Original Article Probing for Congenital Nasolacrimal Duct Obstruction in Older Children Bahram Eshragi, Masoud Aghsaei Fard, Babak Masomian, Mohammadreza Akbari

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ABSTRACT Purpose: The purpose of this study was to evaluate the role of probing in congenital nasolacrimal duct obstruction in children age 2 years and older and to establish factors predictive of the outcome. Materials and Methods: A prospective study was conducted on consecutive patients older than 24 months with congenital nasolacrimal duct obstruction. All patients were treated with a simple nasolacrimal duct probing as primary treatment. Outcome measures included an ophthalmologic examination plus a parental history of residual symptoms at one and 6 months after surgery. Results: A total of 82 children with a mean age of 34.5 months (range, 24 months to 60 months) underwent nasolacrimal duct probing. The complete response rate was 54%. Partial response and failure were observed in 25% and 20.8% of the eyes, respectively. Bilateral obstruction was associated with failure of probing (P = 0.007, Odds Ratio: 5.76). However, age older than 36 months was not associated with the failure rate. Conclusion: Primary probing maintains a high success rate without any age related decline in congenital nasolacrimal duct obstruction.

Website: www.meajo.org DOI: 10.4103/0974-9233.120018 Quick Response Code:

Key words: Congenital Nasolacrimal Obstruction, Probing, Epiphora

INTRODUCTION

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ongenital nasolacrimal duct obstruction (CNLDO) is a common ophthalmic problem and may be present in up to 70% of newborns.1 Conservative management with topical antibiotics and lacrimal sac massage are appropriate during the first 6 months of age and half of CNLDO resolves with conservative management in infants at 6 months to less than 10 months of age.2 Nasolacrimal duct probing is usually considered beyond the age of one year.1,3 Studies vary as to whether delay in probing past 13 months of age might be associated with decreased success.1,4 Some ophthalmologists prefer silicone intubation as the initial surgical procedure for older children (older than 18 month) with CNLDO.3‑5 In contrast, some studies showed that late initial probing after 2 years of age gave a good result.6‑8 The disparate reports in the literature indicate the lack of consensus on the approach for management of CLNDO in older children. The purpose of this study is to determine, the results of nasolacrimal duct probing in children 2 years and older.

MATERIALS AND METHODS In this prospective non‑comparative interventional case series, 96 eyes of 82 consecutive patients between 2 years and 5 years old with CNLDO were probed under general anesthesia by one surgeon from February 2009 to June 2010. The study approved by the research ethics committee. Informed consent was obtained from all parents or guardians of each study patient, and the study adhered to the declaration of Helsinki. CNLDO was diagnosed clinically by the presence of epiphora beginning during the first few weeks of life and presence of at least one sign of CNLDO (epiphora, increased tear lake, and/ or mucopurulent discharge or reflux of contents of the lacrimal sac with pressure in the absence of upper respiratory tract infection, ocular surface irritation or glaucoma).2 Exclusion criteria included history of prior nasolacrimal surgery, craniofacial anomalies, history of trauma, Down syndrome, congenital dacryocystocele, punctum agenesis, and associated ocular disease.

Department of Ophthalmology, Farabi Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran Corresponding Author: Dr. Masoud Aghsaei Fard, Farabi Eye Research Center, Qazvin Sq., Tehran, Iran. E‑mail: [email protected]

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Eshragi, et al.: Probing for CNLDO in Older Children

The procedure was performed by one oculoplastic surgeon under brief inhalation anesthesia. After dilatation of the upper punctum, a Bowman’s probe (0 and 00) was introduced vertically into the punctum and ampulla and then rotated horizontally 90° in the same plane to enter the canaliculus, with lateral tension placed on the lid. The probe was then advanced until it touched a region of bony firmness; this indicated that it had reached the lacrimal sac. Then, the probe was rotated upward 90° and advanced down to the nasolacrimal meatus until it gave way through the membranous resistance into the nasal cavity. At this stage, we used another probe for detection of metal‑to‑metal contact below the inferior turbinate. The patency of the nasolacrimal system was evaluated by irrigation of saline through the superior punctum, flow of saline into the nose was confirmed by a pediatric size suction catheter that was placed below the inferior meatus.3 Patients were placed on topical medication for 2 weeks after the probing. Patients were followed at 1 month and 6 months after probing. At each follow‑up visit, parents were questioned on the symptoms and patients were examined for the presence of epiphora, increased lacrimal lake, mucous discharge, and/or regurgitation with pressure over the lacrimal sac. Complete resolution was defined as the absence of clinical signs of CNLDO on examination and not having the parental history of residual symptoms of CNLDO. The result was graded as partial, the parents reported symptoms of intermittent epiphora or mattering, but clinical examination did not show signs of CNLDO. Both complete and partial resolution was defined as an improvement. Patients with clinical signs of CNLDO on examination and constant symptoms were graded as a failed response. Data are presented as mean values. The t‑test and Chi‑square tests were used to compare means and proportions of categorical factors in different age groups. Statistical analyzes were performed with SPSS version 17.0 (IBM Corp., New York, USA). A P value less than 0.05 was considered statistically significant. Univariate analysis was used to determine factors that were significantly associated with failure of probing. These factors were also tested for association using the binary logistic regression and keeping failure of probing as the outcome variable. Odds ratio (OR) and 95% confidence interval (CI) are reported.

RESULTS Out of 82 patients, 68 with unilateral and 14 with bilateral CNLDO were included in this study. The series consisted of the 96 eyes with CNLDO in 82 patients. The mean patient age was 34.5 months range, (range, 24 months to 60 months). Fifty‑two patients (63.5%) were male. CNLDO was present in the right eye of 32 (39.1%) patients, in the left eye of 36 (43.9%) patients and was bilateral in14 (17%) patients. Of 96 eyes, 350

48 (50%) were aged 24 months to 35 months, 29 (30.2%) were aged 36 months to 47 months and 19 (19.8%) were aged 48 months to 60 months. All of the patients had undergone conservative management for varying duration before coming to our hospital. All children had membranous obstruction. No children had incomplete complex, non‑membranous CNLDO obstruction (with difficulty with probe passage with significant narrowing) or complete obstruction. After probing, 52 (54.2%) eyes were cured and responded completely to the surgery. Twenty‑four (25%) eyes had a partial response and in 20 (20.8%) eyes, probing failed. The cure rate was 50% in patients aged 24 months to 35 months, 66.7% in patients aged 36 months to 47 months and 44.4% in patients aged 48 months to 60 months. The cure rate was not significantly different between these groups (P = 0.23, Chi‑square). The failure rate was 14.7% in patients aged 24 months to 35 months, 30% in patients aged 36 months to 47 months and 22.2% in patients aged 48 months to 60 months. The failure rate was not significantly different between these three groups (P = 0.26, Chi‑square, Figure 1). Bilateral CNLDO was significantly associated with failure of probing on univariate analysis (P = 0.004). Age older than 36 months (P = 0.4), presence of pus (P = 0.6), and constant tearing (P = 0.3) were not associated with failure [Figure 2]. In order to determine the strength of association of each factor with the failure of probing, binary logistic regression was performed with bilateral affection, age older than 36 months, presence of pus, and constant tearing as variables. We found that 20% of failures could be predicted with this model and only bilateral involvement was statistically significantly (P = 0.007) associated with the failure rate (OR: 5.76; 95% CI: 1.59‑20.70). There were no significant differences in cure rate at one month and at the final follow‑up of 6 months (P = 0.65).

DISCUSSION Nasolacrimal duct probing is the standard treatment for CNLDO when conservative management has failed. Probing caries a high success rate in these patients.1,3 Controversy exists regarding the optimal timing of probing.1 Several other studies have reported a decrease in cure rates with delayed probing.4,5,9‑15 Sturrock et  al.11 reported that 86% of those probed under 1 year of age were corrected, compared to 72% of patients between 1 year and 2 years of age and 42% of patients probed who were 2 years old. Young et al.12 reported a cure rate of 54% in patients probed after 2 years of age. Other studies also demonstrated that success of probing correlated negatively with increasing age.13‑15

Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013

Eshragi, et al.: Probing for CNLDO in Older Children 

 

   

 



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Figure 1: Response rate based on age groups

However, a recent large prospective study showed no decline in success rates up to the age of 36 months.6 Robb16 found no prominent effect of age on the cure rate of probing, reporting that in children older than 2 years who underwent probing, the cure rate was 94%. We showed a cure rate (complete response) of 54.2% with probing. We believe that results of probing are not limited to a cure (complete response) or failed response. Some of the patients showed improvement of symptoms and parents were satisfied with the condition, even though their symptoms were not completely resolved. 20% of our patients had a partial response. Therefore, we regarded these results as improvements. According to this, improvement rate was 79.2% in our study. Bilateral CNLDO was significantly associated with failure of probing in our study (OR, 5.76; 95% CI, 1.59‑20.70), which is in agreement with previous studies.9,14 Patients with bilateral obstruction might be anatomically (because of bony narrowing) predisposed to failure of the procedure. Statistical analysis confirmed that there was no significant difference in success rate between age groups. This observation concurs with a previous study.16 In other studies, the cure rate decreased as age increased (especially after 2 years old).4,9,13‑15 Older children are more likely to have complicated, non‑membranous obstructions that might cause a reduction in the cure rate in those studies.5,9 Furthermore, firm obstruction was associated with age older than 36 months.14 Simple membranous obstruction was present in 94% of eyes in one study and success rate of probing was 87%.9 Success rate was 36% for non‑membranous complicated CNLDO.5,9 However, all of our patients had simple membranous obstruction that might explain a high and equal success rate in different age groups. The outcome of the cure rate at the one‑month postoperative follow up was 54.5% that was highly correlated with the result at the 6‑month follow up (53%). Hence, it seems that the early results could represent the final results of probing for CNLDO, which is in agreement with a number of previous studies.5,15

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Figure 2: The comparison of response to naso‑lacrimal duct probing in three different groups with pus reflux, constant tearing, and intermittent tearing at presentation

In our study, the number of patients in each age group varied and a few patients in the 36 months to 47 months group and 48 months to 60 months group might confound our results in terms of improvement rate. Therefore, we believe that for more conclusive results, another study with larger sample size of older children with CNLDO is required. In conclusion, three quarters of patients with late probing in our study had acceptable results. Although, there is controversy about the treatment of CNLDO in old children, in general, initial nasolacrimal duct probing is advised for children aged more than 24 months with simple membranous obstruction.

REFERENCES 1.

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Takahashi Y, Kakizaki H, Chan WO, Selva D. Management of congenital nasolacrimal duct obstruction. Acta Ophthalmol 2010;88:506‑13. Pediatric Eye Disease Investigator Group. Resolution of congenital nasolacrimal duct obstruction with nonsurgical management. Arch Ophthalmol 2012;130:730‑4. Olver J. Paediatric lacrimal surgery. In: Colour Atlas of Lacrimal Surgery. Oxford: Butterworth‑Heinemann; 2002. p. 69‑89. Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94:698‑705. Kushner BJ. The management of nasolacrimal duct obstruction in children between 18 months and 4 years old. J AAPOS 1998;2:57‑60. Pediatric Eye Disease Investigator Group, Repka MX, Chandler DL, Beck RW, Crouch ER 3rd, Donahue S, et al. Primary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years. Ophthalmology 2008;115:577‑584.e3. Maheshwari R. Results of probing for congenital nasolacrimal duct obstruction in children older than 13 months of age. Indian J Ophthalmol 2005;53:49‑51. Maheshwari R. Success rate and cause of failure for late probing for congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 2008;45:168‑71.

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Kashkouli MB, Kassaee A, Tabatabaee Z. Initial nasolacrimal duct probing in children under age 5: Cure rate and factors affecting success. J AAPOS 2002;6:360‑3. Ciftçi F, Akman A, Sönmez M, Unal M, Güngör A, Yaylali V. Systematic, combined treatment approach to nasolacrimal duct obstruction in different age groups. Eur J Ophthalmol 2000;10:324‑9. Sturrock SM, MacEwen CJ, Young JD. Long‑term results after probing for congenital nasolacrimal duct obstruction. Br J Ophthalmol 1994;78:892‑4. Young JD, MacEwen CJ, Ogston SA. Congenital nasolacrimal duct obstruction in the second year of life: A multicentre trial of management. Eye (Lond) 1996;10:485‑91. Mannor GE, Rose GE, Frimpong‑Ansah K, Ezra E. Factors affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction. Am J Ophthalmol 1999;127:616‑7.

14. Honavar SG, Prakash VE, Rao GN. Outcome of probing for congenital nasolacrimal duct obstruction in older children. Am J Ophthalmol 2000;130:42‑8. 15. Kashkouli MB, Beigi B, Parvaresh MM, Kassaee A, Tabatabaee Z. Late and very late initial probing for congenital nasolacrimal duct obstruction: What is the cause of failure? Br J Ophthalmol 2003;87:1151‑3. 16. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology 1998;105:1307‑9; discussion 1309‑10.

Cite this article as: Eshragi B, Fard MA, Masomian B, Akbari M. Probing for congenital nasolacrimal duct obstruction in older children. Middle East Afr J Ophthalmol 2013;20:349-52. Source of Support: Nil, Conflict of Interest: None declared.

Middle East African Journal of Ophthalmology, Volume 20, Number 4, October - December 2013

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Probing for congenital nasolacrimal duct obstruction in older children.

The purpose of this study was to evaluate the role of probing in congenital nasolacrimal duct obstruction in children age 2 years and older and to est...
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