Balloon dacryoplasty: A boon for dacryologists in managing persistent congenital nasolacrimal duct obstructions.

PURPOSE: To study the outcomes of balloon dacryoplasty (BD) or (BDCP) in children with persistent congenital nasolacrimal duct obstruction (pCNLDO) by using new and reused balloon catheters. METHODS: Our retrospective analysis focused on managing pCNLDO by using the BD or BDCP technique. The study included children aged >1 year to <12 years who underwent single or multiple probings before. Our specific lacrimal workup included a detailed history and examination, as published earlier. We used conventional, straight, 2 mm × 13 mm/3 mm × 15 mm lacrimal balloons (FCI, Ophthacath). We have described a technique to use the same catheter for three BD procedures (1 new + 2 reuse). The outcomes were categorized as complete success, partial success, and failure. The minimum follow-up of each child was 6 months. RESULTS: We analyzed 64 children (89 eyes) with a mean age of 58 months (15-132 months). All children (100%) had epiphora with discharge and positive FDDT. All children underwent BD under general anesthesia - new balloons in 59 eyes and reused balloons in 30 eyes. The balloons were plasma sterilized akin to vitrectomy cutters and tubings of phaco machines. We noted three leaks from reused balloons (2 from the balloon tip and 1 from the plastic hub). At a mean follow-up of 14.5 months, complete success was noted in 77 eyes (86.5%) (52 new and 25 reuse), while 8 eyes had partial success (8.9%) (4 new and 4 reuse). Failure of BD was noted in four eyes (4.5%) (3 new and 1 reuse). None had significant complications with new or reused balloons. CONCLUSION: BD or BDCP is a quick, safe, easy, and effective procedure that resolves pCNLDO symptoms satisfactorily. Carefully reusing a conventional balloon catheter is possible with comparable efficacy and no additional complications in pCNLDO.

The incidence of pediatric dacryocystitis among a population-based cohort of infants with congenital nasolacrimal duct obstruction.

PURPOSE: To report the incidence, clinical characteristics, and outcomes of acute dacryocystitis among a large, population-based cohort of children born with congenital nasolacrimal duct obstruction (CNLDO) over a 10-year period. METHODS: This multicenter retrospective, population-based cohort study included all patients diagnosed with acute dacryocystitis in a cohort of patients diagnosed with CNLDO before age 5 years in Olmsted County, Minnesota, United States of America from January 1, 1995, through December 31, 2004. RESULTS: Of 1,998 patients with CNLDO, there were 70 cases (36 female [(51%)]) of acute dacryocystitis during the study, yielding an incidence rate of 243 per 100,000 children (95% CI, 170-316). Mean age at diagnosis was 9.0 months. Patients who developed dacryocystitis were significantly less likely to be born via C-section (OR = 0.29, P = 0.009). Less than half of patients with dacryocystitis were treated with oral/intravenous antibiotics (46%), but whose who were had a significantly higher odds of requiring probing (OR = 8.50, P = 0.004). Spontaneous CNLDO resolution was significantly less likely to occur in patients diagnosed with acute dacryocystitis compared with those without (OR = 2.46, P = 0.001). The median age of spontaneous resolution in the dacryocystitis group (6.0 months) was significantly older than the uncomplicated CNLDO group (P = 0.012). CONCLUSIONS: Pediatric acute dacryocystitis is an uncommon complication of CNLDO and is associated with both a lower likelihood of and older age at spontaneous resolution of CNLDO symptoms.

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.

Ophthalmic features of Lamb-Shaffer syndrome: a case series.

Lamb-Shaffer syndrome (LSS) is a rare neurodevelopmental disorder, genetically diagnosed in fewer than 100 individuals worldwide. We present a case series of 6 pediatric patients with LSS and describe its ophthalmic manifestations. Strabismus was present in 5 patients, with exotropia being most common. All subjects had significant refractive errors; 5 had astigmatism of at least 2 D. All patients had optic nerve abnormalities, including pallor (4), hypoplasia (2), and anomalous appearance (1), with retinal nerve fiber layer thinning demonstrated in a single subject. Other ophthalmic disorders detected were ptosis (1), nasolacrimal duct obstruction (1), and nystagmus (2).

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.

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.

High incidence and recurrence of tympanostomy tube procedures in children who underwent nasolacrimal duct probe and intubation for congenital nasolacrimal duct obstruction.

PURPOSE: To determine the incidence of tympanostomy tube (T-tube) insertion in children who required probing and intubation for congenital nasolacrimal duct obstruction (CNLDO) at a single academic institution and to analyze success rates. METHODS: The medical records of 92 patients who underwent nasolacrimal probing and intubation for CNLDO over a 9-year period were reviewed retrospectively. A preoperative questionnaire was given to the patient's guardian concerning laterality of CNLDO, history of otitis media (OM) antibiotic therapy, history of T-tube placement and number placed. At least 12 months following the initial nasolacrimal duct P&I, a second questionnaire was administered regarding resolution of CNLDO symptoms, additional measures taken to relieve postoperative symptoms if present, and any further history regarding OM episodes or T-tube insertion. RESULTS: Of the 92 children with CNLDO, 37 (40%) required T-tubes either prior to or following nasolacrimal duct probing and intubation, a rate higher than in the general population (P < 0.00001). 21 (56%) of CNLDO probing and intubation patients who required T-tubes required at least two sets, at different times, to relieve OM symptoms. Six of 37 patients (16%) with a history of T-tube placement and 1 of 55 (2%) with no history of T-tube placement had persistent epiphora after nasolacrimal probing and intubation (relative risk, 8.92; P = 0.0388). CONCLUSIONS: In our study cohort, pediatric patients with CNLDO who required nasolacrimal probing and intubation were at higher risk of needing T-tubes for chronic OM than the general population, and those needing T-tubes were at increased risk of residual epiphora.

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.].

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.

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.

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.

Management of congenital nasolacrimal duct obstruction in down syndrome.

BACKGROUND: Congenital nasolacrimal duct obstruction (CNLDO) is common in Down Syndrome (DS), and more difficult to treat. Our purpose was to describe the management of CNLDO in paediatric patients with DS. METHODS: Retrospective cohort study. Medical chart review of all DS patients diagnosed with CNLDO at the Division of Ophthalmology at the Children's Hospital of Philadelphia during a 12-year period (2009-2020). Main outcome measures included: Surgical interventions, primary probing outcome, rate of dacryocystorhinostomy (DCR) and/or conjunctivodacryocystorhinostomy (CDCR), and overall success. RESULTS: 126 patients (236 eyes) were included, mean age of 1.8 ± 2.1 years (range 0.1-11.3 y), 110 (87%) had bilateral CNLDO. Mean follow-up time was 41 months. 84 patients (67%) underwent at least one surgical intervention; the mean number of surgical interventions in this group was 1.8 ± 1.4 per patient (range, 1-6). The most common primary intervention was probing (n = 74, 88%), mostly (n = 57, 68%) with monocanalicular silicone intubation. Probing with silicone intubation had a higher success rate compared to probing alone (P = 0.002). Twenty (24% of 84) patients underwent DCR/CDCR during the follow-up period. Complete resolution was achieved in 123 patients (98%). CONCLUSIONS: CNLDO in Down syndrome is associated with high rates of bilateral obstructions and with less favourable surgical outcomes. Many patients ultimately require a more robust surgical intervention such as DCR or CDCR. The use of monocanalicular stent in initial probing was associated with a higher success rate, and would appear to be appropriate in all CNLDO-DS cases.

Comparison of Endoscopically Assisted Primary Probing and Bicanalicular Silicone Intubation for Congenital Nasolacrimal Duct Obstruction in Children Aged 4 to 7 Years.

PURPOSE: To compare the clinical outcomes of primary nasolacrimal duct probing and primary bicanalicular intubations with endoscopic assistance for congenital nasolacrimal duct obstruction (CNLDO) in children aged 4 to 7 years. METHODS: Forty-three eyes of 43 children (25 boys and 18 girls) with congenital epiphora who underwent primary unilateral probing and bicanalicular intubation were evaluated retrospectively. The tubes were removed 3 to 4 months after their placement, and the children were followed up for another 6 months after their removal. Treatment success was defined as the normal result of the fluorescein dye disappearance test and complete resolution of the lacrimal symptoms and signs of patients. The success rates were compared between the two groups (bicanalicular intubation vs probing). Type of CNLDO (membranous, incomplete complex, and complete complex) was determined with an endonasal endoscope. RESULTS: The mean age was 63.3 ± 11.1 months (range: 48 to 84 months) for the probing group and 64.4 ± 12.1 months (range: 48 to 84 months) for the bicanalicular intubation group (P = .915). The bicanalicular intubation group showed significantly greater treatment success (21 of 24, 87.5%) compared to the probing group (11 of 19, 57.9%; P = .038). Bicanalicular intubation provided higher treatment success among patients with complex CNLDO compared to probing (80.0% vs 11.1%, P = .002). There was no difference in mean age between the patients with successful and failed treatment in both groups (P = .631 and .137, respectively). CONCLUSIONS: Bicanalicular intubation was associated with a higher success rate than probing under nasal endoscopic visualization for the treatment of CNLDO in children aged 4 to 7 years. The type of CNLDO might be the primary factor for the treatment success. [J Pediatr Ophthalmol Strabismus. 2023;60(2):101-107.].

Effect of age on primary balloon dacryocystoplasty and probing success in congenital nasolacrimal duct obstruction.

PURPOSE: To compare the success rates of balloon dacryocystoplasty (BDP) and probing as a primary procedure in congenital nasolacrimal duct obstruction (CNLDO) and investigate the effect of age on both procedures. METHODS: A total of 135 patients (171 eyes) with simple and incomplete complex CNLDO were included in this retrospective study; complete complex CNLDO cases were excluded. The success rates for primary BDP (118 eyes) and for probing (53 eyes) were compared overall and among the age groups; Group 1 (12-24 months old), Group 2 (25-36 months old), and Group 3 (> 36 months old). RESULTS: Mean age of the patients was 41.5 ± 27.2 months for primary BDP, and 21.8 ± 10.8 months for probing (p < 0.001). Overall success rates for primary BDP and probing were 81.1% (43/53) and 76.3% (90/118), respectively (p = 0.481). Success rates for BDP and probing among age groups were 93.8% and 85.3% in Group 1 (p = 0.360), 93.3% and 50.0% in Group 2 (p = 0.012), and 63.6% and 27.3% in Group 3 (p = 0.052), respectively. Cox regression analysis showed that the median ages were 18 months for probing and 36 months for primary BDP. The Poisson regression model showed that for every 1-month increase in patients' age, the success rate of probing decreased by 9.7%. CONCLUSION: Probing success decreased to a point where different treatment options such as primary BDP can be discussed with the patients' parents after 18 months of age. The success of BDP decreased after 36 months, while it maintained a high success rate between 24 and 36 months as primary treatment.

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.