Kashkouli, Mohsen B.; Karimi, Nasser; Khademi, Behzad
Purpose of review After failed conservative management, most clinicians treat congenital nasolacrimal duct obstruction (CNLDO) in a conventional stepwise fashion: starting with probing, then repeat probing, next silicone intubation and/or balloon dilatation, and finally dacryocystorhinostomy. This approach is based on the patient’s age and previously failed procedures and recruits ‘one procedure for all’ CNLDO. A newly introduced approach is based on the type of obstruction and recruits ‘all procedures for one’ CNLDO. The aim of this review is to examine the best available evidence regarding CNLDO management.
Recent findings Recent articles support the concept that through intraoperative evaluation of obstruction in CNLDO, clinicians may predict probing failure and instantaneously employ more appropriate treatment modalities. This review addresses whether an age-based approach should be changed into a one-stage obstruction-based approach.
Summary An age-based approach treats CNLDO as a homogeneous disease and thus treats all patients with one predetermined procedure. A one-stage obstruction-based approach, however, considers CNLDO to be a heterogeneous disease, and therefore allows recruitment of all procedures simultaneously and selects the best intraoperatively. It may allow replacement of the conventional stepwise approach to CNLDO treatment provided that randomized trials verify its efficacy, safety, and cost-effectiveness.
Min Joung Lee, Jinku Park, Namju Kim, Ho-Kyung Choung, Sang In Khwarg
To investigate the clinical outcomes of initial conservative management in infants with congenital dacryocystocele.
Retrospective case series.
A total of 30 congenital dacryocystoceles of 28 Korean infants treated between January 2006 and December 2015.
All patients were managed conservatively with lacrimal sac massage. Clinical courses and outcomes of the patients were retrospectively reviewed, and rates of resolution of dacryocystoceles and development of dacryocystitis were analyzed.
In 27 cases of dacryocystoceles without infection, spontaneous resolution was achieved without any complication in 20 of 27 (74.1%) cases after conservative treatment. The mean duration of treatment was 27.5 days. Lacrimal probing was needed in 5 (18.5%) dacryocystoceles that persisted despite lacrimal sac massage for more than 1 month. Infectious dacryocystitis developed in 2 of 27 (7.4%) cases. Three dacryocystoceles were infected at presentation. Overall, 5 dacryocystoceles were complicated with infection and those cases received prompt systemic antibiotics treatment. External incision and drainage of the lacrimal sac was needed in 3 dacryocystoceles, and all cases were finally resolved without any additional procedures.
In this case series, most of the uninfected dacryocystoceles could be successfully managed with conservative treatment alone. In cases with infection, systemic antibiotics were essential and external drainage was sometimes required, but these cases could be conservatively managed after the remission of infection.
Singh, Swati; Ali, Mohammad Javed
Purpose: To provide a systematic review of the literature on congenital dacryocystoceles (CDCs) and summarize their presentations, investigations, management, and outcomes.
Methods: The authors performed a PubMed search of all articles published in English on CDCs. Data captured include demographics, clinical presentations, investigations, management modalities, complications, and outcomes. Fourteen major series (10 or more than 10 cases) and 89 isolated case reports/series on CDCs with a collective patient pool of 1,063 were studied in detail. Specific emphasis was laid on addressing the controversial issues including initial conservative versus surgical management and the role of endoscopic evaluation.
Results: Numerous terminologies have been used to describe CDC. Congenital dacryocystoceles are rare variants of congenital nasolacrimal duct obstructions and comprise of 0.1% to 0.3% of all such cases. There is a female predilection (64.2%, 683/1,063) and the mean age at presentation is at 7 days of birth. Initial conservative treatment can be a viable option in the absence of an acute dacryocystitis or a respiratory distress. Endoscopy-assisted probing appears to have better outcomes as compared with the in-office probing. Congenital dacryocystoceles with acute dacryocystitis are preferably managed with intravenous antibiotics and an early probing under endoscopy guidance to avoid missing intranasal cysts. Marsupialization is the preferred technique in the management of intranasal cysts. Silicone intubation was rarely used and has no definitive indications. Dacryocystorhinostomy is very rarely needed in the management of CDC.
Conclusions: Congenital dacryocystocele is a commonly accepted term and its use should be advocated to enhance uniformity in reporting. Endoscopic evaluation of CDC is useful in the diagnosis and treatment of associated intranasal cysts and enhances the rates of successful outcomes.
Manpreet Singh, Manjula Sharma, Manpreet Kaur, Aditi Mehta Grewal, Deepti Yadav, Sabia Handa, Sonam Yangzes, Zoramthara Zadeng, Pankaj Gupta
Purpose: To study the clinical presentation, nasal endoscopic features, and outcomes of nasal endoscopy guided (NEG) bicanalicular intubation (BCI) in children with complex persistent congenital nasolacrimal duct obstruction (pCNLDO). Methods: A prospective, interventional study including eligible children (age ≤ 12 years) having complex pCNLDO. The demographics, number of previous probings, nasal endoscopy findings, and outcomes; were noted in all children who underwent NEG-BCI with Crawford’s stents. Matting of eyelashes (MoE, upper, and lower eyelid), tear-film height (TFH), and fluorescein dye disappearance test (FDDT) was assessed pre and postoperatively. The minimum stent in-situ period was 12 weeks, and the minimum follow-up was 6 months (after stent removal). Results: Total 32 children (36 eyes) including 18 females (56.25%) were studied. At a mean age of 4.9 years, all children had epiphora and discharge with MoE (both upper and lower), raised TFH and positive FDDT. Previously, all children underwent conventional probing (s)- once in 12 (33.3%), twice in 18 (50%) and thrice in 6 (16.7%) eyes. The general ophthalmologists performed the majority (n = 21, 58.33%) of those. The BCI was performed under GA in all eyes, and at a mean follow-up of 8.5 months, the “complete” success was noted in 29 eyes (80.5%), ‘partial’ success in 4 (11.1%) and failure in 3 (8.3%). The stent prolapse was seen in three. Conclusion: NEG-BCI may provide a satisfactory resolution to complex pCNLDO after single or multiple failed probings. NEG provides confident and efficient management of coexistent intranasal complexities related to the inferior turbinate and meatus.
Rajabi, Mohammad Taher; Inanloo, Bahman; Salabati, Mirataollah; Rafizadeh, Mohsen; Tabatabaie, Seyed Ziaeddin; Bayat, Reza; Mahmoudzadeh, Raziyeh
Purpose: To evaluate the effect of inferior turbinate fracture in the treatment of congenital nasolacrimal obstruction combined with first attempt probing in children younger than 36 months.
Methods: This prospective case–control study was conducted on 230 eyes from 176 children aged 12 to 36 months with congenital nasolacrimal duct obstruction. All patients underwent simple probing under general anesthesia. Inferior turbinate fracture was performed in case group combined with first probing. Patients were followed up 1, 3, and 6 months after surgery.
Results: Total success rate was 91.2% for patients with turbinate fracture and 86.4% for patients without turbinate fracture. The difference between success rates was not statistically significant (p = 0.269). The authors did not find significant difference between cases and controls in age subgroups. Success rate in combined case and control groups in patients younger than 24 months (success rate: 91.7%) was significantly higher than those older than 24 months (success rate: 71.9%; p = 0.001). In univariate logistic regression analysis, age ≥24 months showed a negative association with the success rate (odds ratio = 0.232; 95% confidence interval: 0.91–0.59; p = 0.002). Other factors like sex, bilaterality of nasolacrimal duct obstruction, method of probing were not significantly associated with response to treatment.
Conclusions: Inferior turbinate fracture does not improve the outcomes of simple probing and is not recommended during the first attempt in treatment of congenital nasolacrimal duct obstruction. Late probing (after 24 months of age) may have a higher failure rate, and increased age is the important factor that predicts failure in probing simple congenital nasolacrimal duct obstruction.
Vaishali Lalit Une, MS; Sushma Subhash Kulkarni, MS, DNB; Varsha Sharad Nandedkar, MS
To determine the effect of probing for congenital nasolacrimal duct obstruction in children older than 2 years.
A prospective interventional case series included 110 eyes of 94 patients with congenital nasolacrimal duct obstruction (CNLDO) aged 2 years or older, with no previous intervention. The diagnosis was based on clinical findings (epiphora, discharge, regurgitation test, and fluorescein dye disappearance test). The children were divided into two groups: 2 to 5 years and 6 to 8 years. Probing of the nasolacrimal duct under general anesthesia was done. Success was predefined as resolution of symptoms and signs that persisted 3 months postoperatively. Another probing was done at 4 to 6 weeks when necessary before considering the final outcome as a failure. The chi-square test was used to analyze the result.
Patients’ ages ranged from 2 to 8 years (average age: 55 months). Twenty-six (28%) patients needed a second probing. The overall success rate was 80%: 85% in the 2 to 5 years group and 73% in the 6 to 8 years group. The success rate was significantly lower in patients with complex obstruction (33.3%). The outcome of probing was not affected by the age of the patients (P = .2305).
Probing is a viable primary surgical option in CNLDO in older children and hence should not be withheld in children who are referred late.
Nozomi Matsumura, Toru Suzuki, Satoshi Goto, Takeshi Fujita, Shin Yamane, Maiko Maruyama-Inoue & Kazuaki Kadonosono
To examine the causes of congenital nasolacrimal duct obstruction (CNLDO) using dacryoendoscopy, and to evaluate the surgical outcomes of primary transcanalicular endoscopic dacryoplasty.
The subjects of this study were a total of 56 eyes of 46 Japanese children aged one to five years old (mean, 29.1 ± 14.0 months old) with clinically diagnosed CNLDO. The blockage was visualized and probed using a dacryoendoscope (MD10 with a 20 G probe, Fiber Tech Co., Ltd., Japan) under general anesthesia. We used a self-retaining bicanalicular lacrimal stent (Lacrifast®, Kaneka Co., Ltd., Japan) for nasolacrimal duct intubation.
In each case the obstruction was found to be caused by a single focal blockage at the distal end of the duct. A nasolacrimal dacryolith was observed in 5 eyes (9%) and successfully removed using the dacryoendoscope. The success rate of probing by subsequent nasolacrimal duct intubation was 100%. No complications were observed.
We obtained a 100% success rate with primary transcanalicular endoscopic dacryoplasty for the treatment of CNLDO. Direct visualization inside the lacrimal passage allowed for precise probing, even in infants, leading to successful treatment of CNLDO without any complications.
Fayet, Bruno; Racy, Emmanuel; Bordonné, Corinne; Katowitz, William R.; Katowitz, James; Brémond-Gignac, Dominique
The authors report the case of a 7-year old child with failed probing with stent intubation, who was found to have an unusual curvature of the nasolacrimal duct on the symptomatic side. CT imaging revealed a permanent maxillary canine tooth adjacent to the duct. It appeared that the relationship of the tooth bud to the curved nasolacrimal duct was most likely responsible for the symptoms of epiphora on this anomalous side.
Alaa S. Bou Ghannam, MD; Carl-Joe Mhanna, MD; Marwan Atallah, MD; Ramzi M. Alameddine, MD
An 18-day-old female neonate presented to clinic with bilateral enlarging infraorbital bluish masses and mucopurulent discharge from both eyes. She was born full term with no complications during pregnancy and delivery. The parents noticed the swelling shortly after birth, with progressive enlargement mostly on the left side associated with labored breathing. Clinical examination revealed bilateral indurated cystic lesions with a bluish hue below the medial canthi, more prominent on the left side (Figure 1). There was overlying skin, soft tissue swelling, and redness. On digital pressure, copious mucopurulent material was expressed onto the ocular surface. The ophthalmologic examination was otherwise unremarkable. The neonate was noted to have audible grunting and respiratory distress. Computed tomography scan showed bilateral large cystic lesions in the lacrimal fossa area associated with intranasal cysts. At 2 months of age, she underwent bilateral probing and irrigations and has since done well.