Success Rate of Late Primary Probing in Congenital Nasolacrimal Duct Obstruction Mohammad Taher Rajabi, MD; Yalda Abrishami; Seyedeh Simindokht Hosseini, MD; Syed Ziaeddin Tabatabaee, MD; Mohammad Bagher Rajabi, MD; Jeffrey J. Hurwitz, MD, FRCSC
ABSTRACT Purpose: To investigate the clinical outcomes of late primary probing in congenital nasolacrimal duct (NLD) obstruction. Methods: A prospective interventional study was designed to recruit children older than 24 months who presented with clinical manifestations of NLD obstruction since February 2008 to Farabi Eye Hospital, Tehran, Iran. No prior surgical intervention for NLD obstruction was performed on these patients; they underwent probing of the nasolacrimal system and irrigation under general anesthesia by oculoplastic surgeons. The outcome of the procedure was assessed 2 to 3 months postoperatively. Data of the patients until February 2013 were considered for analysis.
in those who were 2 to 3 years old, 63% in those who were 3 to 4 years old, and 50% in those who were 4 to 5 years old. In patients with chronic dacryocystitis with mucopurulent discharge, 83% had successful probing and irrigation. In patients with epiphora with no mucopurulent discharge, 59% had successful results with probing. Conclusions: In the cases of congenital NLD obstruction, primary probing before 2 years of age has a high success rate; there is a high overall success rate (75.8%) in the 2- to 5-years age group, but when older than 5 years, further procedures such as intubation and dacryocystorhinostomy would be needed because of the high failure rate of probing.
Results: The total number of patients during the 5-year study was 343. The total success rate considering all of the age groups was 75.8%. The success rate was 85%
[J Pediatr Ophthalmol Strabismus 2014;51(6):360362.]
INTRODUCTION Nasolacrimal duct (NLD) obstruction is one of the most common congenital abnormalities.1 Appropriate time for probing the NLD is still under debate. Up to the age of 1 year, only 4% of cases of congenital NLD obstruction will not resolve spontaneously.2,3 The success rate of early probing at 1 to 2
years of age has been reported overall to be between 70% and 97% in the literature.4 Many surgeons believe that most cases of congenital NLD obstruction treated after 2 years of age by probing only may not be cured and may require an additional operation. The patient population in the current study comprised patients who presented with clinical manifes-
From Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran (MTR, YA, SSH, SZT, MBR); and the Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada (JJH). Submitted: April 14, 2014; Accepted: August 1, 2014; Posted online: September 16, 2014 The authors have no financial or proprietary interest in the materials presented herein. Correspondence: Yalda Abrishami, Eye Research Center, Farabi Eye Hospital, Qazvin Square, South Kargar Avenue, Tehran 1336616351, Iran. E-mail: [email protected] doi: 10.3928/01913913-20140909-02
360
Copyright © SLACK Incorporated
tations of NLD obstruction to Farabi Eye Hospital, Tehran, Iran, when they were older than 2 years. PATIENTS AND METHODS A prospective interventional study was designed to investigate the clinical outcomes and success rate of probing in children older than 2 years. Patients had a history of epiphora and discharge since birth that was considered congenital NLD obstruction, and were referred to Farabi Eye Hospital of Tehran University of Medical Sciences. Patients aged 2 to 5 years without previous treatment were scheduled for probing. The study was implemented in accordance with the tenets of the Declaration of Helsinki and was approved by the local ethics review committee of Tehran University of Medical Sciences. Informed consent of the parents was obtained after a complete explanation of the procedure and its complications. Cases with any craniofacial anomaly, manifest facial deformity, Down syndrome, or any history of trauma to the orbit or nose were not included. All patients underwent a brief slit-lamp examination to rule out punctal atresia. None of these patients underwent probing before and it was the first surgical intervention performed on the NLD. Surgery was performed under general anesthesia with gas mask ventilation. The lower punctum was dilated by an appropriately sized punctum dilator. A Bowman probe size 1.0 or 2.0 was vertically inserted in the punctum, advanced in the ampula, and then rotated horizontally into the lower canaliculus while the lower eyelid was stretched horizontally. After reaching a hard stop, it was rotated 90° radially in the horizontal plane to reach alignment with the NLD pathway and approximately 2 cm of the length of the probe was advanced forward into the NLD; the Bowman probe was then removed and irrigation was performed with a lacrimal cannula. At the same time, there was a suction tube in the same nostril and passage of the fluid visible in the draining suction tube confirmed patency. Topical
TABLE 1
Success Rate of Primary Probing in Different Age Groups
Age Group
Total No.
Success (Complete Success and Improvement)
2 to 3 years
217
184 (85%)
3 to 4 years
62
98 (63%)
4 to 5 years
28
14 (50%)
antibiotic drops were administered for several days after probing. Parents were recommended to return 2 to 3 months postoperatively. Complete success was defined as no pus or discharge and no remaining epiphora in this period after probing. We designed this study to demonstrate how often probing might cure these children. Failure was defined as existing mucopurulent discharge and persistent epiphora at the follow-up visit. Patients who had failed probing underwent NLD intubation or were scheduled for dacryocystorhinostomy. RESULTS There were 343 patients (165 female and 178 male) in the current study. There were 217 patients in the 2- to 3-year-old group, 98 patients in the 3- to 4-year-old group, and 28 patients in the 4- to 5-yearold group based on the age at the time of probing. The age limit was 5 years because there were also 8 patients in the 5- to 6-year-old group who underwent primary probing and had a 45% rate of success, but they were not considered in our analysis. Due to a lower success rate in patients older than 5 years, we decided to limit the study group to those between 2 and 5 years of age. Overall, the total success rate of probing considering all age groups was 75.8% (260 of 343 cases). Patients were categorized based on age groups and presence of mucopurulent discharge; comparable outcomes are shown in Tables 1-2 in different groups.
TABLE 2
Comparison of Clinical Outcomes Between Patients With Congenital NLD Obstruction With and Without Mucopurulent Discharge Group
No.
Complete Success
Improvement
Failure
Chronic dacryocystitis with mucopurulent discharge
231
134 (58%)
58 (25%)
39 (16%)
Epiphora without mucopurulent discharge
88
36 (41%)
16 (18%)
36 (41%)
NLD = nasolacrimal duct
Journal of Pediatric Ophthalmology & Strabismus • Vol. 51, No. 6, 2014
361
Eighteen patients had complex bony NLD obstruction that was diagnosed intraoperatively because the probe could not be advanced easily forward within the NLD and the bony stop could be sensed during probing in that area. Only 7 (38%) of these patients benefitted from probing and the rest needed further intervention. Twenty-four patients had common canalicular obstruction, 16 of whom (66%) had successful passage at the time of probing, but intubation was performed for all of them. None of the patients with bony or common canalicular obstruction were considered in the data analysis. DISCUSSION This study was designed to investigate the rate of success of late primary probing for congenital NLD obstruction. There was a decrease in the rate of complete success and symptom resolution as the children aged. Several studies stated that primary probing at older ages has a lower success rate, which is compatible with our results.2,3,5 The success rate dropped from 96% in the study by Robb3 to 80% in the studies by Al-Faky et al.5 and Maheshwari,6 and to 78% in the study by Arora et al.7 for those older than 2 years. Prolonged inflammation has been supposed to be one of the causes of this relationship with age.3 Al-Faky et al.5 and Mannor et al.2 reported that age is a risk factor for failure in late probing. It is important to note that, with increased age, many of the patients who had milder or more resolvable causes of NLD obstruction were cured spontaneously; it persisted in patients with more complex causes and bony obstructions until older ages, which may cause bias in estimation of the success rate in older ages. In patients with complex causes of obstruction such as common canalicular obstruction or bony obstruction, other interventions should be considered (eg, silicone intubation). In some cases of bony obstruction, dacryocystorhinostomy is a better choice if silicone intubation was unsuccessful. Patients with common canalicular obstruction have preoperative characteristics that differ from NLD obstruction because the discharge in them is not purulent; however, in patients with bony obstructions that occur after the lacrimal sac, the discharge may
362
be purulent and it may not be possible to diagnose before probing unless the patient has facial abnormalities. Patients with these causes of obstruction were not included in the current study. Interestingly, the patients with NLD obstruction who had chronic dacryocystitis with mucopurulent discharge had a higher success rate. We propose that these patients represented neglected cases of complete NLD obstruction who had etiologies similar to younger cases, mostly membranous obstruction of NLD that could be handled with compression and massage in earlier ages and probing. In one prospective study, 138 eyes of 101 patients with ages ranging from 13 to 60 months were recruited. The cure rate was 89% in the 13- to 24-months age group and 72% in those older than 24 months (P = .01). The persistence of complex etiologies in the older patients was considered the cause of decreased success with age.8 Because the current study recruited a large population of cases, it can be considered as a guide for decision making in older ages. For children with congenital NLD obstruction, we propose that primary probing will cure three-fourths of these patients and re-treatment is needed in failed cases. REFERENCES
1. Stager D, Baker J, Frey T, Weakley DR Jr, Birch EE. Office probing of congenital nasolacrimal duct obstruction. Ophthalmologic Surg. 1992;23:482-484. 2. Mannor GE, Rose GE, Frimpong-Ansah K, et al. Factors affecting the success rate of nasolacrimal duct probing for congenital nasolacrimal duct obstruction. Am J Ophthalmol. 1999;127:616-617. 3. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology. 1998;105:1307-1309. 4. Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with probing in children less than four years old. Ophthalmology. 2008;115:577-589. 5. 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. 6. Maheshwari R. Result of probing for congenital nasolacrimal duct obstruction in children older than 13 months of age. Indian J Ophthalmol. 2005;53:49-51. 7. Arora S, Koushan K, Harvey JT. Success rates of primary probing for congenital nasolacrimal obstruction in children. J AAPOS. 2012;16:173-176. 8. 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;87:1151-1153.
Copyright © SLACK Incorporated
ABSTRACT Purpose: To investigate the clinical outcomes of late primary probing in congenital nasolacrimal duct (NLD) obstruction. Methods: A prospective interventional study was designed to recruit children older than 24 months who presented with clinical manifestations of NLD obstruction since February 2008 to Farabi Eye Hospital, Tehran, Iran. No prior surgical intervention for NLD obstruction was performed on these patients; they underwent probing of the nasolacrimal system and irrigation under general anesthesia by oculoplastic surgeons. The outcome of the procedure was assessed 2 to 3 months postoperatively. Data of the patients until February 2013 were considered for analysis.
in those who were 2 to 3 years old, 63% in those who were 3 to 4 years old, and 50% in those who were 4 to 5 years old. In patients with chronic dacryocystitis with mucopurulent discharge, 83% had successful probing and irrigation. In patients with epiphora with no mucopurulent discharge, 59% had successful results with probing. Conclusions: In the cases of congenital NLD obstruction, primary probing before 2 years of age has a high success rate; there is a high overall success rate (75.8%) in the 2- to 5-years age group, but when older than 5 years, further procedures such as intubation and dacryocystorhinostomy would be needed because of the high failure rate of probing.
Results: The total number of patients during the 5-year study was 343. The total success rate considering all of the age groups was 75.8%. The success rate was 85%
[J Pediatr Ophthalmol Strabismus 2014;51(6):360362.]
INTRODUCTION Nasolacrimal duct (NLD) obstruction is one of the most common congenital abnormalities.1 Appropriate time for probing the NLD is still under debate. Up to the age of 1 year, only 4% of cases of congenital NLD obstruction will not resolve spontaneously.2,3 The success rate of early probing at 1 to 2
years of age has been reported overall to be between 70% and 97% in the literature.4 Many surgeons believe that most cases of congenital NLD obstruction treated after 2 years of age by probing only may not be cured and may require an additional operation. The patient population in the current study comprised patients who presented with clinical manifes-
From Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran (MTR, YA, SSH, SZT, MBR); and the Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada (JJH). Submitted: April 14, 2014; Accepted: August 1, 2014; Posted online: September 16, 2014 The authors have no financial or proprietary interest in the materials presented herein. Correspondence: Yalda Abrishami, Eye Research Center, Farabi Eye Hospital, Qazvin Square, South Kargar Avenue, Tehran 1336616351, Iran. E-mail: [email protected] doi: 10.3928/01913913-20140909-02
360
Copyright © SLACK Incorporated
tations of NLD obstruction to Farabi Eye Hospital, Tehran, Iran, when they were older than 2 years. PATIENTS AND METHODS A prospective interventional study was designed to investigate the clinical outcomes and success rate of probing in children older than 2 years. Patients had a history of epiphora and discharge since birth that was considered congenital NLD obstruction, and were referred to Farabi Eye Hospital of Tehran University of Medical Sciences. Patients aged 2 to 5 years without previous treatment were scheduled for probing. The study was implemented in accordance with the tenets of the Declaration of Helsinki and was approved by the local ethics review committee of Tehran University of Medical Sciences. Informed consent of the parents was obtained after a complete explanation of the procedure and its complications. Cases with any craniofacial anomaly, manifest facial deformity, Down syndrome, or any history of trauma to the orbit or nose were not included. All patients underwent a brief slit-lamp examination to rule out punctal atresia. None of these patients underwent probing before and it was the first surgical intervention performed on the NLD. Surgery was performed under general anesthesia with gas mask ventilation. The lower punctum was dilated by an appropriately sized punctum dilator. A Bowman probe size 1.0 or 2.0 was vertically inserted in the punctum, advanced in the ampula, and then rotated horizontally into the lower canaliculus while the lower eyelid was stretched horizontally. After reaching a hard stop, it was rotated 90° radially in the horizontal plane to reach alignment with the NLD pathway and approximately 2 cm of the length of the probe was advanced forward into the NLD; the Bowman probe was then removed and irrigation was performed with a lacrimal cannula. At the same time, there was a suction tube in the same nostril and passage of the fluid visible in the draining suction tube confirmed patency. Topical
TABLE 1
Success Rate of Primary Probing in Different Age Groups
Age Group
Total No.
Success (Complete Success and Improvement)
2 to 3 years
217
184 (85%)
3 to 4 years
62
98 (63%)
4 to 5 years
28
14 (50%)
antibiotic drops were administered for several days after probing. Parents were recommended to return 2 to 3 months postoperatively. Complete success was defined as no pus or discharge and no remaining epiphora in this period after probing. We designed this study to demonstrate how often probing might cure these children. Failure was defined as existing mucopurulent discharge and persistent epiphora at the follow-up visit. Patients who had failed probing underwent NLD intubation or were scheduled for dacryocystorhinostomy. RESULTS There were 343 patients (165 female and 178 male) in the current study. There were 217 patients in the 2- to 3-year-old group, 98 patients in the 3- to 4-year-old group, and 28 patients in the 4- to 5-yearold group based on the age at the time of probing. The age limit was 5 years because there were also 8 patients in the 5- to 6-year-old group who underwent primary probing and had a 45% rate of success, but they were not considered in our analysis. Due to a lower success rate in patients older than 5 years, we decided to limit the study group to those between 2 and 5 years of age. Overall, the total success rate of probing considering all age groups was 75.8% (260 of 343 cases). Patients were categorized based on age groups and presence of mucopurulent discharge; comparable outcomes are shown in Tables 1-2 in different groups.
TABLE 2
Comparison of Clinical Outcomes Between Patients With Congenital NLD Obstruction With and Without Mucopurulent Discharge Group
No.
Complete Success
Improvement
Failure
Chronic dacryocystitis with mucopurulent discharge
231
134 (58%)
58 (25%)
39 (16%)
Epiphora without mucopurulent discharge
88
36 (41%)
16 (18%)
36 (41%)
NLD = nasolacrimal duct
Journal of Pediatric Ophthalmology & Strabismus • Vol. 51, No. 6, 2014
361
Eighteen patients had complex bony NLD obstruction that was diagnosed intraoperatively because the probe could not be advanced easily forward within the NLD and the bony stop could be sensed during probing in that area. Only 7 (38%) of these patients benefitted from probing and the rest needed further intervention. Twenty-four patients had common canalicular obstruction, 16 of whom (66%) had successful passage at the time of probing, but intubation was performed for all of them. None of the patients with bony or common canalicular obstruction were considered in the data analysis. DISCUSSION This study was designed to investigate the rate of success of late primary probing for congenital NLD obstruction. There was a decrease in the rate of complete success and symptom resolution as the children aged. Several studies stated that primary probing at older ages has a lower success rate, which is compatible with our results.2,3,5 The success rate dropped from 96% in the study by Robb3 to 80% in the studies by Al-Faky et al.5 and Maheshwari,6 and to 78% in the study by Arora et al.7 for those older than 2 years. Prolonged inflammation has been supposed to be one of the causes of this relationship with age.3 Al-Faky et al.5 and Mannor et al.2 reported that age is a risk factor for failure in late probing. It is important to note that, with increased age, many of the patients who had milder or more resolvable causes of NLD obstruction were cured spontaneously; it persisted in patients with more complex causes and bony obstructions until older ages, which may cause bias in estimation of the success rate in older ages. In patients with complex causes of obstruction such as common canalicular obstruction or bony obstruction, other interventions should be considered (eg, silicone intubation). In some cases of bony obstruction, dacryocystorhinostomy is a better choice if silicone intubation was unsuccessful. Patients with common canalicular obstruction have preoperative characteristics that differ from NLD obstruction because the discharge in them is not purulent; however, in patients with bony obstructions that occur after the lacrimal sac, the discharge may
362
be purulent and it may not be possible to diagnose before probing unless the patient has facial abnormalities. Patients with these causes of obstruction were not included in the current study. Interestingly, the patients with NLD obstruction who had chronic dacryocystitis with mucopurulent discharge had a higher success rate. We propose that these patients represented neglected cases of complete NLD obstruction who had etiologies similar to younger cases, mostly membranous obstruction of NLD that could be handled with compression and massage in earlier ages and probing. In one prospective study, 138 eyes of 101 patients with ages ranging from 13 to 60 months were recruited. The cure rate was 89% in the 13- to 24-months age group and 72% in those older than 24 months (P = .01). The persistence of complex etiologies in the older patients was considered the cause of decreased success with age.8 Because the current study recruited a large population of cases, it can be considered as a guide for decision making in older ages. For children with congenital NLD obstruction, we propose that primary probing will cure three-fourths of these patients and re-treatment is needed in failed cases. REFERENCES
1. Stager D, Baker J, Frey T, Weakley DR Jr, Birch EE. Office probing of congenital nasolacrimal duct obstruction. Ophthalmologic Surg. 1992;23:482-484. 2. Mannor GE, Rose GE, Frimpong-Ansah K, et al. Factors affecting the success rate of nasolacrimal duct probing for congenital nasolacrimal duct obstruction. Am J Ophthalmol. 1999;127:616-617. 3. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology. 1998;105:1307-1309. 4. Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with probing in children less than four years old. Ophthalmology. 2008;115:577-589. 5. 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. 6. Maheshwari R. Result of probing for congenital nasolacrimal duct obstruction in children older than 13 months of age. Indian J Ophthalmol. 2005;53:49-51. 7. Arora S, Koushan K, Harvey JT. Success rates of primary probing for congenital nasolacrimal obstruction in children. J AAPOS. 2012;16:173-176. 8. 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;87:1151-1153.
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