Nasolacrimal duct obstruction is the most common disorder of the lacrimal system that a pediatric ophthalmologist encounters. It is thought to occur in approximately 5% of all newborns.1,2 Generally, signs of congenital nasolacrimal duct obstruction (CNLDO) do not appear until at least 6 weeks of age. These include epiphora, mattering of eyelashes, and mucopurulent discharge. This is due to the lacrimal glands not becoming fully functional until 6 weeks of age. The most common cause of congenital nasolacrimal duct obstruction is failure to canalize the valve of Hasner, which is located at the distal end of the nasolacrimal duct.3 Generally, patients presenting earlier are likely to have other causes of obstruction, including congenital dacryoceles or fistulas.4
Up to 90% of patients with CNLDO will have a resolution of symptoms by 9 to 12 months.5,6 For those who required conservative management, including the Crigler massage,7 the Pediatric Eye Disease Investigator Group (PEDIG) found a 90% success rate for patients younger than 6 months and a 66% resolution rate for patients 6 to 12 months of age. For those who fail conservative management, primary probing of the nasolacrimal system has a success rate of 70% to 90%.5,6,8–19 There has been an extensive discussion of the appropriate timing for probing these children and the safety and efficacy of performing the probings in the office setting. Additionally, there have been extensive studies examining the cost-benefit analysis of office-based probings compared to probings in the operating room.14–16
We conducted one of the largest retrospective analyses of primary in-office probings for CNLDO and its efficacy.
Patients and Methods
A retrospective chart review approved by the local institutional review board was undertaken at a private pediatric ophthalmology clinic. A total of 1,294 patients were identified based on the diagnosis of CNLDO who also had the CPT code for in-office probing between 2002 and 2016. Records of 1,207 patients who underwent primary in-office probings were included because the rest did not return for follow-up after the probing. A total of 1,227 nasolacrimal duct probings were performed, with 20 of them being bilateral probings.
Inclusion criteria were patients with the diagnosis of CNLDO who underwent an in-office probing for clinical symptoms of a nasolacrimal duct obstruction (eg, epiphora, full tear lakes, delayed dye disappearance test, and mattering of the eyelashes) but had failed conservative therapy, including nasolacrimal massage with or without antibiotics. In general, the PEDIG studies7,14,16,20 were discussed with the parents prior to the decision to perform in-office probings. Parents were urged to wait until their child was 9 months of age without resolution of his or her symptoms with conservative management before scheduling an in-office probing. The patients who had in-office probings before this age were at the insistence of the parents after having their elder children probed in the office with success. Patients were excluded if they had any other medical conditions that might have an effect on the nasolacrimal system (eg, Down syndrome or any craniofacial abnormality) or failure to return for any follow-up appointments. A successful procedure was defined as patients who had resolution of symptoms and the aforementioned objective findings on their follow-up examination. All patients who failed to return for a follow-up examination were excluded.
All patients were restrained using infant restraints and held by an ophthalmic technician. Proparacaine was then instilled in the eye and the nose on the side of the probing. A punctal dilator was used to dilate the lower punctum. A size 1 Bowman probe was used to probe the nasolacrimal duct and complete canalization was confirmed with a size 7 Bowman probe inserted into the nose with metal-to-metal touch beneath the inferior turbinate. If there was difficulty probing the nasolacrimal duct through the inferior punctum, the same procedure was done through the superior punctum.
Descriptive statistics were stated as mean ± standard deviation for continuous variables. Statistical analysis was performed using the chi-square test for the rate of revision. A binary logistic regression was performed to determine the likelihood of needing a second surgery based on age at the time of the first surgery.
There were 1,207 patients who were at least 4 months old (559 [46.3%] female and 648 [53.7%] male), all of whom were noted to have metal-to-metal touch of the probes during the procedure except for 4 who were brought to the operating room due to lack of both the superior and inferior punctae. Of those who had reprobing, 38 were female (6.7% of females) and 44 were male (6.7% of males), for a total of 82 who had reprobing (6.7%). There was no statistically significant association between sex and whether reprobing was done (chi-square = 0.00, P = .9952). Other than mild epistaxis that lasted no longer than 1 to 2 days, there were no other complications for the in-office procedures.
Of the 82 patients who underwent a second procedure, 35 (43%) underwent a second in-office probing with a success rate of 77%. The 8 (22%) patients who failed the second in-office probing underwent a probing and Crawford stent placement in the operating room and all had resolution of their symptoms. Only 1 (2%) the 47 (57%) older children (defined by the pediatric ophthalmologist's comfort level on performing an in-office probing based on size of the child) who failed the primary in-office probing and underwent probing and stent placement in the operating room needed a second probing and stent placement in the operating room.
The mean age at the time of the initial probing was 9.08 ± 3.12 months (range = 4 to 24 months), with 986 patients younger than 12 months (80.4%) and 241 patients 12 months or older (19.6%) (Figure 1). Of the patients who had reprobing, 55 were younger than 12 months (5.6% of those younger than 12 months) and 27 were 12 months or older (11.2% of those at least 12 months old). There was a statistically significant association between these age groups and whether reprobing was done (chi-square = 9.83, P = .0017).
Age distribution at time of initial probing.
A logistic regression to predict reprobing for the two age groups (younger than 12 months and 12 months or older) indicated a statistically significant increase in the odds of reprobing from the younger than 12 months group to the 12 months or older group (odds ratio = 2.136, 95% confidence interval = 1.316 to 3.465, P = .0021), meaning that children who were primarily probed at 12 months or older had a higher reprobing rate. For this logistic regression, the area under the receiver operating characteristic curve was only 0.571, which indicates that age group, although statistically significant, was not a good predictor of the need for reprobing (Figure 2). This indicates that there are likely other factors, in addition to age, that play a role in the need for reprobing.
Logistic regression analysis comparing patients aged 4 to 11 months versus those older than 12 months showing a decreased likelihood of needing a second procedure in the younger age group. ROC = receiving operator characteristic
For primary in-office probings for CNLDO, there was a 93.3% success rate. Of the 1,227 patients who underwent probing for either bilateral or unilateral CNLDO, only 55 (4.5%) needed a procedure in the operating room. There were no complications noted for any of the in-office probings.
CNLDO is one of the more common clinical entities seen by a pediatric ophthalmologist in infants. For decades, there has been debate about when a primary probing should be done5–8,17–19 and in which setting this should be done.7,9–16 The main focus of the disagreement is how long should be allowed for spontaneous resolution with non-invasive management before performing an invasive procedure, whether it be under anesthesia or in the office. Those who oppose early probings believe that the delay may allow for a natural opening of the nasolacrimal duct without surgical intervention. There are also those who do not feel comfortable probing children in the office.
Those who advocate in-office probings have justifications as to why they prefer to not go to the operating room until absolutely necessary. First, and most important, is the risk of general anesthesia for young children, especially those younger than 3 years. There is substantial evidence showing that general anesthesia is not benign and should be postponed until the child is older and the procedure is necessary. In addition to death, major morbidities include brain and heart damage.20–24 The U.S. Food and Drug Administration published a black box warning in December 201625 and again in April 201726 about general anesthesia for children younger than 3 years, telling clinicians to carefully weigh the risks and benefits of doing surgery on children younger than 3 years with general anesthesia because the risks can be great.
Another topic that has been discussed by proponents of in-office probings is its cost-effectiveness. If the ophthalmologist is getting reimbursed at a rate of 100% from Medicaid, the payment for a probing in Miami-Dade County, Florida, is $157.04, regardless of whether it is performed in the office or the operating room. This does not include any of the facility fees for the hospital/ambulatory surgery center or the anesthesia fees for general anesthesia, which may be approximately $3,000 per procedure. There are also ophthalmologists who propose inserting a monocanalicular or bicanalicular stent primarily if bringing the patient to the operating room to decrease the likelihood of needing another procedure. This will increase the payment to the physician to $224.00 and increase the time under general anesthesia.
The PEDIG study14–16 included a cost analysis for early primary in-office probings compared to primary delayed probings in the operating room in a modest number of patients between 6 and 10 months of age. In this cohort, the PEDIG study group concluded that immediate office probings are more cost-effective and largely alleviate the need for general anesthesia, although this may lead to unnecessary probing of up to two-thirds of the patients. There are several differences between our population and that of the PEDIG study. All of our patients had already failed conservative therapy with, at minimum, lacrimal sac massage, whereas the PEDIG group that underwent immediate office-based probings seemed not to have undergone any conservative treatment. Another notable difference is the age range of our patients was much greater than that of the PEDIG study, including many patients older than 10 months.
Another aspect that was specifically not taken into account in the PEDIG study was the indirect costs, such as time for office staff to book the case, time for the parents at the surgery center/hospital operating room and extra return visits, preoperative screenings by pediatricians, more time for the ophthalmologist spent doing any procedure in the operating room versus in the office, using operating room time that is often scarce, and time expended due to cancellations and rebooking of the cases by all involved.
This large retrospective study of in-office nasolacrimal duct probings shows an equivalent or increased efficacy to prior studies of both in-office probings and probings performed in the operating room, which, as stated above, ranges from 70% to 90%.9,11–14,17,18 When deciding at what age to start offering in-office probings, our data show a correlation between the age at initial probing and efficacy of primary in-office probing. Our data show a 2.136-fold increase in the likelihood of needing a second procedure if the initial probing was performed after the age of 12 months and a 1.651 increase in the rate of a second procedure for every increase of 6 months of age. Even with the increased rate of a secondary procedure after 12 months of age, we have found an 88.8% success rate of initial in-office probings on patients older than 12 months. This has a two-fold relevance. First, because there is minimal risk to performing in-office probings with properly trained staff,9 early intervention did not have a clinically significantly higher failure rate than delayed probing. Second, for patients who present after 12 months or whose parents chose to postpone probing until later, in-office probing is a viable, successful, and cost-effective option. As long as the parents and ophthalmologist are amenable, in-office probings would be beneficial as a primary procedure for all children with CNLDO who have not had resolution of symptoms with conservative therapy.
The limitations of this study include that some of the patients were not observed for more than one or two follow-up appointments after the in-office probing. Our failure rate only included those patients without resolution of symptoms who underwent a secondary probing performed by the same pediatric ophthalmology group and it may have missed patients who went elsewhere for further treatment. Our statistics may then include patients who failed probing but went elsewhere for further treatment or who spontaneously resolved months after probing. Also, because the logistic regression analyses do not show the strongest correlation between increasing age and need for reprobing, there are likely other factors that need to be understood that were not addressed in this study. Because the data were de-identified, the logistic regression could not account for possible correlation between the bilateral probings of a single patient, but because these were only 20 of the 1,227 total probings, this is unlikely materially to affect the results.
Our results showed an overall 93.3% success rate of first in-office probing and a success rate of 77% for a repeat in-office probing. We have also shown an 88.8% success rate for in-office probings for patients older than 12 months. These results are at the upper end of successful treatment when looking at both in-office probings and probings in the operating room for patients of any age in prior studies.5–14,17–19,27 This review of in-office probings shows the efficacy of a minimally invasive procedure on all children younger than 24 months. With proper training of staff, nasolacrimal duct obstruction can be treated quickly and safely in the office. This will save time and money for the family, ophthalmologist and his or her staff, and the insurance companies, both public and private.
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- American Academy of Ophthalmology. 2017–2018 Basic and Clinical Science Course, Section 07: Orbit, Eyelids, and Lacrimal System. San Francisco: Author; 2014.
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