Can congenital nasolacrimal-duct obstruction interfere with visual development? A cohort case control study

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.

Anisometropia and refractive status in children with congenital nasolacrimal duct obstruction-a prospective observational study

PURPOSE

To assess the refractive status and anisometropia in children with unilateral and bilateral congenital nasolacrimal duct obstruction (CNLDO).

METHODS

Consecutive children newly diagnosed with CNLDO were prospectively enrolled from November 2017 to May 2019. A complete ophthalmic evaluation including cycloplegic refraction was performed followed by appropriate intervention. Patients were followed for 6 months, and cycloplegic refraction was performed at each visit. The final refractive error was defined as the refractive error obtained from the most recent visit. Amblyogenic risk factors were assessed based on 2013 referral criteria of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

RESULTS

A total of 308 patients with CNLDO were enrolled: 205 (67%) unilateral cases and 103 (33%) bilateral cases. In unilateral cases, the affected eye and unaffected fellow eye showed statistically significant difference in terms of sphere (P < 0.001), cylinder (P = 0.019), and spherical equivalent (P < 0.001); there was no interocular difference in bilateral cases (P > 0.05). Anisometropia was more prevalent in unilateral cases than in bilateral cases (11.2% vs 1.9%; P = 0.005). Based on the 2013 AAPOS referral criteria, 3.9% of the unilateral and 3.9% of bilateral cases exhibited amblyogenic risk factors. Later age of presentation was associated with higher rate of anisometropia (53.8% in the age group >48 months).

CONCLUSIONS

In our study cohort, unilateral CNLDO was associated with a higher prevalence of anisometropia compared with bilateral CNLDO. The affected eye in unilateral CNLDO had higher prevalence of refractive error.

Amblyopia Risk Factors in Newborns With Congenital Nasolacrimal Duct Obstruction

PURPOSE

To investigate the presence of amblyopia risk factors in newborns with congenital nasolacrimal duct obstruction (CNLDO) and age-matched healthy control subjects.

METHODS

This retrospective case-control study involved newborns aged 30 to 60 days with CNLDO and age-matched healthy control subjects. Amblyopia risk factors were identified in accordance with the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee recommendations. The prevalence of amblyopia risk factors was compared in newborns with CNLDO and age-matched healthy control subjects, newborns with unilateral and bilateral CNLDO, and the affected eye and fellow eye of newborns with unilateral CNLDO.

RESULTS

Amblyopia risk factors were found in 18 patients (11.9%) with CNLDO and 19 control subjects (8.7%) (P = .314). Eyes with CNLDO showed a significantly lower spherical equivalent compared to control eyes (2.01 ± 1.21 vs 2.79 ± 1.14 diopters, P < .001). No difference in amblyopia risk factors was found in eyes with unilateral and bilateral CNLDO (11.5% vs 12.1%; P = .908) or in eyes with unilateral CNLDO and fellow eyes (9.8% vs 12.3%; P = .540).

CONCLUSIONS

CNLDO does not seem to be associated with amblyopia risk factors in newborns. Because anisometropia might develop later on, all patients with CNLDO should be monitored for amblyopia. [J Pediatr Ophthalmol Strabismus. 2020;57(1):39-43.].

Amblyopia risk factors in congenital nasolacrimal duct obstruction: A longitudinal case-control study

Purpose

To investigate longitudinal changes in risk factors for amblyopia in children treated with congenital nasolacrimal duct obstruction (CNLDO).

Methods

Retrospective observational case control study. A total of 446 children under 4 years of age who underwent probing and/or intubation for CNLDO between January 2004 and January 2018, and 446 age-matched controls were included. Cycloplegic refraction and ocular alignment were investigated at the time of treatment and after at least one year of symptom improvement. Children were classified as having amblyopia risk factors on the basis of the American Association for Pediatric Ophthalmology and Strabismus guideline in 2013.

Main outcome measures

The prevalence of amblyogenic refractive errors, and determinants associated with the presence of amblyogenic refractive errors in CNLDO patients.

Results

The prevalence of amblyogenic refractive errors in CNLDO patients (5.4%) was similar to that of the control group (6.5%) (P = 0.571). After one year of symptom improvement in CNLDO patients, the prevalence of amblyogenic refractive errors was 4.7%. There was no difference in the prevalence of amblyogenic refractive errors between unilateral and bilateral CNLDO patients. Multivariate analysis revealed that manifest strabismus was the only risk factor related with the presence of amblyogenic refractive errors (odds ratio = 6.383, confidence interval = 1.205–33.826, P = 0.029).

Conclusions

This study found no evidence to suggest that the prevalence of amblyopia risk factors is higher in CNLDO patients compared with normal controls. Manifest strabismus was the only determinant associated with the presence of amblyogenic refractive errors.

Nasolacrimal duct obstruction: Does it really increase the risk of amblyopia in children?

Purpose:

To report the prevalence of amblyopia risk factors in children with congenital nasolacrimal duct obstruction.

Methods:

A retrospective review of records of children with the diagnosis of congenital nasolacrimal duct obstruction (NLDO), who underwent probing from January 2009 to October 2011, was done. All of them underwent a complete ophthalmic evaluation including cycloplegic refraction and strabismus evaluation before probing.

Results:

A total of 142 children were included in this study. The mean age at presentation was 22.38 months (sample standard deviation (SSD) – 15.88). Amblyopia risk factors were defined according to two sets of guidelines: The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) referral criteria guidelines and the new AAPOS Vision Screening Committee guidelines. Twenty-eight (20%) children were found to have some form of amblyopia risk factor based on the referral criteria prescribed by AAPOS. However, on applying modified guidelines described by Donahue et al., to analyze the same cohort, 21 children were found to have amblyogenic risk factors. Of these 28 children, 13 had significant astigmatism (>1.50 D), 8 children had hypermetropia (>3.50 D), and six children had anisometropia (>1.50 D). One child had significant cataract (media opacity >1 mm). None of the children in this series had either myopia or strabismus.

Conclusion:

Prevalence of amblyopia risk factor was found to be 20% in our study based on the older guidelines; however, it reduces to 14.78% by applying the modified guidelines. Despite this reduction, importance of a comprehensive ophthalmic examination including cycloplegic refraction in all children presenting with NLDO cannot be overstated. A close follow-up of these children is also essential to prevent the development of amblyopia.

Comparison of Anisometropia and Refractive Status in Children With Unilateral and Bilateral Congenital Nasolacrimal Duct Obstruction

PURPOSE

To evaluate and compare the refractive state in children diagnosed as having unilateral or bilateral congenital nasolacrimal duct obstruction (CNLDO). This study also compares how the laterality of CNLDO affects the refractive state of the patients.

METHODS

This descriptive cross-sectional study includes consecutive children with unilateral and bilateral CNLDO over a period of 1 year. Cycloplegic refraction was performed on each child who presented with CNLDO followed by appropriate plans for treatment. The refractive errors of patients with unilateral and bilateral CNLDO were compared.

RESULTS

One hundred sixty-one patients with unilateral CNLDO (mean age: 29 ± 19.93 months) and 46 with bilateral CNLDO (mean age: 30 ± 16.21 months) were enrolled from August 2013 to July 2014. The rate of the anisometropia (≥ 1 diopters [D] difference between the two eyes) was 13.7% (n = 22) and 8.6% (n = 4) in patients with unilateral and bilateral CNLDO, respectively. Interocular difference was significant in terms of spherical equivalent (P < .01) but not cylindrical refractive error in patients with unilateral CNLDO. Patients with bilateral CNLDO had insignificant interocular differences in terms of spherical equivalent and cylindrical refractive errors (P > .05).

CONCLUSIONS

Unilateral CNLDO is associated with statistically significant anisometropia compared to bilateral CNLDO, which predisposes children with unilateral CNLDO to amblyopia. It is vital to perform cycloplegic refraction routinely and counsel parents regarding regular follow-ups. [J Pediatr Ophthalmol Strabismus. 2016;53(3):168-172.].

The prevalence of amblyogenic factors in children with persistent congenital nasolacrimal duct obstruction

BACKGROUND

To evaluate the prevalence of amblyopia risk factors in children that underwent probing for persistent congenital nasolacrimal duct obstruction (CNLDO).

METHODS

The medical records of children with CNLDO (after 1 year of age) that underwent probing were reviewed. Amblyopia risk factors, based on the American Association for Pediatric Ophthalmology and Strabismus referral criteria in 2013, were sought in the patientsʹ records before probing. The proportion of the patients with anisometropia >1.5 diopters (D) was separately calculated. In unilateral cases of CNLDO, sphere, astigmatism, and spherical equivalent of the eyes with CNLDO were compared with contralateral eyes in order to assess the effect of CNLDO on refractive error. In the follow-up examinations, the success of the probing or the need for additional procedures (Crawford intubation, Monoka intubation, or dacryocystorhinostomy) was evaluated. The prevalence of anisometropia between 'successful probing' and 'failed probing' groups was compared.

RESULTS

A total of 433 cases were included in the study. 41 cases (9.46 %) had amblyopia risk factors. Twenty-four cases (5.5 %) had anisometropia >1.5 D (spherical or cylindrical). In unilateral cases of CNLDO, the sphere and spherical equivalent of the eyes with CNLDO were significantly greater than those of the contralateral eyes (p < 0.001 for both). Thirty-nine patients (9 %) required other interventions due to failure of probing (failed probing group). There were significantly more anisometropia prevalence in this group, compared with the successful probing group, at the initial examination (p = 0.03).

CONCLUSIONS

The findings of greater prevalence of anisometropia >1.5 D (compared with the prevalence in the general population) and significantly greater sphere and spherical equivalents in the eye with CNLDO (compared with contralateral eye) in unilateral cases with CNLDO, suggested some relationships between anisometropia and long-term untreated CNLDO. The finding of more anisometropia in failed probing cases may support the theory of structural abnormality as an explanation for the possible relationship between congenital nasolacrimal duct obstruction and anisometropia.

Amblyopia risk factors in infants with congenital nasolacrimal duct obstruction

PURPOSE

This study aims to report the prevalence of amblyopia risk factors in patients with congenital nasolacrimal duct obstructions.

METHODS

We recruited patients who were treated for congenital nasolacrimal duct obstruction from April 2007 to December 2011 at Korea University Ansan Hospital. We evaluated visual acuity and refraction, performed strabismus test and slit-lamp examination, and assessed marginal reflex distance 1 (MRD1) to rule out amblyopia risk factors.

RESULTS

We examined 26 children among 115 patients. Ten patients underwent probing procedure and 16 underwent Monoka stent intubation. Nine (35%) patients showed amblyopia risk factors, which occurred in the same eye as the congenital nasolacrimal duct obstruction in 8 (89%) patients. Seven out of 9 patients had refractive error alone, and 2 patients had both refractive error and strabismus. One (11%) had anisometropia, 2 (22%) had hyperopia, and 8 (89%) had astigmatism.

CONCLUSION

Children with congenital nasolacrimal duct obstruction had a higher prevalence of amblyopia risk factors than children in the general population. Children with congenital nasolacrimal duct obstruction require special attention and treatments for refractive error. We recommend early treatment, such as probing or intubation, for congenital nasolacrimal duct obstruction.

Anisometropia and amblyopia in nasolacrimal duct obstruction

PURPOSE

To investigate an association of childhood nasolacrimal duct obstruction (NLDO) with anisometropia and amblyopia.

METHODS

The medical records of patients from newborn to 6 years of age with a diagnosis of NLDO seen from 2000 to 2010 were retrospectively reviewed. Data collected included age at onset of NLDO, laterality of NLDO, cycloplegic refractive error, determination of clinically significant anisometropia (defined as ≥1 D), and diagnosis of amblyopia with amblyopia subtype (anisometropic vs other).

RESULTS

A total of 1,218 patients with NLDO were included. Of these, 887 cases (72.8%) were unilateral; 331 (27.2%), bilateral. Anisometropia was found in 67 (7.6%) unilateral cases and 12 (3.6 %) bilateral cases on initial examination (χ2=5.48, P < 0.01). Same-sided unilateral NLDO was significantly associated with greater hyperopia in the anisometropia patients (χ(2) = 33.01, P < 0.001). Follow-up data were available for 482 NLDO patients and revealed an additional 26 patients with anisometropia for a total of 105 of 1218 (8.6%). Of the 482 patients, 28 (5.8%) developed amblyopia, 16 cases of which were purely attributable to anisometropia. Of 41 patients with anisometropia who were in the follow-up, 9 (22%) developed amblyopia.

CONCLUSIONS

Anisometropia occurred at a greater rate in unilateral NLDO patients compared with bilateral NLDO patients and occurred at a greater rate in this NLDO cohort than expected in the general pediatric population. Several patients with anisometropia developed clinical amblyopia. Measurement of cycloplegic refraction in all NLDO patients at initial examination should be considered. Periodic follow-up is appropriate for patients with NLDO and anisometropia.

Prevalence of amblyopia risk factors in congenital nasolacrimal duct obstruction

PURPOSE

To determine whether children who present to an ophthalmology practice for nasolacrimal duct obstruction are more likely to have risk factors for amblyopia.

METHODS

A retrospective chart review was conducted on all patients presenting to a pediatric oculoplastic specialist between January 1, 2001, and August 8, 2009. The review yielded 402 pediatric patients diagnosed with nasolacrimal duct obstruction. Children were classified as having amblyopia risk factors on the basis of the American Association for Pediatric Ophthalmology and Strabismus referral criteria.

RESULTS

Of 402 patients with nasolacrimal duct obstruction, 100% received a cyclopegic refraction. Of these, 88 patients (22%) were found to have amblyogenic risk factors; 65 of these patients had amblyogenic refractive errors, 9 had strabismus, and 14 had a combination of the two. Of the 88 patients with amblyopia risk factors, 11% had a family history of strabismus compared with 9% of patients without amblyopia risk factors, which was not a statistically significant difference. There was no other significant pathology found on the dilated fundus examinations except for one child known to have persistent hyperplastic primary vitreous and a congenital cataract and one child with previously known CHARGE syndrome before the examination for nasolacrimal duct obstruction.

CONCLUSIONS

Children who present with nasolacromal duct obstructions seem to be more likely to have amblyopia risk factors and therefore should have a full comprehensive pediatric ophthalmological examination, including cycloplegic refraction.

Distribution of refractive error in healthy infants

PURPOSE

Few data exist regarding the upper limits of refractive error distributions in healthy infants; the data that do exist are biased because they were selected from the records of pediatric ophthalmology practices. We sought to obtain these data to validate examination failure criteria for vision screening.

METHODS

We reviewed records from all children age birth to 5 years seen at the Tennessee Lions Eye Center at Vanderbilt Children's Hospital with a billing diagnosis of nasolacrimal duct obstruction and no comorbid ocular diagnoses except for refractive error. This was to avoid referral bias for any condition that could have influenced refractive error. All patients received a complete eye examination and cycloplegic refraction. Cumulative probability distribution (CPD) plots and means for spherical and cylindrical refractive error and anisometropia were prepared.

RESULTS

One hundred thirty patients were studied; mean age was 15.5 +/- 9.9 months (range, 2 days to 66 months). The mean refractive error (spherical equivalent) was +1.4 D +/- 1.1 D. CPD plot analysis showed 95% of hyperopia to be < +3.25 D. Two children had myopia </=-1.00 D. The mean astigmatism was +0.2 D +/- 0.4 D, and 74% of patients had no astigmatism. Seven children had astigmatism > +1.00 D in one eye. CPD plot analysis showed 95% of astigmatism to be < +1.50 D and 95% of meridional anisometropia to be < 1.50 D. Six children had anisometropia >/=1.50 D, and 3 children had anisometropia > 3.00 D.

CONCLUSIONS

At least 95% of children have hyperopia < +3.25 D, astigmatism < +1.50 D, and anisometropia < 1.50 D. This information will prove useful in identifying the natural history and prevalence of amblyogenic factors identified during preschool vision screening.