Outcomes Associated with Indwelling Momentary Probe for Congenital Nasolacrimal Duct Obstruction Treatment.

OBJECTIVE: To compare the outcomes of congenital nasolacrimal duct obstruction (CNLDO) patients undergoing nasolacrimal duct obstruction (NLD) probing in whom momentary probe indwelling was and was not performed. STUDY DESIGN: Randomised controlled trial. PLACE AND DURATION OF STUDY:  Department of Orbital and Oculoplastic Surgery, Eye Hospital, Wenzhou Medical University, Wenzhou, China, from June 1, 2021, to January 30, 2022. METHODOLOGY: Two hundred and four patients with CNLDO (217 eyes) were enrolled and underwent NLD probing. These patients were randomly assigned to undergo NLD probing with or without momentary probe indwelling. Specifically, no indwelling was performed for patients in Group A, whereas probe indwelling for 5 minutes was performed for patients in Group B. Patients were additionally separated into simple and complex CNLDO groups based on intraoperative exploration results. Preoperative characteristics, success rates, and procedure-related complications were compared among these patient groups, with the shortest follow-up time point being 6 months. RESULTS: In total, 205 eyes from 192 patients were included in the final study analyses. The respective success rates in Groups A and B were 92.08% and 94.23%, respectively (p = 0.541). The success rates for simple CNLDO procedures in Groups A and B were 97.65% and 96.43%, respectively (p = 0.640), whereas for complex CNLDO procedures these success rates were 62.50% and 85.00% (p = 0.146). Age, unilateral or bilateral disease, and prior dacryocyst massage were not found to be associated with the risk of operative failure. CONCLUSION: While NLD probing is a beneficial treatment for children affected by CNLDO that is associated with satisfactory outcomes, momentary probe indwelling did not confer any additional benefits and is thus likely to be unnecessary. KEY WORDS: Congenital nasolacrimal duct obstruction, Nasolacrimal duct probing, Indwelling time.

Efficacy of Lacrimal Sac Massage in Management of Congenital Nasolacrimal Duct Obstruction in Infants: An Observational Study of 853 Cases from a Single Institute of Eastern Asia.

PURPOSE: Congenital nasolacrimal duct obstruction (CNLDO) is the most common cause of epiphora in infants. It usually resolves completely by the end of 1st year with conservative management in most cases. Many studies have confirmed high frequency (80%-90%) of spontaneous resolution of symptoms during the 1st year of life. The aim of this study is to determine the effectiveness of the lacrimal sac massage in the treatment of CNLDO. METHODS: The study was done in a tertiary care hospital in eastern Asia over 5 years. Each infant presenting with epiphora and diagnosed as CNLDO was treated with lacrimal sac massage and reviewed after every 1 month. The resolution of CNLDO was judged by the improvement of epiphora and from the fluorescein dye disappearance test. RESULTS: Following conservative management, 740 (86.75%) infants recovered completely after 3 months of continuous lacrimal sac massvage. One hundred and five (12.31%) infants did not recover with sac massage even at 12 months, in which cases probing was done. Repeat probing was needed in six patients (0.07%). Two patients did not recover, and a dacrocystorhinostomy was carried out. About 70.6% of infants recovered within 6 months of age. Earlier the age of presentation, the lesser the morbidity. CONCLUSION: The incidence of CNLDO is about 6%-20% among infants. Several studies showed spontaneous resolution within 1st year of life. In this study, the success rate of resolution of symptoms in CNLDO with sac massage is 86.75%. Conservative management should be the first line of treatment till 12 months of age in CNLDO.

Anatomical and functional outcomes of transcanalicular diode laser assisted dacryocystorhinostomy as a primary procedure.

INTRODUCTION: The goal of this study was to assess the efficacy of transcanalicular diode laser assisted dacryocystorhinostomy (TDL-DCR) for the treatment of primary acquired nasolacrimal duct obstruction. MATERIAL AND METHODS: This was a single center retrospective study. We included all patients who underwent TDL-DCR between July 2015 and October 2017 for chronic epiphora or chronic dacryocystitis. All procedures were performed under local anesthesia with sedation. The anatomical and functional success rates were studied as a function of each operative indication. RESULTS: Thirty-seven patients were included (18 had chronic epiphora and 19 had chronic dacryocystitis). All but one patient had bicanalicular silicone stent intubation. Irrigation of the lacrimal system demonstrated postoperative patency in 78% of patients operated for chronic epiphora and 76% of those with chronic dacryocystitis. The functional success of the surgery (as defined by the Munk score) was higher if the operative indication was chronic dacryocystitis (62%) (whereas it was only 41% for the indication of chronic epiphora). CONCLUSION: TDL-DCR has a lower anatomical and functional success rate than those reported in the literature for external or endonasal dacryocystorhinostomy. However, it retains a place in the treatment of primary acquired nasolacrimal duct obstruction (in particular when it is complicated by chronic dacryocystitis), especially if there is an absolute or relative contraindication to the two other dacryocystorhinostomy techniques.

Outcome of Primary Probing for Simple Membraneous Congenital Nasolacrimal Duct Obstruction in Children Older Than 4 Years.

PURPOSE: To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction. METHODS: The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting. RESULTS: Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement. CONCLUSIONS: This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing. [J Pediatr Ophthalmol Strabismus. 2020;57(1):44-47.].

Comparação de eficácia entre as sondas monocanalicular e bicanalicular no tratamento da obstrução congênita das vias lacrimais / Efficacy of monocanalicular versus bicanalicular intubation in the treatment of congenital nasolacrimal duct obstruction

Resumo Objetivo: Avaliar e comparar a taxa de sucesso da intubação monocanalicular ou bicanalicular em pacientes com obstrução congênita do ducto lacrimonasal (OCDLN), levando-se em consideração a taxa de sucesso, a dificuldade do procedimento e o custo dos tubos. Métodos: Foram analisados retrospectivamente 54 prontuários, totalizando 58 vias lacrimais com diagnóstico de OCDLN, que realizaram intubação das vias lacrimais monocanalicular ou bicanalicular com tubos de silicone. Anamnese, exame oftalmológico geral, testes específicos, como o Teste do Desaparecimento do Corante (TDC) e Teste de Observação de Fluoresceína na Orofaringe (TOFO), e, caso necessário, exames complementares como a dacriocistografia, foram utilizados para diagnóstico e inclusão na pesquisa. Foram tratados com intubação os pacientes sem resposta adequada ao tratamento prévio, ou seja, que permaneceram com sintomas de secreção e epífora contínua após a realização de massagem de Crigler e sondagem. Resultados: A intubação monocanalicular foi realizada em 27 vias lacrimais e a intubação bicanalicular, em 31 vias lacrimais. A taxa de sucesso foi alta em ambos os métodos, com melhora em 26 (96,3%) vias lacrimais com sonda monocanalicular e em 30 (96,8%), com sonda bicanalicular (p=0,718). As duas técnicas apresentaram 100% de sucesso nos pacientes com até 2 anos e acima de 4 anos de idade (p=1). A taxa de sucesso entre os 2 e 4 anos de idade foi de 91,5% para as monocanaliculares e 87,5% para as bicanaliculares, (p=0,652). Conclusão: o presente estudo não mostrou diferença significativa no sucesso da intubação quando utilizando sondas mono ou bicanaliculares. A intubação monocanalicular mostrou-se de mais fácil execução, ao passo que o tubo bicanalicular possui menor custo.

Abstract Objective: to evaluate and to compare the success rate of monocanalicular or bicanalicular intubation in congenital nasolacrimal duct obstruction (CNDO) carriers in terms of success rate, difficulty of the procedure, and cost of the tubes. Methods: fifty-four CNDO carriers with 58 obstructed lacrimal vies (LV) who were submitted to lacrimal system intubation using mono or bicanalicular stent had their medical records analyzed. A clinical history, a general ophthalmologic examination, specific tests such as the fluorescein dye disappearance test (FDDT) and observation test of fluorescein in the oropharynx (OTFO) were used for diagnosis and inclusion in the study. Patients who continued exhibiting discharge and continuous epiphora after previous treatment, Crigler massage and probing, were treated surgically with intubation. Results: Monocanalicular intubation was performed on 27 LV and bicanalicular intubation was performed on 31 LV. High success rates were observed, with improvement in 26 (96.3%) with monocanalicular intubation and in 30 LV (96.8%) with bicanalicular intubation (p=0.718). Furthermore, both techniques were 100% successful in patients up to 2 and over 4 years of age (p=1). The success rates between 2-4 years of age were 91.6% in monocanalicular intubation and 87.5% in bicanalicular intubation (p=0.652). Conclusion: The success rate using monocanalicular or bicanalicular intubation to treat CNDO had no significant difference in the studied children. Furthermore, the monocanalicular tube was easier to use, while the bicanalicular tube had a lower cost.

Comparison of early versus standard timing for silicone stent removal following External Dacrocystorhinostomy under local anaesthesia.

INTRODUCTION: The first line treatment for nasolacrimal duct obstruction (NLDO) is external dacrocystorhinostomy (DCR). Following DCR, patients are required to return to Tilganga Institute of Ophthalmology (TIO) six weeks postoperatively for the removal of a silicone stent. As the majority of patients travel large distances at significant cost to reach TIO, most often patients remain within Kathmandu during this six weeks interval. This places a large financial burden on patients. METHODS: A randomized controlled trial was designed to compare patient outcomes after early (two weeks postoperatively) versus standard (six weeks postoperatively) removal of silicone stents. 50 selected patients were randomized into two equal groups. RESULTS: At the time of publication, 31 patients (14 in group A and 17 in group B) had completed three months follow up. A success rate of 92.9% was noted in Group A and a success rate of 94.1% observed in group B. No significant difference was found between the two groups for success rate and rate of complications. CONCLUSION: Early tube removal post DCR appears to cause no significant difference in outcome or complication rates compared to standard tube removal.

The presentation, clinical features, complications, and treatment of congenital dacryocystocele.

PurposeTo determine the incidence and presenting features of congenital dacryocystocele in the United Kingdom. To report on those cases complicated by dacryocystitis, respiratory compromise, and the treatment undertaken.MethodsA prospective observational study of cases of congenital dacryocystocele presenting in the United Kingdom between September 2014 and October 2015. Infants <3 months of age presenting with a cystic swelling in the medial canthal area were included. Cases were identified via the British Ophthalmology Surveillance Unit (BOSU) reporting system.ResultsA total of 49 cases were reported during the study period. This gives an incidence of 1 in 18 597 live births. There was a 71% response rate to the questionnaire. The average age at presentation was 16.94 days. Dacryocystoceles were unilateral in 91% of cases. Dacryocystitis was a complicating factor in 49% of patients and 17% had respiratory distress. Uncomplicated dacryocystocele responded well to conservative measures in 86%. Surgical intervention was required in 23% of patients. Those cases complicated by dacryocystitis (29%) and nasal obstruction (17%) were more likely to require surgical intervention compared to those with dacryocystocele alone (14%). Digital massage appears to reduce the likelihood of requiring surgical intervention. The mean time to resolution was 19 days.ConclusionsCongenital dacryocystocele is a rare presentation in the United Kingdom. Dacryocystitis and respiratory compromise commonly complicate a dacryocystocele. The use of digital massage as an early intervention is advocated and conservative measures may be sufficient in cases of uncomplicated dacryocystocele.

Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.

OBJECTIVE: To evaluate the use of perforated punctal plugs with adjuvant application of mitomycin-C in the management of acquired external punctal stenosis grades 0 and 1. METHODS: This is a prospective interventional case series including 30 eyes of 30 patients with acquired external punctal stenosis of the lower punctum of grades 0 and 1 presenting with epiphora. They were examined to exclude other causes of lacrimation and epiphora: Slit-lamp assessment of the stenosed punctum and grading was done, probing was done to exclude associated canalicular stenosis, and syringing was done to exclude nasolacrimal duct obstruction. For all cases, dilatation was done, followed by application of mitomycin-C, and perforated punctal plugs were then inserted. Plugs were removed after 6 months, and anatomical and functional success were assessed and followed during and for 6 months after removal of the plugs. RESULTS: The study included 30 patients with acquired external punctal stenosis: 9 males (30%) and 21 females (70%) with a mean age of 62.83 ± 8.3 years. Punctal stenosis grade 0 (no punctum) occurred in 9 cases (30%), and grade 1 (the punctum is covered by a membrane) occurred in 21 cases (70%). Six months after removal of the plugs, epiphora improved in 93.3% of patients, and fluorescein dye disappearance test results improved in 90% of patients; 6.7% of cases had early extrusion of the plug, and 3.3% had granuloma formation. CONCLUSIONS: Application of perforated punctal plugs combined with mitomycin-C is a simple and efficient technique in the management of tight acquired external punctal stenosis.

Probing for congenital nasolacrimal duct obstruction.

BACKGROUND: Congenital nasolacrimal duct obstruction (NLDO) is a common condition causing excessive tearing in the first year of life. Infants present with excessive tearing or mucoid discharge from the eyes due to blockage of the nasolacrimal duct system, which can result in maceration of the skin of the eyelids and local infections, such as conjunctivitis, that may require antibiotics. The incidence of nasolacrimal duct obstruction in early childhood ranges from 5% to 20% and often resolves without surgery. Treatment options for this condition are either conservative therapy, including observation (or deferred probing), massage of the lacrimal sac and antibiotics, or probing the nasolacrimal duct to open the membranous obstruction at the distal nasolacrimal duct. Probing may be performed without anesthesia in the office setting or under general anesthesia in the operating room. Probing may serve to resolve the symptoms by opening the membranous obstruction; however, it may not be successful if the obstruction is due to a bony protrusion of the inferior turbinate into the nasolacrimal duct or when the duct is edematous (swollen) due to infection such as dacryocystitis. Additionally, potential complications with probing include creation of a false passage and injury to the nasolacrimal duct, canaliculi and puncta, bleeding, laryngospasm, or aspiration. OBJECTIVES: To assess the effects of probing for congenital nasolacrimal duct obstruction. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2016, Issue 8); MEDLINE Ovid (1946 to 30 August 2016); Embase.com (1947 to 30 August 2016); PubMed (1948 to 30 August 2016); LILACS (Latin American and Caribbean Health Sciences Literature Database; 1982 to 30 August 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), last searched 14 August 2014; ClinicalTrials.gov (www.clinicaltrials.gov), searched 30 August 2016; and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), searched 30 August 2016. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared probing (office-based or hospital-based under general anesthesia) versus no (or deferred) probing or other interventions (observation alone, antibiotic drops only, or antibiotic drops plus massage of the nasolacrimal duct). We did not include studies that compared different probing techniques or probing compared with other surgical procedures. We included studies in children aged three weeks to four years who may have presented with tearing and conjunctivitis. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion and independently extracted data and assessed risk of bias for the included studies. We analyzed data using Review Manager software and evaluated the certainty of the evidence using GRADE. MAIN RESULTS: We identified two RCTs and no ongoing studies; one of the included RCTs was registered. The studies reported on 303 eyes of 242 participants who had unilateral or bilateral congenital nasolacrimal duct obstruction. For both included studies, the interventions compared were immediate office-based probing to remove the duct obstruction versus deferred probing, if needed, after 6 months of observation or once the child reached a certain age.The primary outcome of the review, treatment success at 6 months, was reported partially in one study. Treatment success was not reported at this time point for all children in the immediate probing group; however, 77 of 117 (66%) eyes randomized to deferred probing had resolved without surgery 6 months after randomization and 40 (34%) eyes did not resolve without probing. For children who had unilateral NLDO, those randomized to immediate probing had treatment success more often than those who were randomized to deferred probing (RR 1.41, 95% CI 1.12 to 1.78; 163 children; moderate-certainty evidence). Treatment success for all children was assessed in the study at age 18 months; as an ad hoc analysis in the included study, results were presented separately for children with unilateral and bilateral NLDO (RR 1.13, 95% CI 0.99 to 1.28 and RR 0.86, 95% CI 0.70 to 1.06, respectively; very low-certainty evidence).In the other small study (26 eyes of 22 children), more eyes that received immediate probing were cured within one month after surgery compared with eyes that were randomized to deferred probing and analyzed at age 15 months (RR 2.56, 95% CI 1.16 to 5.64). We considered the evidence to be low-certainty due to imprecision from the small study size and risk of bias concerns due to attrition bias.One study reported on the number of children that required reoperation; however, these data were reported only for immediate probing group. Nine percent of children with unilateral NLDO and 13% with bilateral NLDO required secondary procedures.One study reported cost-effectiveness of immediate probing versus deferred probing. The mean cost of treatment for immediate probing was less than for deferred probing; however, there is uncertainty as to whether there is a true cost difference (mean difference USD -139, 95% CI USD -377 to 94; moderate-certainty evidence).Reported complications of the treatment were not serious. One study reported that there were no complications for any surgery and no serious adverse events, while the other study reported that bleeding from the punctum occurred in 20% of all probings. AUTHORS' CONCLUSIONS: The effects and costs of immediate versus deferred probing for NLDO are uncertain. Children who have unilateral NLDO may have better success from immediate office probing, though few children have participated in these trials, and investigators examined outcomes at disparate time points. Determining whether to perform the procedure and its optimal timing will require additional studies with greater power and larger, well-run clinical trials to help our understanding of the comparison.

Crigler Massage for Congenital Blockade of Nasolacrimal Duct.

OBJECTIVE: To determine the success rate of non-surgical management of congenital nasolacrimal duct obstruction (CNLDO) with Crigler massage in infants below the age of one year. STUDY DESIGN: A cross-sectional observational study. PLACE AND DURATION OF STUDY: Department of Ophthalmology at HBS General Hospital, Hazrat Bari Sarkar Medical and Dental College, Islamabad from November 2015 to May 2016. METHODOLOGY: One hundred children with watering of eyes, due to congenital blockage of the distal part of the nasolacrimal duct (at the valve of Hasner), unilateral or bilateral were included in the study. Initially, Crigler massage was advised to all the parents for a period of 1-3 months with practical demonstration and the results were documented every fortnight. RESULTS: There were 52 infants up to the age of 6 months and 48 infants between 6-12 months, 53% were boys and 47% were girls. Among them, 67% had unilateral complain while 33% were bilaterally affected. At the end of 1-3 months, 90% of the children achieved patency and only 10% of the cases were subjected to Bowman's probing under short anesthesia. CONCLUSION: CNLDO mostly resolved through conservative approach by Crigler massage as an initial management, if done consistently. Probing and other surgical procedures should not be considered before the age of 12 months.

Endoscopic dacryocystorhinostomy following head and neck radiation therapy.

This article determines the efficacy of endoscopic dacryocystorhinostomy (endoDCR) in patients who have undergone adjuvant external beam radiation therapy (XRT) following head and neck cancer resection. A retrospective chart review was performed on all patients who underwent endoDCR between 2006 and 2014 at a tertiary referral center. Cases were reviewed and selected for the following inclusion criteria: history of adjuvant sinonasal XRT following head and neck cancer resection, preoperative probing and irrigation demonstrating nasolacrimal duct obstruction (NLDO), postoperative probing and irrigation following silicone tube extubation. Exclusion criteria included active dacryocystitis, postoperative follow-up of less than 4 months, presence of epiphora prior to XRT, lack of probing/irrigation at preoperative or postoperative visit, and lid malposition including ectropion, facial palsy, and/or poor tear pump. Six patients (7 eyes) met the selection criteria. EndoDCR was performed at a mean time of 30 months following last radiation treatment (range, 3-71 months). Mitomycin C was used in 4/7 cases. Silicone tube removal occurred between 3-8 months postoperatively. Five out of 6 patients had postoperative sinonasal debridement and nasal saline/corticosteroid irrigation. Five out of 6 patients (83%) had both resolution of epiphora and anatomic patency confirmed by probing and irrigation. Our experience suggests that endoDCR procedures can be effective in patients with NLDO following prior sinonasal XRT for head and neck neoplasms. Postoperative management with sinonasal debridement and combined saline/corticosteroid nasal irrigation may help to improve surgical success in patients with increased post-radiotherapy mucosal inflammation.

A survey of management of congenital nasolacrimal duct obstruction by pediatric primary health care providers in Spain.

PURPOSE: To survey the management of congenital nasolacrimal duct obstruction (CNLDO) by pediatric primary health care providers in Spain. METHODS: This was a descriptive study using a web-based questionnaire to evaluate the perceptions of the members of the Pediatric Primary Care Society in Castilla-León, Spain (APAPCYL), regarding management of CNLDO. The questionnaire contained 14 direct questions and was sent by e-mail to all the pediatricians. All the responses were analyzed by the frequency of occurrence and percentages. RESULTS: Ninety physicians responded to the questionnaire. Massage 2 or 3 times a day was the initial treatment advised by 60.47% of pediatricians. Nearly half of the pediatricians recommended continuing massage until symptoms resolved. Fewer than 50% of children required referral to an ophthalmologist. Reasons for an ophthalmic consult included persistence of symptoms among 87.21% of pediatricians and parental/guardian request among 10.5% of pediatricians. According to 45.6% of pediatricians, their knowledge about CNLDO is limited, and 92.2% would like to receive further training on CNLDO. CONCLUSIONS: Massage was the main initial treatment for managing CNLDO among pediatricians. The outcomes of this survey indicated that massage fails in fewer than 50% of patients and an ophthalmic referral is required for these cases.

Office-based endoscopic revision using a microdebrider for failed endoscopic dacryocystorhinostomy.

This article is to introduce office-based endoscopic revision surgery using a microdebrider for failed endoscopic dacryocystorhinostomy (EN-DCR). The authors conducted retrospective, non-comparative, interventional case series analysis of 27 eyes of 24 patients, treated by office-based revision EN-DCR using a microdebrider. After local anesthesia, anatomical failures (cicatrization, granuloma, synechia) after primary EN-DCR were treated with a microdebrider (Osseoduo 120, Bien-Air Surgery, Le Noirmont, Switzerland) in an office setting, and a bicanalicular silicone tube was placed. Anatomical improvement and functional relief of epiphora were evaluated at 6-months after revision. The causes of failed EN-DCR were rhinostomy site cicatrization (17/27, 63.0 %), granulomatous obstruction (7/27, 25.9 %) and synechial formation (3/27, 11.1 %). The anatomical success rate was 100 %, and 85.2 % cases achieved complete relief of epiphora. The surgery did not exceed 10 min in any case and no complications were observed. Office-based revision EN-DCR using a microdebrider provided prompt management of post-DCR epiphora. The portable nature and all-round ability of the microdebrider allowed office-based surgery, which offered advantage to work with the surgeon's own well-trained office staff. Office-based revision EN-DCR can be both time- and money-saving, and might be regarded the treatment of choice for failed EN-DCR.

Conjunctivodacryocystorhinostomy with Jones tube: a history and update.

PURPOSE OF REVIEW: Current opinions and trends in the management of upper lacrimal obstruction include design variations on the original Lester Jones tube and updated awareness and management of the problems associated with the tubes. This article includes a brief review of the fascinating history of the development of the Jones tube, which sets the perspective for the current scientific dialog. RECENT FINDINGS: First, many design modifications have been proposed to reduce the risk of tube migration and extrusion, with no consensus on the best tube. Second, the issue of retrograde airflow through the Jones tube with the use of continuous positive airway pressure is an increasingly common and challenging problem. Third, bacterial biofilms on the surface of the Jones tube can play a role in recalcitrant infections. Jones tubes can be cleaned or replaced in the office setting with topical anesthesia. SUMMARY: Conjunctivodacryocystorhinostomy (CDCR) with placement of a Jones tube remains the gold standard for management of upper lacrimal obstruction. This article provides an updated perspective on issues with extrusion or migration of the tube, bothersome retrograde airflow with the use of a continuous positive airway pressure device, and management of crusting and possible infectious biofilms on the tube.

The natural process of congenital nasolacrimal duct obstruction and effect of lacrimal sac massage.

This study aimed to examine the rate of symptomatic improvement of congenital nasolacrimal duct obstruction (CNLDO) in infants treated with conservative management within the first year of age. Other purpose of the study is to emphasize the relationship between spontaneous resolution time and effective lacrimal sac massage. Thirty-one infants were diagnosed to have CNLDO by an ophthalmologist prior to 3 months of age. In this study, 36 eyes of 31 patients were included with CNLDO. The patients were divided into two groups. Group 1 (28 eyes of 24 patients) was consisted of the patients who were applied effective lacrimal sac massage regularly during the follow-up period, and patients whose parents did not apply a regular lacrimal passage regularly were accepted as group 2 (8 eyes of 7 patients). Thirty-three eyes of 31 patients (18 rights and 15 left) successfully resolved with only conservative management (91.6 %). In these thirty-three eyes, one eye (3 %) resolved between 0 and 3 months, fourteen eyes (42.5 %) resolved between 4 and 6 months, eleven eyes (33.3 %) resolved between 7 and 9 months, and seven eyes (21.2 %) resolved between 10 and 12 months. CNLDO was resolved in 27 (96.2 %) of 28 eyes in group 1, and in group 2, six eyes (77.7 %) had resolvement. This difference was statistically significant (p = 0.001). The mean age of resolution was 6.8 ± 1.88 months in group 1, 10.3 ± 1.5 months in group 2 (p < 0.001). In light of our study, we believe that conservative management of CNLDO is highly successful. Our study provided a possible objective explanation for the efficacy of lacrimal sac massage. Emphasizing the importance of the massage to parents and describing in detail can reduce the risk of unnecessary surgical interventions.

Factors affecting treatment outcome in congenital nasolacrimal duct obstruction: A retrospective analysis from South India.

PURPOSE: To investigate outcomes for different treatment modalities in congenital nasolacrimal duct obstruction (CNLDO) in an Indian population. DESIGN: Retrospective, interventional, case series. MATERIALS AND METHODS: In an institutional setting, case records of patients with CNLDO from January 2008 to 2012, were reviewed, and data on patient demographics, clinical presentation, and treatment details (sac massage, probing, and/or dacryocystorhinostomy) were recorded. Success of treatment was defined as complete resolution of symptoms and negative regurgitation on pressure over lacrimal sac (ROPLAS) area. RESULTS: Two hundred and ninety-eight eyes of 240 patients with a mean age of 22.2 ± 26.14 months (median = 12 months, interquartile range = 17) were analyzed. Sac massage (n = 226) was successful in 67 eyes (30%). Multivariable logistic regression analyses showed that children with mucoid ROPLAS were almost 6 times more likely (odds ratio [OR] = 5.55 vs. clear ROPLAS, 95% confidence interval [CI] = 2.35-13.09, P < 0.001) to experience failure of sac massage. Overall probing (n = 193) was successful for 143 (74%) eyes. Multivariable logistic regression showed that older children were 25% more likely to experience probing failure (OR = 1.25 for every 6 months increment in age, 95%, CI = 1.09-1.42, P = 0.001). CONCLUSION: Sac massage is successful in only a third of our patients and those with mucoid ROPLAS are more likely to experience failure. Probing is successful in three-quarter of our subjects, and its success declines with a progressive increase in age. Lower socioeconomic status, poor general health, and recurrent respiratory infections are unique to our population and may influence outcomes.

Manejo de obstrucción de vía lagrimal en niños mediante intubación con sonda Monoka®: experiencia inicial en HCUCh / Management of lacrimal duct obstruction in children by intubation with Monoka®: initial experience at HCUCh

Introducción: La obstrucción congénita del ducto nasolacrimal (DNL) es motivo de consulta frecuente en menores de un año. Se encuentra en 6% de los recién nacidos, la mayoría de las veces secundario a la persistencia de una membrana mucosa en la porción distal del DNL (membrana de Hassner). Generalmente se presenta como epífora patológica, es decir, presente después del 3º mes de vida. Esta obstrucción puede evolucionar con resolución espontánea los primeros 12 meses de vida, requerir terapias complementarias o resolución quirúrgica. Objetivo: Analizar los casos de obstrucción de la vía lagrimal en población pediátrica usando sonda Monoka® en pacientes intervenidos en el Hospital Clínico de la Universidad de Chile, que consultaron por epifora; verificando tasas de éxito, complicaciones del procedimiento y seguimiento. Material y método: Se realizó un estudio descriptivo retrospectivo, incluyendo todos aquellos pacientes con diagnóstico de obstrucción de vía lagrimal, mayores de 24 meses de edad, que consultaron en el HCUCh entre julio 2012 y marzo 2014, que requiriesen resolución quirúrgica de su cuadro. Se realizó instalación de sonda Monoka® con la participación conjunta de oftalmología y otorrinolaringología. Resultados: Se reunieron 7 pacientes, obteniendo éxito de 85,7% (6) y 100% de mejoría respecto a los síntomas iniciales. Un paciente presentó una complicación intraoperatoria, definida como un sondeo frustro. La sonda permaneció instalada un promedio de 7,7 meses y fue retirada sin complicaciones. Conclusión: La instalación de sonda Monoka® como procedimiento quirúrgico destinado a la resolución de la obstrucción de vía lagrimal es una técnica sencilla, de fácil acceso, moderado costo y que constituye una solución exitosa para aquellos pacientes afectados. Presenta excelentes resultados a mediano plazo, sin recidiva de la obstrucción de la vía lagrimal y con baja tasa de complicaciones. Es una técnica exitosa que, luego de esta experiencia, podría ser considerada de primera línea en nuestro hospital para aquellos pacientes con diagnóstico de epífora patológica, mayores de 24 meses.

Introduction: Congenital nasolacrimal duct obstruction (DNL) is frequent complaint in under a year. It is found in 6% of infants, the most often secondary to the persistence of a mucous membrane in the distal portion of the nasolacrimal duct (Hassner membrane). It usually occurs as pathological epifora present after the 3rd month of life. This obstruction can evolve spontaneously resolved the first 12 months of life, require complementary therapies or surgical treatment. Aim: To analyze where we have used the Monoka® probe in pediatric population operated in the Clinical Hospital of the University of Chile, who consulted for pathological epiphora; verifying success rates, procedure complications and monitoring. Material and method: A retrospective descriptive study, which were included all patients with the diagnosis of pathological epiphora over 12 months old, who consulted in the HCUCH between July 2012 and March 2014, that required surgical resolution of their condition. Monocanalicular installation silicone catheter was used with the joint participation of ophthalmology and otorhinolaryngology. Results: We had a total of 7 patients with a success rate of 85.7% (6) and 100% improvement over the initial symptoms. Only one patient presented an intraoperative complication, defined as failed intubation. The probe remained installed an average of 7.7 months and was removed without complications. Conclusions: The installation of Monoka® probe as surgical intervention to resolve the pathological epiphora is a simple, easily accessible and amoderate cost procedure. It's a successful solution for those patients affected. It has excellent mid-term results, no recurrence of obstruction of DNL and low complication rate. It is a successful technique that would be considered frontline in our hospital for patients diagnosed with pathological epiphora over 12 months old.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons.

PURPOSE: To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. METHODS: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. RESULTS: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture. CONCLUSION: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

[Treatment of congenital lacrimal duct obstruction: A prospective clinical cohort study]. / Behandlung kindlicher Tränenwegsstenosen : Eine prospektive klinische Kohortenstudie.

BACKGROUND: Pressurized probing and irrigation is the method of choice for congenital lacrimal duct obstruction after conservative therapeutic strategies have failed. The aim of this study was to evaluate age dependence and success rates of different therapeutic options. MATERIAL AND METHODS: A prospective cohort study of children with congenital lacrimal duct obstruction was performed. All children treated during the period between May 2009 and June 2010 were included. Surgical success was defined as the absence of epiphora and mucous discharge for a postoperative follow-up of 3 months. Odds ratios (OR) and 95 % confidence intervals (CI) of different variables were estimated using logistic regression. RESULTS: A total of 111 children (137 eyes) underwent treatment for congenital lacrimal duct obstruction. The mean age of the children was 7.7 months (range 1-30 months). The success rate of probing under local anesthesia was 85.5 % (n = 100). Probing under general anesthesia without intubation of the lacrimal pathway was successful in 28.6 % (n = 2). Treatment under general anesthesia with intubation of the lacrimal pathway had a success rate of 94.2 %. If the primary treatment was complicated the OR was 1.9 (95 % CI: 0.7-5.1), for males the OR was 1.7 (95 % CI: 0.8-3.5) and in cases of a positive family history the OR was 1.5 (95 % CI: 0.7-3.3). With every increasing month of age the risk not to be treated successfully increased (OR: 1.3, 95 % CI: 1.2-1.5). CONCLUSION: Syringing under local anesthesia is an effective therapy. The highest success rates were found at the ages of 1-6 months. Therapy with additional silicone tube intubation was highly successful.