Cesarean section is one of the most common obstetric surgeries, and its use is increasing for multiple indications.1,2 Although maternal and neonatal intraoperative and early postoperative complications of cesarean sections are well known, the long-term impact on the infants is receiving increasing attention. Numerous disorders, such as diabetes mellitus, obesity, asthma, nasal septal deviations, dermatitis, allergies, poorer immune defenses, and celiac disease, have been associated with cesarean sections.1-4
Congenital nasolacrimal duct obstruction (CNLDO) is among the foremost causes of neonatal epiphora and commonly results from failure of canalization of the lowest portion of the nasolacrimal duct into the inferior meatus.5 Two recent reports have shown an association of CNLDO with cesarean section delivery.6,7 The relative risk of developing CNLDO when delivered by cesarean section was found to be 1.7-fold.7 The current study assessed the association of CNLDO with modes of delivery in 200 consecutive patients presenting at a tertiary care dacryology center.
Patients and Methods
The L.V. Prasad Eye Institute's institutional review board approval was obtained, and the patients' identities were protected. A prospective interventional study of 200 consecutive cases of CNLDO presenting at a tertiary care center was performed. Data collected include demographics, mode of delivery, primary or secondary cesarean sections, type of CNLDO (simple or complex), management, and outcomes.
Simple CNLDO was defined as those patients who had a simple membranous obstruction at the lower end of the nasolacrimal duct, which could be overcome easily without much resistance.8 Complex CNLDO is defined as those cases that have embryonic nasolacrimal duct variations, such as buried probe, bony obstructions associated with anlages, and syndromic CNLDOs.9,10 Primary cesarean section was defined as an elective procedure performed before the onset of labor, and secondary cesarean section was defined as a procedure performed after the onset of active phase of labor.7 Statistical analysis was performed to assess the significance of the association between CNLDO, its subtypes, and the modes of delivery. A P value of less than .05 was considered statistically significant.
Of the 200 consecutive patients, 107 were males and 93 were females. Mean age at presentation was 23.3 months (range: 0.5 to 96 months). Among the patients, 97 (48.5%) were vaginal deliveries and 103 (51.5%) were cesarean sections. Three patients in the vaginal group had forceps assistance. Of the 103 patients who had cesarean sections, 57 (55.3%) were primary cesarean sections and the remaining were secondary cesarean sections.
Based on the type of CNLDO, 172 (86%) were simple CNLDO and 28 (14%) were complex CNLDO. The number of patients with vaginal and cesarean modes of delivery was 88 and 84 in the simple CNLDO subgroup, respectively, and 9 and 19 in the complex CNLDO subgroup, respectively.
When categorized by age at presentation to assess older versus younger children, 187 (93.5%) were younger than 48 months and 13 (6.5%) were 48 months and older.
In general, no significant association was found between the incidence of CNLDO and mode of delivery. The association was not significant when different age groups were assessed (P = .83 for younger than 48 months and P = .43 for 48 months and older). Among the complex CNLDO subgroup (n = 28), a significant association was found with delivery by cesarean section (P = .016); however, no such association was noted between vaginal delivery and types of CNLDO (P = .09). All of the patients underwent irrigation and probing with or without intubation under endoscopic guidance, and successful recanalization was achieved in 98.2% (169 of 172) of patients with simple CNLDO and 60.7% (17 of 28) of patients with complex CNLDO.
The current study performed an analysis of 200 consecutive patients with CNLDO and did not find an overall significant association between the disease and the mode of delivery. No associations were found with age at presentation and the mode of delivery; however, patients presenting with complex CNLDO were found to have a significant association with cesarean section delivery. Although the sample size was smaller in certain subgroups for a meaningful analysis, this study refutes the belief that cesarean section is associated with increased risk of developing CNLDO.
Kuhli-Hattenbach et al.6 prospectively studied 107 patients with CNLDO (mean age: 9.2 ± 7.1 months) and noted that 56 were delivered by vaginal mode and 51 by cesarean section. They selected 44 age-matched patients from this cohort and analyzed the data with the help of published rates of cesarean sections in their geographic area. When a total of 88 age-matched patients were analyzed this way, a significant association between CNLDO and delivery by cesarean section was noted (P = .009). Subgroup analysis revealed that this association was significant for primary cesarean sections; however, the prevalence of surgical management was neither significantly different between the groups nor was it statistically significant when compared to modes of delivery.6
Spaniol et al.7 retrospectively studied 386 children with CNLDO and did not find a statistically significant difference between the overall cesarean sections rate and incidence of CNLDO. However, the association was significant between CNLDO and primary cesarean sections for both genders (P < .05). The authors compared their CNLDO data with that of the general population of their geographic area and found that the number of children delivered vaginally was not different; however, the risk of developing CNLDO was 1.7-fold in those delivered by primary cesarean section compared to those delivered vaginally.7
Several factors have been proposed to explain the possible association between CNLDO and cesarean section.6,7 Mechanical alterations of the soft tissues and cartilages of the face while passing through the birth canal and increased intrauterine pressure may influence the hydrostatic pressure within the lacrimal drainage system and facilitate the breakage of membranous obstruction at the lower end of the nasolacrimal duct. Similarly, increased enzymatic activity of collagenolytic enzymes during spontaneous vaginal delivery may aid in dissolution of the membranous obstruction at the lower end of the nasolacrimal duct. Both of these mechanisms are blunted in cesarean sections, and this may explain the increased incidence of CNLDO in this group. However, the current study did not find such an association in patients with simple CNLDO, where membranous obstructions play a major role. The association of complex CNLDO with cesarean sections in the current study cannot be explained by either of these theories.
The strengths of the current study are its large sample of consecutive patients, the analysis of the association based on age groups and complexity of the disease, and the head-on comparison within the CNLDO groups with regard to mode of delivery. The limitations include the lack of comparison with the general population and a smaller sample size within certain subgroups. A large, multicenter, age-matched comparison would better answer the long-term influences of delivery by cesarean section on congenital lacrimal drainage anomalies.
- Kulas T, Bursac D, Zegarac Z, Planinic-Rados G, Hrgovic Z. New views on cesarean section: its possible complications and long-term consequences for children's health. Med Arch. 2013;67:460–463. doi:10.5455/medarh.2013.67.460-463 [CrossRef]
- Cho CE, Norman M. Cesarean section and development of the immune system in the offspring. Am J Obstet Gynecol. 2013;208:249–254. doi:10.1016/j.ajog.2012.08.009 [CrossRef]
- Li HT, Zhou YB, Liu JM. The impact of cesarean section on offspring overweight and obesity: a systematic review and meta-analysis. Int J Obes (Lond). 2013;37:893–899. doi:10.1038/ijo.2012.195 [CrossRef]
- Bonifacio E, Warncke K, Winkler C, Wallner M, Ziegler AG. Cesarean section and interferon-induced helicase gene polymorphisms combine to increase childhood type 1 diabetes risk. Diabetes. 2011;60:3300–3306. doi:10.2337/db11-0729 [CrossRef]
- Kamal S, Ali MJ, Gauba V, Qasem Q. Congenital nasolacrimal duct obstruction. In: Ali MJ, ed. Principles and Practice of Lacrimal Surgery. New Delhi: Springer; 2015:117–132.
- Kuhli-Hattenbach C, Lüchtenberg M, Hofmann C, Kohner T. Increased prevalence of congenital dacryostenosis following cesarean section. Ophthalmologe. 2016;113:675–683. doi:10.1007/s00347-016-0230-z [CrossRef]
- Spaniol K, Stupp T, Melcher C, Beheiri N, Eter N, Prokosch V. Association between congenital nasolacrimal duct obstruction and delivery by cesarean section. Am J Perinatol. 2015;32:271–276.
- Kushner BJ. The management of nasolacrimal duct obstruction in children between 18 months and 4 years old. J AAPOS. 1998;2:57–60. doi:10.1016/S1091-8531(98)90112-4 [CrossRef]
- Ali MJ, Kamal S, Gupta A, Ali MH, Naik MN. Simple vs complex congenital nasolacrimal duct obstructions: etiology, management and outcomes. Int Forum Allergy Rhinol. 2015;5:174–177. doi:10.1002/alr.21435 [CrossRef]
- Gupta A, Kamal S, Javed Ali M, Maik MN. Buried probe in complex congenital nasolacrimal duct obstructions: clinical profiles and outcomes. Ophthal Plast Reconstr Surg. 2015;31:318–320. doi:10.1097/IOP.0000000000000338 [CrossRef]