 8 (12.5%) cases, which had been secondary to trauma. The others were due to primary nasolacrimal duct obstruction. External dacryocystorhinostomy was performed on the failed case. None of the cases with primary nasolacrimal duct obstruction had obstruction after the endocanalicular laser dacryocystorhinostomy operation.

CONCLUSIONS

Endocanalicular laser dacryocystorhinostomy using a multidiode laser appears to be an effective technique in cases unresponsive to medical therapy, probing or intubation of primary nasolacrimal duct obstruction.

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.

Primary pediatric endonasal dacryocystorhinostomy--a review of 58 procedures

OBJECTIVES

The objectives of this study are to report the outcomes of pediatric patients with lacrimal system obstruction who underwent primary endoscopic dacryocystorhinostomy (EDCR).

STUDY DESIGN

The authors conducted a retrospective noncomparative case series.

METHODS

The operative and postoperative data have been collected in 58 children aged between 3 months and 13 years (mean 4.1 years). The total of 58 primary EDCRs has been performed by two surgeons using a standardized surgical technique. The EDCRs were performed 52 times on one eye, 6 times on both eyes (3 times simultaneously, 3 times at the separate sitting with an interval of 4-6 months). The follow-up evaluations include taking history, clinical examinations including a fluorescein disappearance test.

RESULTS

The follow-up interval ranged from 12 to 36 months (mean 17 months, median 15 months). The success rate was 51/58 (87.9%) in all 58 EDCRs. The success rate was 47/51 (92.2%) in the group of postsaccal obstructions, 3/5 (60.0%) in the group of postsaccal and suprasaccal obstrutcions and 1/2 (50.0%) in presaccal obstructions. The procedures were successful in all eight children aged under 1 year old (100%) and in 14 of 15 children between 1 and 2 years old (93.3%). The silicone intubation was used in 54 EDCRs.

CONCLUSIONS

The endoscopic DCR is a safe and effective procedure for most children with the success rate comparable to that achieved in the external DCR and in adults. The success rate of the postsaccal obstructions is significantly higher than in presaccal or combined pre- and postsaccal obstructions.

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.

Endoscopic-assisted reconstructive surgery of the lacrimal duct

Reconstructive surgery of the nasolacrimal duct, or dacryocystorhinostomy, can be performed via an external or endonasal approach. For almost a century external dacryocystorhinostomy was the gold standard for correction of lacrimal duct obstruction. The endonasal approach became a safe surgical procedure using endoscopes and has the same anatomic and functional success rate as the external approach. It can be performed in adults and in children with close collaboration between a rhinologist and an ophthalmologist. An overview is given of the literature and of the authors' experience in this field.

Pediatric endonasal endoscopic dacryocystorhinostomy

Dacryocystorhinostomy (DCR) in children is indicated in cases of common congenital nasolacrimal duct obstruction (CNLDO) unresponsive to medical therapy, probing or intubation. The purpose of this manuscript is to evaluate the effectiveness of endonasal endoscopic pediatric DCR. The authors present a series of eight children (seven boys and one girl) who underwent a pediatric endonasal DCR between September 2007 and December 2008. The mean age was: 4.3 years (range: 8 months to 9 years old). Three children had a craniofacial abnormality. There were ten primary DCRs and one revision DCR. In nine cases, the indication was a pure primary low mechanical obstruction persistent after one or more probings. In the 10th case there was also a stenosis of the inferior canaliculus diagnosed during the DCR. The revision DCR was indicated because of the closure of the stoma created 3 years ago. A silicone intubation was put in place only in two cases: in case of a stenosis of the inferior canaliculus (3 months) and the other in case of revision DCR (1 month). The follow-up for primary DCRs was 10.5 months (range: 6-15) and for revision surgery 6 months (after the retrieve of the stent). In primary DCRs, there was a complete resolution of symptoms in nine out of 10 cases. The 10th case experienced a transient slight epiphora during a viral rhinitis. In case of revision DCR, the child was free of symptoms. In conclusion pediatric DCR is a very effective and safe procedure for the treatment of a low mechanical obstruction of the lacrimal pathway in children unresponsive to previous probings. Stenosis of the inferior canaliculus can give some slight intermittent epiphora despite a wide and patent stoma. Moreover craniofacial abnormalities are more common in children than in adults undergoing a DCR.

Functional endoscopic sinus surgery: indications and complications in the ophthalmic field

Functional Endoscopic Sinus Surgery (FESS) is a highly sophisticated type of surgery, which has revolutionized the surgical management of chronic sinus diseases. In the ophthalmic field, FESS plays a crucial role in the management of a few conditions, but not without risks. Ophthalmic complications associated with FESS are well documented. They mainly occur due to the shared common anatomic areas between ophthalmology and otolaryngology. Ophthalmic complications can vary in severity from very trivial cases such as localized hematoma collection, which is not very problematic to very devastating cases, such as optic nerve damage, which can lead to complete blindness. In order to minimize such complications, safety measures need to be considered prio to the surgery, these include; precise knowledge of detailed anatomy, the operating surgeon's ability to interpret precisely the para nasal sinus CT scan and experienced procedural surgical skills.

Nonlaser endoscopic endonasal dacryocystorhinostomy with adjunctive mitomycin C in children

PURPOSE

To determine the outcome and safety of pediatric endonasal dacryocystorhinostomy with the use of adjunctive mitomycin C.

METHODS

A prospective, nonrandomized and noncomparative interventional case series study was performed in 71 consecutive procedures. Sixty patients 16 years of age and younger underwent nonlaser endonasal dacryocystorhinostomy with the use of adjunctive mitomycin C. Eleven patients had a simultaneous bilateral procedure performed. All patients underwent a standardized procedure, with an endonasal approach to the lacrimal sac and surgical removal of nasal mucosa, lacrimal bone, and a fragment of the frontal process of the maxilla. The medial wall of the lacrimal sac was completely removed and a neurosurgical cottonoid soaked in mitomycin C at 0.5 mg/ml placed at the osteotomy site for 5 minutes. All patients underwent bicanalicular or monocanalicular silicone intubation.

RESULTS

The main outcome measures were the resolution of epiphora, lacrimal discharge, and patency of the ostium confirmed either by endoscopic visualization and/or irrigation at 6 months or a normal dye disappearance test. Thirteen patients' (18%) final evaluation was via telephone survey. The mean follow-up was 12.3 months. Nonlaser endonasal dacryocystorhinostomy with adjunctive mitomycin C was successful in 67 cases (94.4%). African descent was strongly associated with a higher rate of obstruction (p < 0.001). Infection at the time of surgery (p = 0.051) and less than 3 months intubation (p = 0.059) were also borderline significant. Previous trauma, gender, age, and side operated had no influence on the final outcome. No significant complications were encountered.

CONCLUSIONS

Nonlaser endonasal dacryocystorhinostomy with mitomycin C is a safe and successful procedure for the treatment of congenital nasolacrimal duct obstruction in children. It has the advantage of leaving no scar and of preserving the medial canthal structures. It can be successfully performed as a simultaneous bilateral procedure.

Lacrimal drainage obstruction and dacryocystorhinostomy in children

PURPOSE

To determine the outcome of dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction (NLDO) in children.

METHODS

A review of medical records of 104 cases (82 patients) of paediatric DCR who underwent DCR at the Sydney Eye Hospital from 1995 to 2004. The main outcome measures included post-operative symptomatic relief of presenting symptoms, complications, subjective visibility of any scar, and general satisfaction. Statistical methods included chi(2) tests, and Student's t-tests for the comparison of variables among groups.

RESULTS

Ninety-four external, 10 endoscopic primary procedures, and five revision procedures were included. Fifty-six of the cases were primary NLDO, and 48 were secondary NLDO. The mean follow-up was 1.44 years. Average age at surgery was 6.6+/-4.2 years (mean+/-SD). Ninety-one eyes needed DCR for the involvement of the lower lacrimal outflow system, and 13 eyes were NLDO associated with congenital punctual/canalicular dysgenesis.Most of the complications of external DCR were related to Jones tube placement. Five cases (4.8%) needed DCR revision. There was a significantly higher incidence of revision surgery in the non-stented group (P<0.01), and the Jones tube group (P<0.001) as compared with the silicone intubation stent group.

CONCLUSIONS

External DCRs have acceptable long-term clinical and cosmetic results, and low post-operative complication rate. Cases with punctal stenosis or those requiring Jones tube insertion are associated with a higher complication rate. Silicone intubation is associated with a lower need for operative revision.

Pediatric Endoscopic Dacryocystorhinostomy Failures: Who and Why?

OBJECTIVE

The objectives of this study are to report outcomes of pediatric patients with nasolacrimal duct obstruction (NLDO) who underwent primary endoscopic dacryocystorhinostomy (DCR) and discuss causes of failure.

STUDY DESIGN

The authors conducted a retrospective case series.

METHODS

Charts of all patients less than 16 years of age who underwent primary endoscopic DCR from 1997 to 2004 were reviewed. Patients were grouped based on the presence or absence of facial anomalies or syndromes and whether the NLDO was congenital or acquired. Success was defined as complete resolution of symptoms, improvement included anatomic patency or partial symptoms, and failure as no improvement or demonstration of patency.

RESULTS

Thirty-four patients (43 ducts) aged 11 months to 14 years were identified. There were 17 males and 17 females. Follow up ranged from 2 to 54 months (average, 21 months). Twenty-four patients (29 ducts) had congenital NLDO, seven patients (11 ducts) had congenital syndromes associated with craniofacial abnormalities, and three patients (three ducts) had acquired NLDO. In patients with congenital NLDO without craniofacial abnormalities or syndromes, 22 of 29 eyes (76%) were cured with another three (10%) showing improvement. Only one of 11 (9%) eyes of patients with congenital craniofacial abnormality or syndrome experienced complete resolution and only four of 11 (36%) eyes showed improvement. Of the patients with acquired NLDO, two of three (67%) of the eyes were cured and one (33%) improved.

CONCLUSIONS

Endoscopic DCR is safe and effective for most children, although patients with craniofacial abnormalities or syndromes are extremely difficult to cure.

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.

Mechanical Endonasal Dacryocystorhinostomy with Mucosal Flaps

Mechanical endonasal dacryocystorhinostomy (DCR) involves the creation of a large rhinostomy and the preservation of lacrimal and nasal mucosa. It replicates the main advantages of the external approach to DCR using minimally invasive techniques. A thorough knowledge of intranasal anatomy and the close collaboration of a multidisciplinary team are important when converting from the external to the endonasal approach.

Modified laser DCR for paediatric nasolacrimal duct obstruction

AIMS

To evaluate the efficacy, safety, and long-term outcome of modified laser dacryocystorhinostomy (DCR) for primary nasolacrimal duct obstruction, unresponsive to probing.

METHODS

Retrospective, noncomparative case-note review of all paediatric cases operated between September 2000 and November 2003.

PROCEDURE

A fibre optic light, inserted through the canaliculi into the lacrimal sac was visualized endonasally. Nasal mucosa was incised using a keratome and a bony ostium was created with the Holmium : YAG laser. Bicanalicular silicone tubes were inserted.

RESULTS

Five children with a mean follow-up of 25.6 months (range 21-48 months) and a mean age of 7 years were reviewed. Silicone tubes were used in four patients and were removed at a mean 6.5 months (range 3-9 months). One patient developed a mucocele 6 months after the procedure requiring excision of the membrane covering the ostium. There were no other immediate or late postoperative complications. Complete cure of symptoms was achieved in all patients and was maintained at final follow up.

CONCLUSION

Modified paediatric laser DCR appears to be an encouraging technique for primary nasolacrimal duct obstruction unresponsive to probing. This may be attributable to the modification of excision of mucous membrane, which may prevent regrowth.

Endonasal dacryocystorhinostomy in children

Aim

To verify whether our results with endonasal endoscopic dacryocystorhinostomy in children with nasolacrimal duct obstruction allow us to consider this technique a valid treatment alternative for children.

Study design

clinical with transversal cohort.

Material and Method

Twenty-seven endoscopic endonasal dacryocystorhinostomies were performed in children 2 to 12 years of age for nasolacrimal duct obstruction. Previous probings in all patients were unsuccessful. The technique employed uncinectomy and a small lacrimal sac opening. Follow-up time was 3 months.

Results

Twenty-one surgeries (77,8%) were successful. The only complication was silicone prolapse in one case.

Conclusion

Our results confirm endoscopic endonasal dacryocystorhinostomy as an acceptable and safe method for treating children with nasolacrimal duct obstructions that are resistant to probings.

Pediatric Endonasal Dacryocystorhinostomy: A Report of 34 Cases

OBJECTIVES

To present experience with the endoscopic dacryocystorhinostomies (EDCR) at the pediatric age.

STUDY DESIGN

Case series, clinical study.

METHODS

The operative and postoperative data have been collected in 34 pediatric EDCRs (mean age 4.5 years; range 4 months to 13 years). The total of 34 primary and 5 revision procedures have been performed by the same surgeon using a standardized surgical technique. The follow-up evaluations include symptom evaluations and the endoscopic assessment of the newly created ostium with fluorescein testing.

RESULTS

The 28 of 34 primary EDCRs (82.3%) were patent after a mean follow-up of 12 to 36 months: 24 of 27 (88.9%) procedures with subsaccal obstructions, 3 of 5 (60.0%) with combined subsaccal and suprasaccal obstructions, and 1 of 2 (50.0%) with suprasaccal obstructions. Intubation was used in 30 primary EDCRs. We found no differences in the success rate between the group with operative intranasal debridement and the group without it in the follow-up period. EDCRs failed in six patients, five of whom were revised endoscopically with success.

CONCLUSIONS

EDCRs in children appear to provide a safe and successful procedure with the success rate comparable with those achieved with external DCRs and those in adults.

Double Silicone Intubation as Treatment for Persistent Congenital Nasolacrimal Duct Obstruction

PURPOSE

The great majority of children with nasolacrimal duct (NLD) obstruction are successfully treated with probing or conventional silicone tube intubation. A small percentage of patients fail to have their NLD obstruction resolved with these procedures and require dacryocystorhinostomy (DCR). This study was conducted to assess the effectiveness of double bicanalicular silicone intubation with placement of two loops of silicone tubing through the NLD for treatment of persistent NLD obstruction in children as an alternative to DCR.

METHODS

Ten eyes of 9 patients with nasolacrimal duct obstruction who had failed conventional therapies and were to otherwise undergo DCR were instead treated with double bicanalicular silicone tube intubation. Resolution of preoperative symptoms and signs of NLD obstruction were assessed.

RESULTS

At an average follow-up of 40 +/- 5.6 months, all patients had improvement in symptoms and signs. The mean patient age was 31 +/- 3.2 months. The average duration of intubation was 15 +/- 0.73 months. Eight of 10 eyes had complete resolution of NLD obstruction symptoms. Two of 10 treated eyes had occasional symptoms of mattering with upper respiratory infection and exposure to wind or cold but required no further treatment. Nine of 10 eyes were treated for congenital NLD obstruction. The remaining patient had failed conventional bicanalicular intubation after repair of a traumatic common canalicular avulsion.

CONCLUSIONS

Double bicanalicular silicone tube intubation is an effective alternative to DCR in selected children who have failed conventional therapies for NLD obstruction. This treatment obviated DCR in all patients in this study.

Transnasal endoscopic dacryocystorhinostomy for the treatment of lacrimal pathway stenoses in pediatric patients

Lacrimal pathway stenoses in pediatric patients are uncommon after the age of 1 year. Various conservative treatments (massages, hot compresses, topical antibiotics, probing and intubation of the lacrimal pathways) are generally used to resolve these disorders. When non-invasive procedures fail, dacryocystorhinostomy (DCR) is indicated. While this surgical procedure has traditionally been performed by an external approach, a less-invasive endonasal technique has recently been advocated. We herein review a series of six children affected by lacrimal pathway stenosis who were treated at the Department of Pediatric Otorhinolaryngology, Spedali Civili, Brescia (Italy) between November 2000 and January 2002. All patients underwent successful transnasal endoscopic DCR and, to date, no re-stenoses have occurred. A review of the literature focusing on diagnostic work-up and different therapeutic options is also presented.

Obstruction of the lacrimal drainage system

This review covers evolving concepts in lacrimal outflow obstruction. Recent studies have increased our understanding of the surgical anatomy and pathophysiology of the lacrimal drainage system through radiologic, clinical, and microbiologic techniques. While external dacryocystorhinostomy remains an important treatment for nasolacrimal duct obstruction, there have been a number of therapeutic developments worthy of review, including advances in endoscopic and transcanalicular dacryocystorhinostomy, conjunctivodacryocystorhinostomy, and the use of mitomycin C in these procedures. In addition, we summarize recent advances in minimally invasive techniques for lacrimal outflow obstruction, including balloon dacryocystoplasty, lacrimal stents, and conjunctivoplasty. Finally, the roles of probing versus irrigation, nasal endoscopy, and endoscopic dacryocystorhinostomy in children are discussed.