Bony Congenital Nasolacrimal Duct Obstruction: A Novel Phenotype of Aplasia of Lacrimal and Major Salivary Glands.

PURPOSE: Aplasia of lacrimal and salivary glands (ALSG) is a syndromic disorder characterized by aplasia of lacrimal and salivary systems. Reported ophthalmic manifestations of ALSG include aplasia of lacrimal glands, punctal agenesis, lacrimal sac mucocele, and membranous congenital nasolacrimal duct obstruction (CNLDO). Bony CNLDO, a rare clinical entity, has not been associated with any syndromic disorder. This study investigated the relationship between genetic mutations and bony CNLDO in 3 Chinese families with ALSG. DESIGN: Single-center observational case study. PARTICIPANTS: Three Chinese families with bony CNLDO, including 7 affected and 9 healthy family members. METHODS: Slit-lamp ophthalmic examination, comprehensive physical examination, orbital computed tomography (CT) imaging, cervicofacial magnetic resonance imaging, audiometry, and whole exome sequencing on periphery blood were performed. Variants were cross-referenced with 1000 control genomes and various population databases. Pathologic variants were identified using bioinformatic tools. MAIN OUTCOME MEASURES: Clinical examination, diagnostic imaging, whole exome sequencing, and bioinformatic analysis findings. RESULTS: Affected patients showed decreased tear production on the Schimer I test and reduced tear breakup time. Bony CNLDO was observed on CT, showing unilateral or bilateral bony termination at the middle or terminal segment of the nasolacrimal canal. Magnetic resonance imaging showed aplasia or absence of lacrimal, parotid, and submandibular glands. Physical examination revealed normal ears, digits, and facial morphology. Audiometry and dental assessment were conducted on the pediatric patients and yielded normal results. The clinical characteristics of patients aligned with a diagnosis of ALSG. Genomic analysis revealed 3 novel heterozygous missense mutations of the Fgf10 gene: c.316T→C, c.327C→G, and c.332T→G. The inheritance pattern was autosomal dominant with variable penetrance. These variants were not observed in 1000 control genomes and population databases. These variant positions also were shown to be highly conserved across various animal species. Mutated genes and proteins were predicted as deleterious with most computational models, with a few suggesting they may be benign. CONCLUSIONS: Bony CNLDO was identified as a novel phenotype of ALSG implicated by missense mutations of highly conserved residues in the Fgf10 gene. These cases broadened our knowledge of Fgf10-related phenotypes and prompted clinicians to consider syndromic associations in patients with bony CNLDO. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Incidence and clinical characteristics of congenital nasolacrimal duct obstruction with concurrent craniofacial abnormalities among a population-based cohort.

PURPOSE: Data supporting treatment recommendations for congenital nasolacrimal duct obstruction (CNLDO) in patients with craniofacial abnormalities is scarce. This study reports the incidence, clinical features, and outcomes of patients with concomitant craniofacial abnormalities and CNLDO. METHODS: This multi-center, retrospective, population-based cohort study included all patients diagnosed with CNLDO before age 6 during a 10-year period in a single US county. RESULTS: Of the 17,713 live births during the study period, 1998 infants were diagnosed with CNLDO, among whom 41 (2.05%) had associated congenital craniofacial abnormalities, yielding a birth prevalence of 23.1 (95% CI 16.6-31.4) per 10,000 live births. Craniofacial patients were significantly older at time of diagnosis (6.2 months) compared to uncomplicated CNLDO (3.7 months; p = 0.035). There was no significant difference in mean age at spontaneous CNLDO resolution, but 31.7% of craniofacial patients required probing for CNLDO resolution, compared to 14.5% in the CNLDO group (OR 2.76 [95%CI 1.41-5.39] p = 0.003). All but two patients with craniofacial abnormalities had resolution of symptoms after initial probing. Intraoperative probing findings indicated that 8 of 13 craniofacial patients had complex obstructions. CONCLUSIONS: The similar age at spontaneous resolution indicates that watchful waiting until approximately one year of age is a reasonable approach even in patients with craniofacial abnormalities, though more of these patients may require surgical intervention.

Management and outcomes of congenital nasolacrimal duct obstruction in trisomy 21 patients vs. non-trisomy 21 patients within a paediatric population: a 5-year follow-up.

PURPOSE: To assess the management of patients with congenital nasolacrimal duct obstruction (CNLDO) in a paediatric population and review the long-term outcomes over a 5-year interval, with particular emphasis on the difference between patients with trisomy 21 and those without trisomy 21. METHODS: This single-centre, retrospective, cross-sectional, case review study included patients suffering from CNLDO at Alder Hey Children's Hospital NHS foundation Trust. Patients were divided into two groups: Non-trisomy 21 and trisomy 21. Patients were followed-up for a 60-month interval. Patients aged <12 months at the time of surgery, patients with <60 months of follow-up data and patients with acquired nasolacrimal duct obstruction were excluded. The main outcome measures were discharge rates in patients undertaking primary intervention with syringe and probe (S&P), number of patients requiring further treatment with lacrimal intubation or dacryocystorhinostomy (DCR) and overall symptom-free periods post-treatment. RESULTS: Ninety-three patients (142 eyes) were included. The mean number of surgical interventions was 1.53 ± 0.65. The mean interval between the 1st and 2nd intervention was 15.54 ± 16.33 months. There was a trend towards greater success rates non-trisomy 21 patients versus patients with trisomy 21 (p = 0.1352). The average symptom-free period after the final intervention was 44.31 ± 20.68 months, significantly longer in the non-trisomy 21 group compared to the trisomy 21 group (p = 0.0074). CONCLUSIONS: The overall success rate after primary S&P was 55.9%. Our results suggest that in trisomy 21 patients suffering from CNLDO, a one-stage intervention with primary monocanalicular intubation should be considered instead of sequential approach.

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.

Congential nasolacrimal duct obstruction: investigating the role of systemic inflammation through novel biomakers.

OBJECTIVE: Congenital nasolacrimal duct obstruction (CNLDO) is a common lacrimal system anomaly in newborns and infants. We aimed to evaluate the role of inflammation in the pathogenesis of persistent CNLDO and its potential use in diagnosis and follow up, focusing on novel inflammatory biomarkers: Systemic Immune-Inflammation Index (SII), Neutrophil-to-lymphocyte ratio (NLR), Platelet-to-lymphocyte ratio (PLR), Red cell distribution width (RDW), and Mean platelet volume (MPV). METHODS: A retrospective case-control study involving 76 CNLDO patients and 47 age-matched healthy controls was conducted. Complete blood count parameters were analyzed to calculate SII, NLR, PLR, RDW, and MPV. Receiver Operating Characteristic (ROC) analysis determined the diagnostic efficacy of these markers. RESULTS: SII, RDW, and neutrophil count were significantly elevated in the CNLDO group (p < 0.05). An elevated SII (cutoff > 200.9) demonstrated a sensitivity of 63.2% and a specificity of 63.8%. ROC analysis (AUC = 61.7%, p = 0.029) indicated that SII is a more significant marker for diagnosing CNLDO compared to NLR and PLR. CONCLUSION: Elevated SII, indicative of systemic inflammation may serve as a significant biomarker in the diagnosis of CNLDO that does not resolve spontaneously and requires probing. SII > 200.9 acts as a threshold that aids in the diagnosis of persistent CNLDO. Being a valuable biomarker, SII can be used in monitoring patients with CNLDO and in identifying those who will require advanced treatment like probing. Prospective studies are essential to validate these findings.

Nasal endoscopy-guided primary nasolacrimal duct intubation for congenital nasolacrimal duct obstruction in children older than 4 years.

PURPOSE: To evaluate the clinical outcomes of endoscopic guided primary bicanalicular intubation (BCI) for congenital nasolacrimal duct obstruction (CNLDO) in children older than 4 years. METHODS: A total of 40 eyes from 33 children (18 males, 15 females) with CNLDO who underwent bicanalicular intubation were evaluated. The type of CNLDO was determined by endonasal endoscopic visualisation. The mean silicone tube removal time was 4.3 ± 0.9 months (ranging from 3 to 6 months). The children were followed up for 6 months after the removal of tubes. Therapeutic success was defined as the normal result of the fluorescein dye disappearance test and complete resolution of previous lacrimal symptoms and signs. RESULTS: The median age was 80 [48] (range 48-156) months. Treatment success was achieved in 32 of 40 eyes (80.0%). A statistically significant correlation was observed between the age and success rate (p = 0.006). The success rate was lower in older children. Membranous type of CNLDO was observed in 47.5% (19/40) of the cases. The median age of patients with a membranous and complex type of CNLDO were 60 [30] months and 96 [53] months, respectively. Surgical success was 100% in the membranous type of CNLDO and 61.9% in the complex CNLDO group. CONCLUSIONS: Primary BCI using nasal endoscopic visualisation has a favourably high success rate for treating CNLDO in children aged 4 to 13 years. Treatment success was found to be related to both the type of CNLDO and age.

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.

Dacryoendoscopy-assisted incision of Hasner's valve under nasoendoscopy for membranous congenital nasolacrimal duct obstruction after probing failure: a retrospective study.

BACKGROUND: To introduce a treatment option: dacryoendoscopy-assisted incision of Hasner's valve under nasoendoscopy and assess its efficacy in treating membranous congenital nasolacrimal duct obstruction (CNLDO) in children older than 1 year with history of initial probing failure. METHODS: 52 eyes of 43 children with membranous CNLDO who underwent dacryoendoscopy-assisted incision of Hasner's valve under nasoendoscopy between May 2012 and October 2020 were enrolled in this retrospective study. All participants were older than 1 year and all the eyes had gone through probing at least once but still had symptoms of epiphora and discharge. Surgical success was defined as a normal fluorescein dye disappearance test (FDDT) and the absence of pre-operation complaints, including epiphora, muco-purulent discharge, increased tear lake or the symptoms of acute infection such as acute dacryocystitis. Patients' demographics, clinical features and follow-up outcomes were evaluated. RESULTS: Of all these operated cases, surgical success was achieved in 52/52 eyes without any early or late complications. The overall success rate was 100%. CONCLUSIONS: Dacryoendoscopy-assisted incision of Hasner's valve under nasoendoscopy is an effective and minimally invasive surgical treatment in membranous CNLDO patients with initial probing failure.

Success rates of probing for congenital nasolacrimal duct obstruction at various ages.

BACKGROUND: Although nasolacrimal duct probing is the standard treatment for congenital nasolacrimal duct obstruction (CNLDO) among children, the optimal timing of this procedure has been a topic of debate. The aim of the study was to analyze the clinical efficacy of nasolacrimal duct probing among patients with CNLDO symptoms at various ages. METHODS: An 8-year retrospective study involved 2434 patients (3009 eyes), who underwent nasolacrimal duct probing conducted under topical anesthesia in the operating theatre. The study group consisted of 1148 girls (47.2%) and 1286 boys (52.8%) from 2 weeks to 41 months (average age was 8 ± 5.6 months). The participants were divided into nine age groups: 0-2 months, 3-6 months, 7-9 months, 10-12 months, 13-15 months, 16-18 months, 19-21 months, 22-24 months and over 24 months. RESULTS: Bilateral obstruction was present among 575 (23.6%) children and was associated with a higher percentage of unsuccessful procedures compared to patients with unilateral obstruction (16.9% vs 10.2%, p < 0.001 Chi-square test). The success rate of the initial probing was 87.2% for all children and it was shown that it decreased with age. In the above age groups, it was 87.9%; 91.4%; 89.6%; 86%; 76.3%; 71.3%; 70.3%; 70.2%; 65.4%, respectively. CONCLUSIONS: Probing is a safe and effective procedure. However, age at the time of the initial intervention and bilateral surgery constitute significant risk factors for failed probing. Probing between 7 and 9 months appears to be reasonable treatment strategy for children without recurrent infections. Early surgical intervention may be considered for patients with additional signs.

Lacrimal sac bacteriology and susceptibility pattern in infants with congenital nasolacrimal duct obstruction in the 1st year of life: a cross-sectional study.

BACKGROUND: Congenital nasolacrimal duct obstruction (CNLDO) is one of the main causes of epiphora in infants, and antibiotics are usually used as a conservative therapy in the first year. Yet, little is known about the bacteriology of the occluded lacrimal drainage system in this group of patients. The aim of this study was to evaluate the microbiology of lacrimal sac (LS) in Chinese children with CNLDO in their first year of life. METHODS: Patients with CNLDO between May 1, 2017 and August 31, 2018 at a tertiary care children's hospital were enrolled. The study recruited infants who received lacrimal probing under 1 year old, and refluxed discharge from LS was collected. Samples were cultured and susceptibility test was performed for positive culture. RESULTS: Thirty-two patients with CNLDO were included. The ratio of male to female was 23:9. The mean age was 6.7 ± 2.4 (1.7-12) months. Positive cultures was identified in 87.5% of the sample, and presented 38 strains of bacteria. Mixed infection was identified in 10 (31.3%) children. Gram-positive bacteria accounted for 60.5% of all the strains, with Streptococcus (50%) being the most frequent species, whereas Haemophilus (21.1%) and Neisseriae (13.2%) were most common isolates for Gram-negative organisms. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in 2 infants whose symptoms resolved by a routine probing. No difference of bacteriology pattern was detected between patients under 6 months old and those beyond. The pathogens were highly sensitive to chloramphenicol (88%) and levofloxacin (84%), but resistant to erythromycin (40%) and sulfamethoxazole (32%). CONCLUSIONS: Infants with CNLDO under 1 year of age presented predominance of Streptococcus as Gram-positive organism, and Haemophilus as Gram-negative organism. Levofloxacin was an active topical antibiotic agent with few chance of resistance especially for Chinese children. These findings could help clinicians choose optimal medicine for CNLDO as the conservative treatments.

Role of dacryoendoscopy in refractory cases of congenital nasolacrimal duct obstruction.

Purpose: To highlight the importance of dacryoendoscopy in recognizing the factors responsible for failure with successful recanalization obviating the need for dacryocystorhinostomy in a few selective cases.Method: A retrospective study of 13 children undergoing dacryoendoscopy for refractory congenital nasolacrimal duct obstruction (CNLDO) was carried out during a period of 3 years from 2016 to 2018. Children with single or multiple failed probings were included in the study.Results: Out of the total 13 cases included in the study there 9 males and 4 females. The age ranged from 9 months to 36 months with the involvement of the right side in 7 cases and the left side in 6 cases. Four cases had dysgenesis of bony nasolacrimal duct (NLD), 4 cases had dacryolith, 3 cases had an intact membrane at the lower end of NLD and 2 cases had fibrosis of the lower end of NLD and the surrounding area in the inferior meatus (IM) following multiple interventions, (Table 1). Dacryoendoscopic recanalization was done in 7 cases while the endoscopic dacryocystorhinostomy (DCR) was done in 6 cases. Asuccessful outcome was achieved in all the cases and at the end of 6 months, all the children remained asymptomatic.Conclusions: Dacryoendoscopy (DEN) facilitates direct examination of the nasolacrimal system and thus has an added advantage over nasal endoscopy assisted probing in the refractory cases of CNLDO.

Endoscopic dacryocystorhinostomy to treat congenital nasolacrimal canal dysplasia: a retrospective analysis in 40 children.

BACKGROUND: To investigate the therapeutic effectiveness and safety of endoscopic dacryocystorhinostomy (EN-DCR) to treat congenital nasolacrimal canal dysplasia (CNCD). METHODS: Forty children (50 eyes) with congenital nasolacrimal duct obstruction (CNLDO) and lacrimal bony dysplasia, including 8 children with bony atresia (10 eyes) and 32 with bony stenosis (40 eyes), were recruited in this retrospective study. Standardized EN-DCR was performed in all cases. The postoperative observations included relief of symptoms, fluorescein dye disappearance test (FDDT), syringing of lacrimal passages and anastomotic patency under nasal endoscopy. Patients were followed up for 8-18 months. RESULTS: Standardized EN-DCR surgery had a success (cure and improvement) rate of 100%, including a cure rate of 82% and an improvement rate of 18%. The cure rate among 40 cases of bony nasolacrimal duct stenosis was 82.5%, while that of 10 cases of bony nasolacrimal duct atresia was 80%. Statistical analysis showed that nether the receipt of other treatments before surgery nor the type of bony nasolacrimal duct dysplasia affected the cure rate. No significant complications were observed during postoperative follow-up except for four cases (4 eyes) that suffered middle turbinate and nasal mucosal adhesion and two cases with sinusitis. CONCLUSIONS: CNCD is a type of CNLDO that does not respond to conservative and conventional treatment. EN-DCR represents a safe and effective treatment for children with CNCD. In addition, the combination of EN-DCR with lacrimal CT scanning provides advantages over traditional lacrimal surgery in that it has a high success rate with a low incidence of complications.

Surgical outcome and unusual complications of paediatric external dacryocystorhinostomy.

Purpose: To report the surgical outcome of external dacryocystorhinostomy (DCR) in children treated for congenital nasolacrimal duct obstruction (CNLDO) at a single tertiary eye hospital. Materials and Methods: The medical records of 44 consecutive paediatric patients who underwent external DCR with silicon tube intubation from January 2002 to December 2015 were retrospectively reviewed. Age at the time of surgery ranged from 2 to 12 years. Surgical success was defined as resolution of symptoms, normal tear film height, and negative fluorescein dye disappearance test. This study adheres to the principles outlined in the Declaration of Helsinki. Results: Four patients had simultaneous bilateral surgery (9.1%). Four patients had redo surgery following previous unsuccessful DCR. The patients' follow-up ranged between 2 and 10 years. There were no cases of serious immediate post-operative complications, but four children developed subcutaneous emphysema, and in two children operated before the age of 2.5 years agenesis of the ipsilateral upper canine was observed. Of the 42 patients who completed follow-up (46 eyes), 39 (43 eyes, 93.5%) had a successful result with complete cure of symptoms. Conclusions: Paediatric external DCR can successfully treat CNLDO with a low rate of complications. As the bud of the upper canine may be very close to the site of the rhinostomy when this is performed before the age of 3, it cannot be excluded that the agenesis of the ipsilateral upper canine, an unusual finding in Caucasian populations, might be related to the size and the site of the rhinostomy.

Prevalence of buried probe in complex congenital nasolacrimal duct obstruction and evaluation of its success rate post 'probing and irrigation': a single-centre retrospective study.

INTRODUCTION: The aim of this study was to determine the prevalence of buried probe variant of complex congenital nasolacrimal duct obstruction (CNLDO) and to evaluate the outcome of probing and irrigation in such cases. Institutional review board approval was taken. MATERIAL & METHODS: A total of 309 eyes (258 patients) were diagnosed with CNLDO during the study period of January 2014-March 2017. A retrospective file review of 25 lacrimal systems of 20 patients diagnosed as buried probe variant of complex CNLDO was carried out during the study period. RESULT: Buried probe variant of complex CNLDO was found to be 8% of the total CNLDO cases during the study period. Mean age at presentation was 1.7 years (range 8-48 months). Discharge and matting of eyelashes were the presenting symptoms in 22 out of 25 (88%) cases, whereas the only epiphora was the presenting symptom in three (12%) cases. Regurgitation of mucopurulent discharge on pressure over lacrimal sac area was positive in 16 out of 25 (64%) eyes. Associated lacrimal and nasal pathologies were seen in six out of 25 cases (24%). Success rate in buried probe variant cases of CNLDO in our study at 3-month follow-up was 88% (22 of 25 cases). CONCLUSION: A high period prevalence of 8% out of all CNLDO cases in our study suggests that the buried probe should be considered in selective cases of CNLDO and earlier unsuccessful probing.

Comparison of the success rate between monocanalicular and bicanalicular intubations in incomplete complex congenital nasolacrimal duct obstruction.

This article compares the success rate between monocanalicular (MCI) and bicanalicular intubations (BCI) in incomplete complex congenital nasolacrimal duct obstruction (CNLDO) and evaluate the factors responsible for the success of intubation. First, 99 patients with incomplete complex CNLDO underwent MCI (Monoka) or BCI (Crawford). Therapeutic success was defined as dye disappearance test grade 0-1 and complete resolution of previous symptoms at 12 months' follow-up. The success rates were compared between two groups. In all cases, the correlation of the age, gender, history of probing, and the presence of purulent discharges with the improvement in CNLDO symptoms were evaluated. 52 cases in the MCI and 47 cases in the BCI group were included. Then, 48 patients (48.5%) had history of probing. 26 patients (26.3%) had purulent discharges. The patients in the MCI group had lower success rate (59.6%) than the patients in the BCI group (74.4%) but the difference was not significant (p = 0.11). No complication occurred in the BCI group. In 4 cases (7.6%) in the MCI group, the tubes were lost before time of planned removal. In all cases, only preoperative absence of the pus was significantly correlated with success (p = 0.09 and OR = 0.39). BCI may be a better treatment for the patients with incomplete complex CNLDO. In silicone intubation for these cases, preoperative absence of purulent discharges could increase the success rate.

Pushed monocanalicular intubation versus probing for the treatment of simple and incomplete complex types of congenital nasolacrimal duct obstruction in children older than 18 months old.

This article compares the success rate of pushed monocanalicular intubation (Masterka) versus probing for the treatment of congenital nasolacrimal duct obstruction (CNLDO) in children older than 18 months. In a non-random comparative study, 90 eyes with CNLDO underwent either Masterka (45 eyes) or probing (45 eyes). All procedures were performed by one oculoplastic surgeon. The tubes were removed 2 months after the operation. Complete resolution was defined as complete absence of clinical signs and symptoms of CNLDO at 6 months after the procedure. The mean age at the time of treatment was 28 ± 18.2 months for Masterka and 26.7 ± 18.6 months for probing group. Treatment success was achieved in 33 of 45 eyes (73.3%) in the Masterka group compared with 22 of 45 eyes (48.9%) in the probing group. The difference between the two groups was statistically significant (p = 0.017). For the treatment of CNLDO, Masterka might be more effective than probing in children older than 18 months.

Endoscopic-assisted retrieval of retained lacrimal stent material in congenital nasolacrimal duct obstruction without dacryocystorhinostomy.

We report a 3-year-old child with history of congenital nasolacrimal duct obstruction who failed lacrimal probing and underwent bicanalicular intubation. Removal of stent from the superior punctum was unsuccessful and it was trapped in the lacrimal sac. We performed endonasal endoscopic-assisted retrieval of retained stent material without necessitating dacryocystorhinostomy (DCR). There was no recurrence of infection and nasolacrimal duct obstruction symptoms during 6 months of follow-up.

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.

Lacrimal and nasal masquerades of congenital nasolacrimal duct obstructions: etiology, management, and outcomes.

The purpose of this study was to report various conditions masquerading as congenital nasolacrimal duct obstruction (CNLDO). Retrospective review was designed in a tertiary hospital setting. 92 eyes of 65 consecutive patients were included in this study. All patients presenting with CNLDO symptomatology but where the diagnosis of CNLDO was subsequently ruled out were included in the study. The study patients were recruited from a single surgeon's (MJA) tertiary eye care practice over a 3-year period from 2011 to 2013. A detailed clinical evaluation and a further lacrimal system evaluation were performed under general anesthesia. The main outcome measure was other lacrimal and nasal conditions masquerading as CNLDO. Average age at presentation was 43.49 ± 31.78 months. All cases had symptoms of either watering or discharge with an increase tear meniscus or abnormal fluorescein dye disappearance test. The commonest masquerades of congenital nasolacrimal duct obstruction include incomplete punctal canalisation (27.2 %), functional epiphora (14.1 %), punctal agenesis (14.1 %), monocanalicular obstructions (10.8 %), and presaccal stenosis (8.7 %). Each masquerade was managed specifically and at the last follow-up of 5.85 ± 10.85 months, 63 % eyes (58/92) had no epiphora and 2.2 % (2/92) eyes had occasional epiphora. Parents of patients with punctal agenesis were counseled for option of conjunctivodacryocystorhinostomy in future. Incomplete punctal canalisation is the commonest masquerade among many conditions that may mimic CNLDO and mandates a careful evaluation. Specific management of each masquerade results in satisfactory outcomes.