Probing and intubation as primary treatment for nasolacrimal duct obstruction?

Probing and intubation as primary treatment for nasolacrimal duct obstruction? Richard M. Robb, MD Assistant Editor In the current issue of J AAPOS, J. Mark Engel and colleagues1 report their experience using probing plus monocanalicular silicone tube intubation as the primary treatment of congenital nasolacrimal duct obstruction. They have reviewed their results in treating 635 patients with a total of 803 obstructed ducts, gleaned from the practices of three ophthalmologists working in different locations. The tubes were left in place for a median of 8 weeks, although 15% of them were found absent or dislodged before the time of planned removal. Treatment was undertaken only beyond 6 months of age, always under general anesthesia, but not always with endotracheal intubation. A successful result, including as successful those who had tearing only with an upper respiratory infection or with exposure to wind, was obtained in slightly better than 97% of eyes in patients younger than 24 months of age, and in 90% of eyes in patients over 24 months of age. Corneal abrasions from the collarette of the silicone tube were encountered in 2% of cases, but these healed with prompt removal of the tubing. There was no difference in the apparent success rate among the three surgeons, no difference between unilateral and bilateral obstructions, and no difference between spontaneous dislocation of the tubes and planned removal in the office. The authors’ observations about perceived differences in the nature of the obstructions were incomplete, but again no differences in outcome could be ascribed to the level or type of obstruction. Do these results suggest that probing plus a monocanalicular tube should be used as a primary procedure in all patients? I think probably not. It is more than most patients will require. Standard probing yields a success rate of slightly over 90%.2-4 Subsequent use of silicone tubes cures approximately 80% of the failures from standard probing.5-7 Engel’s overall success rate of 96% is close to what one would expect by combining these procedures. Unfortunately the authors have not analyzed a series of their own patients treated with standard probing alone. They were evidently unhappy enough with their results from probing alone that they switched to the combined procedure, presumably after discussing the matter among themselves. Nevertheless they properly stopped short of recommending the combined procedure for all patients, J AAPOS 2007;11:113. Copyright © 2007 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2007/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2006.12.050

Journal of AAPOS

recognizing the high success rates reported by others with standard probing. Inserting and retrieving silicone tubing is not an insignificant addition to probing alone. General anesthesia must be used, and most surgeons will want an endotracheal tube or laryngeal mask to allow easier access to the nostrils. Most of the time the silicone tube can be removed in the office, but doing so is an unpleasant, if not painful, procedure for the patient. Fortunately the complication rate from the monocanalicular tube is small, but patients need to be watched for corneal abrasions. The issue of age at the time of first probing may be a factor in deciding whether to use the combined procedure. Engel and colleagues and some other surgeons have noted a drop in success rates at older ages,8 but others have had good results from standard probing in older children,3,4 perhaps depending on the nature of the obstruction found at the time of the procedure.9 To sort out these finer distinctions in the management of congenital nasolacrimal duct obstruction, I would agree with Engel and colleagues that a large prospective randomized and controlled study would be helpful. Fortunately from the patients’ standpoint the various options for treatment of this common condition are all highly successful, and this is partly why it is difficult to establish the superiority of one procedure over another.

References 1. Engel JM, Hichie-Schmidt C, Khammar A, Ostfeld BM, Vyas A, Ticho BH. Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction. JAAPOS 2007;11: 183-6. 2. Baker JD. Treatment of congenital nasolacrimal system obstruction. J Pediatr Ophthalmol Strabismus 1985;22:34-5. 3. El-Mansoury J, Calhoun JH, Nelson LB, Harley RD. Results of late probing for congenital nasolacrimal duct obstruction. Ophthalmology 1986;93:1052-4. 4. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology 1998;105:1307-10. 5. Leone CR, Van Gemert JV. The success rate of silicone intubation in congenital lacrimal obstruction. Ophthalmic Surg 1990;21:90-2. 6. Al-Hussain H, Nasr AM. Silastic intubation in congenital nasolacrimal duct obstruction: a study of 129 eyes. Ophthalmic Plast Reconstr Surg 1993;9:32-7. 7. Lim CS, Martin F, Beckenham T, Cumming RG. Nasolacrimal duct obstruction in children: outcome of intubation. J AAPOS 2004;8:46672. 8. Katowitz JA, Welch MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94: 698-705. 9. Kushner BJ. The management of nasolacrimal duct obstruction in children between 18 months and 4 years old. J AAPOS 1998;2:57-60.

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