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Results of Late Probing for Congenital Nasolacrimal Duct Obstruction
Results of Late Probing for Congenital Nasolacrimal Duct Obstruction JEYLAN EL-MANSOURY, MD, JOSEPH H. CALHOUN, MD, LEONARD B. NELSON, MD, ROBISON D. HARLEY, MD
Abstract: One hundred four consecutive patients (138 eyes) with congenital nasolacrimal duct obstruction were probed after the age of 13 months. One hundred twenty-nine eyes (93.5) were cured after the first probing. Based on this study and others showing the effectiveness of medical management, it is the current practice of the authors to delay probing until the patient is at least 13 months of age. [Key words: late probing, nasolacrimal duct obstruction.] Ophthalmology 93: 1052-1 054, 1986
Nasolacrimal duct obstruction is the most common abnormality of the infant lacrimal system, occurring in as many as 6% of newborn infants. 1 Opinions vary as to when children with nasolacrimal duct obstruction should be probed. Many ophthalmologists believe that late probing should be avoided because the failure rate of probing is said to be higher. The purpose of this study is to evaluate the results and complications of nasolacrimal duct probings performed after the patient is 13 months of age and to compare the results with reported series probed earlier.
METHODS We reviewed the records in the Pediatric Ophthalmology Service of Wills Eye Hospital of 104 consecutive patients from 1979 to 1984 who were first probed after 13 months of age for congenital nasolacrimal duct obstruction. None of these patients had signs of acute dacrocystitis or abscess formation before probing. All patients had a history of tearing and/or intermittent mucopurulent discharge beginning during the first few weeks of life. The age of the patients ranged at the time of probing from 13 months to 7 years, with an average of 22 months. A total From the Pediatric Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania. Reprint requests to Joseph H. Calhoun, MD, Department of Pediatric Ophthalmology, Wills Eye Hospital, 9th and Walnut Streets, Philadelphia, PA
19107.
1052
of 138 eyes were probed, the right eye in 68 and the left eye in 70. All patients were followed after probing by the authors either by examination or by a phone call. The average interval until seen in the office was 5 weeks, whereas the average interval in which the patients were called was 20 weeks. We define cure as resolution of tearing and/or intermittent mucopurulent discharge under normal circumstances or when the child had tearing only with an upper respiratory tract infection.
METHODS OF PROBING '...... Probing was performed while the patient was under general inhalation anesthesia. In all cases, probing was performed through the upper canaliculus. The size of Bowman's probe used was number 1 or 2. In order to confirm the presence of the probe in the nasal cavity, one of three methods or a combination was used. The first method involved the placement of a larger size probe under the inferior turbinate to touch and move the probe in the nasolacrimal duct. This method was used in 69 eyes. In the second method, Betadine® soap was applied on the nares and air injected through the lower canaliculus, patency confirmed by the creation of a bubble in the soap? This method was used in 64 eyes. The third method involved irrigating the nasolacrimal passage with saline colored with fluorescein and its recovery from the nasal cavity. This method was used in 11 eyes. In some patients more than one method was used. Inferior turbinate fracture was performed in three cases.
EL-MANSOURY, et al
•
NASOLACRIMAL DUCT OBSTRUCTION
Table 1. Percent Resolution of Nasolacrimal Duct Obstruction by First, Second, or Third Probings
Ffooks 5 Baker 7 Kushner 3 This series *
First Probing
Second Probing
Third Probing or Tube
79 93.5 89 93.5
17 6 4 6.5
4 0.5 7 0
* Three percent lost to follow-up.
RESULTS One hundred four patients (138 eyes) were probed. Of these, 134 eyes were available for follow-up. One hundred twenty-nine (93.5%) required only one probing. Nine eyes (6.5%) required a second probing. The average interval between the first and second probing was three months. No specific cause for the initial failure in nine eyes was found. One hundred nineteen eyes had complete resolution of symptoms. In 15 eyes, tearing occurred occasionally with an upper respiratory tract infection, but the patients' parents were happy and did not ask for further treatment. In our series a third probing or silicone intubation was not required.
DISCUSSION Controversy continues to exist about when to probe infants with congenital nasolacrimal duct obstructions. Some who advocate early probing believe that delay might lead to the formation of acute dacrocystitis, fistula, or orbital cellulitis. 3 Some fear that delay might compromise the effectiveness of probing when performed later.4-6 Some argue that early probing in the office without anesthesia is safe and effective and avoids for the child and the family the months of cosmetically displeasing epiphora, mucopurulent discharge, and travails of medical management. 3 ,7 On the other hand, others document that most congenital nasolacrimal duct obstructions clear either spontaneously or with medical management. Paul found an 89% cure rate with medical management by the time the patient was 16 months of age. 8 Petersen and Robb also found that 58 of 65 (89%) obstructed nasolacrimal ducts cleared with medical management by the time the patient was 13 months ofage. 9 Nelson et al reported a 94% cure rate with conservative medical management by the time the patient was 13 months of age. 10 This definite tendency toward natural resolution had been noted by others several decades earlier. 1,5,1 I This study reviews the results of probing in patients from 13 months to 7 years of age. During the period covered by this study, no conscious effort was made to encourage the patients to delay probing. The age at which
the probing was performed must have been determined to a large extent by the burden that the symptoms created for the family and, to a lesser extent, by the medical judgment of the primary care physician who initiated the referral. Nonetheless, a review of these cases provides a test for the thesis that a delay in probing adversely affects the results of probing. This study clearly shows that probing after a patient is 13 months of age has a very high success rate for resolution of symptoms with one probing and (in this study) all of the remainder with a second probing (excluding four lost to follow-up). How does the success rate of probing after a patient is 13 months compare with reported large series probed earlier? Ffooks probed all children under general anesthesia, most by seven months of age. 5 Of 386 probings, 305 (79%) required one probing; 64 (17%), two probings; and 17 (4%), three or more probings. Baker reported 860 eyes of children ages 3-14 months of age probed in the office without general anesthesia. 7 Only 6% required a second probing and 0.5%, a third. In Kusher's series of 148 eyes, most were probed in the office at an average age of eight months. 3 Of these 148 eyes, 132 (89%) were relieved of the symptoms by one probing, 6 (4%) required a second probing, and 10 (7%) required a silicone tube intubation. These data show that probing while the patient is under general anesthesia after he or she is 13 months of age is not associated with poorer results but is as successful or better than probing performed on awake infants at a younger age in the office or under general anesthesia (Table 1). Where does all these lead the ophthalmologist who is presented with a child with the typical symptoms of nasolacrimal duct obstruction? In prospective studies it is clearly shown that 89% or more nasolacrimal duct obstructions resolve with medical management. 8- 10 In none of these prospective studies were complications of severe infection reported while these patients were being observed. That argument for early probing has not been documented. How well the families tolerate the inconvenience of the symptoms and the medical management must to some degree be a reflection of the opinion of the physician as to the proper time for probing. 7 In our practice, families and primary care physicians seem to be content with medical management. If the policy of early probing is followed, many infants who would otherwise resolve with medical management are probed prematurely, or unnecessarily, depending on one's point of view. One report on early probing in the office suggests a 7% incidence of obstruction of the nasolacrimal duct that eventually requires silicone tube intubation for relief of the symptoms, a procedure requiring general anesthesia for placement and another in six months for removal. 3 Perhaps in an awake, restrained, and struggling infant, the delicate tactile sensitivity needed for proper passage of the probe is somewhat reduced, leading to some damage and stricture to the lining epithelium of the canaliculus or nasolacrimal duct. Based on the data reported here and by others, we recommend that infants with congenital obstruction of the
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nasolacrimal duct be managed medically until at least 13 months of age, perhaps even longer. If resolution does not occur, probing should be performed while the patient is under general anesthesia.
REFERENCES 1. Guerry D III, Kendig EL Jr. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol1948; 39:193-204. 2. Broughton WL, Lederman ME. The air-bubble test for lacrimal system patency. Am J Ophthalmol1982; 93:652-3. 3. Kushner BJ. Congenital nasolacrimal system obstruction. Arch Ophthalmol1982; 100:597-600. 4. Veirs ER. Disorders of the nasolacrimal apparatus in infants and children. J Pediatr Ophthalmol1966; 3(1):32-4.
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5. Ffooks 00. Dacryocystitis in infancy. Br J OphthalmoI1962; 46:42234. 6. Koke MP. Treatment of occluded nasolacrimal ducts in infants. Arch Ophthalmol1950; 43:750-4. 7. Baker JD. Treatment of congenital nasolacrimal system obstruction. J Pediatr Ophthalmol Strabismus 1985; 22:34-5. 8. Paul TO. Medical management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 1985; 22:68-70. 9. Petersen RA, Robb RM. The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 1978; 15: 246-50. 10. Nelson LB, Calhoun JH, Menduke H. Medical management of congenital nasolacrimal duct obstruction. Ophthalmology 1985; 92:118790. 11. Price HW Dacryostenosis. J Pediatr 1947; 30:302-5. 12. Riser RO. Dacryostenosis in children. Am J Ophthalmol 1935; 18: 1116-22.
Abstract: One hundred four consecutive patients (138 eyes) with congenital nasolacrimal duct obstruction were probed after the age of 13 months. One hundred twenty-nine eyes (93.5) were cured after the first probing. Based on this study and others showing the effectiveness of medical management, it is the current practice of the authors to delay probing until the patient is at least 13 months of age. [Key words: late probing, nasolacrimal duct obstruction.] Ophthalmology 93: 1052-1 054, 1986
Nasolacrimal duct obstruction is the most common abnormality of the infant lacrimal system, occurring in as many as 6% of newborn infants. 1 Opinions vary as to when children with nasolacrimal duct obstruction should be probed. Many ophthalmologists believe that late probing should be avoided because the failure rate of probing is said to be higher. The purpose of this study is to evaluate the results and complications of nasolacrimal duct probings performed after the patient is 13 months of age and to compare the results with reported series probed earlier.
METHODS We reviewed the records in the Pediatric Ophthalmology Service of Wills Eye Hospital of 104 consecutive patients from 1979 to 1984 who were first probed after 13 months of age for congenital nasolacrimal duct obstruction. None of these patients had signs of acute dacrocystitis or abscess formation before probing. All patients had a history of tearing and/or intermittent mucopurulent discharge beginning during the first few weeks of life. The age of the patients ranged at the time of probing from 13 months to 7 years, with an average of 22 months. A total From the Pediatric Ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania. Reprint requests to Joseph H. Calhoun, MD, Department of Pediatric Ophthalmology, Wills Eye Hospital, 9th and Walnut Streets, Philadelphia, PA
19107.
1052
of 138 eyes were probed, the right eye in 68 and the left eye in 70. All patients were followed after probing by the authors either by examination or by a phone call. The average interval until seen in the office was 5 weeks, whereas the average interval in which the patients were called was 20 weeks. We define cure as resolution of tearing and/or intermittent mucopurulent discharge under normal circumstances or when the child had tearing only with an upper respiratory tract infection.
METHODS OF PROBING '...... Probing was performed while the patient was under general inhalation anesthesia. In all cases, probing was performed through the upper canaliculus. The size of Bowman's probe used was number 1 or 2. In order to confirm the presence of the probe in the nasal cavity, one of three methods or a combination was used. The first method involved the placement of a larger size probe under the inferior turbinate to touch and move the probe in the nasolacrimal duct. This method was used in 69 eyes. In the second method, Betadine® soap was applied on the nares and air injected through the lower canaliculus, patency confirmed by the creation of a bubble in the soap? This method was used in 64 eyes. The third method involved irrigating the nasolacrimal passage with saline colored with fluorescein and its recovery from the nasal cavity. This method was used in 11 eyes. In some patients more than one method was used. Inferior turbinate fracture was performed in three cases.
EL-MANSOURY, et al
•
NASOLACRIMAL DUCT OBSTRUCTION
Table 1. Percent Resolution of Nasolacrimal Duct Obstruction by First, Second, or Third Probings
Ffooks 5 Baker 7 Kushner 3 This series *
First Probing
Second Probing
Third Probing or Tube
79 93.5 89 93.5
17 6 4 6.5
4 0.5 7 0
* Three percent lost to follow-up.
RESULTS One hundred four patients (138 eyes) were probed. Of these, 134 eyes were available for follow-up. One hundred twenty-nine (93.5%) required only one probing. Nine eyes (6.5%) required a second probing. The average interval between the first and second probing was three months. No specific cause for the initial failure in nine eyes was found. One hundred nineteen eyes had complete resolution of symptoms. In 15 eyes, tearing occurred occasionally with an upper respiratory tract infection, but the patients' parents were happy and did not ask for further treatment. In our series a third probing or silicone intubation was not required.
DISCUSSION Controversy continues to exist about when to probe infants with congenital nasolacrimal duct obstructions. Some who advocate early probing believe that delay might lead to the formation of acute dacrocystitis, fistula, or orbital cellulitis. 3 Some fear that delay might compromise the effectiveness of probing when performed later.4-6 Some argue that early probing in the office without anesthesia is safe and effective and avoids for the child and the family the months of cosmetically displeasing epiphora, mucopurulent discharge, and travails of medical management. 3 ,7 On the other hand, others document that most congenital nasolacrimal duct obstructions clear either spontaneously or with medical management. Paul found an 89% cure rate with medical management by the time the patient was 16 months of age. 8 Petersen and Robb also found that 58 of 65 (89%) obstructed nasolacrimal ducts cleared with medical management by the time the patient was 13 months ofage. 9 Nelson et al reported a 94% cure rate with conservative medical management by the time the patient was 13 months of age. 10 This definite tendency toward natural resolution had been noted by others several decades earlier. 1,5,1 I This study reviews the results of probing in patients from 13 months to 7 years of age. During the period covered by this study, no conscious effort was made to encourage the patients to delay probing. The age at which
the probing was performed must have been determined to a large extent by the burden that the symptoms created for the family and, to a lesser extent, by the medical judgment of the primary care physician who initiated the referral. Nonetheless, a review of these cases provides a test for the thesis that a delay in probing adversely affects the results of probing. This study clearly shows that probing after a patient is 13 months of age has a very high success rate for resolution of symptoms with one probing and (in this study) all of the remainder with a second probing (excluding four lost to follow-up). How does the success rate of probing after a patient is 13 months compare with reported large series probed earlier? Ffooks probed all children under general anesthesia, most by seven months of age. 5 Of 386 probings, 305 (79%) required one probing; 64 (17%), two probings; and 17 (4%), three or more probings. Baker reported 860 eyes of children ages 3-14 months of age probed in the office without general anesthesia. 7 Only 6% required a second probing and 0.5%, a third. In Kusher's series of 148 eyes, most were probed in the office at an average age of eight months. 3 Of these 148 eyes, 132 (89%) were relieved of the symptoms by one probing, 6 (4%) required a second probing, and 10 (7%) required a silicone tube intubation. These data show that probing while the patient is under general anesthesia after he or she is 13 months of age is not associated with poorer results but is as successful or better than probing performed on awake infants at a younger age in the office or under general anesthesia (Table 1). Where does all these lead the ophthalmologist who is presented with a child with the typical symptoms of nasolacrimal duct obstruction? In prospective studies it is clearly shown that 89% or more nasolacrimal duct obstructions resolve with medical management. 8- 10 In none of these prospective studies were complications of severe infection reported while these patients were being observed. That argument for early probing has not been documented. How well the families tolerate the inconvenience of the symptoms and the medical management must to some degree be a reflection of the opinion of the physician as to the proper time for probing. 7 In our practice, families and primary care physicians seem to be content with medical management. If the policy of early probing is followed, many infants who would otherwise resolve with medical management are probed prematurely, or unnecessarily, depending on one's point of view. One report on early probing in the office suggests a 7% incidence of obstruction of the nasolacrimal duct that eventually requires silicone tube intubation for relief of the symptoms, a procedure requiring general anesthesia for placement and another in six months for removal. 3 Perhaps in an awake, restrained, and struggling infant, the delicate tactile sensitivity needed for proper passage of the probe is somewhat reduced, leading to some damage and stricture to the lining epithelium of the canaliculus or nasolacrimal duct. Based on the data reported here and by others, we recommend that infants with congenital obstruction of the
1053
OPHTHALMOLOGY
•
AUGUST 1986 •
nasolacrimal duct be managed medically until at least 13 months of age, perhaps even longer. If resolution does not occur, probing should be performed while the patient is under general anesthesia.
REFERENCES 1. Guerry D III, Kendig EL Jr. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol1948; 39:193-204. 2. Broughton WL, Lederman ME. The air-bubble test for lacrimal system patency. Am J Ophthalmol1982; 93:652-3. 3. Kushner BJ. Congenital nasolacrimal system obstruction. Arch Ophthalmol1982; 100:597-600. 4. Veirs ER. Disorders of the nasolacrimal apparatus in infants and children. J Pediatr Ophthalmol1966; 3(1):32-4.
1054
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NUMBER 8
5. Ffooks 00. Dacryocystitis in infancy. Br J OphthalmoI1962; 46:42234. 6. Koke MP. Treatment of occluded nasolacrimal ducts in infants. Arch Ophthalmol1950; 43:750-4. 7. Baker JD. Treatment of congenital nasolacrimal system obstruction. J Pediatr Ophthalmol Strabismus 1985; 22:34-5. 8. Paul TO. Medical management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 1985; 22:68-70. 9. Petersen RA, Robb RM. The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 1978; 15: 246-50. 10. Nelson LB, Calhoun JH, Menduke H. Medical management of congenital nasolacrimal duct obstruction. Ophthalmology 1985; 92:118790. 11. Price HW Dacryostenosis. J Pediatr 1947; 30:302-5. 12. Riser RO. Dacryostenosis in children. Am J Ophthalmol 1935; 18: 1116-22.