Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Nasolacrimal Duct Probing for Young Children With Congenital Nasolacrimal Duct Obstructions in China: A 10-Year Systematic Review

Qin Xiang, MM; Xu Gao, MD; Xinke Chen, MM; Jian Qi, MD; Jing Fang, MD

Abstract

Purpose:

To investigate the success rate of probing for young children with nasolacrimal duct obstructions and the risk factors involved.

Methods:

The medical records of 3,143 patients (3,928 eyes) who received nasolacrimal duct probing in southwest China were collected. These included delivery method, age and gender, preoperative treatments, anesthesia methods, probing procedure, and follow-up clinical records. Then the relationship between the success rates of the probing and a few probable risk factors were analyzed.

Results:

Children delivered by eutocia were more likely than those delivered by cesarean section to have nasolacrimal duct obstruction. The total success rate of the probing was 85.2%. Patients older than 19 months had a lower completion rate compared with those younger than 1 year (P < .01). In the follow-up observations, the younger age groups were more likely to have higher success rates than the older ones (P < .05) using pairwise comparison. The success rates also had a significant relationship with the type of obstruction and older patients were more likely to have complex obstruction (odds ratio: 1.13, 95% confidence interval: 1.08 to 1.19, P < .001).

Conclusions:

This large-scale study proved several factors affect the success rate of nasolacrimal duct probing, and confirmed children delivered by eutocia were more likely to have nasolacrimal duct obstruction.

[J Pediatr Ophthalmol Strabismus. 2019;56(6):365–372.]

Abstract

Purpose:

To investigate the success rate of probing for young children with nasolacrimal duct obstructions and the risk factors involved.

Methods:

The medical records of 3,143 patients (3,928 eyes) who received nasolacrimal duct probing in southwest China were collected. These included delivery method, age and gender, preoperative treatments, anesthesia methods, probing procedure, and follow-up clinical records. Then the relationship between the success rates of the probing and a few probable risk factors were analyzed.

Results:

Children delivered by eutocia were more likely than those delivered by cesarean section to have nasolacrimal duct obstruction. The total success rate of the probing was 85.2%. Patients older than 19 months had a lower completion rate compared with those younger than 1 year (P < .01). In the follow-up observations, the younger age groups were more likely to have higher success rates than the older ones (P < .05) using pairwise comparison. The success rates also had a significant relationship with the type of obstruction and older patients were more likely to have complex obstruction (odds ratio: 1.13, 95% confidence interval: 1.08 to 1.19, P < .001).

Conclusions:

This large-scale study proved several factors affect the success rate of nasolacrimal duct probing, and confirmed children delivered by eutocia were more likely to have nasolacrimal duct obstruction.

[J Pediatr Ophthalmol Strabismus. 2019;56(6):365–372.]

Introduction

Congenital nasolacrimal duct obstruction (NLDO) is one of the most common diseases among infants in eye clinics, with a prevalence of 5% to 6%.1 Symptoms of NLDO include epiphora and mucopurulent discharge without any inflammatory presentations, such as conjunctival congestion or photophobia. The main treatments for NLDO include antibiotic eye drops to control the infection and reduce secretions in the lacrimal sac, massage to promote spontaneous resolution, and nasolacrimal duct probing to resolve the remaining symptoms. Several studies reported that conservative treatments such as massage or no treatment had a high cure rate, and 96% of infants can spontaneously recover on reaching 1 year of age.2–4 On the other hand, other reports advocate for initial probing prior to 1 year of age.5,6 It has been suggested that early intervention can prevent complications such as acute dacryocystitis, periorbital cellulitis, palpebral eczema, or possible inflammatory sequelae.5,7 However, there is controversy regarding the optimal timing for patients to receive probing.

In our clinics, we found that parents were more likely to choose the earlier intervention rather than waiting because they did not want their children to suffer from these symptoms longer than necessary. Long-term tears always caused palpebral eczema and conjunctivitis, which led the infants to constantly scratch the palpebrae. Long-term eczema could also result in the pigmentation of the palpebral skin. Additionally, these children may repeatedly visit the hospital, which could increase the risk of infection of communicable diseases.

Some studies showed that the success rate was negatively associated with the infants' age.3,5,6,8,9 Nasolacrimal duct probing has been proven by many reports5,10–12 to be both a safe and effective method despite potential complications, including the creation of a false passage; injury to the nasolacrimal duct, canaliculi, and puncta; nasal bleeding; laryngospasm; or aspiration. Through our previous observations, we attempted to identify the relationship between age and success rate, assess the probability of complications, and determine the risk factors that lead to failure to give more effective and scientific advice to the patients and their parents or guardians.

Patients and Methods

This was a retrospective analysis. We had access to information that could identify individual participants through their operation agreements, but there was no personal information of the patients involved in our research. The diagnosis of congenital NLDO was made according to the signs of NLDO (ie, epiphora, increased tear lake, and/or mucous discharge in the absence of other infections). The physicians noted the clinical symptoms of the affected eyes. Patients younger than 3 months were not included because of a high rate of spontaneous resolution and few records could be found in our department. Cases with other diseases, such as congenital diseases, upper respiratory tract infections, acute dacryocystitis, and periorbital cellulitis, were excluded. Cases that had prior nasolacrimal duct surgery including simple probing in other institutions, nasolacrimal intubation, balloon catheter dilation, or dacryocystorhinostomy were excluded. Finally, medical records of 3,143 children (3,928 eyes) with ages ranging from 3 to 68 months who had received probing in the Children's Hospital of Chongqing Medical University from 2007 to 2017 were enrolled for analyses.

According to the medical records, probing for patients younger than 24 months was performed under brief inhalation anesthesia in the clinic by our well-trained pediatric ophthalmologists, whereas patients older than 24 months were under brief general anesthesia. Before the probing, the lacrimal duct was irrigated. Then, a 23-gauge lacrimal cannula was used for probing through the upper lacrimal punctum, which measures 0.25 mm at the aspiration port. The size was determined according to the diameter of the horizontal canaliculus for cases and stiffness for operation. The location of the obstruction was recorded after the operation.

Simple obstruction was defined as membranous, with little inflammation, and the probe encountered little resistance during the procedure. Complex obstruction was defined as inflammatory obstruction, meaning the probe encountered more resistance in addition to the presence of mingled pus and blood through the probe. The third type of obstruction was stenosis, which also had complete obstruction at the time of irrigation. It was characterized by a lack of resistance to the probe until it entered the nasolacrimal duct, at which point the probe was felt to fit snugly within the nasolacrimal duct. The definitions were based on the feel and findings of the surgeon during the operation, due to the lack of endoscopy in our department.

The patency of the nasolacrimal duct was confirmed by observing the swallowing reflex or fluid coming out of the naris (especially during the brief general anesthesia), and this was defined as procedure completion. The postoperative medication was levofloxacin eye drops (Santen Pharmaceutical Co., Ltd., Osaka, Japan) applied four times a day for 1 week. Patients were reevaluated at regular intervals of 1 week, 1 month, and 3 months. Success of the probing was defined as complete disappearance of lacrimation and discharge, with no evidence of recurrence during this study period. Failure was defined as the probing procedure was completed but showed signs of NLDO and irrigation failed in the follow-up observations. Neither systemic nor ocular side effects were noted in this study. No cases of choking or aspiration were noted in the anesthetized children.

The clinical data of the 3,143 patients were collected and analyzed using SPSS software (version 19.0; SPSS, Inc., Chicago, IL). A statistical analysis was performed using the chi-square test.

Results

Clinical Findings

This study included 3,143 children (3,928 eyes) with ages ranging from 3 to 68 months (785 patients with NLDO). The main clinical symptoms included epiphora (3,928 [100%]), mucous discharge (3,007 [76.6%]), palpebral eczema (596 [15.2%]), conjunctivitis (153 [3.9%]), and dacryocystitis (1,117 [28.4%]). Most patients had undergone conservative treatments such as nasolacrimal massage, topical antibiotics, or both for varying durations before probing. Nearly two-thirds of children with NLDO were delivered by eutocia (n = 2,445), whereas nearly one-third were delivered by cesarean section (n = 1,483) (Table 1).

Clinical Findings of Patients With Congenital Nasolacrimal Duct Obstruction

Table 1:

Clinical Findings of Patients With Congenital Nasolacrimal Duct Obstruction

Completion Rates of the Primary Probing

In our observations, the operation was incomplete for 16 (13 patients) of the 3,928 eyes. These 16 cases required further external dacryocystorhinostomy or silicone intubation and may have had bony obstruction or bone abnormalities that could not be penetrated by the probe. However, we did not study these cases further because they were not the purpose of the current study. The clinical data for these 13 incomplete patients are also shown in Table 1. There was no significant difference in the completion rates of patients' gender, laterality of eyes, or different delivery methods (P = .231, .515, and .983, respectively) (Table 2).

Completion of Primary Probing for Congenital Nasolacrimal Duct Obstruction

Table 2:

Completion of Primary Probing for Congenital Nasolacrimal Duct Obstruction

The completion rates of primary probing in different age subgroups are shown in Table 3. We found that the completion rates became lower as the patients became older. There were no significant differences in the completion rates among the 3 to 6 months group, the 7 to 12 months group, and the 13 to 18 months group, using a pairwise comparison (P > .05). The patients in the 19 to 24 months group had a lower completion rate than the two subgroups younger than 12 months, according to a pairwise comparison (P < .01). The completion rates decreased remarkably in the 25 to 68 months group compared with the three subgroups younger than 18 months, using pairwise comparison (P < .05) (Table 3).

Comparison of the Completion and Success Rates in Different Age Subgroups

Table 3:

Comparison of the Completion and Success Rates in Different Age Subgroups

Success Rates of the Primary Probing During the Follow-up Observations

Patients were reevaluated 1 week, 1 month, and 3 months after the primary probing and the failure rates were 13.8% (541 of 3,912), 14.5% (569 of 3,912), and 14.8% (580 of 3,912), respectively (data not shown). In total, the success rate of the primary probing was 85.2%. Then we divided patients into five subgroups according to their age. We found the success rates of probing were negatively correlated with increasing age (P < .05) (Table 3).

Factors Affecting the Success Rate

We continued to analyze the patients' clinical observation data, which were suspected to have some relationship with the success rate. We found that patients who had no mild nasal bleeding during the probing procedure were more likely to succeed than the cases who had (P < .01). The patients with dacrocystitis or conjunctivitis had a dramatically lower success rate than the groups without (P < .01 and < .01, respectively). Compared with the group who received neither of the previous treatments, those who received massage and both treatments had remarkably higher success rates (P < .01). There was no difference between those who received eye drops and those who received neither of the previous treatments (P = .525). There was no statistically significant difference in the success rates between the laterality of the eyes (P = .053) or between the groups with or without mucous discharge (P = .368) (Table 4).

Observations of Different Risk Factors Affecting the Success Rate

Table 4:

Observations of Different Risk Factors Affecting the Success Rate

We further analyzed the effect of different lacrimal duct obstruction types on the success rate. Patients with simple obstruction were significantly more likely to experience successful probing (2,923 eyes) than those with complex obstruction (409 eyes) (P < .01). The failure rate was much higher in patients with stenosis (180 eyes) of the nasolacrimal duct than in patients without stenosis (400 eyes) (P < .01).

We also explored whether age had some relationship with the type of obstruction. We found that the older patients were more likely to develop complex obstruction than the younger ones (odds ratio: 1.13, 95% confidence interval: 1.08 to 1.19, P < .001) (data were not shown).

Discussion

In this retrospective study, we found that nasolacrimal duct probing for congenital NLDO in infants had a high completion rate. The results showed that the completion rate had nothing to do with the patients' gender, laterality of the eye, or different delivery methods, but was associated with age. Nearly two-thirds of the patients with NLDO were delivered by eutocia, which was consistent with the new report13 and indicated that natural birth was less likely to cause NLDO because of the extrusion from the birth canal, which could help keep the Hasner's valve open; however, it had nothing to do with the completion rates. When patients were older than 19 months, the completion rates significantly decreased compared with the patients younger than 12 months.

The success rates had a significantly negative relationship with age. Moreover, we found some new factors related to the success rate that have never been reported before. Patients with dacrocystitis, conjunctivitis, or intraoperative mild nasal bleeding had markedly lower success rates than those without (P < .01 for all). The percentage differences were small at 4% and 5% for the presence of nasal bleeding and dacryocystitis, respectively, so as to be of little practical clinical significance. Patients with previous treatments, including nasolacrimal massage or both topical antibiotics and massage, had clearly higher success rates compared with patients without previous treatments (P < .01 for both). There was also a markedly significant difference between different obstruction types. Patients with a simple obstruction had a much higher success rate compared with those who had complex obstruction (P < .01). Patients with a stenosis of the nasolacrimal duct were more likely to experience success than patients without (P < .01). Further research indicated that older patients were more likely to have complex obstruction.

There has been controversy regarding the optimal timing to perform primary probing in children with congenital NLDO. Several studies reported a decrease in cure rates with delayed probing,6,14–17 whereas other researchers claimed that there was no relationship between age and the operation's success rate.10,15,18–20 In this study, the success rate had a significantly negative correlation with age. The older the patients were, the lower their success rate. This result was consistent with previous reports.8 Why were older patients with congenital NLDO more likely to fail? Our research showed that older children were more likely to have complicated, non-membranous obstructions, which may cause a reduction in the cure rate, and this was consistent with previous reports.12,14,21 According to our clinical experience, we speculated that the secondary fibrosis induced by prolonged inflammation and infection might be another cause of failure.3,10,12,21 In addition to age, we also found other risk factors that affected the success rate of the operation. The failure happened more often in children with nasal bleeding during surgery. Intraoperative bleeding hinted that the nasolacrimal duct, canaliculi, or puncta may be injured during the probing. Injury during the operation could exacerbate the postoperative inflammatory reaction and increase nasolacrimal duct edema, which would lead to a failure of the operation. Clotting blood may also obstruct the lacrimal duct.

We also found that cases with dacrocystitis and conjunctivitis during the operation had a remarkably lower success rate than those without. The results may be due to topical inflammation, which could cause topical tissue hyperemia and edema. The more serious the topical inflammation was, the more easily failure happened. More studies are needed to verify these findings.

In this study, preoperative therapy such as massage with and without the use of antibiotics was found to have a clearly positive relationship with the success rate, but there was no relationship between using topical antibiotics and the success rate. Similarly, a statistically significant association between the outcome of endoscopic intranasal surgery and previous treatment history was reported by Dhiman et al.22 Although topical antibiotics can theoretically remit dacrocystitis and conjunctivitis, which could increase the success rate, regular massage before the operation appears to be more effective. The reason for this could be that most parents of children with NLDO would perform the daily massages under the guidance of a physician rather than continuously using topical antibiotics. Parents' use of eye drops varied and could not be verified. Further prospective research is required to evaluate these risk factors.

The opening of the nasolacrimal duct into the nose through an ostium in the inferior nasal meatus was usually partially covered by a mucosal fold called Hasner's valve. The obstruction often happened at Hasner's valve.21,23–25 In our study, we found that the most common obstruction type was simple rather than complex, and cases with single simple obstruction had a much higher success rate compared with complex cases. In addition, the success rate was much lower in patients with stenosis of the nasolacrimal duct than in patients without stenosis. These data indicated that the success rate of the initial probing was related to the type of obstruction. Many reports have confirmed this and their findings were consistent with our results.12,16,21,23,26,27 Kushner21 and Honavar et al.28 showed that the complex congenital NLDO was more likely to be found in older patients. Katowitz and Welsh5 believed that increasing age after 13 months not only decreases the cure rate, but also increases the number and complexity of future procedures. That is also consistent with what we found. It seemed that the significance of the increasing age on reduction of the success rate in patients may affect complex congenital NLDO. This may be due to prolonged inflammation and fibrosis in the lacrimal drainage system with increasing age, which could lead the obstruction to become complex.

In this study, we had a large amount of data. Although some of the data were new, much of it had been published and discussed in previous reports. However, this was by far the largest source of data on the subject from a single institution. Also, although many previous reports discussed one or two issues regarding NLDO (eg, success rate in complicated vs simple obstructions), this study discussed many concerns all in one report and from one center.

It should be noted that there were limitations in our study. This study was retrospective, so a prospective, randomized trial is needed to definitively evaluate the efficacy of initial probing. As with all retrospective studies, imperfect standardization of probing techniques and postoperative examination intervals might have acted as confounding factors. Additionally, too few patients who did not complete the initial probing were enrolled to accurately reach a conclusion regarding the statistical differences of the completion rate between different age groups. Therefore, further studies that enlarge the size of these samples are needed. We found that children delivered by eutocia were more likely to have NLDO than those delivered by cesarean section, but this needs further research to confirm the relationship between different delivery methods and morbidity. It is possible that membranous obstructions would clear spontaneously, albeit at a diminishing rate over time, leaving only the more pathologically malformed/bony obstructed ducts to remain as the observed population ages at the time of probing. This skew would result in the observed low success rates among older patients.

Conclusions

Our results identified some factors (ie, age, type of the obstruction, dacrocystitis, conjunctivitis, intraoperative nasal bleeding, and preoperative regular massage) related to the success rate of probing, and children delivered by cesarean section were more likely to have NLDO, so better management of these risk factors before the probing could increase the success rate. Furthermore, because the data indicated that probing was still the safest and most effective treatment, patients who had a long but ineffective conservative treatment could choose the probing.

References

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Clinical Findings of Patients With Congenital Nasolacrimal Duct Obstruction

FindingsReceived Probing Eyes (n = 3,928)Uncompleted Eyes (n = 16)
Epiphora3,928 (100%)16
Mucous discharge3,007 (76.6%)16
Palpebral eczema596 (15.2%)4
Conjunctivitis153 (3.9%)2
Dacryocystitis1,117 (28.4%)14
Prior nasolacrimal massage1,192 (30.4%)7
Prior topical antibiotics1,391 (35.4%)6
Prior topical antibiotics and massage965 (24.6%)1
With no prior treatment380 (9.7%)2
3 to 6 months939 (23.9%)2
7 to 12 months2,307 (58.7%)6
13 to 18 months511 (13.0%)3
19 to 24 months87 (2.2%)2
25 to 68 months84 (2.1%)3
Right eye1,891 (48.1%)9
Left eye2,037 (51.9%)7
Eutocia2,445 (62.2%)10
Cesarean section1,483 (37.8%)6

Completion of Primary Probing for Congenital Nasolacrimal Duct Obstruction

VariableCompleted (Eyes)Uncompleted (Eyes)Completion Rate (%)P
Patients (n = 3,143).231
  Male1,722599.7
  Female1,408899.4
Eyes (n = 3,928).515
  Right1,882999.5
  Left2,030799.7
Delivery method (n = 3,928).983
  Eutocia2,4351099.6
  Cesarean section1,477699.6

Comparison of the Completion and Success Rates in Different Age Subgroups

Age (Months)Completed (Eyes)Uncompleted (Eyes)Completion Rate (%)PaPbPcPd
Completion group
  3 to 6937299.8NANANANA
  7 to 122,301699.7.806NANANA
  13 to 18508399.4.246.236NANA
  19 to 2485297.7< .01< .01.105NA
  25 to 6881396.4< .01< .01.011.621
  Total3,9121699.6NANANANA
Success group
  3 to 68469190.3NANANANA
  7 to 121,98731486.4< .01NANANA
  13 to 1840510379.7< .01< .01NANA
  19 to 24553064.7< .01< .01< .01NA
  25 to 68394248.1< .01< .01< .01< .05
  Total3,33258085.2NANANANA

Observations of Different Risk Factors Affecting the Success Rate

Observation IndexFailure (Eyes)Success (Eyes)Success Rate (%)P
Nasal bleeding18487282.6%< .01
Without bleeding3962,46086.1%
Dacrocystitis20390081.6%< .01
Without dacrocystitis3772,43286.6%
Conjunctivitis3411777.5%< .01
Without conjunctivitis5463,21585.5%
Mucous discharge4352,55685.5%.368
Without mucous discharge14577684.3%
Right eye3011,58184.0%.053
Left eye2791,75186.3%
Previous treatment
  Massage1231,06289.6%< .01a
  Antibiotics2931,09278.8%.525a
  Both7888691.9%< .01a
  Neither8629277.2%NA
Authors

From the Department of Ophthalmology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China (QX, XG, XC, JF); China International Science and Technology Cooperation Basis of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China (QX, XG, XC, JF); the Department of Ophthalmology, Bi Shan Hospital of Chongqing, Chongqing, China (XG); and First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, Chongqing, China (JQ).

Supported by National Natural Science Foundation Project (No. 81770916 and No. 81400389); Chongqing Applied Basic Research Projects and Cutting-Edge Technology (No. stc2014jcyjA10111); and Research Incubation Fund of Chongqing Medical University (No. 201407).

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank all patients and their parents enrolled in the current study. They also thank Xiurong Chen for assistance with the data collection.

Correspondence: Jing Fang, MD, Department of Ophthalmology, Children's Hospital, Chongqing Medical University, Chongqing 400014, China. E-mail: 576119717@qq.com

Received: May 13, 2019
Accepted: August 30, 2019

10.3928/01913913-20190923-04

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