Congenital Nasolacrimal Duct Obstruction: Common Management Policies Among Pediatric Ophthalmologists Gad Dotan, MD; Leonard B. Nelson, MD
ABSTRACT Purpose: To study common management policies of congenital nasolacrimal duct obstruction (CNDLO) among pediatric ophthalmologists. Methods: A 21-question survey was sent to members of the American Association for Pediatric Ophthalmology and Strabismus in April 2014. The questions focused on treatment of CNLDO during the first year of life, primary and secondary surgical interventions, surgical techniques, and amblyopia assessment. Results: One hundred twenty-seven members completed the survey and 121 responses were analyzed after replies of 6 candidates in training were excluded. Eighty-two percent of respondents instructed caregivers to massage the nasolacrimal duct during the first year of life; however, 55% did not perform the Crigler massage in the office. Outpatient probing was done by 17% of pediatric ophthalmologists who took the survey, almost all of whom (95%) have been in practice more than 10 years. Ninety-one percent recommended
INTRODUCTION Congenital nasolacrimal duct obstruction (CNLDO) occurs in approximately 6% to 20% of newborns.1 Many obstructions resolve spontaneously or with simple medical treatment during the first
surgery for CNLDO close to the age of 1 year and 79% performed probing as initial treatment at that age. If treatment is delayed to the age of 2 years, 53% favored silicone tube intubation and/or balloon dacryoplasty. Following failed probing, silicone tube intubation was performed by 51% of practitioners. Ninety-one percent of respondents routinely checked refraction of infants with CNLDO and recommended reexamination even if initial assessment was entirely normal. Conclusions: This study highlights the striking lack of consensus among pediatric ophthalmologists in many aspects of management of CNLDO and allows practitioners to compare their practice patterns regarding CNLDO management with those of their peers; however, because it provides only the opinions of a limited group of pediatric ophthalmologists, it does not imply that less common practices are wrong. [J Pediatr Ophthalmol Strabismus 20XX;XX(X):XXXX.]
year of life; however, unresolved cases typically require surgical intervention, occasionally more than once.2 In recent years, there were several developments concerning CNLDO, including publication of multiple multicenter studies conducted by the
From the Department of Ophthalmology, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (GD); and Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania (GD, LBN). Submitted: September 24, 2014; Accepted: October 2, 2014; Posted online: November 4, 2014 The authors have no financial or proprietary interest in the materials presented herein. Dr. Nelson did not participate in the editorial review of this manuscript. Correspondence: Gad Dotan, MD, Department of Ophthalmology, Tel Aviv Medical Center, 6 Weizmann Street, Tel Aviv 64239, Israel. E-mail: [email protected] doi: 10.3928/01913913-20141028-01
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Pediatric Eye Disease Investigator Group (PEDIG), reports on association of CNLDO with ametropia and amblyopia, and introduction of new surgical techniques and instrumentation.3-8 In this study, we evaluated how these changes affected the management of CNLDO by pediatric ophthalmologists. MATERIALS AND METHODS A survey questioning CNLDO management was sent in April 2014 to 1,495 members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) through an e-mail communication containing a hyperlink to an electronic survey (www. surveymonkey.com). A reminder to take the survey was sent 2 weeks later through the listserv of the organization. The survey contained 21 multiple-choice questions (Appendix A, available in the online version of this article) that included demographic information of the respondent regarding type of AAPOS membership, length of practice, experience with surgical treatment of CNLDO, and number of procedures performed yearly. Questions on CNLDO management focused on treatment during the first year of life, preferred primary treatments at increasing ages, preferred repeat procedure following prior probing failure, silicone tube intubation policies, and assessment of ametropia and amblyopia. Respondents were allowed to skip questions they did not want to reply to and were allowed to choose an “other” option whenever the provided options did not match their policies. The surveys were completely anonymous and did not contain any identifying information. To ensure that it was impossible to link responses with their providers, the Internet protocol address (an automatic numerical value allocated to every computer connected to the Web) was removed from individual responses at the time of analysis. The International Review Board committee of the Wills Eye Hospital, Philadelphia, Pennsylvania, considered this study to be exempt from International Review Board review and approval. Statistical analysis was performed using Prism 6 statistical software (GraphPad Software, Inc., San Diego, CA). Descriptive statistics are provided, mostly summarizing positive responses and percentages, calculated from the total answers provided to each question. All statistical inference testing was two-tailed at an alpha level of 5%. Analysis of counts of categorical variables was performed using Fisher’s exact test. Proportion of responses of North American (from the United States and Canada) 2
versus international members was compared using a two-proportions test. RESULTS Respondents
One hundred twenty-seven AAPOS members completed the survey. Responses of 6 candidates in training were excluded from analysis because it was assumed that their replies reflected more the attitudes of their mentors rather than their own personal experience, causing a potential source of bias if their instructors also took the survey. The survey was completed by many more North American pediatric ophthalmologists (84%, 101 of 121) than international members (16%, 20 of 121); however, these differences reflected their different proportions in the organization: 101 of 1,181 (8.5%) North American AAPOS members took the survey compared to 20 of 314 (6.3%) international members, and this difference was not statistically significant (P = .173). There was also a greater response from pediatric ophthalmologists who had been in practice more than 10 years (76%, 92 of 121) than from members with fewer years of experience (24%, 29 of 121). Almost all (95%, 115 of 121) members who took the survey responded that they regularly treat children with CNLDO and have experience performing surgery for this condition; 59% (71 of 121) estimated that they perform more than 20 lacrimal system surgeries per year. CNLDO Treatment During the First Year of Life
Forty-five percent (53 of 118) of respondents replied that they perform the Crigler maneuver on the initial visit of a child younger than 6 months old with CNLDO, and 82% (99 of 121) instruct caregivers to massage the nasolacrimal duct at home. Seventeen percent (20 of 121) confirmed that they perform office probing. Recommendation of caregivers to massage the nasolacrimal duct and performance of Crigler maneuver was similarly reported by pediatric ophthalmologists with more than 10 years of experience and those with less duration of practice (Table 1). However, a considerable difference existed between these groups in regard to office probing; 3% (1 of 29) of clinicians with less than 10 years of experience reported performing outpatient probing compared to 21% (19 of 92) of those in practice at least 10 years (P = .041). Many of those who perform outpatient probing replied that they would consider outpatient probing in a 12-month-old infant (65%, 13 of 20), whereas others Copyright © SLACK Incorporated
TABLE 1
Comparison of CNLDO Treatment During the First Year of Life by Pediatric Ophthalmologists With ≤ and > 10 Years of Practicea ≤ 10 Years in Practice (n = 29)
> 10 Years in Practice (n = 92)
All (n = 121)
Pb
Recommend caregivers to massage the NLD
26 (90%)
73 (79%)
99 (82%)
.275
Perform the Crigler maneuver
12 (41%)
41 (46%)
53 (45%)
.674
Perform probing in the office
1 (3%)
19 (21%)
20 (17%)
.041b
Treatment
CNLDO = congenital nasolacrimal duct obstruction; NLD = nasolacrimal duct obstruction a Numbers represent positive responses and percentages are calculated from the total number of respondents of the category. b Statistically significant results. TABLE 2
Preferred Surgical Treatment at Increasing Ages Divided by Length of Practicea Age at Initial Surgery (mo) 12
24
36
Repeat procedure
Length of Practice (y)
Probing
Silicone Intubation
Balloon Dacryoplasty
Balloon & Silicone Intubation
Othersb
P .219
≤ 10
23 (80%)
5 (17%)
0
1 (3%)
0
> 10
72 (79%)
15 (16%)
4 (4%)
0
0
All
95 (79%)
20 (17%)
4 (3%)
1 (< 1%)
0
≤ 10
10 (34%)
7 (24%)
9 (31%)
2 (7%)
1 (3%)
> 10
45 (50%)
28 (31%)
16 (18%)
1 (1%)
0
All
55 (46%)
35 (29%)
25 (21%)
3 (3%)
1 (< 1%)
≤ 10
7 (24%)
10 (34%)
10 (34%)
1 (3%)
1 (3%)
> 10
31 (34%)
35 (39%)
18 (20%)
5 (6%)
1 (1%)
All
38 (32%)
45 (38%)
28 (24%)
6 (5%)
2 (2%)
≤ 10
2 (7%)
12 (41%)
10 (34%)
2 (7%)
3 (10%)
> 10
10 (11%)
48 (54%)
17 (19%)
9 (10%)
5 (6%)
All
12 (10%)
60 (51%)
27 (23%)
11 (9%)
8 (7%)
.096
.389
.304
Numbers indicate positive responses and number in parentheses are percentages of total responses. P values represent the result of chi-square test comparing preferred procedure of practitioners with ≤ 10 versus > 10 years of practice. b Others include responses that do not fit any category, such as referral to oculoplastics. a
(25%, 5 of 20) reported that they consider the age of 9 months to be maximal for office probing. Surgical Treatment
Seventy-nine percent (95 of 121) replied that they start recommending surgical intervention under general anesthesia for unresolved CNLDO at the age of 13 months. An additional 12% (14 of 121) recommend surgery for infants who are 10 to 12 months old. Seventy-nine percent (95 of 120) chose probing as primary CNLDO treatment in children who are 1 year old, followed by silicone tube intubation (17%, 20 of 120). In children who first have surgery at the age of 2 years, 53% (63 of 119) chose non-probing procedures (ie, silicone tube intubation and/or balloon dacryoplasty) for initial treat-
ment, even though probing was the most common single response (46%, 55 of 119). In children whose initial surgical treatment is further delayed to the age of 3 years, the proportion of practitioners who reported performing silicone tube intubation and/or balloon dacryoplasty increased to 67% (79 of 119). In case prior probing fails to resolve CNLDO and a second intervention is required, most respondents elected to perform silicone intubation either alone (51%, 60 of 118) or in combination with balloon dacryoplasty (9%, 11 of 118); an additional 23% (27 of 118) chose balloon dacryoplasty as the preferred treatment and 10% (12 of 118) replied that they would attempt another probing alone. Preference of surgical procedure was not different based on length of practice of providers (Table 2).
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Figure 1. Recommended duration of silicone tube intubation.
Silicone Intubation
Sixty-four percent (67 of 105) of respondents who perform silicone intubation preferred monocanalicular tubes, which are nearly equally placed in the lower (48%, 39 of 81) and upper (42%, 34 of 81) puncti, usually using the pulled technique (80%, 62 of 78). Silicone tubes are most commonly left in place between 3 and 4 months (52%, 55 of 106), followed by intubation of 5 to 6 months (29%, 31 of 106) (Figure 1). Of bicanalicular tubes, two-thirds (48 of 73) are removed in the office and the remaining third (25 of 73) are removed in the operating room under general anesthesia. Risk of Amblyopia
Ninety-one percent (106 of 117) of respondents reported that they regularly check refraction of a 6-month-old infant with CNLDO at the time of initial visit or soon thereafter. Assuming that refraction findings were normal at initial examination, 45% (53 of 119) recommend rechecking refraction at the age of 1 to 2 years, 29% (35 of 119) at 3 to 4 years, and 4% (5 of 119) when the child starts school. However, 22% (26 of 119) of providers replied that they would never reexamine refraction of such a child. DISCUSSION This study reports on common attitudes of pediatric ophthalmologists in different aspects of CNLDO management and compared preferences of providers with more than 10 years of experience to those with fewer years of practice. Many cases of CNLDO resolve during the first year of life either spontaneously or with conservative treatment.9 Recently, it was reported that two-thirds of children who had CNLDO symptoms at the age of 6 months were cured with conservative treatment alone within the following 6 months.2 In our study, 4
it was determined that nasolacrimal duct massage is a frequently recommended treatment for children with CNLDO during the first year of life. However, there is no proof that parents’ massage actually improves the recovery rate because it is impossible to be certain that they actually perform the massage at home or that their technique is correct. Crigler was the first to suggest that CNLDO can be resolved with a forceful pressure over the nasolacrimal system that increases hydrostatic pressure, hopefully leading to rupture of the membrane obstructing the nasolacrimal duct at its lower end.10 Kushner11 reported that, when using this technique, he had 31% success in resolving CNLDO in children younger than 1 year. More recently, Stolovitch and Michaeli12 reported that their success with this maneuver was maximal when performed in the first 2 months of life (56% success), declining significantly in children older than 6 months (28% success). They also found that more than one try is often needed because more than half of their successes were achieved at the second or third attempts. Our study shows that despite these favorable reports, less than half of pediatric ophthalmologists routinely perform the Crigler maneuver in children younger than 6 months of age at the initial office visit. Office probing is another treatment option for infants with CNLDO, usually performed when CNLDO did not self-resolve by the age of 6 months. Its advantages include immediate resolution of symptoms, avoidance of general anesthesia, reduced number of office visits, and lower cost of treatment.11,13 However, it is also possible that many of these cases would eventually spontaneously resolve, negating the need for early surgical intervention. Recently, PEDIG published their findings that office probing was successful in resolving CNLDO in threefourths of children aged 6 to 15 months.14 Some authors believe that office probing is by far less stressful and traumatic to the parents than a visit to the operating room that involves general anesthesia.11,15 In our survey, it was determined that office probing is performed by a minority of pediatric ophthalmologists, done almost exclusively by practitioners with more than 10 years of practice. In our survey, more than 90% of pediatric ophthalmologists believed that initial surgical intervention for CNDLO under general anesthesia should be performed around the age of 1 year. This recommendation coincides with prior studies finding a high spontaneous cure rate of CNLDO in children younger than 13 months old and a dramatic decline in surgical success beyond that age.16,17 Nearly 80% of responCopyright © SLACK Incorporated
TABLE 3
Findings of PEDIG Studies on Primary and Repeat Treatment of CNLDO at Increasing Agesa Procedure
Year of Publication
12 to 24 m
24 to 36 m
36 to 48 m
Primary probing
2008
79% (74% to 83%)
79% (65% to 88%)
56% (26% to 82%)
Primary balloon dacryoplasty
2008
86% (76% to 92%)
75% (60% to 86%)
Primary silicone intubation
2008
92% (86% to 96%)
84% (77% to 93%)b
Repeat probing
2009
56% (33% to 76%)
Repeat balloon dacryoplasty
2009
77% (65% to 85%)
Repeat silicone intubation
2009
84% (74% to 91%)
Primary treatment
Repeat treatment after failed probing
PEDIG = Pediatric Eye Disease Investigator Group; CNLDO = congenital nasolacrimal duct obstruction a Presented as percentage of successful cases at corresponding age. Percentages in parentheses are 95% confidence interval. b Maximal age of that group at that study was 45 months.
dents chose probing as primary surgical treatment at the age 13 months; however, when initial treatment is delayed to an older age, many preferred silicone tube intubation and/or balloon dacryoplasty over probing alone. Multiple PEDIG studies showed that silicone tube intubation and balloon dacryoplasty have better chances of resolving CNLDO compared to probing in older children; however, overlapping 95% confidence intervals of surgical success rates and the fact that these studies were non-randomized reflect inability to conclude on absolute superiority (Table 3).3-5 Increased cost of silicone tube intubation and balloon dacryoplasty compared to probing alone and increased risk of related complications are other factors taken into consideration when deciding on treatment preferences. When probing fails and symptoms recur, another surgical intervention is often required. Kushner11 reported that when initial probing failed, a second probing was usually similarly unsuccessful. Katowitz and Welsh found that second probing was successful in only 30% of children aged 13 to 24 months and was never attempted by them in children older than 2 years.17 In our study, it was determined that the most commonly performed procedures for secondary treatment of CNLDO after failed probing are silicone tube intubation and balloon dacryoplasty. Only 10% of respondents reported that they attempt re-probing alone in this situation. These responses reflect the findings of PEDIG studies in which repeat treatment with
silicone tube intubation and balloon dacryoplasty had higher success rates compared to probing alone (84% and 77% vs 56%); however, because these were nonrandomized, non-comparative studies, it is impossible to compare their results directly and conclude on superiority of any single intervention.18,19 Monocanalicular intubation was introduced approximately 20 years ago as an alternative to the bicanalicular approach.20 Easier insertion during surgery and subsequent removal in the office with a comparable success rate to bicanalicular intubation caused many surgeons to favor this intubation method.21 In our survey, it was determined that twice as many pediatric ophthalmologists preferred monocanalicular over bicanalicular intubations. The recommended duration of intubation required for achieving a successful outcome is controversial. Some authors believe that intubation of 4 to 6 weeks is sufficient,22,23 whereas others believe that the tubes should remain in place much longer.20 PEDIG reported that surgical success is diminished when duration of intubation is less than 2 months.19 Pediatric ophthalmologists responding to our survey most commonly prefer leaving the tubes in place between 3 and 4 months, followed by those who leave the tubes in place 5 to 6 months. The association between CNLDO and increased risk of amblyopia was discovered in recent years.6,7,24 Accordingly, more than 90% of pediatric ophthalmol-
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ogists responded that they regularly check refraction in children with CNLDO. Most of them would reexamine refraction during childhood at least once more even if initial examination was completely normal. There are several limitations to our study, mainly that less than 10% of AAPOS members responded to our survey. It is possible that this response rate reflects saturation of members toward taking surveys, which are sent to them by e-mail every 3 months. However, almost all of our responses were from pediatric ophthalmologists who routinely treat children with CNLDO and perform multiple surgeries for this condition. It is possible that other members with less clinical or surgical experience treating CNLDO were less inclined to take the survey. Although selection bias is an inherent flaw of survey studies, we have no reason to believe that the opinions of members who took the survey are different than those who did not. Another limitation is that the respondents were not balanced geographically; we received many more responses from North America than from the rest of the world. Therefore, the results of our study reflect more the policies of American and Canadian pediatric ophthalmologists than those of international members. Another important limitation is that these are self-reported practice preferences of pediatric ophthalmologists taking the time to respond to a survey questioning their attitudes toward CNLDO management and not the results of a randomized clinical trial; therefore, interpretation should be limited to realizing what is more commonly done, without stating that less common behaviors are necessarily wrong. This study highlights the striking lack of consensus among pediatric ophthalmologists in many aspects of management of CNLDO. Practitioners should reflect on their management policies compared to those presented in this study, while realizing that many factors are usually taken into account when reaching a treatment preference. Socioeconomic, geographic, and climatic differences are just a few factors that can differ significantly in different practices, causing variances in preferred treatments for children with CNLDO. REFERENCES
1. MacEwen CJ, Young JD. Epiphora during the first year of life. Eye (Lond). 1991;5:596-600. 2. Pediatric Eye Disease Investigator Group. Resolution of congenital nasolacrimal duct obstruction with nonsurgical management. Arch Ophthalmol. 2012;130:730-734. 3. Repka MX, Chandler DL, Beck RW, et al.; Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct ob-
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struction with probing in children younger than 4 years. Ophthalmology. 2008;115:577-584.e3. 4. Repka MX, Melia BM, Beck RW, et al.; Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age. J AAPOS. 2008;12:445-450. 5. Repka MX, Wallace DK, Melia BM, et al.; Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with balloon catheter dilation in children younger than 4 years of age. J AAPOS. 2008;12:451-455. 6. Matta NS, Silbert DI. High prevalence of amblyopia risk factors in preverbal children with nasolacrimal duct obstruction. J AAPOS. 2011;15:350-352. 7. Piotrowski JT, Diehl NN, Mohney BG. Neonatal dacryostenosis as a risk factor for anisometropia. Arch Ophthalmol. 2010;128:1166-1169. 8. Fayet B, Katowitz WR, Racy E, Ruban JM, Katowitz JA. Pushed monocanalicular intubation: an alternative stenting system for the management of congenital nasolacrimal duct obstructions. J AAPOS. 2012;16:468-472. 9. Nelson LR, Calhoun JH, Menduke H. Medical management of congenital nasolacrimal duct obstruction. Pediatrics. 1985;76:172-175. 10. Crigler LW. The treatment of congenital dacryocystitis. JAMA. 1923;81:23-24. 11. Kushner BJ. Congenital nasolacrimal system obstruction. Arch Ophthalmol. 1982;100:597-600. 12. Stolovitch C, Michaeli A. Hydrostatic pressure as an office procedure for congenital nasolacrimal duct obstruction. J AAPOS. 2006;10:269-272. 13. Frick KD, Hariharan L, Repka MX, Chandler D, Melia BM, Beck RW; Pediatric Eye Disease Investigator Group. Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruction in infants: the importance of the spontaneous resolution rate. Arch Ophthalmol. 2011;129:603-609. 14. Miller AM, Chandler DL, Repka MX, et al. Office probing for treatment of nasolacrimal duct obstruction in infants. J AAPOS. 2014;18:26-30. 15. Kapadia MK, Freitag SK, Woog JJ. Evaluation and management of congenital nasolacrimal duct obstruction. Otolaryngol Clin North Am. 2006;39:959-977, vii. 16. Al-Faky YH, Al-Sobaie N, Mousa A, et al. Evaluation of treatment modalities and prognostic factors in children with congenital nasolacrimal duct obstruction. J AAPOS. 2012;16:53-57. 17. Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology. 1987;94:698-705. 18. Repka MX, Chandler DL, Bremer DL, Collins ML, Lee DH; Pediatric Eye Disease Investigator Group. Repeat probing for treatment of persistent nasolacrimal duct obstruction. J AAPOS. 2009;13:306-307. 19. Repka MX, Chandler DL, Holmes JM, et al. Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing. Arch Ophthalmol. 2009;127:633-639. 20. Kaufman LM, Guay-Bhatia LA. Monocanalicular intubation with Monoka tubes for the treatment of congenital nasolacrimal duct obstruction. Ophthalmology. 1998;105:336-341. 21. Andalib D, Gharabaghi D, Nabai R, Abbaszadeh M. Monocanalicular versus bicanalicular silicone intubation for congenital nasolacrimal duct obstruction. J AAPOS. 2010;14:421-424. 22. Lee H, Ahn J, Lee JM, Park M, Baek S. Clinical effectiveness of monocanalicular and bicanalicular silicone intubation for congenital nasolacrimal duct obstruction. J Craniofac Surg. 2012;23:1010-1014. 23. 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. 24. Matta NS, Singman EL, Silbert DI. Prevalence of amblyopia risk factors in congenital nasolacrimal duct obstruction. J AAPOS. 2010;14:386-388.
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Congenital Nasolacrimal Duct Obstruction Management Policies
*1. What type of AAPOS member are you? Active
Associate Affiliate
International
Candidate-in-training Orthoptist
Other (please specify)
*2. How many years have you been in practice? Less than 5 years
Between 5-10 years
Between 11-20 years More than 20 years
*3. Do you perform surgery for congenital nasolacrimal duct obstruction (CNLDO)? Yes No
*4. How many procedures do you perform yearly? N/A (I never perform this procedure)
Less than 10 cases Between 10-20 cases Between 21-50 cases More than 50 cases
5. Do you recommend parents to massage the nasolacrimal duct of an infant less than 6 months old with CNLDO? Yes No
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Congenital Nasolacrimal Duct Obstruction Management Policies 6. Do you perform the Crigler maneuver on the initial visit of a child less than 6 months old with CNLDO? Yes No
7. Do you perform probing in the office for infants with CNLDO? Yes No
8. What is the maximum age you perform probing in the office? N/A (I never perform this procedure in the office) 3 months 6 months 9 months
12 months
9. At what age do you usually begin recommending surgical treatment for CNLDO under general anesthesia? Age of 13-16 months Age of 17-24 months Age of 24-36 months
Age of more than 36 months Other (please specify)
10. What is your usual primary CNLDO surgical treatment for a 13 months old infant (first intervention, assuming you were operating at that age)? Probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
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Congenital Nasolacrimal Duct Obstruction Management Policies 11. What is your usual primary CNLDO surgical treatment for a 24 months old child (first intervention)? Probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
12. What is your usual primary CNLDO surgical treatment for 36 months old child (first intervention)? Probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
13. What is your usual secondary procedure for persistent CNLDO following failed probing (records indicate simple obstruction)? Repeat probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
14. What is your preferred method of silicone intubation? N/A (I never perform silicone intubations) Monocanalicular
Bicanalicular
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Congenital Nasolacrimal Duct Obstruction Management Policies 15. For monocanalicular intubation, which is your preferred canaliculus for placement of the silicone tube? N/A (I never perform monocanalicular intubations) Upper Lower
I don’t have a preference
16. For monocanalicular intubation, what is your preferred technique? N/A (I never perform monocanalicular intubations) Pulled
Pushed
I don’t have a preference
Other (please specify)
17. For bicanalicular intubation, where do you usually retrieve the tube? N/A (I never perform bicanalicular intubations) In the office
In the operating room (under general anesthesia)
18. How long do you usually keep the silicone tube in place? N/A (I never perform silicone intubations) 1 month
2 months
3-4 months 5-6 months
Other (please specify)
19. Do you think it is necessary to check refraction of a 6-month-old infant with CNLDO on initial visit or soon thereafter? Yes No
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Congenital Nasolacrimal Duct Obstruction Management Policies 20. Assuming that a 6-month-old infant with CNLDO has refraction within normal limits, at what age would you reexamine refraction? 1-2 years 3-4 years 5-6 years Never
21. Do you regularly follow children with CNLDO for development of amblyopia? Yes No
Page 5
ABSTRACT Purpose: To study common management policies of congenital nasolacrimal duct obstruction (CNDLO) among pediatric ophthalmologists. Methods: A 21-question survey was sent to members of the American Association for Pediatric Ophthalmology and Strabismus in April 2014. The questions focused on treatment of CNLDO during the first year of life, primary and secondary surgical interventions, surgical techniques, and amblyopia assessment. Results: One hundred twenty-seven members completed the survey and 121 responses were analyzed after replies of 6 candidates in training were excluded. Eighty-two percent of respondents instructed caregivers to massage the nasolacrimal duct during the first year of life; however, 55% did not perform the Crigler massage in the office. Outpatient probing was done by 17% of pediatric ophthalmologists who took the survey, almost all of whom (95%) have been in practice more than 10 years. Ninety-one percent recommended
INTRODUCTION Congenital nasolacrimal duct obstruction (CNLDO) occurs in approximately 6% to 20% of newborns.1 Many obstructions resolve spontaneously or with simple medical treatment during the first
surgery for CNLDO close to the age of 1 year and 79% performed probing as initial treatment at that age. If treatment is delayed to the age of 2 years, 53% favored silicone tube intubation and/or balloon dacryoplasty. Following failed probing, silicone tube intubation was performed by 51% of practitioners. Ninety-one percent of respondents routinely checked refraction of infants with CNLDO and recommended reexamination even if initial assessment was entirely normal. Conclusions: This study highlights the striking lack of consensus among pediatric ophthalmologists in many aspects of management of CNLDO and allows practitioners to compare their practice patterns regarding CNLDO management with those of their peers; however, because it provides only the opinions of a limited group of pediatric ophthalmologists, it does not imply that less common practices are wrong. [J Pediatr Ophthalmol Strabismus 20XX;XX(X):XXXX.]
year of life; however, unresolved cases typically require surgical intervention, occasionally more than once.2 In recent years, there were several developments concerning CNLDO, including publication of multiple multicenter studies conducted by the
From the Department of Ophthalmology, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel (GD); and Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania (GD, LBN). Submitted: September 24, 2014; Accepted: October 2, 2014; Posted online: November 4, 2014 The authors have no financial or proprietary interest in the materials presented herein. Dr. Nelson did not participate in the editorial review of this manuscript. Correspondence: Gad Dotan, MD, Department of Ophthalmology, Tel Aviv Medical Center, 6 Weizmann Street, Tel Aviv 64239, Israel. E-mail: [email protected] doi: 10.3928/01913913-20141028-01
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Pediatric Eye Disease Investigator Group (PEDIG), reports on association of CNLDO with ametropia and amblyopia, and introduction of new surgical techniques and instrumentation.3-8 In this study, we evaluated how these changes affected the management of CNLDO by pediatric ophthalmologists. MATERIALS AND METHODS A survey questioning CNLDO management was sent in April 2014 to 1,495 members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) through an e-mail communication containing a hyperlink to an electronic survey (www. surveymonkey.com). A reminder to take the survey was sent 2 weeks later through the listserv of the organization. The survey contained 21 multiple-choice questions (Appendix A, available in the online version of this article) that included demographic information of the respondent regarding type of AAPOS membership, length of practice, experience with surgical treatment of CNLDO, and number of procedures performed yearly. Questions on CNLDO management focused on treatment during the first year of life, preferred primary treatments at increasing ages, preferred repeat procedure following prior probing failure, silicone tube intubation policies, and assessment of ametropia and amblyopia. Respondents were allowed to skip questions they did not want to reply to and were allowed to choose an “other” option whenever the provided options did not match their policies. The surveys were completely anonymous and did not contain any identifying information. To ensure that it was impossible to link responses with their providers, the Internet protocol address (an automatic numerical value allocated to every computer connected to the Web) was removed from individual responses at the time of analysis. The International Review Board committee of the Wills Eye Hospital, Philadelphia, Pennsylvania, considered this study to be exempt from International Review Board review and approval. Statistical analysis was performed using Prism 6 statistical software (GraphPad Software, Inc., San Diego, CA). Descriptive statistics are provided, mostly summarizing positive responses and percentages, calculated from the total answers provided to each question. All statistical inference testing was two-tailed at an alpha level of 5%. Analysis of counts of categorical variables was performed using Fisher’s exact test. Proportion of responses of North American (from the United States and Canada) 2
versus international members was compared using a two-proportions test. RESULTS Respondents
One hundred twenty-seven AAPOS members completed the survey. Responses of 6 candidates in training were excluded from analysis because it was assumed that their replies reflected more the attitudes of their mentors rather than their own personal experience, causing a potential source of bias if their instructors also took the survey. The survey was completed by many more North American pediatric ophthalmologists (84%, 101 of 121) than international members (16%, 20 of 121); however, these differences reflected their different proportions in the organization: 101 of 1,181 (8.5%) North American AAPOS members took the survey compared to 20 of 314 (6.3%) international members, and this difference was not statistically significant (P = .173). There was also a greater response from pediatric ophthalmologists who had been in practice more than 10 years (76%, 92 of 121) than from members with fewer years of experience (24%, 29 of 121). Almost all (95%, 115 of 121) members who took the survey responded that they regularly treat children with CNLDO and have experience performing surgery for this condition; 59% (71 of 121) estimated that they perform more than 20 lacrimal system surgeries per year. CNLDO Treatment During the First Year of Life
Forty-five percent (53 of 118) of respondents replied that they perform the Crigler maneuver on the initial visit of a child younger than 6 months old with CNLDO, and 82% (99 of 121) instruct caregivers to massage the nasolacrimal duct at home. Seventeen percent (20 of 121) confirmed that they perform office probing. Recommendation of caregivers to massage the nasolacrimal duct and performance of Crigler maneuver was similarly reported by pediatric ophthalmologists with more than 10 years of experience and those with less duration of practice (Table 1). However, a considerable difference existed between these groups in regard to office probing; 3% (1 of 29) of clinicians with less than 10 years of experience reported performing outpatient probing compared to 21% (19 of 92) of those in practice at least 10 years (P = .041). Many of those who perform outpatient probing replied that they would consider outpatient probing in a 12-month-old infant (65%, 13 of 20), whereas others Copyright © SLACK Incorporated
TABLE 1
Comparison of CNLDO Treatment During the First Year of Life by Pediatric Ophthalmologists With ≤ and > 10 Years of Practicea ≤ 10 Years in Practice (n = 29)
> 10 Years in Practice (n = 92)
All (n = 121)
Pb
Recommend caregivers to massage the NLD
26 (90%)
73 (79%)
99 (82%)
.275
Perform the Crigler maneuver
12 (41%)
41 (46%)
53 (45%)
.674
Perform probing in the office
1 (3%)
19 (21%)
20 (17%)
.041b
Treatment
CNLDO = congenital nasolacrimal duct obstruction; NLD = nasolacrimal duct obstruction a Numbers represent positive responses and percentages are calculated from the total number of respondents of the category. b Statistically significant results. TABLE 2
Preferred Surgical Treatment at Increasing Ages Divided by Length of Practicea Age at Initial Surgery (mo) 12
24
36
Repeat procedure
Length of Practice (y)
Probing
Silicone Intubation
Balloon Dacryoplasty
Balloon & Silicone Intubation
Othersb
P .219
≤ 10
23 (80%)
5 (17%)
0
1 (3%)
0
> 10
72 (79%)
15 (16%)
4 (4%)
0
0
All
95 (79%)
20 (17%)
4 (3%)
1 (< 1%)
0
≤ 10
10 (34%)
7 (24%)
9 (31%)
2 (7%)
1 (3%)
> 10
45 (50%)
28 (31%)
16 (18%)
1 (1%)
0
All
55 (46%)
35 (29%)
25 (21%)
3 (3%)
1 (< 1%)
≤ 10
7 (24%)
10 (34%)
10 (34%)
1 (3%)
1 (3%)
> 10
31 (34%)
35 (39%)
18 (20%)
5 (6%)
1 (1%)
All
38 (32%)
45 (38%)
28 (24%)
6 (5%)
2 (2%)
≤ 10
2 (7%)
12 (41%)
10 (34%)
2 (7%)
3 (10%)
> 10
10 (11%)
48 (54%)
17 (19%)
9 (10%)
5 (6%)
All
12 (10%)
60 (51%)
27 (23%)
11 (9%)
8 (7%)
.096
.389
.304
Numbers indicate positive responses and number in parentheses are percentages of total responses. P values represent the result of chi-square test comparing preferred procedure of practitioners with ≤ 10 versus > 10 years of practice. b Others include responses that do not fit any category, such as referral to oculoplastics. a
(25%, 5 of 20) reported that they consider the age of 9 months to be maximal for office probing. Surgical Treatment
Seventy-nine percent (95 of 121) replied that they start recommending surgical intervention under general anesthesia for unresolved CNLDO at the age of 13 months. An additional 12% (14 of 121) recommend surgery for infants who are 10 to 12 months old. Seventy-nine percent (95 of 120) chose probing as primary CNLDO treatment in children who are 1 year old, followed by silicone tube intubation (17%, 20 of 120). In children who first have surgery at the age of 2 years, 53% (63 of 119) chose non-probing procedures (ie, silicone tube intubation and/or balloon dacryoplasty) for initial treat-
ment, even though probing was the most common single response (46%, 55 of 119). In children whose initial surgical treatment is further delayed to the age of 3 years, the proportion of practitioners who reported performing silicone tube intubation and/or balloon dacryoplasty increased to 67% (79 of 119). In case prior probing fails to resolve CNLDO and a second intervention is required, most respondents elected to perform silicone intubation either alone (51%, 60 of 118) or in combination with balloon dacryoplasty (9%, 11 of 118); an additional 23% (27 of 118) chose balloon dacryoplasty as the preferred treatment and 10% (12 of 118) replied that they would attempt another probing alone. Preference of surgical procedure was not different based on length of practice of providers (Table 2).
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Figure 1. Recommended duration of silicone tube intubation.
Silicone Intubation
Sixty-four percent (67 of 105) of respondents who perform silicone intubation preferred monocanalicular tubes, which are nearly equally placed in the lower (48%, 39 of 81) and upper (42%, 34 of 81) puncti, usually using the pulled technique (80%, 62 of 78). Silicone tubes are most commonly left in place between 3 and 4 months (52%, 55 of 106), followed by intubation of 5 to 6 months (29%, 31 of 106) (Figure 1). Of bicanalicular tubes, two-thirds (48 of 73) are removed in the office and the remaining third (25 of 73) are removed in the operating room under general anesthesia. Risk of Amblyopia
Ninety-one percent (106 of 117) of respondents reported that they regularly check refraction of a 6-month-old infant with CNLDO at the time of initial visit or soon thereafter. Assuming that refraction findings were normal at initial examination, 45% (53 of 119) recommend rechecking refraction at the age of 1 to 2 years, 29% (35 of 119) at 3 to 4 years, and 4% (5 of 119) when the child starts school. However, 22% (26 of 119) of providers replied that they would never reexamine refraction of such a child. DISCUSSION This study reports on common attitudes of pediatric ophthalmologists in different aspects of CNLDO management and compared preferences of providers with more than 10 years of experience to those with fewer years of practice. Many cases of CNLDO resolve during the first year of life either spontaneously or with conservative treatment.9 Recently, it was reported that two-thirds of children who had CNLDO symptoms at the age of 6 months were cured with conservative treatment alone within the following 6 months.2 In our study, 4
it was determined that nasolacrimal duct massage is a frequently recommended treatment for children with CNLDO during the first year of life. However, there is no proof that parents’ massage actually improves the recovery rate because it is impossible to be certain that they actually perform the massage at home or that their technique is correct. Crigler was the first to suggest that CNLDO can be resolved with a forceful pressure over the nasolacrimal system that increases hydrostatic pressure, hopefully leading to rupture of the membrane obstructing the nasolacrimal duct at its lower end.10 Kushner11 reported that, when using this technique, he had 31% success in resolving CNLDO in children younger than 1 year. More recently, Stolovitch and Michaeli12 reported that their success with this maneuver was maximal when performed in the first 2 months of life (56% success), declining significantly in children older than 6 months (28% success). They also found that more than one try is often needed because more than half of their successes were achieved at the second or third attempts. Our study shows that despite these favorable reports, less than half of pediatric ophthalmologists routinely perform the Crigler maneuver in children younger than 6 months of age at the initial office visit. Office probing is another treatment option for infants with CNLDO, usually performed when CNLDO did not self-resolve by the age of 6 months. Its advantages include immediate resolution of symptoms, avoidance of general anesthesia, reduced number of office visits, and lower cost of treatment.11,13 However, it is also possible that many of these cases would eventually spontaneously resolve, negating the need for early surgical intervention. Recently, PEDIG published their findings that office probing was successful in resolving CNLDO in threefourths of children aged 6 to 15 months.14 Some authors believe that office probing is by far less stressful and traumatic to the parents than a visit to the operating room that involves general anesthesia.11,15 In our survey, it was determined that office probing is performed by a minority of pediatric ophthalmologists, done almost exclusively by practitioners with more than 10 years of practice. In our survey, more than 90% of pediatric ophthalmologists believed that initial surgical intervention for CNDLO under general anesthesia should be performed around the age of 1 year. This recommendation coincides with prior studies finding a high spontaneous cure rate of CNLDO in children younger than 13 months old and a dramatic decline in surgical success beyond that age.16,17 Nearly 80% of responCopyright © SLACK Incorporated
TABLE 3
Findings of PEDIG Studies on Primary and Repeat Treatment of CNLDO at Increasing Agesa Procedure
Year of Publication
12 to 24 m
24 to 36 m
36 to 48 m
Primary probing
2008
79% (74% to 83%)
79% (65% to 88%)
56% (26% to 82%)
Primary balloon dacryoplasty
2008
86% (76% to 92%)
75% (60% to 86%)
Primary silicone intubation
2008
92% (86% to 96%)
84% (77% to 93%)b
Repeat probing
2009
56% (33% to 76%)
Repeat balloon dacryoplasty
2009
77% (65% to 85%)
Repeat silicone intubation
2009
84% (74% to 91%)
Primary treatment
Repeat treatment after failed probing
PEDIG = Pediatric Eye Disease Investigator Group; CNLDO = congenital nasolacrimal duct obstruction a Presented as percentage of successful cases at corresponding age. Percentages in parentheses are 95% confidence interval. b Maximal age of that group at that study was 45 months.
dents chose probing as primary surgical treatment at the age 13 months; however, when initial treatment is delayed to an older age, many preferred silicone tube intubation and/or balloon dacryoplasty over probing alone. Multiple PEDIG studies showed that silicone tube intubation and balloon dacryoplasty have better chances of resolving CNLDO compared to probing in older children; however, overlapping 95% confidence intervals of surgical success rates and the fact that these studies were non-randomized reflect inability to conclude on absolute superiority (Table 3).3-5 Increased cost of silicone tube intubation and balloon dacryoplasty compared to probing alone and increased risk of related complications are other factors taken into consideration when deciding on treatment preferences. When probing fails and symptoms recur, another surgical intervention is often required. Kushner11 reported that when initial probing failed, a second probing was usually similarly unsuccessful. Katowitz and Welsh found that second probing was successful in only 30% of children aged 13 to 24 months and was never attempted by them in children older than 2 years.17 In our study, it was determined that the most commonly performed procedures for secondary treatment of CNLDO after failed probing are silicone tube intubation and balloon dacryoplasty. Only 10% of respondents reported that they attempt re-probing alone in this situation. These responses reflect the findings of PEDIG studies in which repeat treatment with
silicone tube intubation and balloon dacryoplasty had higher success rates compared to probing alone (84% and 77% vs 56%); however, because these were nonrandomized, non-comparative studies, it is impossible to compare their results directly and conclude on superiority of any single intervention.18,19 Monocanalicular intubation was introduced approximately 20 years ago as an alternative to the bicanalicular approach.20 Easier insertion during surgery and subsequent removal in the office with a comparable success rate to bicanalicular intubation caused many surgeons to favor this intubation method.21 In our survey, it was determined that twice as many pediatric ophthalmologists preferred monocanalicular over bicanalicular intubations. The recommended duration of intubation required for achieving a successful outcome is controversial. Some authors believe that intubation of 4 to 6 weeks is sufficient,22,23 whereas others believe that the tubes should remain in place much longer.20 PEDIG reported that surgical success is diminished when duration of intubation is less than 2 months.19 Pediatric ophthalmologists responding to our survey most commonly prefer leaving the tubes in place between 3 and 4 months, followed by those who leave the tubes in place 5 to 6 months. The association between CNLDO and increased risk of amblyopia was discovered in recent years.6,7,24 Accordingly, more than 90% of pediatric ophthalmol-
Journal of Pediatric Ophthalmology & Strabismus • Vol. xx, No. x, 20XX
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ogists responded that they regularly check refraction in children with CNLDO. Most of them would reexamine refraction during childhood at least once more even if initial examination was completely normal. There are several limitations to our study, mainly that less than 10% of AAPOS members responded to our survey. It is possible that this response rate reflects saturation of members toward taking surveys, which are sent to them by e-mail every 3 months. However, almost all of our responses were from pediatric ophthalmologists who routinely treat children with CNLDO and perform multiple surgeries for this condition. It is possible that other members with less clinical or surgical experience treating CNLDO were less inclined to take the survey. Although selection bias is an inherent flaw of survey studies, we have no reason to believe that the opinions of members who took the survey are different than those who did not. Another limitation is that the respondents were not balanced geographically; we received many more responses from North America than from the rest of the world. Therefore, the results of our study reflect more the policies of American and Canadian pediatric ophthalmologists than those of international members. Another important limitation is that these are self-reported practice preferences of pediatric ophthalmologists taking the time to respond to a survey questioning their attitudes toward CNLDO management and not the results of a randomized clinical trial; therefore, interpretation should be limited to realizing what is more commonly done, without stating that less common behaviors are necessarily wrong. This study highlights the striking lack of consensus among pediatric ophthalmologists in many aspects of management of CNLDO. Practitioners should reflect on their management policies compared to those presented in this study, while realizing that many factors are usually taken into account when reaching a treatment preference. Socioeconomic, geographic, and climatic differences are just a few factors that can differ significantly in different practices, causing variances in preferred treatments for children with CNLDO. REFERENCES
1. MacEwen CJ, Young JD. Epiphora during the first year of life. Eye (Lond). 1991;5:596-600. 2. Pediatric Eye Disease Investigator Group. Resolution of congenital nasolacrimal duct obstruction with nonsurgical management. Arch Ophthalmol. 2012;130:730-734. 3. Repka MX, Chandler DL, Beck RW, et al.; Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct ob-
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struction with probing in children younger than 4 years. Ophthalmology. 2008;115:577-584.e3. 4. Repka MX, Melia BM, Beck RW, et al.; Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age. J AAPOS. 2008;12:445-450. 5. Repka MX, Wallace DK, Melia BM, et al.; Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with balloon catheter dilation in children younger than 4 years of age. J AAPOS. 2008;12:451-455. 6. Matta NS, Silbert DI. High prevalence of amblyopia risk factors in preverbal children with nasolacrimal duct obstruction. J AAPOS. 2011;15:350-352. 7. Piotrowski JT, Diehl NN, Mohney BG. Neonatal dacryostenosis as a risk factor for anisometropia. Arch Ophthalmol. 2010;128:1166-1169. 8. Fayet B, Katowitz WR, Racy E, Ruban JM, Katowitz JA. Pushed monocanalicular intubation: an alternative stenting system for the management of congenital nasolacrimal duct obstructions. J AAPOS. 2012;16:468-472. 9. Nelson LR, Calhoun JH, Menduke H. Medical management of congenital nasolacrimal duct obstruction. Pediatrics. 1985;76:172-175. 10. Crigler LW. The treatment of congenital dacryocystitis. JAMA. 1923;81:23-24. 11. Kushner BJ. Congenital nasolacrimal system obstruction. Arch Ophthalmol. 1982;100:597-600. 12. Stolovitch C, Michaeli A. Hydrostatic pressure as an office procedure for congenital nasolacrimal duct obstruction. J AAPOS. 2006;10:269-272. 13. Frick KD, Hariharan L, Repka MX, Chandler D, Melia BM, Beck RW; Pediatric Eye Disease Investigator Group. Cost-effectiveness of 2 approaches to managing nasolacrimal duct obstruction in infants: the importance of the spontaneous resolution rate. Arch Ophthalmol. 2011;129:603-609. 14. Miller AM, Chandler DL, Repka MX, et al. Office probing for treatment of nasolacrimal duct obstruction in infants. J AAPOS. 2014;18:26-30. 15. Kapadia MK, Freitag SK, Woog JJ. Evaluation and management of congenital nasolacrimal duct obstruction. Otolaryngol Clin North Am. 2006;39:959-977, vii. 16. Al-Faky YH, Al-Sobaie N, Mousa A, et al. Evaluation of treatment modalities and prognostic factors in children with congenital nasolacrimal duct obstruction. J AAPOS. 2012;16:53-57. 17. Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology. 1987;94:698-705. 18. Repka MX, Chandler DL, Bremer DL, Collins ML, Lee DH; Pediatric Eye Disease Investigator Group. Repeat probing for treatment of persistent nasolacrimal duct obstruction. J AAPOS. 2009;13:306-307. 19. Repka MX, Chandler DL, Holmes JM, et al. Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing. Arch Ophthalmol. 2009;127:633-639. 20. Kaufman LM, Guay-Bhatia LA. Monocanalicular intubation with Monoka tubes for the treatment of congenital nasolacrimal duct obstruction. Ophthalmology. 1998;105:336-341. 21. Andalib D, Gharabaghi D, Nabai R, Abbaszadeh M. Monocanalicular versus bicanalicular silicone intubation for congenital nasolacrimal duct obstruction. J AAPOS. 2010;14:421-424. 22. Lee H, Ahn J, Lee JM, Park M, Baek S. Clinical effectiveness of monocanalicular and bicanalicular silicone intubation for congenital nasolacrimal duct obstruction. J Craniofac Surg. 2012;23:1010-1014. 23. 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. 24. Matta NS, Singman EL, Silbert DI. Prevalence of amblyopia risk factors in congenital nasolacrimal duct obstruction. J AAPOS. 2010;14:386-388.
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Congenital Nasolacrimal Duct Obstruction Management Policies
*1. What type of AAPOS member are you? Active
Associate Affiliate
International
Candidate-in-training Orthoptist
Other (please specify)
*2. How many years have you been in practice? Less than 5 years
Between 5-10 years
Between 11-20 years More than 20 years
*3. Do you perform surgery for congenital nasolacrimal duct obstruction (CNLDO)? Yes No
*4. How many procedures do you perform yearly? N/A (I never perform this procedure)
Less than 10 cases Between 10-20 cases Between 21-50 cases More than 50 cases
5. Do you recommend parents to massage the nasolacrimal duct of an infant less than 6 months old with CNLDO? Yes No
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Congenital Nasolacrimal Duct Obstruction Management Policies 6. Do you perform the Crigler maneuver on the initial visit of a child less than 6 months old with CNLDO? Yes No
7. Do you perform probing in the office for infants with CNLDO? Yes No
8. What is the maximum age you perform probing in the office? N/A (I never perform this procedure in the office) 3 months 6 months 9 months
12 months
9. At what age do you usually begin recommending surgical treatment for CNLDO under general anesthesia? Age of 13-16 months Age of 17-24 months Age of 24-36 months
Age of more than 36 months Other (please specify)
10. What is your usual primary CNLDO surgical treatment for a 13 months old infant (first intervention, assuming you were operating at that age)? Probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
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Congenital Nasolacrimal Duct Obstruction Management Policies 11. What is your usual primary CNLDO surgical treatment for a 24 months old child (first intervention)? Probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
12. What is your usual primary CNLDO surgical treatment for 36 months old child (first intervention)? Probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
13. What is your usual secondary procedure for persistent CNLDO following failed probing (records indicate simple obstruction)? Repeat probing
Balloon catheter dilatation Silicone intubation
Balloon catheter dilatation and silicone intubation Other (please specify)
14. What is your preferred method of silicone intubation? N/A (I never perform silicone intubations) Monocanalicular
Bicanalicular
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Congenital Nasolacrimal Duct Obstruction Management Policies 15. For monocanalicular intubation, which is your preferred canaliculus for placement of the silicone tube? N/A (I never perform monocanalicular intubations) Upper Lower
I don’t have a preference
16. For monocanalicular intubation, what is your preferred technique? N/A (I never perform monocanalicular intubations) Pulled
Pushed
I don’t have a preference
Other (please specify)
17. For bicanalicular intubation, where do you usually retrieve the tube? N/A (I never perform bicanalicular intubations) In the office
In the operating room (under general anesthesia)
18. How long do you usually keep the silicone tube in place? N/A (I never perform silicone intubations) 1 month
2 months
3-4 months 5-6 months
Other (please specify)
19. Do you think it is necessary to check refraction of a 6-month-old infant with CNLDO on initial visit or soon thereafter? Yes No
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Congenital Nasolacrimal Duct Obstruction Management Policies 20. Assuming that a 6-month-old infant with CNLDO has refraction within normal limits, at what age would you reexamine refraction? 1-2 years 3-4 years 5-6 years Never
21. Do you regularly follow children with CNLDO for development of amblyopia? Yes No
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