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  5. FP843 : Outcome of late probing for congenital nasolacrimal duct obstruction

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Dr. Kuldeep Kumar Srivastava, S06431

Purpose: To evaluate the outcome of late probing for congenital nasolacrimal duct obstruction (CNLDO).

Method: Medical records of children who underwent probing for CNLDO between January 2011 and December 2016 were reviewed and children aged over 24 months at the time of probing were included in the study. Prior to probing, each patient had a trial of massage and topical antibiotics. Successful probing was defined as a resolution of symptoms within 1 month after probing.

Results: Forty nine eyes of forty one children fulfilled our inclusion criteria for this study. The mean age at probing was 36 months (range, 24 months to 60 months). The mean follow up was 22 months (range, 1 month to 5 years). Probing was successful in 75.5% (37/49 eyes) of eyes.

Conclusion: Late probing between 24 months and 5 years appears to be an effective and should be attempted prior to going for complex procedures.

Congenital Nasolacrimal duct obstruction (CNLDO) is one of the most common congenital abnormalities which occur in 1.75 to 20% of infants.1 Infants with CNLDO usually present with watering & discharge starting from few days after birth. The site of obstruction is most often in the inferior portion of the nasolacrimal duct at Hasner’s valve. However obstruction may occur at any level of the nasolacrimal system including the puncti, canaliculi, common canaliculus and the Rosenmuller valve etc.2 Most cases of CNLDO improve spontaneously by lacrimal sac massage and do not require surgical intervention. However around 10% children do not improve with conservative treatment and require probing of NLD. Difference of opinion exists between surgeons regarding the optimal time of intervention in persistent cases. Some authors advocate early probing of NLD which may be performed under topical anesthesia.3-5 On the other hand, others argue that 96% of these cases improve spontaneously up to the age of one year with no need for intervention.6-10 The present study was performed to evaluate the outcome of nasolacrimal duct probing in patients with CNLDO after the age of 24 months.

METHODS  

This was a retrospective study conducted between January 2011 and December 2016 at Indira Gandhi Eye Hospital and research Centre, Lucknow India. The medical records of patients with CNLDO who had undergone probing for the first time at the age of 24 months or later, during the study period were reviewed. Only patients operated by author and followed for at least one month were included in this study. Patients with history of acute dacryocystitis, punctal or canalicular abnormalities and history of probing in the past were also excluded from the study. Probing was performed according to a uniform protocol under general anesthesia: after dilatation of the superior punctum and passing a Bowman lacrimal probe through the nasolacrimal duct. Postoperative regimen included moxifloxacin 0.5% and dexamethasone 0.1% eye drops 3 times a day for one month. The procedure was considered to be successful if the epiphora and/or discharge was resolved within one month after probing.

RESULTS 

During the study period, a total of 257 probing procedures were performed. Out of 257, 160 were older than 24 months and 132 were between 24 months & 5 years of age. After applying the exclusion criteria, 49 eyes of 41 children were available for analysis. Sixteen (39%) children were male and 25 (61%) were female. Unilateral and bilateral probing was performed in 33 (80.5%) and 8 (19.5%) subjects respectively. Mean age at the time of initial probing was 36 months (range, 1 month to 5 years). The mean follow up was 22 months (range, 1 month to 5 years). Overall, initial probing was successful in 37(75.5%) cases and failed in 12 (24.5%) cases.

 DISCUSSION 

Probing of nasolacrimal duct is the standard treatment for CNLDO. However, controversy exists regarding the success rate of probing in older children. The present study demonstrated the effectiveness of initial probing for CNLDO in patients between 24 months & 5 years. The success rate in our study was 75.5%. Sturrock and colleagues reported a success rate of 72% in the second year and 42% in children more than 2 years of age.11 Young and associates stated a cure rate of 54% in children underwent initial probing after 2 years of age.12 Kashkouli et al  reported a cure rate of 71.7%, in children undergone probing between 25 and 60 months of age.13 Maheshwari reported an overall success rate of 76.92% in children probed between 2 and 6 years of age.14 Abrishami M et al  reported an overall success rate of 75% in children probed over 15 month of age.15 In our study the success rate of initial probing between 24 months and 5 years of age was reasonably good but lower than success rate of probing done during first two years of age. Katowitz and Welsh believed that increasing age after 13 months not only decreases the cure rate but also increases the number and complexity of future procedures.5 There are two schools of thought for the lower cure rate with probing in older children. Some investigators suggested that it might be a result of chronic infection and fibrosis with increasing age.5 Alternatively, Paul and Shepherd  considered that it might be due to a self selection process.4 They suggested that possibly older children with CNLDO are more likely to represent the pool of children born with a more complicated type of obstruction.

 

CONCLUSION

In conclusion, late initial probing between 24 months and 5 years appears to be an effective and should be attempted prior to going for complex procedures.

REFERENCES

  1. Stager D, Baker J, Frey T, Weakley DR, Birch EE. Office probing of congenital nasolacrimal duct obstruction. Ophthalmic Surg 1992;23:482-484.
  2. Burns SJ, Kipioti A. Follow-up after probing for congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 2001;38:163-165.
  3. Baggio E, Ruban JM, Sandon K. Analysis of the efficacy of early probing in the treatment of symptomatic congenital lacrimal duct obstruction in infants. J Fr Ophthalmol 2000,23:655-662.
  4. Paul TO, Shepherd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatric Ophthalmol Strabismus 1994;31:362-367.
  5. Katowitz J, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94:698-705.
  6. Mannor GE, Rose GE, Frimpong-Ansah K, Ezra E. Factors affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction. Am J Ophthalmol 1999;127:616-617.
  7. El-Mansoury J, Calhoun JH, Nelson LB, Harley RD. Results of late probing for congenital nasolacrimal duct obstruction. Ophthalmology 1986;93:10521054.
  8. Yap EY, Yip CC. Outcome of late probing for congenital nasolacrimal duct obstruction in Singapore children. Int Ophthalmol 1997-98;21:331334.
  9. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology 1998;105:1307-1309.
  10. Da Pozzo S, Pensiero S, Perissuti P. Management of congenital nasolacrimal duct obstruction. Timing of probing. Minerva Pediatr 1995;47:209-213.
  11. Sturrock SM, MacEwen CJ, Young JDH. Long term results after probing for congenital nasolacrimal duct obstruction. Br J Ophthalmol 1994;78:892-894.
  12. Young JDH, MacEwen CJ, Ogston SA. Congenital nasolacrimal duct obstruction in second year of life: a multicenter trial of management. Eye 1996;10:485–91.
  13. Kashkouli M B, Beigi B, Parvaresh M M, Kassaee A, Tabatabaee Z. Late and very late initial probing for congenital nasolacrimal duct obstruction: what is the cause of failure?. Br J Ophthalmol 2003;87:1151–1153.
  14. Maheswari R. Success rate and cause of failure for late probing for congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 2008;45:168-171.
  15. Abrishami M, Bagheri A, Salour SH, Mirdehghan A. Late Probing for Congenital NLDO. Journal of Ophthalmic and Vision Research 2009; 4:102-4.

 

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