Nelson: For dus discussion, let us consider a 19-mondi-old child who presented with persistent unilateral tearing in the left eye only. He underwent a probing and irrigation procedure at age 13 mondis by another pediatric ophrhalmologist. The parents were told die probe got through, but the tearing was better for only 2-3 weeks. Now die child wakes up every morning wirh his eyelids stuck together. He was treated once with amoxicillin for 10 days for otitis, and symptoms improved during that period of time only. How would you manage this problem?
Granet: It doesn't seem mat any topical antibiotics were administered at any point, only oral antibiotics. I would probably start with just a topical antibiotic to treat and stop die current infection. However, we know die infection is not die problem - the problem is truly a blockage at some point.
The child has had persistent tearing for the last 6 mondis after the initial probing. Even though I didn't do the probing, I would assume that a qualified pediatric ophthalmologist did, and I would tell the parents that conservative management was unlikely to work. I would plan to return to the operating room, and depending on what I found in die operating room and what was done previously, I might consider putting in Silastic tubes.
Nelson: For the second probing or the second time you go into the operating room with this patient, how do you decide what you are going to do?
Granet: If I performed the first probing and it eidier fails or the problem reccurs this quickly and I've done infracture of the turbinate, I would plan to put Silastic tubes in the second time I go into the operating room. The only reason I would hesitate with this particular patient is because I didn't do die first probing and I might find something different in the operating room.
Nelson: Do you infracture the inferior turbinate as a primary procedure?
Granet: When needed.
Olitsky: I think this is a classic example of the 5% or 10% of patients who are going to fail the initial probing. My thoughts would be that this is not going to get better, and I would talk to die parents about another procedure.
My second procedure has differed somewhat because of the change in die way I put silicone tubes in. Previously, I would have performed a second probing. However, when you put a tube in, you have the option of putting it in a spot mat requires another trip to the operating room or tying the tube in a circle and removing it in the office.
I have switched to using a monocanicular tube, which is essentially just one additional step to probing. My second procedure has become to put the tube in place.
Nelson: Do you ever just do a probing as a second procedure?
Olitsky: Before I used dus tube, I did. Now, I find diat it is essentially one extra step pulling a tube out of die nose. The footplate sits right on the puncta. It's easy to remove in the office, and you don't have to tie it into the nose.
Nelson: If you put a tube in, do you intubate the patient?
Olitsky: No, not with this procedure. I find it easy enough just to reach in and pull it right out. In fact, I don't even go in with the probe first anymore. I put the tube in right at the start.
Burke: After failure of the first probing, I like to wait at least 2 months before reprobing to give the chance of spontaneous resolution. My original treatment is to do a probing only without an infracture. If that fails, traditionally, up until about the past year, I would go back, reprobe, and infracture. I reserve tubes for failure of a second probing. In the past year, my second procedure, which has decreased the amount of tubes, is to reprobe, infracture, and then do pneumo dilatation.
Nelson: What do you mean by pneumo dilatation?
Burke: Pneumo dilatation is a new instrument mat has a bag at the bottom of the probe. The bag is inflated and left open for 60-90 seconds. This is done twice in two different spots. It takes about 5 minutes per side and pushes other membranes out of the way. I don't think the bony canal is expanded, but it seems to make a difference.
Nelson: Prior to probing for the first time, what do you tell parents your statistics are?
Burke: I tell parents that between 10% and 20% of children are going to fail the initial probing.
Nelson: Do you ever just reprobe a patient as a second procedure?
Burke: My second procedure always includes an infracture.
Granet; I tell parents diat if 100 kids come in, 80 to 90 of those families walk out thinking they went to the best doctor in the world and 1 0 to 20 wonder if they should have gone somewhere else.
For a second procedure, I start thinking about putting tubes in. If I find something different or if I had difficulty getting through the first time. Interestingly, even in 80% of cases where you thought you failed on the first probe in the operating room, you still have a success.
If the second time around I get through, I might consider not putting the tubes in. But if it's similar the second time to the first, I go ahead and put the tubes in.
Nelson: Do you irrigate the first time?
Granet: My basic approach is to inspect the puncta first to see if they are open. Then I dilate die puncta and go to die upper system and irrigate with fluoroscien tinted BSS. If diat fails, I will begin to pass a probe.
Nelson: What do you tell parents about the success rate for the second procedure?
Granet: I tell them that each time we're looking at an 90% success rate.
Nelson: What do you do if the second procedure isn't successful?
Granet: I don't do dacryocystorhinostomies; I would turn to my oculoplastic colleague.
Olitsky. For die first procedure, I tell parents there is about a 10% failure rate. My initial procedure is probing under mask anesthesia, and I don't irrigate because I don't want to intubate.
Nelson: If your second procedure is not successful, what do you do?
Olitsky: I had just been doing a second probing, but that was because of the way I had been doing tubes. When you look at that second procedure, you look at the success rate. The success rate with the second probing is very good. But you also look at the cost and additional steps in the procedure.
I've used pneumo dilatation, and it's a nice procedure. You intubate the patient. However, the equipment is expensive. I like the monocanicular tube because it's inexpensive, you don't have to intubate patients, and it's easy to retrieve. Maybe it increases the success rate slighdy at the cost of just a few extra dollars. That's why I switched.
Nelson: How long would you wait before doing a second probing?
Olitsky: I would do die second probing in 1 or 2 months.
Nelson: What is your success rate for the second procedure?
Olitsky: If the tube stays in, I would give them about a success rate.
Nelson: How long do you leave the tube in?
Olitsky: Three or 4 months. With this tube, there's really no extra steps in die procedure and the additional cost is minimal. I don't consider it extravagant to put this tube in.
Nelson: Has anyone had any experience using the balloon catheter?
Olitsky: The reason I'm getting away from that is die cost.
Nelson: If you saw a patient for the first time at 19 or 20 mondis of age with die classic signs of nasolacrimal duct obstruction, but the child had never been treated, how would you proceed?
Burke: Generally speaking, up until the past 2 or 3 years, I would have probed and waited to see what happened. I would probably do a stage 2 now, which is probing and infracture wirh pneumo-dilation.
The reason we would want to treat such a child is because we are concerned that the chronic inflammation in the nasolacrimal duct eventually will cause more obstruction than the probable membranous obstruction that is die typical cause of congenital nasolacrimal obstruction.
That's the reason I educate the parents. It's just that I really don't want to do it at 6 months anymore, but once they get to 1 2 months, you need to get them to me.
Nelson: So you think the success rate for a first probing goes down.
Burke: After about 1 5 mondis.
Nelson: What would you tell parents in terms of your success rate for die first probing at a later date?
Biuke: Well, die success rate starts to decrease. I'd say we are probably down to a third that would recur by 1 5 mondis; I don't think I get less dian diat. I diink whedier I do it 2, 3, or 4 times, I'm still not having to place tubes in the majority of patients.
Granet: I think die literature is fairly clear diar it is certainly worthwhile ro do probing and irrigation, which I do with an infracture in die older patient. I'm not sure if what we see in the older patient are patients who were going to get better, got better, and what we are left with is the more difficult cases. I'm not sure if it means our success is truly worse in this age group.
I don't think there is much difference when treating the 19 month old. I do tell the parents the success rate is lower than for a 12 month old.
Nelson: How do you evaluate a child after probing in terms of evaluating whether die procedure was successful? Do you use just the history or fluorescein dye?
Granet: I don't use any of the sugar tests. I sometimes use the dye disappearance test, if what the parents are telling me is different than what I am seeing in die office. I don't diink theres any need to do a dye disappearance test for a child who comes in with crusting and discharge.
If the parents say their child is tearing and has infections all of the time and the child comes in the office and there is no tearing and it looks wonderful, I get a little worried. When the parents say to me, no, we haven't had any problem and the child has copious discharge or crusting, I would watch and see how long it takes for this to go away. Otherwise, I don't routinely test the nasolacrimal duct in this group.
Nelson: If you do your primary procedure probing and you fracture the turbinate, do you see that child again?
Granet: I give die parents TobraDex drops to use for a week after surgery for the anti-inflammatory and antiviral effect and I tell them to stop for a week and then come back. I see them in 2 weeks to evaluate how diings are going, to hold dieir hand, to talk to them, review any information, answer questions, and see what's going on. At that point, if die procedure failed, we'll start to see it happen.
Nelson: Do you ever see a child at 2 weeks postoperatively who seems to be perfecdy fine and then something occurs at a later date?
Granet: In my experience, that is extremely rare. I do occasionally get a frantic call from parents about their child who has an eye infection and a cold. I tell parents it's okay for this to happen. I have seen very few full-blown failur1es after treatment.
Nelson: If you probe a child and give the TobraDex for a week, would it be reasonable to just have the parents call you and talk to you over the phone?
Granet: That is exacdy what I do for patients who live far away. I call the parents the next day and talk to them, and then I tell them to call in a couple of weeks to let me know how things are going.
I find that a lot of my patients like to come in, show the child off, talk to me about it, and have their questions answered. I think there's a value to that to some extent. But I'm not going to drag someone in to see me who Uves an hour and a half away. I'll be glad to do diat over the phone.
Nelson: How do you evaluate a patient following your probing at a first procedure?
Olitsky: I have the parents call me in a mondi. I do not see them. These parents are experts in the tearing child. They know if the tearing is going away.
I don't care what the dye disappearance shows; if the parents are happy and die child doesn't seem to be tearing, he or she is cured. I also think some patients like to come in. However, I wouldn't want someone to take a day off from work to come in and hear what I could tell them over the phone.
If there is any question, 1 have patients come in. For patients who live far away and are clear-cut failures, I don't see those patients again, I just go ahead and schedule a second procedure.
Nelson: What do you give them postoperatively?
Olitsky: Nothing. It is the very rare child who is clear in a month and comes back a year later tearing again.
Burke: Postoperatively, I have patients use TobraDex for a week, then nothing for a week, and then I have them call me. The parents are experts, and they will know if it's recurring. Parents know by the end of the second week if die problem is recurring. The exception to this would be if the child has a cold. Then I tell parents to wait until the child has been cold-free for a week and then call me. Patients will get discharge in their eye when they have a cold, and this not a failure of our probing.
I prescribe drops for a week, have patients call me in a week. and I never see the patient again if he or she is one of the 80% who get cured.
Nelson: Some doctors give nose drops postoperatively. Do any of you use nose drops postoperatively?
Burke: The only time I use nose drops is right before I do infracture. I use Neosynephrine, but I don't give it to the parents to take home.
Nelson: Do any of you advocate doing an early or initial probing in the office?
Olitsky: I don't. I think if you suggest to die parent that probing in the office avoids anesthesia and all the risks associated with it, the parent will like that. If you explain to the parent that you think it is a painful procedure that shouldn't be done in the office, rhey won't like it. So I think people who say they are happy with one or the other approach is because of the way they discuss it with the parents.
Granet: I've only done a few office probings and I didn't like it. I think we are doing procedures on kids who are going to get better anyway. As a parent, I understand trying to ease the parents' burden. However, I agree that the way you explain the procedure determines what the parents will choose. If you say to the parents, "I can pin your child under brute force and jam this wire down his or her nose," versus "We can use a very safe anesthetic to do this procedure when your child gets older," parents opt for the latter.
Burke: I don't do nasolacrimal duct probings in the office because a majority resolve spontaneously and I would be probing too many children in my office.