CLINICAL STUDY
Clinical Effectiveness of Monocanalicular Silicone Intubation for Congenital Nasolacrimal Duct Obstruction Under Nasal Endoscopic Visualization of the Terminal End of the Obstructed Nasolacrimal Duct Ji Yun Han, MD, Hwa Lee, MD, PhD, Minwook Chang, MD, PhD,y Minsoo Park, MD, PhD,z Joon Sik Lee, MD, and Sehyun Baek, MD, PhD 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 From the Department of Ophthalmology, Korea University College of Medicine, Seoul, South Korea; yDepartment of Ophthalmology, Ilsan Hospital, Dongguk University, Goyang, South Korea; and zDepartment of Ophthalmology, KEPCO Medical Center, Seoul, South Korea. Received April 27, 2014. Accepted for publication September 9, 2014. Address correspondence and reprint requests to Sehyun Baek, MD, PhD, Department of Ophthalmology, Guro Hospital, Korea University College of Medicine, 148, Guro-dongro, Guro-gu, Seoul, South Korea; E-mail: [email protected] None of the authors have any commercial or proprietary interests in any of the instruments or materials used in this work. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001713
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nasolacrimal duct can be an effective procedure for the management of CNLDO. Key Words: Congenital nasolacrimal duct obstruction, monocanalicular intubation, nasal endoscopic visualization, type of the terminal end of the obstructed nasolacrimal duct (J Craniofac Surg 2015;26: 1328–1331)
C
ongenital nasolacrimal duct obstruction (CNLDO) is not uncommon among young children. The prevalence of CNLDO ranges from 1.25% to 12.5%.1 – 3 Spontaneous resolution occurs in the vast majority of patients by 12 months of age.4 Probing and irrigation of the duct are often the first line of treatment for persistent CNLDO.5,6 If the first probing fails, repeated probing is required, often with supplementary silicone tube intubation or balloon catheter dilatation. Because of the technical ease associated with its insertion and the low-reactivity to it from the surrounding tissues, silicone is the most widely used tube material.7 Numerous surgical techniques have been described; these techniques can be divided into monocanalicular silicone intubation (MCI) and bicanalicular silicone intubation (BCI). Monocanalicular silicone intubation is generally less traumatic than BCI because it presents no risk of injury to the other canaliculus, is relatively simple to perform, and allows for easy tube removal in an office setting.8,9 Intranasal endoscopic visualization not only minimizes nasal trauma, but also prevents formation of an inadvertent false passage and avoids the need to perform inferior turbinate infracture to facilitate tube retrieval in the nose.10 The aim of this study was to evaluate the cause of nasolacrimal duct obstruction by confirming its diagnosis with nasal endoscopic findings of Hasner’s valve and to report the success rate of MCI for the management of CNLDO.
PATIENTS AND METHODS This was a retrospective, interventional, and noncomparative study conducted in the Department of Ophthalmology at Korea University Hospital. This study included 77 eyes from 56 patients with CNLDO who underwent endoscopic probing and MCI with Monoka tubes (FCI Ophthalmics, Issy-les-Moulineaux, France) at Korea University Ansan Hospital and Guro Hospital between October 2008 and March 2013. All surgeries were performed by a single surgeon (S.H.B.), who was also involved in patient clinical assessment. All operations were performed in the standard manner under general anesthesia. The patients’ noses were prepared by placing a
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
cotton-tipped applicator soaked with adrenaline 1:1000 in the inferior meatus before surgery. For easier insertion of the endoscope into the inferior meatus, the inferior turbinate was either lightly pushed medially or fractured with a Freer elevator. Next, a Bowman probe was inserted and a video endoscope (Stortz, Tricam SL Endoscope, Tutlingen, Germany) was introduced into the nasal cavity and used to ensure that the probe was coming out of the inferior nasal meatus and not any false passages. This was helpful to confirm true probe passage, to view the shape of Hasner’s valve and to reduce injury to the nasal mucosa and the inferior meatus. After standard probing, intubation with the monocanalicular silicone tube was performed. A Monoka tube was inserted through the inferior punctum, allowing the surgeon to advance the probe, which was connected to the monocanalicular tube. The punctal anchor at the proximal end of the tube was securely placed in the inferior punctum using gentle traction at the distal end with a hemostat. While making every effort to avoid tension, the distal end of the Monoka tube, located in the nose, was identified with the endoscope. The distal end was fixated with 6-0 Prolene in the lateral nostril. The distal tubing was cut short at the naris and repositioned in the posterior nasal passage. The Monoka tube remained in place for 2–3 months and was removed during a visit to the hospital under topical anesthesia. An assistant firmly held the patient’s head while the punctal anchor was grasped at the inferior punctum with forceps and the tube was removed with gentle traction. Success was defined as the complete disappearance of epiphora symptoms by a minimum of 2 months postremoval of the tubing. Failure was defined as either an absence of improvement or worsening of symptoms during the last follow-up appointment. In addition to collecting clinical data, we reviewed patient charts for demographic information, including age, sex, endoscopic findings, follow-up periods, and complications.
Congenital Nasolacrimal Duct Obstruction
FIGURE 1. The probe (white arrow) protruding through the thin obstructing membrane.
RESULTS This study included 77 eyes of 56 patients. The mean (SD) patient age was 29.8 (26.9) months (range: 6 months to 12 years). Thirty patients were boys (42 eyes) and 26 were girls (35 eyes) (Table 1). Under nasal endoscopic view, 45 ducts (58.4%) had a thin membranous obstruction or a simple stenotic opening of Hasner’s valve (Fig. 1). The probe failed to perforate a thick obstructing membrane in 7 ducts (9.1%); in these cases probe passage occurred under the lateral nasal mucosa (Fig. 2). Among 23 ducts (29.9%), the probe tip was protruding through the nasal mucosa at Hasner’s valve, which all had a balloon-like structure (Fig. 3). The probe protruded through a stretchable orifice in two ducts (2.6%), which was demonstrated by orifice re-closure after the probe was drawn up from the valve area (Fig. 4). Our surgical procedures were successful in 89.6% (69/77) of patients (Table 2). The incidence of tube prolapse and tube loss was 18.2% (14 eyes) and 13.0% (10 eyes), respectively. The success rate for eyes with tubes removed early because of tube prolapse or tube loss was 83.3% (20/24). The success rate for eyes with tubes removed at the standard time was 92.5% (49/53). There was no statistically significant difference between the
FIGURE 2. A thick obstructing membrane with probe (black arrow) passage under the mucosa of the lateral nasal wall (white arrow) (submucosal passage).
success rates of the group with early tube removal and the group with normal tube removal (P > 0.05, Mann-Whitney U test). Other complications, such as punctal slitting, granuloma, or corneal abrasion, were not observed (Table 3).
TABLE 1. Demographic Characteristics Male/female (no. of eyes (patients)) Right/left (no. of eyes) Mean age (months, range)
#
2015 Mutaz B. Habal, MD
42(30)/35(26) 39/38 29.8 (6 mo to 12 y)
FIGURE 3. The probe (white arrow) protruding through a balloon-like nasal mucosa at Hasner’s valve.
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Han et al
Volume 26, Number 4, June 2015
TABLE 3. Postoperative Complicationsa and Success Rate of Two Groups—Early Tube Removal and Normal Tube Removal Early Tube Removal Complications Rates (eyes) Success rate, % (eyes) P-value
Tube Prolapse 18.2 (14)
Early Tube Loss
13.0 (10) 83.3 (20/24)
Normal Tube Removal 68.8 (53) 92.5 (49/53)
0.227b
a Except for tube prolapse and early tube loss, other complications were not observed. b Mann-Whitney U test.
FIGURE 4. A, Probe (white arrow) passing through a stretchable valve. B, Reclosed valve (black arrow) after the probe was taken out of it (Elastic stenotic valve).
TABLE 2. Overall Surgical Success Rate and Cause of Hasner’s Valve Obstruction Nasal Endoscopic Findings
% (No. of Eyes)
Thin membrane or simple stenotic valve Thick membrane (submucosal passage) Ballooned nasal mucosa Elastic stenotic valve Overall success rate
58.4 9.1 29.9 2.6
(45/77) (7/77) (23/77) (2/77)
Success Rate, % (No. of Eyes) 88.9 (40/45) 71.4 (5/7) 100 (23/23) 50 (1/2) 89.6 (69/77)
DISCUSSION Conventional probing is a blind procedure with unclear failure mechanisms,11 which results in unpredictable, unexplainable, and frustrating outcomes. To overcome this problem, surgical probing has been combined with nasal endoscopy to enable direct visualization.12– 14 Direct nasal endoscopic visualization shows the probing course and allows the surgeon to see if there is any obstructions to avoid, which is the most likely causes of probing failure. Obstructions at the terminal end of the nasolacrimal duct vary. Hakim et al15 reported that thin membranous obstructions and simple stenotic valvular obstructions comprised 69% of duct obstructions. Thick membranous obstructions comprised 12% of primary CNLDO, causing the probe to pass under the lateral nasal mucosa (lateral false passage). Redundant membranes with
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ballooned nasal mucosa comprise 10% of all obstructions. Reclosure by a membrane ‘‘trapdoor’’ was the cause of probing failure in these cases. An elastic stenotic valve leads to reclosure of a stretchy membrane in 7% of all obstructions. In our study, the most common causes of obstruction at Hasner’s valve were thin membranes and simple stenotic valves (58.4%). However ballooned nasal mucosa (29.9%) was a more common finding than thick membrane causing submucosal passage (9.1%). These results do not correspond with earlier reports. In our patients, many of the CNLDO cases were caused by inflammation of the lacrimal sac because of a ballooned nasal mucosa. Previously, we reported on CNLDO patients (a total of 23 eyes) with enlarged lacrimal sac and chronic dacryocystitis. In these cases, nasal endoscopic findings revealed that probe tips protruded through a balloon-like nasal mucosa around Hasner’s valve and that pus was stagnating in the mucosa. This opening was susceptible to reclosure because of redundant membranes. An abnormally enlarged lacrimal sac can cause fluid turbulence and, consequently, lacrimal stasis, which negatively influences the functional efficacy of simple probing; thus, after simple probing, ballooning of the nasal mucosa around Hasner’s valve often does not resolve. For complete sac decompression, monocanalicular intubation with pus drainage by manual compression over the lacrimal sac fossa and antibiotic irrigation is more effective than simple probing.16 Further study about the different causes of CNLDO based on patient ethnicity are needed. Silicone tube intubation is commonly carried out after failed probing, and its success rate ranges from 62% to 100%.8,17,18 Kaufman et al19 reported that MCI for 48 congenitally obstructed nasolacrimal ducts had an overall success rate of 93% when the tube was in place for 4–6 months. Because of complications, the success rate diminished to 62% when early tube removal was required. Engel et al8 reported that MCI as the primary treatment for CNLDO has a very high success rate (97% in patients younger than 24 months of age, and 90% in patients older than 24 months of age) and a low complication rate (conjunctival or corneal abrasion occurs in 2% of cases). In our study, the success rate in patients younger than 24 months of age was 100% (40/40), and was 78.4% (29/37) in patients older than 24 months of age. After the age of 24 months, the success rate decreased significantly (P ¼ 0.002, Mann-Whitney U test). The importance of the timing for surgical intervention for CNLDO is controversial. Our results show a correlation between success rate and age at the time of operation. However, the number of patients included in our study was relatively small, so further studies with a greater sample size are needed. The main advantages of MCI over BCI are the technical ease of insertion and tube removal. Our results further indicate that the operation time could be shortened. Moreover, the tubing does not increase risk of damage to the unprobed part of the lacrimal #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
drainage system, including the other canaliculus, so there is no need to adjust the tension on the proximal end of the tubing at the inner canthus. Removal of the Monoka tube is far easier than tube removal after BCI and takes only seconds.19 In our study, the Monoka tube was removed under topical anesthesia in all cases. There is no consensus on the optimal timing for tube removal. Recommendations for timing of tube removal range from 6 weeks to 18 months.20 Peterson et al21 reported that early dislodgement in patients younger than 2 years did not decrease the success rate. Fayet et al22 found that success rate was not correlated with intubation duration after 1 month; however, they did find a correlation with time to removal and complication rates. In our study, the incidence of tube prolapse was 18.2% (14/77) and early tube loss was 13.0% (10/77). The success rate among eyes with early tube removal because of tube prolapse or early tube loss was 83.3% (20/24). The success rate among eyes with normally timed tube removal was 92.5% (49/53); there was no significant difference between these success rates (P > 0.05) (Table 3). Previously, we reported the incidence of tube prolapse after BCI and MCI; the incidence was 13.3% (4/30) for BCI and 16.7% (5/30) for MCI.7 In this study, we found no statistically significant effects of tube prolapse and timing of tube removal on the success rates of these two procedures (P > 0.05).7 Results from the prior and current studies suggest that the duration of tube intubation may not be a critical factor for surgical success. Finally, it is necessary for the surgeon to instruct the parents of the patient to be careful that their child must avoid eye rubbing to minimize the incidence of these complications.
CONCLUSIONS In conclusion, there are several important findings of duct obstructions by endoscopy that makes more often probing failures, such as the presence of thin membrane or simple stenotic valve, thick membrane causing submucosal passage, ballooned nasal mucosa, and elastic stenotic valve. In these situations, silicone intubation should be considered. Considering the main advantages of MCI, such as the technical ease of insertion and tube removal, MCI under nasal endoscopic visualization of the terminal end of the obstructed nasolacrimal duct could be an effective procedure for the management of CNLDO.
REFERENCES 1. Guerry D 3rd, Kendig EL Jr. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol 1948;39:193–204 2. Noda S, Hayasaka S, Setogawa T. Congenital nasolacrimal duct obstruction in Japanese infants: its incidence and treatment with massage. J Pediatr Ophthalmol Strabismus 1991;28:20–22 3. Paul TO, Shepherd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 1994;31:362–367
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Congenital Nasolacrimal Duct Obstruction
4. Kakizaki H, Takahashi Y, Kinoshita S, et al. 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;2:291–294 5. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology 1998;105:1307–1309 6. Stager D, Baker JD, Frey T, et al. Office probing of congenital nasolacrimal duct obstruction. Ophthalmic Surg 1992;23:482–484 7. Lee H, Ahn J, Lee JM, et al. Clinical effectiveness of monocanalicular and bicanalicular silicone intubation for congenital nasolacrimal duct obstruction. J Craniofac Surg 2012;23:1010–1014 8. Engel JM, Hichie-Schmidt C, Khammar A, et al. Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction. J AAPOS 2007;11:183–186 9. Anderson RL, Edwards JJ. Indications, complications and results with silicone stents. Ophthalmology 1979;86:1474–1487 10. Orhan M, Onerci M. Intranasal endoscopic silicone intubation for congenital obstruction of the nasolacrimal duct in children. Int J Pediatr Otorhinolaryngol 1997;41:273–278 11. Lim CS, Martin F, Beckenham T, et al. Nasolacrimal duct obstruction in children: outcome of intubation. J AAPOS 2004;8:466–472 12. Orhan M, Cal P, Onerci M, et al. Conventional or endoscopic probing for congenital nasolacrimal duct obstruction. Eur J Ophthalmol 2001;11:215–217 13. Ingels K, Kestelyn P, Meire F, et al. The endoscopic approach for congenital nasolacrimal duct obstruction. Clin Otolaryngol 1997;22:96–99 14. MacEwen CJ, Young JDH, Barras CW, et al. Value of nasal endoscopy and probing in the diagnosis and management of children with congenital epiphora. Br J Ophthalmol 2001;85:314–318 15. Hakim OM, Mandour W, Elbaz E. Nasal endoscopic visualization and management of the leading causes of probing failure. J Pediatr Ophthalmol Strabismus 2010;47:214–219 16. Lee H, Ahn J, Shin HH, et al. Effectiveness of primary monocanalicularnasal intubation with Monoka tubes and nasal endoscopic findings for congenital nasolacrimal duct obstruction with enlarged lacrimal sac and chronic dacryocystitis. J Craniofac Surg 2012;23:1638–1641 17. Dortzbach RK, France TD, Kushner BJ, et al. Silicone intubation for obstruction of the nasolacrimal duct in children. Am J Ophthalmol 1982;94:585–590 18. Leone CR Jr, Van Gemert JV. The success rate of silicone intubation in congenital lacrimal obstruction. Ophthalmic Surg 1990;21:90–92 19. Kaufman LM, Guay-Bhatia LA. Monocanalicular intubation with Monoka tubes for the treatment of congenital nasolacrimal duct obstruction. Ophthalmology 1998;105:336–341 20. Welsh MG, Katowitz JA. Timing of silastic tubing removal after intubation for congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg 1989;5:43–48 21. Peterson NJ, Weaver RG, Yeatts RP. Effect of short-duration silicone intubation in congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg 2008;24:167–171 22. Fayet B, Assouline M, Bernard JA. Monocanalicular nasolacrimal duct intubation. Ophthalmology 1998;105:1795–1796
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Clinical Effectiveness of Monocanalicular Silicone Intubation for Congenital Nasolacrimal Duct Obstruction Under Nasal Endoscopic Visualization of the Terminal End of the Obstructed Nasolacrimal Duct Ji Yun Han, MD, Hwa Lee, MD, PhD, Minwook Chang, MD, PhD,y Minsoo Park, MD, PhD,z Joon Sik Lee, MD, and Sehyun Baek, MD, PhD 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 From the Department of Ophthalmology, Korea University College of Medicine, Seoul, South Korea; yDepartment of Ophthalmology, Ilsan Hospital, Dongguk University, Goyang, South Korea; and zDepartment of Ophthalmology, KEPCO Medical Center, Seoul, South Korea. Received April 27, 2014. Accepted for publication September 9, 2014. Address correspondence and reprint requests to Sehyun Baek, MD, PhD, Department of Ophthalmology, Guro Hospital, Korea University College of Medicine, 148, Guro-dongro, Guro-gu, Seoul, South Korea; E-mail: [email protected] None of the authors have any commercial or proprietary interests in any of the instruments or materials used in this work. The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001713
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nasolacrimal duct can be an effective procedure for the management of CNLDO. Key Words: Congenital nasolacrimal duct obstruction, monocanalicular intubation, nasal endoscopic visualization, type of the terminal end of the obstructed nasolacrimal duct (J Craniofac Surg 2015;26: 1328–1331)
C
ongenital nasolacrimal duct obstruction (CNLDO) is not uncommon among young children. The prevalence of CNLDO ranges from 1.25% to 12.5%.1 – 3 Spontaneous resolution occurs in the vast majority of patients by 12 months of age.4 Probing and irrigation of the duct are often the first line of treatment for persistent CNLDO.5,6 If the first probing fails, repeated probing is required, often with supplementary silicone tube intubation or balloon catheter dilatation. Because of the technical ease associated with its insertion and the low-reactivity to it from the surrounding tissues, silicone is the most widely used tube material.7 Numerous surgical techniques have been described; these techniques can be divided into monocanalicular silicone intubation (MCI) and bicanalicular silicone intubation (BCI). Monocanalicular silicone intubation is generally less traumatic than BCI because it presents no risk of injury to the other canaliculus, is relatively simple to perform, and allows for easy tube removal in an office setting.8,9 Intranasal endoscopic visualization not only minimizes nasal trauma, but also prevents formation of an inadvertent false passage and avoids the need to perform inferior turbinate infracture to facilitate tube retrieval in the nose.10 The aim of this study was to evaluate the cause of nasolacrimal duct obstruction by confirming its diagnosis with nasal endoscopic findings of Hasner’s valve and to report the success rate of MCI for the management of CNLDO.
PATIENTS AND METHODS This was a retrospective, interventional, and noncomparative study conducted in the Department of Ophthalmology at Korea University Hospital. This study included 77 eyes from 56 patients with CNLDO who underwent endoscopic probing and MCI with Monoka tubes (FCI Ophthalmics, Issy-les-Moulineaux, France) at Korea University Ansan Hospital and Guro Hospital between October 2008 and March 2013. All surgeries were performed by a single surgeon (S.H.B.), who was also involved in patient clinical assessment. All operations were performed in the standard manner under general anesthesia. The patients’ noses were prepared by placing a
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
cotton-tipped applicator soaked with adrenaline 1:1000 in the inferior meatus before surgery. For easier insertion of the endoscope into the inferior meatus, the inferior turbinate was either lightly pushed medially or fractured with a Freer elevator. Next, a Bowman probe was inserted and a video endoscope (Stortz, Tricam SL Endoscope, Tutlingen, Germany) was introduced into the nasal cavity and used to ensure that the probe was coming out of the inferior nasal meatus and not any false passages. This was helpful to confirm true probe passage, to view the shape of Hasner’s valve and to reduce injury to the nasal mucosa and the inferior meatus. After standard probing, intubation with the monocanalicular silicone tube was performed. A Monoka tube was inserted through the inferior punctum, allowing the surgeon to advance the probe, which was connected to the monocanalicular tube. The punctal anchor at the proximal end of the tube was securely placed in the inferior punctum using gentle traction at the distal end with a hemostat. While making every effort to avoid tension, the distal end of the Monoka tube, located in the nose, was identified with the endoscope. The distal end was fixated with 6-0 Prolene in the lateral nostril. The distal tubing was cut short at the naris and repositioned in the posterior nasal passage. The Monoka tube remained in place for 2–3 months and was removed during a visit to the hospital under topical anesthesia. An assistant firmly held the patient’s head while the punctal anchor was grasped at the inferior punctum with forceps and the tube was removed with gentle traction. Success was defined as the complete disappearance of epiphora symptoms by a minimum of 2 months postremoval of the tubing. Failure was defined as either an absence of improvement or worsening of symptoms during the last follow-up appointment. In addition to collecting clinical data, we reviewed patient charts for demographic information, including age, sex, endoscopic findings, follow-up periods, and complications.
Congenital Nasolacrimal Duct Obstruction
FIGURE 1. The probe (white arrow) protruding through the thin obstructing membrane.
RESULTS This study included 77 eyes of 56 patients. The mean (SD) patient age was 29.8 (26.9) months (range: 6 months to 12 years). Thirty patients were boys (42 eyes) and 26 were girls (35 eyes) (Table 1). Under nasal endoscopic view, 45 ducts (58.4%) had a thin membranous obstruction or a simple stenotic opening of Hasner’s valve (Fig. 1). The probe failed to perforate a thick obstructing membrane in 7 ducts (9.1%); in these cases probe passage occurred under the lateral nasal mucosa (Fig. 2). Among 23 ducts (29.9%), the probe tip was protruding through the nasal mucosa at Hasner’s valve, which all had a balloon-like structure (Fig. 3). The probe protruded through a stretchable orifice in two ducts (2.6%), which was demonstrated by orifice re-closure after the probe was drawn up from the valve area (Fig. 4). Our surgical procedures were successful in 89.6% (69/77) of patients (Table 2). The incidence of tube prolapse and tube loss was 18.2% (14 eyes) and 13.0% (10 eyes), respectively. The success rate for eyes with tubes removed early because of tube prolapse or tube loss was 83.3% (20/24). The success rate for eyes with tubes removed at the standard time was 92.5% (49/53). There was no statistically significant difference between the
FIGURE 2. A thick obstructing membrane with probe (black arrow) passage under the mucosa of the lateral nasal wall (white arrow) (submucosal passage).
success rates of the group with early tube removal and the group with normal tube removal (P > 0.05, Mann-Whitney U test). Other complications, such as punctal slitting, granuloma, or corneal abrasion, were not observed (Table 3).
TABLE 1. Demographic Characteristics Male/female (no. of eyes (patients)) Right/left (no. of eyes) Mean age (months, range)
#
2015 Mutaz B. Habal, MD
42(30)/35(26) 39/38 29.8 (6 mo to 12 y)
FIGURE 3. The probe (white arrow) protruding through a balloon-like nasal mucosa at Hasner’s valve.
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The Journal of Craniofacial Surgery
Han et al
Volume 26, Number 4, June 2015
TABLE 3. Postoperative Complicationsa and Success Rate of Two Groups—Early Tube Removal and Normal Tube Removal Early Tube Removal Complications Rates (eyes) Success rate, % (eyes) P-value
Tube Prolapse 18.2 (14)
Early Tube Loss
13.0 (10) 83.3 (20/24)
Normal Tube Removal 68.8 (53) 92.5 (49/53)
0.227b
a Except for tube prolapse and early tube loss, other complications were not observed. b Mann-Whitney U test.
FIGURE 4. A, Probe (white arrow) passing through a stretchable valve. B, Reclosed valve (black arrow) after the probe was taken out of it (Elastic stenotic valve).
TABLE 2. Overall Surgical Success Rate and Cause of Hasner’s Valve Obstruction Nasal Endoscopic Findings
% (No. of Eyes)
Thin membrane or simple stenotic valve Thick membrane (submucosal passage) Ballooned nasal mucosa Elastic stenotic valve Overall success rate
58.4 9.1 29.9 2.6
(45/77) (7/77) (23/77) (2/77)
Success Rate, % (No. of Eyes) 88.9 (40/45) 71.4 (5/7) 100 (23/23) 50 (1/2) 89.6 (69/77)
DISCUSSION Conventional probing is a blind procedure with unclear failure mechanisms,11 which results in unpredictable, unexplainable, and frustrating outcomes. To overcome this problem, surgical probing has been combined with nasal endoscopy to enable direct visualization.12– 14 Direct nasal endoscopic visualization shows the probing course and allows the surgeon to see if there is any obstructions to avoid, which is the most likely causes of probing failure. Obstructions at the terminal end of the nasolacrimal duct vary. Hakim et al15 reported that thin membranous obstructions and simple stenotic valvular obstructions comprised 69% of duct obstructions. Thick membranous obstructions comprised 12% of primary CNLDO, causing the probe to pass under the lateral nasal mucosa (lateral false passage). Redundant membranes with
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ballooned nasal mucosa comprise 10% of all obstructions. Reclosure by a membrane ‘‘trapdoor’’ was the cause of probing failure in these cases. An elastic stenotic valve leads to reclosure of a stretchy membrane in 7% of all obstructions. In our study, the most common causes of obstruction at Hasner’s valve were thin membranes and simple stenotic valves (58.4%). However ballooned nasal mucosa (29.9%) was a more common finding than thick membrane causing submucosal passage (9.1%). These results do not correspond with earlier reports. In our patients, many of the CNLDO cases were caused by inflammation of the lacrimal sac because of a ballooned nasal mucosa. Previously, we reported on CNLDO patients (a total of 23 eyes) with enlarged lacrimal sac and chronic dacryocystitis. In these cases, nasal endoscopic findings revealed that probe tips protruded through a balloon-like nasal mucosa around Hasner’s valve and that pus was stagnating in the mucosa. This opening was susceptible to reclosure because of redundant membranes. An abnormally enlarged lacrimal sac can cause fluid turbulence and, consequently, lacrimal stasis, which negatively influences the functional efficacy of simple probing; thus, after simple probing, ballooning of the nasal mucosa around Hasner’s valve often does not resolve. For complete sac decompression, monocanalicular intubation with pus drainage by manual compression over the lacrimal sac fossa and antibiotic irrigation is more effective than simple probing.16 Further study about the different causes of CNLDO based on patient ethnicity are needed. Silicone tube intubation is commonly carried out after failed probing, and its success rate ranges from 62% to 100%.8,17,18 Kaufman et al19 reported that MCI for 48 congenitally obstructed nasolacrimal ducts had an overall success rate of 93% when the tube was in place for 4–6 months. Because of complications, the success rate diminished to 62% when early tube removal was required. Engel et al8 reported that MCI as the primary treatment for CNLDO has a very high success rate (97% in patients younger than 24 months of age, and 90% in patients older than 24 months of age) and a low complication rate (conjunctival or corneal abrasion occurs in 2% of cases). In our study, the success rate in patients younger than 24 months of age was 100% (40/40), and was 78.4% (29/37) in patients older than 24 months of age. After the age of 24 months, the success rate decreased significantly (P ¼ 0.002, Mann-Whitney U test). The importance of the timing for surgical intervention for CNLDO is controversial. Our results show a correlation between success rate and age at the time of operation. However, the number of patients included in our study was relatively small, so further studies with a greater sample size are needed. The main advantages of MCI over BCI are the technical ease of insertion and tube removal. Our results further indicate that the operation time could be shortened. Moreover, the tubing does not increase risk of damage to the unprobed part of the lacrimal #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
drainage system, including the other canaliculus, so there is no need to adjust the tension on the proximal end of the tubing at the inner canthus. Removal of the Monoka tube is far easier than tube removal after BCI and takes only seconds.19 In our study, the Monoka tube was removed under topical anesthesia in all cases. There is no consensus on the optimal timing for tube removal. Recommendations for timing of tube removal range from 6 weeks to 18 months.20 Peterson et al21 reported that early dislodgement in patients younger than 2 years did not decrease the success rate. Fayet et al22 found that success rate was not correlated with intubation duration after 1 month; however, they did find a correlation with time to removal and complication rates. In our study, the incidence of tube prolapse was 18.2% (14/77) and early tube loss was 13.0% (10/77). The success rate among eyes with early tube removal because of tube prolapse or early tube loss was 83.3% (20/24). The success rate among eyes with normally timed tube removal was 92.5% (49/53); there was no significant difference between these success rates (P > 0.05) (Table 3). Previously, we reported the incidence of tube prolapse after BCI and MCI; the incidence was 13.3% (4/30) for BCI and 16.7% (5/30) for MCI.7 In this study, we found no statistically significant effects of tube prolapse and timing of tube removal on the success rates of these two procedures (P > 0.05).7 Results from the prior and current studies suggest that the duration of tube intubation may not be a critical factor for surgical success. Finally, it is necessary for the surgeon to instruct the parents of the patient to be careful that their child must avoid eye rubbing to minimize the incidence of these complications.
CONCLUSIONS In conclusion, there are several important findings of duct obstructions by endoscopy that makes more often probing failures, such as the presence of thin membrane or simple stenotic valve, thick membrane causing submucosal passage, ballooned nasal mucosa, and elastic stenotic valve. In these situations, silicone intubation should be considered. Considering the main advantages of MCI, such as the technical ease of insertion and tube removal, MCI under nasal endoscopic visualization of the terminal end of the obstructed nasolacrimal duct could be an effective procedure for the management of CNLDO.
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Congenital Nasolacrimal Duct Obstruction
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
