Tomomichi Nakayama, Akihide Watanabe, Saul Rajak, Yukito Yamanaka, Chie Sotozono
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.
Heather de Beaufort, MD; Alina V. Dumitrescu, MD; Michael A. Kipp, MD; Rudolph S. Wagner, MD
Bothra, Nandini; Gupta, Nishi; Nowak, Rafal; Ali, Mohammad Javed
To assess the efficacy of commonly available coronary angioplasty balloon catheters as a low-cost alternative to the traditional dacryoplasty catheters in select patients of congenital nasolacrimal duct obstruction.
A prospective, interventional study was performed between July 2018 and December 2018 in children with congenital nasolacrimal duct obstruction, who underwent balloon dacryoplasty using the coronary angioplasty balloon catheters (2.75 × 10 mm, SPALNO, Cardiomac, Haryana, India). The inclusion criteria were children ≥4 years of age, and/or previously failed probing and/or previous failed intubation. Parameters documented were demographics, techniques, costs, complications, and postoperative outcomes.
Twenty-three eyes of 22 children underwent balloon dacryoplasty using coronary angioplasty balloon catheters. The mean age of the patients was 4.33 years (range 1.5–10 years). The procedure was performed in 8 patients (8 eyes, 35%) as the primary procedure. The remaining 14 patients (15 eyes, 65%) had a history of probing, of which 4 eyes had it twice earlier. All eyes underwent balloon dacryoplasty as per standard protocols. The insertion profile and trackability of the coronary catheters were good. At a mean follow up of 6.17 months (range 1.5–9 months), anatomical and functional success was obtained in 87% cases (n = 20/23). No lacrimal passage trauma or injuries were noted during the procedure. The cost of coronary balloon catheter was approximately $60.
The present pilot study has shown that outcomes of balloon dacryoplasty in patients with congenital nasolacrimal duct obstruction with coronary balloon catheters is comparable to that of traditional balloons and offers significant economic advantage for developing nations.
Nishi Gupta, Poonam Singla, Sunil Kumar, Suma Ganesh, Nidhi Dhawan, Parul Sobti & Shreya Aggarwal
Purpose: To highlight the importance of dacryoendoscopy in recognizing the factors responsible for failure with successful recanalization obviating the need for dacryocystorhinostomy in a few selective cases.
Method: A retrospective study of 13 children undergoing dacryoendoscopy for refractory congenital nasolacrimal duct obstruction (CNLDO) was carried out during a period of 3 years from 2016 to 2018. Children with single or multiple failed probings were included in the study.
Results: Out of the total 13 cases included in the study there 9 males and 4 females. The age ranged from 9 months to 36 months with the involvement of the right side in 7 cases and the left side in 6 cases. Four cases had dysgenesis of bony nasolacrimal duct (NLD), 4 cases had dacryolith, 3 cases had an intact membrane at the lower end of NLD and 2 cases had fibrosis of the lower end of NLD and the surrounding area in the inferior meatus (IM) following multiple interventions, (Table 1). Dacryoendoscopic recanalization was done in 7 cases while the endoscopic dacryocystorhinostomy (DCR) was done in 6 cases. A successful outcome was achieved in all the cases and at the end of 6 months, all the children remained asymptomatic.
Conclusions: Dacryoendoscopy (DEN) facilitates direct examination of the nasolacrimal system and thus has an added advantage over nasal endoscopy assisted probing in the refractory cases of CNLDO.
Arpita Nayak, Tarjani Vivek Dave, Mohammad Javed Ali & Arundhati Tiwari
Purpose: To study the prevalence and types of lacrimal drainage system (LDS) anomalies inchildren with congenital microphthalmia anophthalmia coloboma (MAC) complex.Methods: This is a prospective, consecutive, non-comparative, case series of LDS anomalies in 31 children presenting with MAC complex. Previously untreated children with MAC complex, enrolled for socket surface and volume expansion during the study period from January 2017 to April 2018 were included.Results: Thirty-one patients with MAC complex were evaluated for LDS anomalies. Incidence of LDS anomalies in children presenting with MAC complex was 68% (42 of 62 lacrimal systems evaluated). Mean age of the patients at the time of examination under anaesthesia was 27 ± 25 (median 15 months, range 3–108 months). Proximal bicanalicular block (BCB) was the commonest LDS anomaly, noted in 15 (48%) cases. In patients with unilateral ocular disease (n = 20), LDS was affected in 14 (70%) patients and in 9 (45%) patients ipsilateral side LDS was affected. In patients with bilateral ocular disease (n = 11), LDS was affected in 7 (64%) patients. Three patients with unilateral anophthalmos (25%) had an ipsilateral upper canalicular block and contralateral nasolacrimal duct obstruction, of which one patient had a single canalicular wall hypoplasia along with CNLDO. No patient had punctal anomalies.Conclusions: LDS anomalies are seen in nearly two-thirds (68%) of children with MAC complex. The lacrimal drainage system anomaly is not limited to the side of the MAC complex. Commonest LDS anomaly is proximal bicanalicular blocks while punctal anomalies are unusual.
A 2-year-old child presented with watering and discharge since birth in right eye (RE) with regurgitation of pus through the canaliculion on pressure over lacrimal sac. The child was posted for RE endoscopic guided probing and syringing. Intraoperatively, there was a thin membrane over valve of Hasner which was pierced with probe making the passage patent [Figure 1]a and [Figure 1]b. As a protocol, her left eye was checked for syringing, to look for patency, endoscope was introduced in left side and a foreign body was found impacted in the nostril [Figure 1]c. The foreign body was removed under endoscopic guidance [Figure 1]d. Parents were unaware about the impacted foreign body. A similar case has been reported where a vegetative foreign body caused obstruction at opening of nasolacrimal duct leading to symptoms of congenital nasolacrimal duct obstruction. In the presented case, the foreign body was impacted in the other nostril and hence shows importance of bilateral examination.
Aldo Vagge, MD, PhD; Claudia Tulumello, MD; Marco Pellegrini, MD; Marco Di Maita, MD; Michele Iester, MD, PhD; Carlo Enrico Traverso, MD
To investigate the presence of amblyopia risk factors in newborns with congenital nasolacrimal duct obstruction (CNLDO) and age-matched healthy control subjects.
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.
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).
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.
Margaret Reynolds, MD; Gregg Lueder, MD
To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction.
The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting.
Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement.
This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing.
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.
Jaee Milind Naik, Milind N Naik & Mohammad Javed Ali
Rubinstein–Taybi syndrome is a rare multisystem disorder characterized by broad thumbs and first toes, short stature, microcephaly, delayed milestones, beak nose, and hypertelorism. Lacrimal drainage anomalies are not uncommon in this syndrome. We present a patient with Rubinstein–Taybi syndrome with bilateral congenital nasolacrimal duct obstruction and left-sided grossly dilated nasolacrimal duct.