Results of dacryoscintigraphy in massage of the congenitally blocked nasolacrimal duct

Spontaneous resolution rates in congenital nasolacrimal duct obstruction managed with massage or topical antibiotics compared with observation alone

BACKGROUND/AIMS

To determine if nasolacrimal massage or topical antibiotics are associated with higher rates of resolution compared with observation alone in a population-based cohort of infants with congenital nasolacrimal duct obstruction (CNLDO).

METHODS

The medical records of all children <5 years diagnosed with CNLDO while residing in Olmsted County, Minnesota from 1 January 1995 through 31 December 2004 were retrospectively reviewed for type of management and non-surgical resolution of tearing.

RESULTS

Among 1958 infants diagnosed and followed for CNLDO, 516 (26.4%) were merely observed, 506 (25.8%) were prescribed massage alone, 485 (24.8%) were prescribed at least one course of topical antibiotics, 397 (20.3%) were prescribed both topical antibiotics and massage, and 54 (2.8%) had no documented therapy. Non-surgical resolution, occurring in 1669 (85.2%) during a median follow-up of 3.1 months (range: 1 week-248 months), was 74.6% for the merely observed, 89.7% for those prescribed digital massage, 87.0% for those prescribed antibiotics and 90.7% for those treated with both. This comparison was significant in unadjusted (p<0.001) and multivariable comparisons (p<0.001).

CONCLUSION

Prescribing topical antibiotics or digital massage for infants with CNLDO in this cohort, individually or in combination, was associated with a higher rate of spontaneous resolution than observation alone.

The Effect of Lateral Osteotomy of Septorhinoplasty on Nasolacrimal Duct Functions: A Radionuclide Imaging Study

Background

The aim of this study was to evaluate the effects of lateral osteotomy of septorhinoplasty on nasolacrimal duct functions by dacryoscintigraphy.

Methods

The study group comprised 60 nasolacrimal systems of 30 consecutive patients who underwent septorhinoplasty. Dacryoscintigraphy images were taken in the preoperative period and postoperative 1st week and 3rd month. After Tc-99m pertechnetate instillation, dynamic images were obtained every 15 seconds. For cases of normal drainage, the study was terminated after 10 minutes but when obstruction was suspected, external ocular massage and rapid nasal inspiration were applied and the test was extended for an additional 10 minutes. Systems were classified either as passage without massage (normal nasolacrimal test), passage with massage (physiological obstruction), or presac or postsac obstruction (partial or complete obstruction) according to test results. Transit time was determined for cases with normal test or physiological obstruction.

Results

In the preoperative period eight systems (two presac and six postsac) had obstruction. There were a total of 11 (18.3%) additional systems with obstruction (4 presac and 7 postsac) in the 1st postoperative week and patient symptoms were not in complete agreement with the test results in this period. By the 3rd month, nine systems (three presac and six post sac) had obstruction. Transit time was prolonged in both the postoperative 1st week and the postoperative 3rd month tests compared with the preoperative tests (p = 0.000 and p = 0.023, respectively).

Conclusion

We did not encounter any permanent obstructions after lateral osteotomy of rhinoplasty. Temporary obstructions in the 1st postoperative week improved to normal preoperative status by the postoperative 3rd month.

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.

The rate of symptomatic improvement of congenital nasolacrimal duct obstruction in Japanese infants treated with conservative management during the 1st year of age

This study aimed to examine the rate of symptomatic improvement of congenital nasolacrimal duct obstruction (CNLDO) in Japanese infants treated with conservative management within the 1st year of age. Thirty-five lacrimal ducts in 27 patients diagnosed with CNLDO were included in the study. During the observational period, lacrimal ducts were massaged. As well, antibiotic eye drops, to be administered 4 times a day, were sometimes prescribed for obvious conjunctivitis. Two lacrimal ducts in 2 patients were probed before the 1st year of age because of dacryocystitis or severe blepharitis; these patients were included in the unimproved group. Twenty-nine lacrimal ducts in 21 patients resolved during the period (82.9%); with 16 lacrimal ducts resolving before six months of age. Therefore, a comparatively high percentage of resolution for CNLDO (82.9%) following conservative management was shown before the 1st year of age in Japanese infants.

Management of congenital nasolacrimal duct obstruction

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Pathology and Imaging of the Lacrimal Drainage System

The lacrimal drainage apparatus drains tears from the eye. The system is susceptible to a multitude of pathologic findings, including obstruction, infection, inflammation, and neoplasms. The diagnosis of several of these processes is aided by the use of radiologic studies. In conjunction with dacryocystography, cross-sectional modalities, such as CT and MR imaging have improved the ability of diagnostic imaging to characterize the obstructive nature and soft tissue or osseous changes of various disease processes.

A different concept in the application of dacryoscintigraphy

PURPOSE

Current dacryoscintigraphy methods have several potential pitfalls, the most important of which is the outflow of tears. Another is the difficulty in fixing the head with the patient seated. To overcome these difficulties, a new method was applied.

MATERIALS AND METHODS

The study included 77 persons: 43 controls and 34 patients with epiphora. Two methods were applied to the two groups. In the first, protocol 1 (the current conventional protocol), the patient was seated in front of a gamma camera and one drop (50 microl) Tc-99m pertechnetate containing 50 to 100 microCi radioactivity was instilled in the inferior fornix or outer canthus of the eye and dynamic and static images were obtained for approximately 15 to 20 minutes. In the other, protocol 2 (our protocol), 100 microCi (10 microl) Tc-99m pertechnetate was instilled in the outer canthus of the eye using a micropipette with the patient in the supine position under the gamma camera. Dynamic images were taken for only 5 minutes.

CONCLUSION

The pitfalls and difficulties seen with protocol 1 were lessened to a great degree in protocol 2.

Congenital nasolacrimal duct obstruction: therapeutic management

PURPOSE

Congenital nasolacrimal duct obstruction is a common condition, and its diagnosis must be based more on regular in-time epiphora than mattering. The purpose of this study is to better define the diagnostic criteria and therapeutic strategy.

METHODS

We have retrospectively evaluated 1563 subjects treated from 1990-1997 at the Pediatric Ophthalmological Service of Modena University Eye Clinic. The mean age at first examination was 5.7 months. According to symptoms and age, patients were treated with antibiotic therapy, office probing, or general anesthesia probing. Recovery was confirmed only after a 3-month symptom-free period.

RESULTS

More than 29% of patients recovered spontaneously or with topical antibiotic therapy. Office probing reduced the number of patients who needed a general anesthesia probing (from 62.97% from 1990-1993 to 33.61% from 1994-1997). In the period from 1994-1997, we changed the technique and especially the age of patients, obtaining a clearing of the obstruction in about 86% of cases compared with a 39% rate in the earlier period. Since 1994, in cases of general anesthesia probing, we have used a midazolam and ketamine anesthesiologic technique that has reduced risks and increased parental satisfaction and cost-effectiveness. Also, our data show that age at first attempt highly influenced probing failure rate.

CONCLUSION

If the first ophthalmologic examination is precocious and correctly timed, the possibility of curing the patient using the simplest method is increased. Better results can be obtained with cooperation among pediatricians, ophthalmologists, and anesthesiologists.