One of the most common problems seen by pediatric ophthalmologists is congenital nasolacrimal duct obstruction (CNLDO), with an estimated prevalence of 6%.1 Medical management consists of lacrimal sac massage with or without use of topical antibiotics. Controversy exists regarding the timing and the appropriate environment for probing. Early probing advocates cite the advantages of quicker relief of symptoms, decreased risk of complications, and alleviated parental anxiety. Early probing (between 6 and 9 months) may allow for the procedure to be done in the office, which may appeal to parents as a quicker and cost-effective method that avoids the need for general anesthesia. Alternatively, delayed probing in the operating room may allow time for spontaneous resolution. A randomized prospective trial by the Pediatric Eye Disease Investigator Group (PEDIG) compared these two approaches and found similar success rates, with in-office probing being slightly less expensive.2 Our retrospective review expands on the findings from several preceding studies by examining the frequency of spontaneous resolution of CNLDO in children older than 1 year during the interval between booking and date of surgery.
Ethical approval was received from the institutional review board at Wills Eye Hospital for a retrospective review of patient records and the study was in compliance with the Health Insurance Portability and Accountability Act of 2011 guidelines.
A retrospective chart review over a 10-year period (May 2001 to May 2011) was conducted in the practice of one physician (BMS). This included all patients older than 1 year who either underwent probing for CNLDO or were scheduled for a probing but had resolution of their CNLDO prior to the planned surgery date. A list of all patients who were scheduled for a probing but had resolution of their CNLDO prior to the planned surgery date was maintained by one of the authors (BMS). The patients who underwent probing were identified by the surgical log. All patients had complete CNLDO confirmed with a dye disappearance test. Patients with a recurrent or acquired nasolacrimal duct obstruction were excluded.
Data collected included: gender of patient, age of patient at initial booking, age of patient at surgery or resolution, time interval between booking and surgery or resolution, laterality (right or left eye), bilateral/unilateral disease, and presence or absence of spontaneous resolution. If families called to report that the symptoms had resolved, the procedure was cancelled and the family was asked to return to the office to confirm resolution by the dye disappearance test. Similarly, the probing was not performed if the family reported resolution on the day of surgery. Spontaneous resolution was recorded when the chart had documentation of resolution as confirmed by a return visit and the dye disappearance test.
Exclusion criteria were as follows: children younger than 12 months, with any congenital comorbidities or craniofacial or midline abnormalities, who had prior probing or any prior procedure of the nasolacrimal duct system, and who had acquired nasolacrimal duct obstruction. Statistical analysis was done using SAS software (version 9.2; SAS Institute, Cary, NC). To determine whether younger patients were more likely to experience spontaneous resolution prior to their planned procedure, an odds ratio was performed.
Three hundred eighty-seven eyes met the inclusion criteria. The resolution group (n = 17) contained 12 males and 5 females, 6 right eyes and 11 left eyes, and 13 unilateral and 4 bilateral cases. The non-resoultion group (n = 370) contained 192 males and 178 females, 198 right eyes and 172 left eyes, and 212 unilateral and 158 bilateral cases. The patients' ages ranged from 12 to 89 months.
Seventeen of 387 (4.4%) eyes resolved prior to scheduled probing. None of the patients who reported symptomatic improvement required subsequent probing at a later date. The mean age at scheduling for probing was 15.6 months (range: 12 to 21 months) in the resolution group and 18.3 months (range: 12 to 89 months) in the non-resolution group (P = .22). The mean number of days from scheduling to surgery date was 38.9 (range: 6 to 81 days) in the resolution group and 32.03 (range: 1 to 107 days) in the non-resolution group (P = .13). The odds ratio for resolution prior to surgery date for 15 months or younger versus older than 15 months was 2.30 (95% confidence interval: 0.71 to 7.43, P = .14). Table 1 summarizes the subgroup analyses, such as age (in months), gender, and laterality, none of which appeared to be significantly associated with resolution.
Controversy in management of CNLDO stems from the findings that the obstruction has a high rate of spontaneous resolution in the first year of life. In his prospective study of 62 eyes, Paul reported that 89% of patients had spontaneous resolution by 16 months of age.3 This was followed by the PEDIG study, which confirmed that a majority (66%) of CNLDO cases resolve within a 6-month follow-up interval in patients presenting with symptoms from age 6 to 10 months.4 Young et al.5 expanded on these findings with a mixed randomized prospective and observational study that compared the cure rate between patients who had probing between 11 and 15 months with patients who were observed for resolution during the second year of life. The study found that 60% of patients with CNLDO at 1 year of age resolved by age 2 years.
Our data support the probability that spontaneous resolution of CNLDO occurs in children beyond 12 months of age. We suspect that our observed percentage of spontaneous resolution after 1 year of age is lower than Young et al.5 found for several reasons. First, as a retrospective review of patients in one clinician's practice, the observation period for our study was limited to the interval between scheduling and the date the probing was either performed or cancelled due to resolution of symptoms. Our observed rate of 4.4% may be a function of the lead time between booking and date of surgery, which was, on average, less than 6 weeks for both groups. The non-resolution group also had a shorter interval between booking and date of probing, which may suggest that resolution could have occurred had the probing been scheduled later. Additionally, it is likely the observed rate of spontaneous resolution would have been higher had we performed a confirmatory dye disappearance test preoperatively for all patients undergoing probing. However, because this is not usually performed on the day of the procedure, obstruction was presumed based on the lack of reported resolved symptoms.
Our observation supports that spontaneous resolution of CNLDO not only occurs after the first year of life, but, not uncommonly, within the short interval between scheduling and probing. However, this must be measured against some reports that the success rate of probing declines with advancing age.6 With these findings, we recommend that parents be counseled to notify their child's ophthalmologist should resolution of symptoms occur before planned probing to avoid an unnecessary procedure.
- MacEwen CJ, Young JD. Epiphora during the first year of life. Eye (Lond). 1991;5:596–600. doi:10.1038/eye.1991.103 [CrossRef]
- Pediatric Eye Disease Investigator Group. A randomized trial comparing the cost-effectiveness of 2 approaches for treating unilateral nasolacrimal duct obstruction. Arch Ophthalmol. 2012;130:1525–1533. doi:10.1001/archophthalmol.2012.2853 [CrossRef]
- Paul TO. Medical management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus. 1985;22:68–70.
- Pediatric Eye Disease Investigator Group. Resolution of congenital nasolacrimal duct obstruction with nonsurgical management. Arch Ophthalmol. 2012;130:730–734.
- Young JDH, MacEwen CJ, Ogston SA. Congenital nasolacrimal duct obstruction in the second year of life: a multicentre trial of management. Eye (Lond). 1996;10:485–491. doi:10.1038/eye.1996.107 [CrossRef]
- Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology. 1987;94:698–705. doi:10.1016/S0161-6420(87)33392-5 [CrossRef]
|Comparison||Univariable Logistic Regression Model||Multivariable Logistic Regression Model|
|OR||95% CI||P||OR||95% CI||P|
|Age, 16 vs 12 to 15 months||2.30||0.71 to 7.43||.16||2.72||0.77 to 9.61||.12|
|Male vs female||2.11||0.71 to 6.35||.18||2.74||0.85 to 8.80||.09|
|Right vs left eye||0.61||0.37 to 1.02||.06||0.65||0.43 to 0.99||.04|
|10-day increase in time to probing||1.26||0.99 to 1.60||.07||1.39||1.04 to 1.86||.03|
|Unilateral vs bilateral||2.41||0.53 to 10.94||.25||–||–||–|