Comparative Analysis of Silicone Tube Intubation Versus Probing and Balloon Dilation for Congenital Nasolacrimal Duct Obstruction: A Systematic Review and Meta-Analysis.

OBJECTIVE: Congenital nasolacrimal duct obstruction (CNLDO) is a pediatric disorder with a wide range of pathology. If untreated, the condition may end up with serious complications. Multiple treatment options for CNLDO exist throughout the literature, and there is an ongoing debate on the best intervention for each disease subgroup and the best timing of such interventions. This study compares the success and failure rates of silicone tube intubation (STI) against probing and balloon dilation (BD). METHODS: The authors searched the literature for relevant articles using PubMed, Scopus, web of Science, and Cochrane Library until January 2024. Using RevMan 5.4, the authors compared STI's success and failure rates to probing and BD using risk ratios (RRs) and a random-effect model. In addition, the complication rate of monocanalicular intubation (MCI) versus bicanalicular intubation (BCI) was investigated. The authors used the leave-one-out method to check for influential studies and to resolve heterogeneity. RESULTS: The screening process resulted in 23 eligible articles for inclusion in the authors' review. Silicone tube intubation had a higher chance of resolving the symptoms of CNLDO than probing (RR = 1.11; 95% CI: 1.04, 1.20; P = 0.004) while having less risk of surgical failure (RR = 0.48; 95% CI: 0.30, 0.76; P = 0.002]. Monocanalicular intubation showed no statistically significant difference when compared with BCI in terms of surgical success and failure; however, MCI had a lower risk of complications (RR = 0.68; 95% CI: 0.48, 0.97; P = 0.04). In addition, STI did not demonstrate any significant difference from BD. CONCLUSION: There was no significant difference in success/failure between MCI and BCI; monocanalicular had fewer complications. Silicone tube intubation did better in terms of surgical success than probing, especially in children over 12 months, suggesting that it is the preferred intervention for older patients with CNLDO.

Unlocking the secrets of success in probing for congenital nasolacrimal duct obstruction: investigating the factors that matter.

PURPOSE: The objective of this study was to analyze the impact of different factors on the success rate of probing for congenital nasolacrimal duct obstruction (CNLDO). METHODS: A retrospective analysis was conducted on 239 eyes of 202 patients who underwent probing for CNLDO between 2014 and 2019. Patients were divided into three age groups (12-24 months, 25-36 months, and over 36 months) and two groups based on the type of membranous obstruction (MO) and incomplete complex obstruction (ICO), with complete complex obstruction (CCO) cases being excluded. The study involved administering general anesthesia (GA) to all participants during the probing procedure. The patients were then monitored at scheduled intervals for up to 6 months after the surgery. Success was defined as an improvement in symptoms and signs, and logistic regression and Fisher's exact test were used for statistical analysis. RESULTS: The mean age of the patients was 25.48 ± 13.38 months, and the total success rate was 86.61%. The success rate for MO was 92.8%, 95.87%, and 97% in age groups 1, 2, and 3, respectively. The success rate for ICO was 91.17%, 80%, and 23.52% in age groups 1, 2, and 3, respectively. The success rate for MO was significantly higher than ICO in all age groups. The success rate for ICO was significantly lower in age group 3 (p = 0.009). CONCLUSION: The study found that probing performed within the first 36 months had high success rates regardless of age and type of obstruction. However, the success rate significantly decreased in patients undergoing probing for ICO at 36 months or later.

Probing versus primary nasal endoscopy for the treatment of congenital dacryocystoceles.

PURPOSE: To compare outcomes and complications of three surgical techniques for the treatment of congenital dacryocystoceles: nasolacrimal probing and irrigation (P+I), P+I plus nasal endoscopy (NE) with intranasal cyst marsupialization, and primary NE with intranasal cyst marsupialization. METHODS: The medical records of children ≤2 years of age at a single academic center with a diagnosis of dacryocystocele from 2012 to 2022 were retrospectively identified and reviewed. The primary outcome was resolution of the dacryocystocele (ie, elimination of the medial canthal mass and resolution of tearing or discharge) after a single procedure ("primary success"). Surgical techniques were compared using exact logistic regression. RESULTS: Of 54 patients, 21 (39%) underwent P+I, 23 (43%) underwent P+I plus nasal endoscopy, and 10 (18%) underwent primary NE. Primary success was 76% for P+I and 100% for the other two cohorts. Most patients (89%) who underwent P+I received general anesthesia compared with none who underwent primary nasal endoscopy. Most complications were related to the use of general anesthesia, with a complication rate of 10% for P+I, 48% for P+I plus NE, and 0% for primary NE. Most P+I procedures required hospital admission compared to half of primary NE procedures. CONCLUSIONS: In our study cohort, primary NE provided good outcomes and was associated with a lower complication rate than P+I with or without NE.

Otoscopy-assisted intranasal cyst marsupialization for congenital dacryocystocele.

We describe 3 infants with congenital dacryocystocele resistant to conservative treatment who were treated with a novel, simple intranasal cyst marsupialization (ICM) technique. Otoscopy-guided ICM was performed by an otolaryngologist in the manner of otoscopic myringotomy for cases with nasal cyst distension. All 3 infants were treated successfully by a single surgical procedure under topical anesthesia in an office setting.

Management of Congenital Dacryocystocele: A Case Series and Literature Review.

Congenital dacryocystocele presents with a distinct bluish swelling in the medial canthal region in neonates. The authors present four illustrative cases with differing courses and a literature review on dacryocystocele management to raise awareness of the importance of prompt diagnosis, initiation of conservative management, and appropriate referral for surgical assessment. [J Pediatr Ophthalmol Strabismus. 2023;60(3):e31-e34.].

Bilateral Congenital Nasolacrimal Duct Obstruction in Williams-Beuren Syndrome.

A 23-year-old patient with Williams-Beuren syndrome presented with ocular irritation and bilateral persistent tearing. Despite probing as an infant which showed bilateral nasolacrimal duct obstruction, dacryocystorhinostomy had been avoided due to the patient's syndromic supravalvular stenosis and related anesthesia risk. As the known diminished production of elastin in Williams-Beuren syndrome causes an array of associated vascular diseases, this case report hypothesizes that the lacrimal duct becomes obstructed through a similar mechanism. This case presents the unique findings of bilateral congenital nasolacrimal duct stenosis in a Williams-Beuren syndrome patient.

Evaluating the outcomes of children undergoing lacrimal surgery for congenital nasolacrimal duct obstruction with the aim of developing a patient pathway for children presenting to a tertiary paedatric service with epiphora.

OBJECTIVE: Nasolacrimal duct obstruction is the most common cause of epiphora in children. Management has classically focused on probing and syringing followed by stent insertion and dacryocystorhinostomy either externally or endonasally. This study aimed to assess the effectiveness and safety of these procedures. METHODS: This was a retrospective analysis of the outcomes of all patients under the age of 16 who have undergone a surgical lacrimal intervention for nasolacrimal duct obstruction under general anaesthetic over a 10-year period. Outcomes included success rates and complications. RESULTS: A total of 432 patients were identified. Primary probe and syringing had a success rate of 83 per cent. Primary endonasal dacryocystorhinostomy had a success rate of 71 per cent, and revision surgery had a success rate of 82 per cent. CONCLUSION: Endonasal dacryocystorhinostomy is an effective and safe technique for the treatment of epiphora, and this study has provided a suggested protocol for management of patients presenting with epiphora.

The Evolving Story of CNLDO: Serial Photographic Documentation and Parental Perspectives.

PURPOSE: The purpose of this study is to report the temporal sequence of symptomatology of bilateral congenital nasolacrimal duct obstruction and parental perspectives of 2 established lacrimal surgeons studying the natural history of their newborn child. METHODS: Prospective observational report. Once epiphora was noted, a daily assessment and documentation of several symptoms and signs were initiated using iPhone 11 pro camera. These include epiphora, associated discharge, tear meniscus level, matting of lashes, day-night variation in symptomatology, difficulty in eye-opening upon waking up, conjunctival congestion, periocular changes, especially in the tear trough area and lateral canthus, changes in symptom severity with time, regurgitation on pressure over lacrimal sac area, the fullness of the lacrimal sac area or palpable lacrimal sac swelling, and other associated clinical findings. RESULTS: The weekly course of congenital nasolacrimal duct obstruction showed similar patterns in OU, although the phase of severe symptoms was spaced by a 6-week interval between the eyes. The epiphora appeared first, followed by rapidly increasing discharge, the severity of which was alarming to the parents. Periocular skin developed excoriation due to persistent epiphora and cleaning attempts. Focused and regular lacrimal sac compressions resulted in abrupt resolution of epiphora at different time points in each eye. The baby was comfortable when compressions were performed during breastfeeding. Cleaning the discharge regularly can be a daunting task for the new parents. The use of wet 'eye wipes' was more effective and comfortable than a cotton bud or cloth piece. Both the parents were lacrimal surgeons, and they did not overtly feel socially embarrassed due to the congenital nasolacrimal duct obstruction, but questions from family and friends were discomforting. CONCLUSION: Parental perspectives of the temporal sequence of congenital nasolacrimal duct obstruction provide better insights into disease management and counseling.

Microdebridement of Intranasal Cysts Associated With Congenital Dacryocystoceles.

PURPOSE: The surgical management of congenital dacryocystoceles has evolved in recent decades. The aim of this study was to explore the effectiveness of endoscopic examination and powered microdebridement in the management of nasal cysts associated with congenital dacryocystoceles. METHODS: In this retrospective case series, all patients with congenital dacryocystoceles who underwent surgical intervention under general anesthesia at a single institution over a 12-year period (2009-2020) were included. RESULTS: Thirty-seven lacrimal drainage systems from 29 patients were included, 8 patients (28%) had bilateral dacryocystoceles. Twenty-two (76%) were females, and 5 (17%) patients had a history of prematurity. Mean (±SD) age at diagnosis was 15 ± 28 days, and 1.4 ± 1.7 months at surgical intervention. Mean follow-up was 7.5 months. The right side was more commonly involved (20 [69%] OD vs. 17 [59%] OS). Dacryocystitis was diagnosed at presentation in 23 lacrimal drainage systems (62%). Intraoperatively, intranasal cysts were observed in 32 lacrimal drainage systems (86%), and a powered microdebrider was used to excise each cyst. In 6 of the 21 supposed unilateral cases (29%), a contralateral cyst was identified and treated. The average birth age of patients with intranasal cysts was 39 weeks versus 36 weeks of patients without ( p = 0.03). Surgical success was found in 36 of 37 sides treated (97%); one case (3%) underwent unilateral endoscopic dacryocystorhinostomy during the follow-up period due to persistent symptoms. CONCLUSIONS: Congenital dacryocystoceles are associated with intranasal cysts in most cases. Surgical intervention with microdebrider is associated with a favorable outcome. Bilateral endonasal examination is ideal in all cases.

Co-existing lacrimal drainage anomalies in eyes with congenital Glaucoma.

AIM: To evaluate the occurrence of co-existing congenital nasolacrimal duct obstruction (CNLDO) and other lacrimal anomalies in eyes with congenital glaucoma (CG). METHODS: Retrospective analysis of children aged ≤1-year with co-existing CG and CNLDO seen between 1998 and 2019, treatment interventions and outcomes. RESULTS: During the study period, 1993 children had CG and 6203 children had CNLDO, among the children aged 1-year or less. Of these, 51 children (73 eyes) had co-existing CG and CNLDO. The prevalence of CNLDO in CG was 2.5% (51/1993) and the prevalence of CG among CNLDO was 0.8% (51/6203). Median age (Interquartile range, IQR) was 53 days (IQR: 8, 155), when they were diagnosed with CG. Among the children with CNLDO, 68 eyes (93.1%) had simple CNLDO, and 5 eyes (6.9%) had complex CNLDO. Associated lacrimal anomalies were present in 7/73 eyes, including congenital lacrimal fistula in two eyes, upper punctal agenesis and upper mid-canalicular obstruction in two eyes each, and upper single canalicular-wall hypoplasia in one eye. Lacrimal syringing and probing were successful in 69/72 eyes (95.8%), and failed in 3 eyes (4.2%). These 3 eyes had complex CNLDO and underwent Dacryocystorhinostomy (DCR) with Mitomycin-C and intubation. Sixty-two eyes underwent combined trabeculotomy and trabeculectomy, and two eyes underwent trabeculectomy. Median age at glaucoma surgery was 87 days (IQR: 54, 193). Median time delay for glaucoma surgery after probing was 18 days (IQR: 12, 35). CONCLUSION: Among children aged ≤1-year presenting with congenital glaucoma coexisting lacrimal drainage anomalies was noted in 2.5% and simple CNLDO was the commonest. Early intervention is of paramount importance to prevent sight-threatening intraocular infection with CNLDO, and to minimize the delay of glaucoma surgery. The outcomes of lacrimal probing were excellent, however complex CNLDO required DCR.

Congenital Nasolacrimal Duct Obstruction Update Study (CUP Study): Paper 4-Infantile Acute Dacryocystitis (InAD)-Presentation, Management, and Outcomes.

PURPOSE: To study the presentation, management, and outcomes of infantile acute dacryocystitis. METHODS: Retrospective study of infants diagnosed with acute dacryocystitis over a period from June 2016 to December 2019. Data collected include demographics, clinical history, presenting features, management, complications, and outcomes. Treatment provided was intensive medical care followed by early probing under endoscopic guidance. Further interventions, where needed, were performed based on intraoperative findings during probing. Successful outcomes were defined as resolution of infection, subjective relief from epiphora, and anatomical patency determined by a normal fluorescein dye disappearance test. RESULTS: Twenty-seven eyes of 27 infants were analyzed during the study period. The mean age of infants was 3.26 months, and males were more affected than females (male:female 15:12). The mean duration of symptoms was 4.66 weeks, with 96% (26/27) presenting with symptoms of redness, watering, discharge, and swelling. Preseptal cellulitis was seen in 74% (20/27) infants, lacrimal abscess in 67% (18/27) infants, and lacrimal fistula in 37% (10/27). Most infants had complex congenital nasolacrimal duct obstruction (62%, 13/27), of which 7 also had intranasal cysts. One infant successfully underwent endoscopic dacryocystorhinostomy. At a mean follow-up period of 7.95 months, successful outcomes were observed in 90.4% (19/21) infants. The 2 failed cases were complex congenital nasolacrimal duct obstruction with associated sac diverticula and are scheduled for an endoscopic dacryocystorhinostomy. CONCLUSION: Infantile acute dacryocystitis is a distinct clinical entity. The outcomes of systemic antibiotics and early probing are excellent.

Update on the Long-Term Outcomes Following the Management of Incomplete Punctal Canalization.

PURPOSE: To study the clinical profile, associated lacrimal disorders, and long-term outcomes following a membranotomy, in patients with incomplete punctal canalization (IPC). METHODS: Retrospective interventional study was performed of all the patients diagnosed with IPC during the study period over 5 years from January 2015 to December 2020. The diagnosis of IPC was made based on the earlier published guidelines. A combination of rapid and slow taper Nettleship's punctal dilators were used for an effective membranotomy, followed by further assessment of the lacrimal drainage passage. Appropriate interventions for associated lacrimal disorders were performed. Data collected on chart reviews include demographics, clinical presentation, laterality, type of IPC, associated lacrimal anomalies, management modalities, and long-term outcomes. RESULTS: Ninety-eight puncta of 62 eyes of 46 patients with IPC were examined in the clinic. Incomplete punctal canalization-external membrane variant was seen in 62% (61/98) and internal membrane variant in 38% (37/98). Seventy-eight puncta (78/98, 79.5%) in 39 patients underwent membranotomy using Nettleship's punctal dilator. Associated lacrimal drainage pathway deformities were seen in 31% of patients (12/39). Three puncta had mini-monoka insertion for associated canalicular stenosis and canalicular obstruction. Five patients with associated congenital nasolacrimal duct obstruction underwent probing, of which 3 patients needed dacryocystorhinostomy for complex congenital nasolacrimal duct obstruction. Associated punctal agenesis was noted in 3 patients involving the other punctum of the same eye. Canalicular wall hypoplasia involving 3 walls of the canaliculus was seen in 1 patient. At a mean follow up of 28 months, the anatomical and functional outcomes were noted in 100% and 97.4%, respectively. CONCLUSIONS: The long-term outcomes of membranotomy for IPC are excellent. Associated congenital lacrimal drainage anomalies are common with IPC.

Efficacy of probing for congenital nasolacrimal duct obstruction in a private tertiary hospital: 10-year experience / Eficácia de sondagem para obstrução congênita de ducto nasolacrimal em hospital terciário privado: 10 anos de experiência

ABSTRACT Objetive: To evaluate the success rate of initial and repeated probing as treatment approach for congenital nasolacrimal duct obstruction (CNLDO) in children between 2 and 46 months. Methods: A restrospective review of 73 children diagnosed with CNLDO who underwent probing of the NLD from March 2010 to 2020 was conducted. Data were colected from Hospital Oftalmológico de Anápolis in Anápolis, Goiás. Results: The procedure was performed in 90 eyes. The study sample was constituted of 36 males and 37 females. Bilateral involvement occurred in 18 (24.6%) children whereas 55 (75.3%) of them were unilaterally affected. The age ranges of the patients were divided into 4 groups: A - up to 6 months old (5.5% of the eyes), B - 7 to 12 months (27.5%), group C - 13 to 24 months (39.5%) and group D - older than 24 months (26.4%). The mean age of the sample was 18.6 months. Initial probing obtained an overall success rate of 88.8% and group B showed the best percentage (96%) from all age ranges. The second intervention had a lower outcome, successfuly in 55.5% of the cases. Conclusion: All age ranges showed high success rates for initial probing, although there was a decrease in subsequent procedures outcomes. Our results demonstrate that the success rate for primary probing is not affected by age.

RESUMO Objetivo: avaliar a taxa de sucesso de sondagem inicial e de repetição como abordagem de tratamento para obstrução congênita do ducto nasolacrimal em crianças entre 2 e 46 meses. Métodos: conduziu-se uma revisão retrospectiva de 73 crianças diagnosticadas com obstrução congênita do ducto nasolacrimal que se submeteram à sondagem do ducto nasolacrimal de março de 2010 a 2020. Os dados foram coletados no Hospital Oftalmológico de Anápolis em Anápolis, Goiás. Resultados: o procedimento foi realizado em 90 olhos. A amostra do estudo constitui-se em 36 pacientes do sexo masculino e 37 do sexo feminino. O acometimento foi bilateral em 18 crianças, enquanto 55 (75,3%) delas foram afetadas de forma unilateral. Os pacientes foram divididos em 4 grupos, de acordo com a faixa etária: A- até 6 meses de vida (5,5% dos olhos); B- 7 a 12 meses (27,5%); grupo C- 13 a 24 meses (39,5%) e grupo D- mais que 24 meses (26,4). A média de idade de amostra foi de 18,6 meses. A sondagem inicial teve uma taxa de sucesso global de 88,8%, e o grupo B mostrou a melhor porcentagem (96%) de todas as faixas etárias. A segunda intervenção teve uma taxa de sucesso menor, de 55,5% dos casos. Conclusão: todas as faixas etárias mostraram altas taxas de sucesso na sondagem, embora tenha havido um decréscimo nos resultados dos procedimentos subsequentes. Nossos resultados demonstram que a taxa de sucesso na sondagem primária não é afetada pela idade

Office- or Facility-Based Probing for Congenital Nasolacrimal Duct Obstruction: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature assessing the efficacy and safety of in-office probing compared with facility-based probing to treat congenital nasolacrimal duct obstruction (NLDO). METHODS: Literature searches were conducted in March 2020 in the PubMed database with no date restrictions and limited to studies published in English and in the Cochrane Library database with no restrictions. The combined searches yielded 281 citations. Of these, 21 articles were deemed appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. Four articles were rated level I, 2 articles were rated level II, and 15 articles were rated level III. RESULTS: Treatments consisted of observation, in-office nasolacrimal probing, or facility-based nasolacrimal probing. Success rates and complications or recurrences were recorded from 1 week to 6 months after surgery. Complete resolution of symptoms after surgery ranged from 66% to 95.6% for office-based procedures versus 50% to 97.7% for facility-based procedures. Level I evidence indicated that 66% of cases spontaneously resolved after 6 months of observation in infants between 6 and 10 months of age. Success rates for in-office probing were lower for bilateral than for unilateral NLDO (67% vs. 82%), whereas success rates were high in both unilateral (83%) and bilateral (82%) patients who underwent facility-based probing after 6 months of observation. Cost data did not indicate a definitive cost savings of either treatment method ($562 for in-office vs. $701 for facility-based, depending on cost models predicting spontaneous resolution rates at different ages). No serious adverse events with treatment or anesthesia were reported for either treatment method. CONCLUSIONS: Evidence supports the efficacy and safety of both in-office and facility-based surgery for congenital NLDO. However, treating bilateral NLDO in a facility setting may be better. Because a significant percentage of children achieved resolution spontaneously before 12 months of age, deferring treatment until 12 to 18 months of age is a reasonable option. Additional research may address symptom burden on families and the impact of anesthesia and emotional trauma of nonsedated office probings on patients and may explore further the cost of treatment for each treatment method.

Balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction.

PURPOSE: The aim of this study is to report the outcome of balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction in children of all ages. METHODS: A 10-year retrospective study of 148 children (270 eyes), aged 9 to 159 months (mean age: 29.6 ± 17.7 months), who previously had not undergone a nasolacrimal surgical procedure and who presented with clinical signs of nasolacrimal duct obstruction, was conducted. All children underwent balloon catheter dilation of the nasolacrimal duct. RESULTS: Treatment success, defined as complete resolution of nasolacrimal duct obstruction symptoms present at follow-up visits at 1 week and up to 6 months after surgery, was 87% (234 of 270 eyes). Partial success was defined as occasional tearing which was acceptable to parents and present in 3% (nine eyes). Only 10% of the children underwent a second procedure due to complete failure. In a sub-analysis by age groups-under 18 months, between 18 and 36 months, and above 36 months-complete resolution rates were 85%, 93%, and 77%, and partial success rates were 3%, 3%, and 4%, respectively. There was a statistically significant difference between the age groups (p = .007). CONCLUSION: In this large cohort of patients with nasolacrimal duct obstruction, balloon catheter dilation was successful as a primary treatment for congenital nasolacrimal duct obstruction, particularly under the age of 36 months.

A rare association of blepharophimosis-ptosis-epicanthus inversus case with congenital nasolacrimal duct obstruction.

PURPOSE: The aim of reporting this case is to describe a rare combination of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction. A variety of lacrimal anomalies have been seen in blepharophimosis-ptosis-epicanthus inversus syndrome but the occurrence of nasolacrimal duct obstruction is rare. METHOD: The blepharophimosis-ptosis-epicanthus inversus syndrome is an autosomal dominant rare genetic defect with clinical manifestation of dysplasia of the eyelids, palpebral fissures, flat nasal bridge, and ptosis. A 20-month-old boy was referred with the complaints of watering and discharge from his right eyes since birth. On examination, the child had all the features of blepharophimosis-ptosis-epicanthus inversus syndrome with right congenital nasolacrimal duct obstruction in line with the published reports. RESULT: On endoscopic probing and irrigation, the probe could not be visualized into the inferior meatus. On dacryoendoscopy, the membranous part of the nasolacrimal duct was found to be completely obliterated with no light transmission into the nose indicating a malformed nasolacrimal duct. The child was managed by endoscopic dacryocystorhinostomy. We could find only one case report published so far on the combination of congenital nasolacrimal duct obstruction with blepharophimosis-ptosis-epicanthus inversus syndrome. This study adds one more case of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction and adjuvant use of dacryoendoscopy.