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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lacrimal sac massage for congenital nasolacrimal duct obstruction: a multicentre randomised controlled trial

AIM

Congenital nasolacrimal duct obstruction (CNLDO) is the most common cause of epiphora and mucous discharge in the newborn. We conducted a multicentre randomised controlled trial to determine whether Crigler massage promotes the resolution of CNLDO in infants under 1 year of age.

METHODS

A total of 102 infants aged 3-11 months with unilateral CNLDO were enrolled in the study. Patients were randomly assigned to the massage and non-massage groups (n=51/group). As an allocation adjustment factor, the patients were divided into age groups of 3-5, 6-8 and 9-11 months. In the massage group, the guardian performed 10 strokes two times per day for each day until resolution or 1 month. The primary endpoint was a comparison of the 1-month resolution rate in the massage and non-massage groups.

RESULTS

This study included 49 male and 53 female patients with a mean age of 6.4±2.4 months. Overall, in this study, the resolution rate was not significantly different between the massage and non-massage groups (31.4% and 33.3%, respectively). However, the resolution rate was higher in the massage group in the 3-5 months age group among the protocol-compliant patients after excluding those with insufficient massage frequency (the massage group, 68.8% and the non-massage group, 28.6%, p=0.022).

CONCLUSIONS

There was no increase in the resolution rate after 1 month of lacrimal sac massage in patients 3-11 months old with unilateral CNLDO. However, in protocol-compliant younger age groups, Crigler massage may be effective.

TRIAL REGISTRATION NUMBER

UMIN Clinical Trial Registry (UMIN000032840; www.umin.ac.jp/).

Assessment of Office-Based Probing with Dacryoendoscopy for Treatment of Congenital Nasolacrimal Duct Obstruction: A Retrospective Study

We aimed to evaluate the safety and efficacy of office-based probing with dacryoendoscopy under local anesthesia for congenital nasolacrimal duct obstruction (CNLDO). This single-institution study retrospectively reviewed data on 72 eyes of 64 consecutive children (38 boys, 43 eyes; 26 girls, 29 eyes), aged between 6 and 17 (mean age: 10.0 ± 2.7) months with suspected CNLDO, from July 2016 to February 2022. These patients underwent probing with dacryoendoscopy under local anesthesia. CNLDO was diagnosed clinically based on the presence of epiphora and sticky eyes due to mucous discharge commencing within the first 3 months of life, increased tear meniscus height, and fluorescein dye disappearance test results. A total of 63 of the 72 eyes had narrowly defined CNLDO, and 9 eyes had other types of obstructions. The intervention success rate was 100% (63/63 eyes) for patients with typical CNLDO and 97.2% (70/72 eyes) for the entire study cohort. Moreover, CNLDO was classified into five types based on the features of the distal end of the nasolacrimal duct. Probing with dacryoendoscopy is safe and yields a high success rate in pediatric patients with CNLDO. This is the first study to assess the safety and efficacy of probing with dacryoendoscopy under local anesthesia in pediatric patients with CNLDO.

Preferred Practice Patterns of Congenital Nasolacrimal Duct Obstruction in Jordan

Purpose

Congenital nasolacrimal duct obstruction (CNLDO) is fairly common in newborns. The main aim of this cross-sectional study is to assess the preferred practice patterns of CNLDO among ophthalmologists in Jordan.

Methods

This cross-sectional study was conducted across all ophthalmological practices in Jordan, using convenience sampling. An online questionnaire, designed through Google Forms, was distributed through social media. The survey contained four domains: baseline characteristics of participants and the diagnosis (7 items), medical management (3 items), and surgical management (11 items) of CNLDO. Descriptive statistics were conducted using SPSS (IBM SPSS Corp, SPSS Statistics ver. 26, USA).

Results

Eighty-three physicians responded to the survey, with an average age of 40.6 ± 8.6. More than half of the participants (53.0%, n = 44) were general ophthalmologists. Only 37.3% of our sample (n = 31) regularly evaluated the refraction of a child presenting with epiphora suggestive of CNLDO. Criggler's nasolacrimal duct massage was recommended by 62.7% of respondents (n = 52) for up to 12 months. In addition, 72.3% of respondents (n = 60) recommended 12 months as the minimum age for primary probing of CNLDO. Silicon intubation was considered for primary probing starting at 24 months by 31.3% of ophthalmologists (n = 20). Monocanalicular stent was preferred by 42.2% of respondents (n = 27) while 31.3% (n = 20) preferred bicanalicular stent.

Conclusion

There is considerable variability in preferred practice patterns regarding the diagnosis and management of CNLDO in Jordan. Our findings highlight the gaps in optimum practices which need to be addressed for better management.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Conservative Treatment for Congenital Nasolacrimal Duct Obstruction – Factors Affecting the Success

Aim

To examine the success rate and factors affecting the effect of conservative treatment for congenital nasolacrimal duct obstruction (CNLDO) in children.

Methodology

A prospective study was made on 167 eyes of 131 patients with clinical signs of CNLDO. All of them were initially treated nonsurgically with Crigler massage. The curative effect of this management was evaluated on the basis of no history of watery eyes, negative regurgitation test, and dye disappearance test 0 or 1 grade. Exploratory analyses assessed whether baseline characteristics including age, gender and laterality were associated with the probability of CNLDO resolving without surgery. If the nonsurgical treatment failed, probing was done in the Eye Clinic in Pleven.

Results

The conservative treatment for CNLDO with Crigler massage was successful in the majority of treated cases – in 115 out of 167 eyes with CNLDO (68,9%). The remaining 52 (31,1%) eyes were probed. Age (p = 0,001) and laterality (p = 0,001) were found to be associated with resolution of the clinical signs.

Conclusions

Nonsurgical management for CNLDO was successful initial treatment in patients with this pathology. The Crigler massage was more effective in children up to 12 months of age with unilateral obstruction.

Dacriocistorrinostomía externa, conjuntivo-dacriocistorrinostomía y cirugía de la vía lagrimal en el meato inferior

Introducción y objetivo: Realizar una revisión sobre la dacriocistorrinostomía externa (DCR-ext), sondaje de la vía lagrimal y conjuntivodacriocistorrinostomía(CDCR) empleadas ante la obstrucción de la vía lagrimal. Material y métodos : Revisión bibliográfica sobre técnicas quirúrgicas mencionadas. Discusión: La obstrucción de la vía lagrimal puede dividirse según su localización en proximales y distales. Ante obstrucciones distales, la DCR ext es la técnica gold standard con porcentajes de éxito superiores al 95%, y la CDCR en caso de obstrucciones proximales.El sondaje de la vía lagrimal es la primera indicación quirúrgica en obstrucción congénita.

Endoscopic marsupialization of nasolacrimal duct cysts under topical anaesthesia: 5 years of a single institute experience

OBJECTIVE

To present the outcomes of neonatal nasolacrimal duct cysts treated through endoscopic intranasal marsupialization under topical anaesthesia.

METHODS

A retrospective study of 19 infants diagnosed with congenital nasolacrimal duct cyst, with or without dacryocystocele, diagnosed and treated between March 2015 through March 2020. Data were extracted for descriptive purposes and included: birth weight, main presenting symptom, stertor or dyspnoea, unilateral or bilateral occurrence. Follow-up one month after intervention included recurrence of symptoms, physical examination and fibreoptic naso-endoscopy.

RESULTS

Nineteen infants with intranasal cyst were presented to our department at the age of 1 day. Four-teen infants had unilateral and 5 infants had bilateral intranasal cysts. There were 8 boys and 11 girls. Mean gestational age at birth was 39 weeks, mean birth weight was 3351 g. 42.1% of infants presented with dacryocystocele, 31.5% with stertor, and 26.3% with dyspnoea. 80% of infants with bilateral cysts presented with dyspnoea. Follow up ranged from 6 to 48 months, no recurrence of symptoms was reported.

CONCLUSION

Intranasal endoscopic marsupialization under topical anaesthesia is a successful, safe, low cost procedure for treating neonatal nasolacrimal duct cysts while avoiding general anaesthesia for infants.

Lacrimal sac bacteriology and susceptibility pattern in infants with congenital nasolacrimal duct obstruction in the 1st year of life: a cross-sectional study

Background

Congenital nasolacrimal duct obstruction (CNLDO) is one of the main causes of epiphora in infants, and antibiotics are usually used as a conservative therapy in the first year. Yet, little is known about the bacteriology of the occluded lacrimal drainage system in this group of patients. The aim of this study was to evaluate the microbiology of lacrimal sac (LS) in Chinese children with CNLDO in their first year of life.

Methods

Patients with CNLDO between May 1, 2017 and August 31, 2018 at a tertiary care children’s hospital were enrolled. The study recruited infants who received lacrimal probing under 1 year old, and refluxed discharge from LS was collected. Samples were cultured and susceptibility test was performed for positive culture.

Results

Thirty-two patients with CNLDO were included. The ratio of male to female was 23:9. The mean age was 6.7 ± 2.4 (1.7–12) months. Positive cultures was identified in 87.5% of the sample, and presented 38 strains of bacteria. Mixed infection was identified in 10 (31.3%) children. Gram-positive bacteria accounted for 60.5% of all the strains, with Streptococcus (50%) being the most frequent species, whereas Haemophilus (21.1%) and Neisseriae (13.2%) were most common isolates for Gram-negative organisms. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in 2 infants whose symptoms resolved by a routine probing. No difference of bacteriology pattern was detected between patients under 6 months old and those beyond. The pathogens were highly sensitive to chloramphenicol (88%) and levofloxacin (84%), but resistant to erythromycin (40%) and sulfamethoxazole (32%).

Conclusions

Infants with CNLDO under 1 year of age presented predominance of Streptococcus as Gram-positive organism, and Haemophilus as Gram-negative organism. Levofloxacin was an active topical antibiotic agent with few chance of resistance especially for Chinese children. These findings could help clinicians choose optimal medicine for CNLDO as the conservative treatments.

Congenital nasolacrimal duct obstruction update study (CUP study): paper I-role and outcomes of Crigler's lacrimal sac compression

PURPOSE

To assess the exclusive role and outcomes of Crigler's lacrimal sac compression in the management of congenital nasolacrimal duct obstruction (CNLDO).

METHODS

Retrospective interventional case-series was performed on patients diagnosed with CNLDO and who were advised Crigler's lacrimal sac compression (CLSC) at a tertiary care Dacryology Institute from Jan 2016 to June 2019. CNLDO patients who were practicing incorrect techniques of lacrimal sac compression at presentation were separately assessed. All the patients were assigned to four groups (Gr 1: 0-3 months, Gr 2: >3 & <6 months, Gr 3: >6 & <9 months and Gr 4: >9 and <12 months) based on the age at which the CLSC was initiated and followed up quarterly or as needed till at least 1 year of age. The parameters studied include patient demographics, clinical presentation, age of initiation of CLSC, success rate with CLSC, and need for additional interventions. 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.

RESULTS

A total number of 1240 patients with CNLDO were assessed. Of these, 1037 patients were advised correct techniques of CLSC from the beginning, and the remaining 203 patients were referred but performing it incorrectly at presentation. Of the 1037 patients, 236 were lost to follow-up; hence, a total of 1004 patients (801 + 203) were included for final analysis. CLSC was found to be an effective conservative strategy in the management of CNLDO. The rate of resolution of CNLDO in Gr 1 to Gr 4 was 87.3%, 78.9%, 77.9%, and 76.8%, respectively. There were no statistically significant differences in the outcomes based on the age of CLSC initiation. The referred patients whose techniques were rectified following the initial incorrect techniques showed a resolution of 61.2% (79/129). The correct techniques of CLSC appeared to influence the outcomes. However, the age of its initiation did not substantially impact the outcomes. Significantly high resolution was noted even beyond nine months of age and encouraging results beyond 12 months of age.

CONCLUSIONS

It is crucial to initiate the correct techniques of Crigler's lacrimal sac compression to achieve favourable outcomes. Age of initiation of CLSC in infancy does not appear to influence the outcomes. The resolution rate continued to be significantly high up to 1 year of age. There is a need to assess the role of CLSC beyond 12 months of age.

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Is there an association between congenital nasolacrimal duct obstruction and cesarean delivery?

PURPOSE

The aim of this study was to research the relationship between types of birth and congenital nasolacrimal duct obstruction.

METHOD

The study enrolled 665 infantile patients with prediagnosis of congenital nasolacrimal duct obstruction due to associated ophthalmic symptoms. Age, gender, family history, delivery type, and patient medical records were investigated. Patients were grouped and compared according to their birth type and whether it was the first birth.

RESULTS

The number of the infants with and without congenital nasolacrimal duct obstruction was 227 (34.1%) and 438 (65.9%), respectively. Comparison of the congenital nasolacrimal duct obstruction and non-congenital nasolacrimal duct obstruction groups according to the first births showed that ratio of cesarean section was significantly higher in the congenital nasolacrimal duct obstruction group than the non- congenital nasolacrimal duct obstruction group (58.7% and 20.7%, respectively). Number with positive family history also was significantly higher in the congenital nasolacrimal duct obstruction group.

CONCLUSION

Cesarean section in first birth and positive family history of congenital nasolacrimal duct obstruction appear to be important risk factors in the etiopathogenesis of congenital nasolacrimal duct obstruction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Congenital Nasolacrimal Duct Obstruction (CNLDO): A Review

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

Insights in the treatment of congenital nasolacrimal duct obstruction

Introduction: Congenital nasolacrimal duct obstruction is one of the most common causes of epiphora in newborns and the main cause of this condition is the persistence of Hasner membrane. Several treatment options are available, like conservative treatment, probing, irrigation, or more complex techniques.

Objective: The objective of this paper is to discuss the efficiency of different treatment options addressing congenital nasolacrimal duct obstruction based on trials reported in literature.

Methods: Clinical trials were identified on PubMed. The results were discussed regarding patient age, type of treatment and efficiency of the treatment.

Results: 41 trials were reviewed. The rate of resolution according to different treatment options was the following: conservative treatment 14.2-96%, probing 78-100%, irrigation 33-100%, silicon tube intubation 62-100%, inferior turbinate fracture 54.7-97%, balloon dacryocystoplasty 77%, endoscopic intranasal surgery 92.72%, and dacryocystorhinostomy 88.2-93.33%.

Conclusions: The first choice in uncomplicated cases should be a conservative treatment, which can be followed until the age of 1 year, while in complicated cases other solutions should be considered.

Abbreviations: CNDO = Congenital nasolacrimal duct obstruction, DCR = Dacryocystorhinostomy, MCI = Monocanalicular intubation, BCI = Bicanalicular intubation

Selection of surgical intervention for congenital dacryocystocele

PURPOSE:

To evaluate the surgical intervention and its effect on congenital dacryocystocele.

METHODS:

A total of 531 children with congenital dacryocystocele admitted to the Department of Ophthalmology of Beijing Children's Hospital, Shanghai Aier Eye Hospital, Nanjing Aier Eye Hospital, and the First Affiliated Hospital of Jinzhou Medical University between January 2007 and January 2017 were retrospectively analyzed.

RESULTS:

A total of 531 patients were followed up for 3-24 months, with an average of 13.3 months. No serious intraoperative complications (such as bleeding and tissue damage) and postoperative complications (bleeding, infection, and hole atresia) were found. We classified the outcomes into three categories based on the signs (overflowing tears and empyema) and objective routine follow-up by endoscopy. Cure indicated that mass, overflow of tears, and breathing difficulties disappeared, and 81.5% cases (433/531) were postoperatively cured. Improvement indicated disappearance of mass, overflow empyema, and the presence of residual tears (due to trocar and tears puncture), and 18.5% cases (98/531) were postoperatively improved. Unhealed indicated overflowing pus and tears, and 0% cases did not heal after surgery.

CONCLUSIONS:

Nasal endoscopic surgery is relatively safe, with high success rate for treatment of congenital dacryocystocele. Systematic training is required to promote the application of nasal endoscopy, so that more ophthalmologists can learn this technique.

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.

Bicanalicular versus monocanalicular intubation after failed probing in congenital nasolacrimal duct obstruction

AIM

To investigate the clinical outcomes of different intubation techniques in the cases of failed primary probing.

METHODS

This retrospective study was performed on 338 patients with the diagnosis of congenital nasolacrimal duct obstruction with age 1-4y that had failed primary probing. Intubation was performed under light sedation in operating room and the stent was left 3mo in place. Clinical outcome was investigated 3mo after tube removal.

RESULTS

Bicanalicular intubation method had higher complete and relative success rates compared to monocanalicular intubation (P=0.00). In addition, Monoka intubation had better outcomes compared to Masterka technique (P=0.046). No difference was found between genders but the higher the age, the better the outcomes with bicanalicular technique rather than monocanalicular.

CONCLUSION

Overall success rate of bicanalicular intubation is superior to monocanalicular technique especially in older ages. Also, based upon our clinical outcomes, Masterka intubation is not recommended in cases of failed probing.

Indian survey on practice patterns of lacrimal and eyelid disorders (iSUPPLE) report 1: Congenital nasolacrimal duct obstruction

BACKGROUND

To assess the preferred practice patterns in the management of congenital nasolacrimal duct obstruction (CNLDO) among oculoplastic surgeons in India. The survey was aimed at obtaining data on the timing of intervention, procedure of choice, and the use of adjunctive techniques such as silicone intubation and nasal endoscopy.

METHODS

An anonymized survey that included questions on the management of lacrimal disorders was sent in April 2015 to members of the Oculoplastic Association of India (OPAI), through an e-mail communication. The results were tabulated and analyzed.

RESULTS

A large proportion (84%) of respondents indicated that they advise lacrimal sac compression up to 1 year of age. Fourteen percent (12/87) indicated 2 years as their upper age limit for advising sac compression. One year is the preferred minimum age for advising primary nasolacrimal duct (NLD) probing by majority (45%) of respondents and the upper age limit being 5 years for 62% of respondents. Based on experience, younger surgeons (<10 years experience) when compared to more experienced surgeons are more likely to offer a trial of primary probing in children between 8 and 12 years age (29% versus 8%). Nasal endoscope is used by 50% (44/88) respondents during primary NLD probing. Nearly a third of the respondents (29/88) use intubation in all cases of NLD probing. Eighty one percent (71/88) of the surgeons would rather repeat NLD probing with adjunctive procedures over dacryocystorhinostomy (17%). Balloon Dacryoplasty is rarely used for CNLDO amongst our respondents.

CONCLUSIONS

This study highlights the variation in practice pattern in the management of CNLDO across India. While there are certain trends that are global phenomena, such as the shift towards the use of a nasal endoscope; use of silicone intubation in repeated procedures and time of performing primary NLD probing; issues like the use of balloon dacryoplasty showed lesser degree of agreement.

The natural process of congenital nasolacrimal duct obstruction and effect of lacrimal sac massage

This study aimed to examine the rate of symptomatic improvement of congenital nasolacrimal duct obstruction (CNLDO) in infants treated with conservative management within the first year of age. Other purpose of the study is to emphasize the relationship between spontaneous resolution time and effective lacrimal sac massage. Thirty-one infants were diagnosed to have CNLDO by an ophthalmologist prior to 3 months of age. In this study, 36 eyes of 31 patients were included with CNLDO. The patients were divided into two groups. Group 1 (28 eyes of 24 patients) was consisted of the patients who were applied effective lacrimal sac massage regularly during the follow-up period, and patients whose parents did not apply a regular lacrimal passage regularly were accepted as group 2 (8 eyes of 7 patients). Thirty-three eyes of 31 patients (18 rights and 15 left) successfully resolved with only conservative management (91.6 %). In these thirty-three eyes, one eye (3 %) resolved between 0 and 3 months, fourteen eyes (42.5 %) resolved between 4 and 6 months, eleven eyes (33.3 %) resolved between 7 and 9 months, and seven eyes (21.2 %) resolved between 10 and 12 months. CNLDO was resolved in 27 (96.2 %) of 28 eyes in group 1, and in group 2, six eyes (77.7 %) had resolvement. This difference was statistically significant (p = 0.001). The mean age of resolution was 6.8 ± 1.88 months in group 1, 10.3 ± 1.5 months in group 2 (p < 0.001). In light of our study, we believe that conservative management of CNLDO is highly successful. Our study provided a possible objective explanation for the efficacy of lacrimal sac massage. Emphasizing the importance of the massage to parents and describing in detail can reduce the risk of unnecessary surgical interventions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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 of congenital nasolacrimal duct obstruction with dacryoendoscope

BACKGROUND

A congenital nasolacrimal duct obstruction (CNLDO) is a relatively common disease in infants. We evaluated the results of probing three patients with CNLDO, under direct view, with a dacryoendoscope.

METHODS

Three cases of CNLDO were examined and treated by probing with a dacryoendoscope, under intravenous anesthesia. The diameter of the dacryoendoscope probe was 0.7 mm, and we were able to observe the inner walls of the lacrimal duct and able to guide the probe through the duct.

RESULTS

In all cases, the site of obstruction was detected, and the probe was used to remove the obstruction. At 2 weeks after the removal of the obstruction, there was no epiphora or mucopurulent discharge in any of the cases. No complications were detected intra- and postoperatively.

CONCLUSION

Although only three cases were studied, we believe that probing with a dacryoendoscope is a safe and effective method of treating a CNLDO. More cases need to be studied.

Process of spontaneous resolution in the conservative management of congenital dacryocystocele

Purpose

To assess efficacy of the conservative management of patients with congenital dacryocystocele.

Materials and methods

This was a retrospective case series involving six sides of five infants with a dacryocystocele treated at Osaka Kaisei Hospital, Osaka, Japan. The conservative management protocol consisted of the application of warm compresses and massage over the mass, with the addition of antibiotics when dacryocystitis developed. Patient age at the time of resolution, presence of retrograde outflow of contents of dacryocystoceles from the puncta, and development of dacryocystitis were recorded.

Results

The dacryocystocele was unilateral in four patients and bilateral in one patient. A nasal cyst was present in four patients without respiratory distress. The median patient age at the time of the diagnosis was 7 days (range 2–10 days). Conservative management was selected in all patients, and the dacryocystocele was resolved in all patients at a median patient age of 14.5 days (range 11–105 days). Two sides developed dacryocystitis, which resolved in a few days with antibiotic treatment. In those two sides, rupture of the dacryocystoceles to the common canaliculus with retrograde discharge of the contents from the puncta before the dacryocystitis developed was noted. For the other four treated sides, no such discharge or development of dacryocystitis was observed.

Conclusion

The findings of this study show that a dacryocystocele has a good chance of resolving spontaneously with conservative management and careful observation, and that rupture of the dacryocystocele to the common canaliculus might be an important precursor of dacryocystitis.

Risk factors for developing congenital nasolacrimal duct obstruction

Objective

To identify potential risk factors for developing congenital nasolacrimal duct obstruction (CNLDO).

Study design and methods

A cross-sectional study. A quantitative questionnaire was distributed to a sample of mothers attending the Pediatrics Clinic at King Khalid University Hospital, Riyadh, Saudi Arabia.

Results

A total of 756 mothers responded to our questionnaire. Of the 756 filled questionnaires, 389 (51.67%) were male children. 5.3% of the mothers lived in non-urban settings. CNLDO was reported in the children attending the clinic by 17.1% (129/756) of their mothers. Average age (±SD) of infants when persistent tearing was noticed was 3.2 ± 2.7 months, while average age (±SD) of resolution was 9.6 ± 3.7 months. Of the children with CNLDO, 37.2% (48/129) still have persistent tearing at the time of distributing the questionnaire. Among the group with CNLDO, 17% (22/129) of their mothers have experienced an infection during pregnancy (p = 0.022). Within the same group, 14.7% (19/129) of the affected children were reported by their mothers to have other children with CNLDO which was statistically significant (p = <0.001).

Conclusion

CNLDO could have a genetic predisposition and maternal infection is a possible risk factor for developing CNLDO. Surgical management awareness should be emphasized to relieve children from this relatively common and benign condition.

Congenital nasolacrimal duct obstruction in premature children

PURPOSE

To determine the incidence of congenital nasolacrimal duct obstruction (CNLDO) in premature and full-term children.

METHODS

Medical records of 200 premature and 200 full-term children from July 2004 to November 2009 at the Peri-Peri Health Center were retrospectively reviewed. Fifty-three nasolacrimal ducts in 32 premature children (21 patients were bilateral) and 9 nasolacrimal ducts in 7 full-term children (2 patients were bilateral) diagnosed as having CNLDO were retrospectively examined.

RESULTS

Of the 200 premature children, 32 (16%) had CNLDO compared with 7 (3.5%) of the 200 full-term infants (P < .0001). Thirty premature infants and five full-term children underwent conservative treatment. Bilateral obstruction was found in all 3 extremely premature children (gestational age < 28 weeks), in 9 (69.23%) moderately premature children (gestational age of 28 to 31 weeks), in 9 (56.25%) mildly premature children (gestational age of 32 to 36 weeks), and in 2 (28.57%) full-term children (gestational age > 37 weeks).

CONCLUSIONS

This study reported a higher incidence of CNLDO in preterm infants when compared to full-term infants. This might be expected in light of the normal development of the nasolacrimal duct system, the patency of which normally occurs after the preterm infant is born.

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.