Original Article
271
Association between Congenital Nasolacrimal Duct Obstruction and Delivery by Cesarean Section Carola Melcher, MD3
1 University Eye Hospital Düsseldorf, Düsseldorf, Germany 2 University Eye Hospital Münster, Münster, Germany 3 University Womeń s Hospital Düsseldorf, Düsseldorf, Germany
Nadja Beheiri, MD2
Nicole Eter, MD2
Address for correspondence Kristina Spaniol, MD, University Eye Hospital Düsseldorf, Moorenstraße 5, Düsseldorf 40545, Germany (e-mail: [email protected]).
Am J Perinatol 2015;32:271–276.
Abstract
Keywords
► neonatal epiphora ► lacrimal drainage system ► amblyopia ► birth
Objective Congenital nasolacrimal duct obstruction (CNDO) is the most common cause of neonatal epiphora. Persistence can lead to chronic dacryocystitis and amblyopia. This study analyzed the association between the incidence of CNDO and delivery by cesarean section. Study Design This was a retrospective cohort study of 386 children with CNDO (born between 2000 and 2008). The incidence of the delivery mode in patients with CNDO was compared with data from a corresponding population derived from annual birth statistics. Results There was no statistically significant association between the overall cesarean section rate and the incidence of CNDO, but primary cesarean section was significantly more frequent among patients with CNDO (73.15%, p < 0.05). The difference was significant for both genders for the period from 2000 to 2008 (p < 0.05%). The relative risk for CNDO was 1.7-fold increased in children delivered by primary cesarean section. Conclusion Primary cesarean section may be a risk factor for CNDO.
Congenital nasolacrimal duct obstruction (CNDO) is one of the most common reasons for neonatal epiphora.1 The patients present with overflow of tears and crusting of the lashes whereas the conjunctiva remains white as long as no bacterial superinfection occurs.2 The first-line therapy for CNDO is massage of the lacrimal sac with antibacterial eye drops for the therapy of bacterial superinfections. In case of failure, probing and irrigation of the nasolacrimal drainage system are applied.3 Persisting CNDO is associated with the risk of chronic dacryocystitis, which may require invasive surgical interventions such as silicone tube intubation or dacryocystorhinostomy.4,5 Moreover, there appears to be a higher risk of amblyopia in children with a history of CDNO.6,7 In cases of CNDO, a thin mucous membrane, known as Hasner
membrane (HM), persists after birth and occludes the lacrimal passage from the lacrimal duct into the nasal cavity.1 In more than 90% of cases, HM opens spontaneously within the first weeks of life before the onset of regular tear flow. However, in approximately 2 to 6% of cases CNDO persists.4,8–10 Little is known about the risk factors for this condition. Several studies have documented the influence of mode of delivery on subsequent child development.11,12 Primary/ prelabor CS rates, which have increased to 25% in the United Kingdom and 46% in Brazil, are a matter of continuous debate.13–15 On the one hand, CS provides benefits for both, the mother and the child as it lowers the risk of pelvic floor damage, reduces the rates of urinary incontinence and neo-
received February 24, 2014 accepted after revision May 15, 2014 published online June 27, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1383847. ISSN 0735-1631.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Kristina Spaniol, MD1 Tobias Stupp, MD2 Verena Prokosch, MD2
Congenital Nasolacrimal Duct Obstruction and Mode of Delivery natal injuries, and obviates the need for emergency CS.16 On the other hand, the lack of labor and passage through the birth canal might be related to higher rates of obesity, type 1 diabetes, and asthma in the offspring.11,12 During labor and vaginal delivery the neonatal soft tissue, cartilage, and bony structures are altered.17 Further, labor induces the activity of collagenolytic enzymes in the amniotic fluid.18 These mechanical and enzymatic alterations might also influence the lacrimal drainage system. The aim of this study was to determine the possible association between the incidence of CNDO and delivery by primary and secondary CS compared with vaginal delivery.
Patients and Methods This study was performed in accordance with the tenets of the Declaration of Helsinki. A total of 613 patients with typical symptoms of CNDO (epiphora, mattering of the lashes) were referred to our tertiary eye-care center in the period 2000 to 2008. All children underwent probing and irrigation of the nasolacrimal drainage system under short anesthesia. The probing showed a soft stop at the membranous HM. The irrigation showed a reflux through the contralateral lacrimal point proofing the postsaccal location of the stenosis and the missing patency of the lacrimal drainage system.10 Further, the patients in this study were subject to the following inclusion criteria: • Year of birth between 2000 and 2008 • Age at first presentation with CNDO of < 1 year • No previous conservative or surgical treatment for lacrimal duct stenosis • Mode of delivery definitively confirmed in medical records Patients who did not comply with these criteria and patients with congenital malformations as aplasia or atresia of the lacrimal puncta, lacrimal canaliculi or nasolacrimal duct, diverticula of the lacrimal sac or nasolacrimal duct, colobomas of the lacrimal drainage system or facial clefts were excluded from the study. After exclusion, a final total of 386 patients were included in this retrospective cohort study. The incidence of the mode of delivery in the corresponding cohort representing the normal population was extracted from the annual birth statistics from the Medical Council of North Rhine-Westphalia (NRW, a federal state of Germany) for the years 2000 to 2008. CS was classified as primary or secondary CS. Primary CS was defined as an elective CS before the onset of labor and rupture of the membranes. Secondary CS was defined as a CS
Spaniol et al.
after the onset of the active phase of labor (after cervical dilation or rupture of the membranes). Statistical analyses were conducted using PASW Statistics 18 (IBM, Armonk, NY). The level of statistical significance was set at p 0.05. Confidence intervals (CIs) were used to describe the significance of differences. The odds ratio was calculated to describe the relative risk.
Results Epidemiological Data The incidences of primary and secondary CS and vaginal birth in CNDO patients were compared with the ratio of corresponding modes of delivery within the normal population of the study region (NRW) to determine whether either of these modes of delivery was associated with an increased risk of CNDO. The frequencies of total (primary þ secondary) CS in the cohort and in the NRW population and the corresponding CIs from 2000 to 2008 are shown in ►Table 1. The overlapping CIs indicated an equal rate of CSs in the cohort compared with the NRW population. Further, the frequency of CS was distributed equally within both sexes (►Table 2).
Comparison of Primary CS versus Secondary CS versus Vaginal Birth-Frequencies from 2000 to 2008 ►Fig. 1 gives an overview over the mean frequencies of the different modes of delivery from 2000 to 2008. In the cohort, primary CS was significantly more frequent (20.46% of all birth) compared with the population in NRW (12.75%). Secondary CS was less frequent in the cohort (8.55%) compared with the NRW population (15.46%) while there was no significant difference in the frequency of vaginal delivery (70.98 vs. 71.80%).
Comparison of Primary CS to Nonprimary CS Birth from 2000 to 2008 Comparing the frequency of primary CS to all nonprimary CS deliveries (children born by secondary CS or vaginal birth), there was a significant higher rate of primary CS in the cohort compared with the NRW population indicated by the nonoverlapping CIs (CI cohort [0.64; 0.81], CI NRW [0.51; 0.52]. Calculation of the odds ratio revealed a 1.7 higher risk of CNDO when delivered by primary CS compared with a nonprimary CS delivery.
Comparison of Primary CS Frequencies According to Year (2000–2008) The frequencies of primary and secondary CSs on all CSs were analyzed for the individual years between 2000 and
Table 1 Distribution of vaginal deliveries and CSs in the investigated cohort and in NRW in the years 2000 to 2008
Total n (%)
All cases of the cohort
Number of CS in the cohort
All deliveries in NRW
Number of CS in NRW
386 (100)
112 (29.02)
673,040 (100)
189,910 (28.22)
CI
0.245; 0.338
Abbreviations: CI, confidence interval; CS, cesarean section; NRW, North Rhine-Westphalia. American Journal of Perinatology
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0.281; 0.2836
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Table 2 Gender distribution regarding all deliveries and CSs in the investigated cohort and in NRW in the years 2000 to 2008 Male n (%) All cases of the cohort
CI
201 (52.07)
Number of CS in the cohort
57 (50.89)
All deliveries in NRW
344,359 (51.16)
Number of CS in NRW
100,731 (53.04)
Female n (%)
CI
185 (47.93) 0.222; 0.351
55 (49.11)
0.291; 0.294
328,681 (48.84) 0.232; 0.369
89,179 (46.96)
0.270; 0.273
2008. ►Fig. 2 provides an overview of the primary CS frequencies in the cohort and the NRW population. There was a slight increase in the frequency of primary CSs relative to all CSs in the NRW population, with a minimum of 48.01% and a maximum of 54.08%. Data from the present cohort revealed fluctuating frequencies of primary CS, with a minimum of 58.33% and a maximum of 90%. The frequency of primary CS was higher among the CNDO patients than in the corresponding NRW population for all of the investigated years. This difference was significant (p < 0.05) for all years pooled and for the individual years 2003 and 2005.
Comparison of Primary CS Frequency According to Gender The gender-related frequency of primary CS was analyzed. The mean frequency of primary CS was significantly higher among male (75%) and female (71.15%) patients with CNDO than among children of the corresponding gender from the NRW population (53.16% for males and 46.84% for females; ►Fig. 3).
Discussion Dysfunction of the lacrimal drainage system—as CNDO—leads to excessive tearing (epiphora). Persisting CNDO, which occurs in 2 to 6% of all cases carries the risk of chronic dacryocystitis and amblyopia. CNDO is a common ophthal-
mological disease of the neonate that is encountered by obstetrics, neonatologists, pediatrics, and ophthalmologists but risk factors for this condition are barely investigated.19 The present study found no association between the incidence of CNDO and delivery by CS in general. Further, the amount of children delivered vaginally did not differ between the CNDO-cohort and the population of NRW. However, the relative risk of CNDO was 1.7-fold increased in children delivered by primary CS compared with children delivered vaginally or by secondary CS. Thus, the absence of certain physiological birth mechanisms in case of primary CS might increase the risk of persisting CNDO. Although, primary CS significantly changes the birth conditions of an infant, there is no known link between the pathomechanism of CNDO and primary CS.12
Relevance of Pressure The lack of labor and pressure is the main characteristic of primary CS, while in secondary CS the neonate is still exposed to labor to some degree.20 It is well known that pressure plays an important role in the course of CNDO. Manual massage of the lacrimal sac, which is the first-line therapy in cases of CNDO, leads to an increase in hydrostatic pressure therein.21 This results in fluid being transported downward and toward HM, causing it to open.21,22 Nelson et al reported a success rate of 94.7% after 8 months of such treatment, with the success rate increasing with the treatment duration.23 If
Fig. 1 Mean frequency of primary CS versus secondary CS versus vaginal delivery (y-axis) from 2000 to 2008 comparing data from the cohort and data from NRW (y-axis), p < 0.05. CS, cesarean section; NRW, North Rhine-Westphalia. American Journal of Perinatology
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No. 3/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Abbreviations: CI, confidence interval; CS, cesarean section; NRW, North Rhine-Westphalia.
Congenital Nasolacrimal Duct Obstruction and Mode of Delivery
Fig. 2 Percentage of primary CS on all CS (y-axis) in the cohort and in NRW in the individual years 2000 to 2008 (x-axis). CS, cesarean section; NRW, North Rhine-Westphalia.
Spaniol et al.
occurrence of alterations in the neonatal soft-tissue structures during labor. They found a significantly stronger severity of paralysis in children with meningomyelocele who were delivered after the induction of labor.27 Deformations of bony and cartilage structures might also play a role. Various studies have confirmed the occurrence of labor-induced deformations of the neonatal facial structures. Gray investigated nasal septal deformities and argued that pressures during pregnancy and parturition were responsible for deformation of the anterior septal cartilage and maxilla.28 Accordingly, Jeppesen and Windfeld found a higher incidence of nasal septal deformities in cases of second-stage labor lasting longer than 15 minutes.29 The lacrimal sac and distal lacrimal duct adhere to the surrounding periosteum of the lacrimal bone, maxilla, and concha.30 Thus, pressure-induced dislocation of the bony structures will be transmitted to the soft tissue of the lacrimal drainage system, as a result causing deformation and distension of HM. As distension causes thinning of the tissues and loss of tensile strength, such alterations may induce HM opening. 31 HM might be especially sensitive to early intrauterine deformation and distension during labor. It is possible that early labor-induced manipulations of HM are a prerequisite for easier opening of HM after birth. This hypothesis is supported by CNDO appearing to be more sensitive to therapeutic treatment in younger children.4,32
Role of Enzymes
Fig. 3 Mean percentage of male and female children delivered by primary CS from 2000 to 2008 (y-axis) comparing the cohort and data from NRW, p < 0.05. CS, cesarean section; NRW, North RhineWestphalia.
manual massage fails, high-pressure irrigation was found to open HM with a success rate of 100% after two attempts.24 Thus, the placement of hydrostatic pressure on HM—by either manual massage or irrigation—was found to be an effective method of forming a patent lacrimal drainage system in CNDO. Labor creates intrauterine pressure, rising from 50 to 60 mm Hg during the first labor pains up to 200 mm Hg during the pushing contractions.25 As the amniotic fluid cannot be compressed, and pressure will be transmitted to the neonatal body, causing temporary deformations. The face and head of the fetus are particularly exposed to elevations in the intrauterine pressure. The head is the largest part of a term neonatal body, and some type of deformational molding is present in around 30% of newborns.26 Thus, intrauterine pressure on the lacrimal sac area might induce movement of fluid contents toward HM, and consequently opening thereof. Missing or reduced exposure to such pressure-induced alterations—as in primary CS—might negatively affect this process and increase the risk of CNDO. Luthy et al confirmed the American Journal of Perinatology
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Collagenolytic enzymes are induced during labor, which are thought to be involved in rupture of the chorioamniotic membranes during delivery.33 Vadillo-Ortega et al showed that increased activity of the collagenolytic enzyme matrix metalloproteinase 9 in the amniotic fluid is closely linked to the induction of labor.18 Therefore, the chorioamniotic membranes of neonates delivered by primary CS exhibit greater extensibility and tensile strength compared with those of neonates delivered by vaginal deliveries.33 As the amniotic fluid is swallowed by the neonate and flows into the nasal cavity, it will also contact HM. It may be that the labor-induced increase in collagenolytic activity in the amniotic fluid softens the mucosal tissue of HM and enables easier opening thereof. Thus, primary CS, with the consequent lack of labor and reduced activity of collagenolytic enzymes, might be an additional factor underlying the persistence of HM blockage in primary CS children. In summary this study found a 1.7-fold increased risk for CNDO after a delivery by primary CS compared with a vaginal birth or delivery by secondary CS. Possible pathomechanisms include a lack of the labor-induced mechanical and enzymatic alterations that may influence the tensile strength of HM and play a role in the development of a patent lacrimal drainage system. Children delivered by primary CS presenting with symptoms of CNDO (epiphora, crusting of the lashes) should be referred to an ophthalmologist as CNDO-persistence carries the risk of dacryocystitis and amblyopia. Prospective studies need to verify the findings of this study.
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17 Kent SE, Reid AP, Nairn ER, Brain DJ. Neonatal septal deviations. J R
Soc Med 1988;81(3):132–135 18 Vadillo-Ortega F, González-Avila G, Villanueva-Diaz C, Bañales JL,
References 1 MacEwen CJ, Young JD. Epiphora during the first year of life. Eye 2 3
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(Lond) 1991;5(Pt 5):596–600 Schnall BM. Pediatric nasolacrimal duct obstruction. Curr Opin Ophthalmol 2013;24(5):421–424 Paul TO, Shepherd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 1994;31(6):362–367 Takahashi Y, Kakizaki H, Chan WO, Selva D. Management of congenital nasolacrimal duct obstruction. Acta Ophthalmol (Copenh) 2010;88(5):506–513 Prokosch V, Busse H, Thanos S, Eter N, Stupp T. Impact of age on success rate of lacrimal duct irrigation with silicone tube intubation in connatal lacrimal duct stenosis [in German]. Klin Monatsbl Augenheilkd 2013;230(10):1020–1024 Matta NS, Silbert DI. High prevalence of amblyopia risk factors in preverbal children with nasolacrimal duct obstruction. J AAPOS 2011;15(4):350–352 Piotrowski JT, Diehl NN, Mohney BG. Neonatal dacryostenosis as a risk factor for anisometropia. Arch Ophthalmol 2010;128(9):1166–1169 Young JD, MacEwen CJ. Managing congenital lacrimal obstruction in general practice. BMJ 1997;315(7103):293–296 Usha K, Smitha S, Shah N, Lalitha P, Kelkar R. Spectrum and the susceptibilities of microbial isolates in cases of congenital nasolacrimal duct obstruction. J AAPOS 2006;10(5):469–472 Guerry D III, Kendig ELJ Jr. Congenital impatency of the nasolacrimal duct. Arch Ophthal 1948;39(2):193–204 Cho CE, Norman M. Cesarean section and development of the immune system in the offspring. Am J Obstet Gynecol 2013; 208(4):249–254 Hyde MJ, Modi N. The long-term effects of birth by caesarean section: the case for a randomised controlled trial. Early Hum Dev 2012;88(12):943–949 Moore B. Appropriate technology for birth. Lancet 1985;2(8452): 436–437 Bulger T, Howden-Chapman P, Stone P. A cut above: the rising Caesarean section rate in New Zealand. N Z Med J 1998;111(1059): 30–33 Althabe F, Sosa C, Belizán JM, Gibbons L, Jacquerioz F, Bergel E. Cesarean section rates and maternal and neonatal mortality in low-, medium-, and high-income countries: an ecological study. Birth 2006;33(4):270–277 McFarland LV, Raskin M, Daling JR, Benedetti TJ. Erb/Duchenne’s palsy: a consequence of fetal macrosomia and method of delivery. Obstet Gynecol 1986;68(6):784–788
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Selman-Lama M, Alvarado Durán A. Human amniotic fluid modulation of collagenase production in cultured fibroblasts. A model of fetal membrane rupture. Am J Obstet Gynecol 1991;164(2): 664–668 Kapadia MK, Freitag SK, Woog JJ. Evaluation and management of congenital nasolacrimal duct obstruction. Otolaryngol Clin North Am 2006;39(5):959–977, vii Kiechle M. Gynäkologie und Geburtshilfe. 1st ed. München: Elsevier, Urban und Fischer; 2007 Kakizaki H, Takahashi Y, Kinoshita S, Shiraki K, Iwaki M. The rate of symptomatic improvement of congenital nasolacrimal duct obstruction in Japanese infants treated with conservative management during the 1st year of age. Clin Ophthalmol 2008;2(2): 291–294 Crigler LW. The treatment of congenital dacryocystitis. J Am Med Assoc 1923;81:23–24 Nelson LB, Calhoun JH, Menduke H. Medical management of congenital nasolacrimal duct obstruction. Pediatrics 1985;76(2): 172–175 Alagöz G, Serin D, Celebi S, Kükner S, Elçioğlu M, Güngel H. Treatment of congenital nasolacrimal duct obstruction with high-pressure irrigation under topical anesthesia. Ophthal Plast Reconstr Surg 2005;21(6):423–426 Wolfs GM, van Leeuwen M. Electromyographic observations on the human uterus during labour. Acta Obstet Gynecol Scand Suppl 1979;90:1–61 Bronfin DR. Misshapen heads in babies: position or pathology? Ochsner J 2001;3(4):191–199 Luthy DA, Wardinsky T, Shurtleff DB, et al. Cesarean section before the onset of labor and subsequent motor function in infants with meningomyelocele diagnosed antenatally. N Engl J Med 1991; 324(10):662–666 Gray LP. Deviated nasal septum. Incidence and etiology. Ann Otol Rhinol Laryngol Suppl 1978;87(3 Pt 3, Suppl 50):3–20 Jeppesen F, Windfeld I. Dislocation of the nasal septal cartilage in the newborn. Aetiology, spontaneous course and treatment. Acta Obstet Gynecol Scand 1972;51(1):5–15 Schiebler TH. Anatomie. 9th ed. Heidelberg: Springer DE; 2005 Cannon TW, Wojcik EM, Ferguson CL, Saraga S, Thomas C, Damaser MS. Effects of vaginal distension on urethral anatomy and function. BJU Int 2002;90(4):403–407 Stolovitch C, Michaeli A. Hydrostatic pressure as an office procedure for congenital nasolacrimal duct obstruction. J AAPOS 2006; 10(3):269–272 Helmig R, Oxlund H, Petersen LK, Uldbjerg N. Different biomechanical properties of human fetal membranes obtained before and after delivery. Eur J Obstet Gynecol Reprod Biol 1993;48(3): 183–189
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Acknowledgment The authors would like to thank the faculty of Münster for supporting their work.
Spaniol et al.
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
271
Association between Congenital Nasolacrimal Duct Obstruction and Delivery by Cesarean Section Carola Melcher, MD3
1 University Eye Hospital Düsseldorf, Düsseldorf, Germany 2 University Eye Hospital Münster, Münster, Germany 3 University Womeń s Hospital Düsseldorf, Düsseldorf, Germany
Nadja Beheiri, MD2
Nicole Eter, MD2
Address for correspondence Kristina Spaniol, MD, University Eye Hospital Düsseldorf, Moorenstraße 5, Düsseldorf 40545, Germany (e-mail: [email protected]).
Am J Perinatol 2015;32:271–276.
Abstract
Keywords
► neonatal epiphora ► lacrimal drainage system ► amblyopia ► birth
Objective Congenital nasolacrimal duct obstruction (CNDO) is the most common cause of neonatal epiphora. Persistence can lead to chronic dacryocystitis and amblyopia. This study analyzed the association between the incidence of CNDO and delivery by cesarean section. Study Design This was a retrospective cohort study of 386 children with CNDO (born between 2000 and 2008). The incidence of the delivery mode in patients with CNDO was compared with data from a corresponding population derived from annual birth statistics. Results There was no statistically significant association between the overall cesarean section rate and the incidence of CNDO, but primary cesarean section was significantly more frequent among patients with CNDO (73.15%, p < 0.05). The difference was significant for both genders for the period from 2000 to 2008 (p < 0.05%). The relative risk for CNDO was 1.7-fold increased in children delivered by primary cesarean section. Conclusion Primary cesarean section may be a risk factor for CNDO.
Congenital nasolacrimal duct obstruction (CNDO) is one of the most common reasons for neonatal epiphora.1 The patients present with overflow of tears and crusting of the lashes whereas the conjunctiva remains white as long as no bacterial superinfection occurs.2 The first-line therapy for CNDO is massage of the lacrimal sac with antibacterial eye drops for the therapy of bacterial superinfections. In case of failure, probing and irrigation of the nasolacrimal drainage system are applied.3 Persisting CNDO is associated with the risk of chronic dacryocystitis, which may require invasive surgical interventions such as silicone tube intubation or dacryocystorhinostomy.4,5 Moreover, there appears to be a higher risk of amblyopia in children with a history of CDNO.6,7 In cases of CNDO, a thin mucous membrane, known as Hasner
membrane (HM), persists after birth and occludes the lacrimal passage from the lacrimal duct into the nasal cavity.1 In more than 90% of cases, HM opens spontaneously within the first weeks of life before the onset of regular tear flow. However, in approximately 2 to 6% of cases CNDO persists.4,8–10 Little is known about the risk factors for this condition. Several studies have documented the influence of mode of delivery on subsequent child development.11,12 Primary/ prelabor CS rates, which have increased to 25% in the United Kingdom and 46% in Brazil, are a matter of continuous debate.13–15 On the one hand, CS provides benefits for both, the mother and the child as it lowers the risk of pelvic floor damage, reduces the rates of urinary incontinence and neo-
received February 24, 2014 accepted after revision May 15, 2014 published online June 27, 2014
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1383847. ISSN 0735-1631.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Kristina Spaniol, MD1 Tobias Stupp, MD2 Verena Prokosch, MD2
Congenital Nasolacrimal Duct Obstruction and Mode of Delivery natal injuries, and obviates the need for emergency CS.16 On the other hand, the lack of labor and passage through the birth canal might be related to higher rates of obesity, type 1 diabetes, and asthma in the offspring.11,12 During labor and vaginal delivery the neonatal soft tissue, cartilage, and bony structures are altered.17 Further, labor induces the activity of collagenolytic enzymes in the amniotic fluid.18 These mechanical and enzymatic alterations might also influence the lacrimal drainage system. The aim of this study was to determine the possible association between the incidence of CNDO and delivery by primary and secondary CS compared with vaginal delivery.
Patients and Methods This study was performed in accordance with the tenets of the Declaration of Helsinki. A total of 613 patients with typical symptoms of CNDO (epiphora, mattering of the lashes) were referred to our tertiary eye-care center in the period 2000 to 2008. All children underwent probing and irrigation of the nasolacrimal drainage system under short anesthesia. The probing showed a soft stop at the membranous HM. The irrigation showed a reflux through the contralateral lacrimal point proofing the postsaccal location of the stenosis and the missing patency of the lacrimal drainage system.10 Further, the patients in this study were subject to the following inclusion criteria: • Year of birth between 2000 and 2008 • Age at first presentation with CNDO of < 1 year • No previous conservative or surgical treatment for lacrimal duct stenosis • Mode of delivery definitively confirmed in medical records Patients who did not comply with these criteria and patients with congenital malformations as aplasia or atresia of the lacrimal puncta, lacrimal canaliculi or nasolacrimal duct, diverticula of the lacrimal sac or nasolacrimal duct, colobomas of the lacrimal drainage system or facial clefts were excluded from the study. After exclusion, a final total of 386 patients were included in this retrospective cohort study. The incidence of the mode of delivery in the corresponding cohort representing the normal population was extracted from the annual birth statistics from the Medical Council of North Rhine-Westphalia (NRW, a federal state of Germany) for the years 2000 to 2008. CS was classified as primary or secondary CS. Primary CS was defined as an elective CS before the onset of labor and rupture of the membranes. Secondary CS was defined as a CS
Spaniol et al.
after the onset of the active phase of labor (after cervical dilation or rupture of the membranes). Statistical analyses were conducted using PASW Statistics 18 (IBM, Armonk, NY). The level of statistical significance was set at p 0.05. Confidence intervals (CIs) were used to describe the significance of differences. The odds ratio was calculated to describe the relative risk.
Results Epidemiological Data The incidences of primary and secondary CS and vaginal birth in CNDO patients were compared with the ratio of corresponding modes of delivery within the normal population of the study region (NRW) to determine whether either of these modes of delivery was associated with an increased risk of CNDO. The frequencies of total (primary þ secondary) CS in the cohort and in the NRW population and the corresponding CIs from 2000 to 2008 are shown in ►Table 1. The overlapping CIs indicated an equal rate of CSs in the cohort compared with the NRW population. Further, the frequency of CS was distributed equally within both sexes (►Table 2).
Comparison of Primary CS versus Secondary CS versus Vaginal Birth-Frequencies from 2000 to 2008 ►Fig. 1 gives an overview over the mean frequencies of the different modes of delivery from 2000 to 2008. In the cohort, primary CS was significantly more frequent (20.46% of all birth) compared with the population in NRW (12.75%). Secondary CS was less frequent in the cohort (8.55%) compared with the NRW population (15.46%) while there was no significant difference in the frequency of vaginal delivery (70.98 vs. 71.80%).
Comparison of Primary CS to Nonprimary CS Birth from 2000 to 2008 Comparing the frequency of primary CS to all nonprimary CS deliveries (children born by secondary CS or vaginal birth), there was a significant higher rate of primary CS in the cohort compared with the NRW population indicated by the nonoverlapping CIs (CI cohort [0.64; 0.81], CI NRW [0.51; 0.52]. Calculation of the odds ratio revealed a 1.7 higher risk of CNDO when delivered by primary CS compared with a nonprimary CS delivery.
Comparison of Primary CS Frequencies According to Year (2000–2008) The frequencies of primary and secondary CSs on all CSs were analyzed for the individual years between 2000 and
Table 1 Distribution of vaginal deliveries and CSs in the investigated cohort and in NRW in the years 2000 to 2008
Total n (%)
All cases of the cohort
Number of CS in the cohort
All deliveries in NRW
Number of CS in NRW
386 (100)
112 (29.02)
673,040 (100)
189,910 (28.22)
CI
0.245; 0.338
Abbreviations: CI, confidence interval; CS, cesarean section; NRW, North Rhine-Westphalia. American Journal of Perinatology
Vol. 32
No. 3/2015
0.281; 0.2836
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
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Congenital Nasolacrimal Duct Obstruction and Mode of Delivery
Spaniol et al.
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Table 2 Gender distribution regarding all deliveries and CSs in the investigated cohort and in NRW in the years 2000 to 2008 Male n (%) All cases of the cohort
CI
201 (52.07)
Number of CS in the cohort
57 (50.89)
All deliveries in NRW
344,359 (51.16)
Number of CS in NRW
100,731 (53.04)
Female n (%)
CI
185 (47.93) 0.222; 0.351
55 (49.11)
0.291; 0.294
328,681 (48.84) 0.232; 0.369
89,179 (46.96)
0.270; 0.273
2008. ►Fig. 2 provides an overview of the primary CS frequencies in the cohort and the NRW population. There was a slight increase in the frequency of primary CSs relative to all CSs in the NRW population, with a minimum of 48.01% and a maximum of 54.08%. Data from the present cohort revealed fluctuating frequencies of primary CS, with a minimum of 58.33% and a maximum of 90%. The frequency of primary CS was higher among the CNDO patients than in the corresponding NRW population for all of the investigated years. This difference was significant (p < 0.05) for all years pooled and for the individual years 2003 and 2005.
Comparison of Primary CS Frequency According to Gender The gender-related frequency of primary CS was analyzed. The mean frequency of primary CS was significantly higher among male (75%) and female (71.15%) patients with CNDO than among children of the corresponding gender from the NRW population (53.16% for males and 46.84% for females; ►Fig. 3).
Discussion Dysfunction of the lacrimal drainage system—as CNDO—leads to excessive tearing (epiphora). Persisting CNDO, which occurs in 2 to 6% of all cases carries the risk of chronic dacryocystitis and amblyopia. CNDO is a common ophthal-
mological disease of the neonate that is encountered by obstetrics, neonatologists, pediatrics, and ophthalmologists but risk factors for this condition are barely investigated.19 The present study found no association between the incidence of CNDO and delivery by CS in general. Further, the amount of children delivered vaginally did not differ between the CNDO-cohort and the population of NRW. However, the relative risk of CNDO was 1.7-fold increased in children delivered by primary CS compared with children delivered vaginally or by secondary CS. Thus, the absence of certain physiological birth mechanisms in case of primary CS might increase the risk of persisting CNDO. Although, primary CS significantly changes the birth conditions of an infant, there is no known link between the pathomechanism of CNDO and primary CS.12
Relevance of Pressure The lack of labor and pressure is the main characteristic of primary CS, while in secondary CS the neonate is still exposed to labor to some degree.20 It is well known that pressure plays an important role in the course of CNDO. Manual massage of the lacrimal sac, which is the first-line therapy in cases of CNDO, leads to an increase in hydrostatic pressure therein.21 This results in fluid being transported downward and toward HM, causing it to open.21,22 Nelson et al reported a success rate of 94.7% after 8 months of such treatment, with the success rate increasing with the treatment duration.23 If
Fig. 1 Mean frequency of primary CS versus secondary CS versus vaginal delivery (y-axis) from 2000 to 2008 comparing data from the cohort and data from NRW (y-axis), p < 0.05. CS, cesarean section; NRW, North Rhine-Westphalia. American Journal of Perinatology
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Abbreviations: CI, confidence interval; CS, cesarean section; NRW, North Rhine-Westphalia.
Congenital Nasolacrimal Duct Obstruction and Mode of Delivery
Fig. 2 Percentage of primary CS on all CS (y-axis) in the cohort and in NRW in the individual years 2000 to 2008 (x-axis). CS, cesarean section; NRW, North Rhine-Westphalia.
Spaniol et al.
occurrence of alterations in the neonatal soft-tissue structures during labor. They found a significantly stronger severity of paralysis in children with meningomyelocele who were delivered after the induction of labor.27 Deformations of bony and cartilage structures might also play a role. Various studies have confirmed the occurrence of labor-induced deformations of the neonatal facial structures. Gray investigated nasal septal deformities and argued that pressures during pregnancy and parturition were responsible for deformation of the anterior septal cartilage and maxilla.28 Accordingly, Jeppesen and Windfeld found a higher incidence of nasal septal deformities in cases of second-stage labor lasting longer than 15 minutes.29 The lacrimal sac and distal lacrimal duct adhere to the surrounding periosteum of the lacrimal bone, maxilla, and concha.30 Thus, pressure-induced dislocation of the bony structures will be transmitted to the soft tissue of the lacrimal drainage system, as a result causing deformation and distension of HM. As distension causes thinning of the tissues and loss of tensile strength, such alterations may induce HM opening. 31 HM might be especially sensitive to early intrauterine deformation and distension during labor. It is possible that early labor-induced manipulations of HM are a prerequisite for easier opening of HM after birth. This hypothesis is supported by CNDO appearing to be more sensitive to therapeutic treatment in younger children.4,32
Role of Enzymes
Fig. 3 Mean percentage of male and female children delivered by primary CS from 2000 to 2008 (y-axis) comparing the cohort and data from NRW, p < 0.05. CS, cesarean section; NRW, North RhineWestphalia.
manual massage fails, high-pressure irrigation was found to open HM with a success rate of 100% after two attempts.24 Thus, the placement of hydrostatic pressure on HM—by either manual massage or irrigation—was found to be an effective method of forming a patent lacrimal drainage system in CNDO. Labor creates intrauterine pressure, rising from 50 to 60 mm Hg during the first labor pains up to 200 mm Hg during the pushing contractions.25 As the amniotic fluid cannot be compressed, and pressure will be transmitted to the neonatal body, causing temporary deformations. The face and head of the fetus are particularly exposed to elevations in the intrauterine pressure. The head is the largest part of a term neonatal body, and some type of deformational molding is present in around 30% of newborns.26 Thus, intrauterine pressure on the lacrimal sac area might induce movement of fluid contents toward HM, and consequently opening thereof. Missing or reduced exposure to such pressure-induced alterations—as in primary CS—might negatively affect this process and increase the risk of CNDO. Luthy et al confirmed the American Journal of Perinatology
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Collagenolytic enzymes are induced during labor, which are thought to be involved in rupture of the chorioamniotic membranes during delivery.33 Vadillo-Ortega et al showed that increased activity of the collagenolytic enzyme matrix metalloproteinase 9 in the amniotic fluid is closely linked to the induction of labor.18 Therefore, the chorioamniotic membranes of neonates delivered by primary CS exhibit greater extensibility and tensile strength compared with those of neonates delivered by vaginal deliveries.33 As the amniotic fluid is swallowed by the neonate and flows into the nasal cavity, it will also contact HM. It may be that the labor-induced increase in collagenolytic activity in the amniotic fluid softens the mucosal tissue of HM and enables easier opening thereof. Thus, primary CS, with the consequent lack of labor and reduced activity of collagenolytic enzymes, might be an additional factor underlying the persistence of HM blockage in primary CS children. In summary this study found a 1.7-fold increased risk for CNDO after a delivery by primary CS compared with a vaginal birth or delivery by secondary CS. Possible pathomechanisms include a lack of the labor-induced mechanical and enzymatic alterations that may influence the tensile strength of HM and play a role in the development of a patent lacrimal drainage system. Children delivered by primary CS presenting with symptoms of CNDO (epiphora, crusting of the lashes) should be referred to an ophthalmologist as CNDO-persistence carries the risk of dacryocystitis and amblyopia. Prospective studies need to verify the findings of this study.
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17 Kent SE, Reid AP, Nairn ER, Brain DJ. Neonatal septal deviations. J R
Soc Med 1988;81(3):132–135 18 Vadillo-Ortega F, González-Avila G, Villanueva-Diaz C, Bañales JL,
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American Journal of Perinatology
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Acknowledgment The authors would like to thank the faculty of Münster for supporting their work.
Spaniol et al.
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of American Journal of Perinatology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
