Lacrimal sac abscess usually occurs because of an obstruction of the distal nasolacrimal duct or after acute dacryocystitis.1,2 If the obstruction progresses, pain and swelling of the lacrimal sac region occur and cellulitis may develop.3 Conventional treatment of lacrimal sac abscess includes the use of systemic antibiotics, percutaneous drainage of the abscess, and probing of the canaliculi and nasolacrimal duct.4–6 However, conventional therapy may not cure the underlying etiology and if unresolved may lead to recurrent infections and complications such as chronic dacryocystitis, mucocele, cutaneous fistula formation, skin scarring, cicatrical ectropion, damage of the sac, corneal ulcer, endophthalmitis, orbital cellulitis, and cavernous sinus thrombosis.7–10 Different treatment options available for cases that remain unresolved with conventional therapy are probing with silicon intubation, balloon dacryocystoplasty, endoscopic intranasal surgery, and dacryocystorhinostomy (DCR) with or without intubation.11
External DCR has been established as an effective surgical treatment for complete nasolacrimal duct obstruction (NLDO) in adults, yielding a success rate in excess of 90%.7,12 DCR is usually not preferred in children younger than 6 years.13 However, several studies favored DCR in even younger children14–16 and it is necessary when there is recurrence of abscess in small children requiring the repeated use of systemic antibiotics.
Bicanalicular silicone intubation is a widely used method in both external and internal DCR because it improves the success rate.17,18 It aims to maintain canalicular and anastomotic patency during the healing period.19,20 DCR with intubation is indicated in patients with chronic dacryocystitis who are at high risk of surgical failure, in revision surgeries, and in cases with canalicular problems, traumatic NLDO, or flap rupture.11,12,18,19
On an extensive search of the review literature, we did not find any study conducted exclusively for recurrent lacrimal abscess in children younger than 6 years. The aim of our study was to report our experience of performing pediatric external DCR with silicone intubation in high risk cases of congenital NLDO with lacrimal abscess in children younger than 6 years.
Patients and Methods
After obtaining ethical approval from the institutional ethical committee, a retrospective medical record search was done over a period of 3 years from May 2014 to April 2017 in a tertiary eye care center. The study complied with the tenets of the Declaration of Helsinki. Only those children who were younger than 6 years and underwent external DCR with silicone intubation for recurrent lacrimal abscess with at least 6 months of follow-up were included in the study. Written informed consent was obtained from all parents of the children undergoing surgery. The following parameters were documented: age at presentation, age during surgical intervention, laterality, number and type of previous procedures, postoperative success rate, and complications.
The diagnosis was based on ophthalmic history and evaluation that showed an increased tear meniscus height, crusting, and regurgitation on pressure over sac area. Only those children with recurrent lacrimal abscess that remained unresolved after incision and drainage, frequent use of systemic antibiotics, and probing and syringing on at least two occasions were included in the study. Our cases were severe enough because all children in the study presented with features of preseptal cellulitis as per the record. Children with punctal or canalicular problems, craniofacial anomalies, having syndromic association, and acquired NLDO (trauma, rhinitis, nasal polyp, tuberculosis, syphilis, deviated nasal septum, or nasal tumors) were excluded from the study. DCR with silicone intubation was performed in all cases. Intraoperative difficulties were noted. Tube removal was done after 3 months.
Surgeries were done after resolution of infection with incision and drainage and systemic antibiotics. Necessary preoperative blood investigations and pre-anesthetic check-up was done in all cases. External DCR with intubation was performed by equally experienced surgeons, under general anesthesia. Nasal packing was done with a combination of 2% lignocaine jelly, 1:1000 adrenaline, and 0.5% bupivacaine. Infiltration of the medial canthal area was done with 0.5% xylocaine with 1:200,000 epinephrine.
The surgical techniques used were as per standard protocols for external DCR.21 A tear trough incision of 6 to 7 mm was created 3 to 4 mm from the medial canthus. Dissection of the subcutaneous tissue and the periosteum over the anterior lacrimal crest was done. The angular vein was retracted out of the operative field. The periosteum was incised in a vertical fashion from the edge of the medial canthal tendon along the anterior lacrimal crest. Osteotomy was performed by fracture of the thin lacrimal bone with the blunt end of a hemostat, which was then enlarged to approximately 10 mm in diameter with a bone punch. We ensured that no bony obstruction was in front of the probe while passing through the canaliculi into the sac. A large anterior nasal mucosal flap was created with a 3.2-mm keratome. After tenting the lacrimal sac with a probe, a keratome was used to cut the lacrimal sac from the fundus to the neck, creating the anterior and posterior flaps. Posterior flaps were excised. Bicanalicular silicone intubation was performed and both ends were tied together.
Anterior lacrimal and anterior nasal flaps were sutured with 6-0 polyglactin and anchored with the superior muscle flap. The incision site was sutured with 6-0 polyglactin subcutaneously.22,23 Repacking of the nasal cavity was done if there were chances of excessive bleeding. DCR along with fistulectomy was done in cases having a lacrimal abscess with fistula.
Postoperative systemic antibiotics and anti-inflammatory medications were used for 7 days and topical steroid and antibiotics drops were used for 15 days. Follow-up was done at 1 week, 1 month, 3 months, and 6 months. At each follow-up visit, children were assessed for skin wound and suture, tube positioning, scar size, inflammation, discharge, tear meniscus height, regurgitation, and swelling. Parents were asked about resolution of previous symptoms. Success of surgery was defined as relief of symptoms of watering. Silicon tube removal was done after 3 months under general anesthesia and sac syringing was performed at the same sitting and 6 months postoperatively to investigate the patency of the lacrimal system. Reoperation was reserved for failed cases.
Statistical analysis was performed with SPSS software (version 20; SPSS, Inc., Chicago, IL). Quantitative variables were reported as mean ± standard deviation. The chi-square test was used to assess the differences in the success and complication rates between the two groups (those who underwent incision and drainage more than twice vs once). The same test was also used to compare the success according to different age groups, gender, and laterality. P values of less than .05 were considered significant. We estimated the cumulative percentages of success and the failure rates over time with the Kaplan–Meier method.
During the study period, 926 children who were younger than 6 years presented with congenital NLDO in our outpatient clinic; of these, 253 children underwent probing with 71.54% (n = 181) success and failed cases (n = 72) underwent for repeat probing with success of 18.05% (n = 13). External DCR with intubation was done in 177 pediatric patients who were 6 to 16 years old and in 52 children who were younger than 6 years. Of these 52 children, 46 eyes of 40 children met the inclusion criteria. Six children underwent bilateral surgery. There were 27 boys and 13 girls. The mean age at surgery was 4.93 ± 0.93 years (range: 3 to 6 years). Most of the children were between 5 and 6 years old; the youngest child was 3 years old. The mean duration of follow-up was 11.80 ± 11.87 months (range: 6 to 84 months). All patients received systemic antibiotics twice or more either at our institute or elsewhere previous to DCR. Thirty of 46 eyes underwent incision and drainage of the lacrimal abscess twice, whereas the remaining 16 underwent incision and drainage once before DCR.
Demographic data of patients according to age group, gender, and laterality of eye involved with their success rate are shown in Table 1. Resolution of symptoms occurred in 38 (82.61%) eyes, including eyes requiring fistulectomy. DCR failure occurred in 8 cases with recurrence of symptoms. Of these, 6 had undergone incision and drainage of the abscess twice and the remaining two once. One patient had granuloma formation at the wound site, which was excised. Tube extrusion occurred in 3 children and the tube was repositioned. After tube removal, 1 of these 3 children had failed DCR. Sequential bilateral surgery was done in 6 cases, of which 3 cases had lacrimal fistula requiring fistulectomy. The survival curve in Figure 1 shows 79.5% of patients were free of symptoms at 84 months postoperatively. Intraoperative surgical difficulties and anatomical variations were also assessed (Table 2). Extensive fibrosis with intrasaccal adhesions were seen in the subcutaneous tissue surrounding the lacrimal sac in 28 cases, of which 21 had undergone incision and drainage of the abscess twice (P = .08). Excessive bleeding occurred in 24 cases on dissecting the fibrous tissues, which was controlled only by applying pressure with the cotton gauze. Of these, 18 had undergone incision and drainage of the abscess twice (P = .15). Thicker lacrimal bone was encountered in 6 children, but adequate osteotomy was performed.
Success Rate of DCR
Kaplan–Meier survival curve of the success of the dacryocystorhinostomy with intubation in children younger than 6 years.
The challenges in treating lacrimal sac abscess are well known. Early incision and drainage of a lacrimal sac abscess is a simple procedure that results in immediate resolution of pain and promotes rapid healing from infection. However, skin incisions can cause scarring, leading to cicatricial ectropion. These modalities may also lead to lacrimal sac cutaneous fistula and can result in recurrent infections and serious complications such as corneal ulcer, endophthalmitis, orbital cellulitis, and cavernous sinus thrombosis.7–10 The basic pathology in lacrimal abscess is NLDO. Nasolacrimal intubation is considered a second-line treatment for congenital NLDO with a higher success rate, but although it is cost-effective, it may be associated with complications such as higher dropout rate, punctal/canalicular damage, corneal abrasion, and granuloma formation.24
External DCR is an effective surgical treatment for complete NLDO in adults, wherein communication is established between the lacrimal sac and nasal mucosa, enabling the tear to flow into the middle meatus and thus bypassing the blocked duct. However, external DCR is less successful in the pediatric age group. Hakin et al.14 reported a cumulative success rate of 79% to 96% in pediatric DCR (age < 16 years) with and without intubation. A similar success rate was reported by Dave et al.15 in children up to 16 years of age. The lower success rate in the pediatric age group may be due to the changing anatomy (shallow lacrimal sac area, poorly developed anterior lacrimal crest, and anteriorly placed ethmoidal air cells), rapidly growing facial bone centers,13 and a vigorous healing process causing more inflammation, fibrosis, and hyperplastic scar, and hence blockage of common canalicular opening into the sac. Silicone tube intubation increases the success rate of the procedure in pediatric cases, which may be up to 97%.16 In the current study, because the children had lacrimal abscess recurring even after incision and drainage and frequent use of antibiotics, we chose DCR with silicon intubation. Our success rate of 82.61% is comparable with the above-mentioned studies.
In our study, congenital NLDO with lacrimal abscess was found to be more common in males than females, in contrast to other studies. Noda et al.25 and Nemet et al.26 reported no sex predilection for congenital NLDO. However, Shen et al.27 found NLDO to be more common in females. This may be due to the smaller diameter, oblique lacrimal canal, and inferior bony lacrimal fossa making it more vulnerable to obstruction. In the current study, having fewer female patients was due to the rural set-up of our center, where the population is more concerned about male children. The success was not influenced by the laterality of the eye and gender in our study, similar to the findings of Sodhi et al.17
Intraoperatively, we found excessive subcutaneous fibrosis and perisaccal adhesions with more bleeding during dissection. These complications were more prevalent in eyes that underwent incision and drainage twice, but the difference was statistically not significant. This may be attributed to the fact that recurrent inflammation and incision and drainage of the abscess causes more fibrovascular proliferation and scarring.28–30 These findings are similar to the study done by Mito et al.,31 who found squamous metaplasia, adhesion, and fibrosis in the cadaveric specimen of the inflamed lacrimal sac of elderly patients. Our study favors early DCR in such cases to avoid excessive complications intraoperatively.
In the early postoperative period (within 1 month), granuloma formation occurred in one case, which was medically managed initially and later excised because of a poor response to medical treatment. In the late postoperative period (after 1 month), tube extrusion occurred in 3 cases. These tubes were repositioned; 1 case resulted in failed DCR. Cheese wiring of the lower canaliculi was reported in one case, so early tube removal was done. The patient was free of any symptoms at the last follow-up visit. None of the patients developed a hypertrophic scar.
Being retrospective in nature, this study has inherent limitations, but we had enough cases as far as the pediatric population is concerned with good follow-up. It is difficult to compare the results of our study with those of others because this study included children with recurrent lacrimal abscess who were younger than 6 years exclusively, both of which are risk factors for failure of DCR. However, based on our findings, DCR with intubation is satisfactory in these high risk cases of lacrimal abscess. Future studies are warranted exclusively in the same age group with uncomplicated NLDO to prove its efficacy in total.
External DCR with silicone tube intubation is a safe and effective surgical approach for treating dacryocystitis with recurrent lacrimal abscess in children younger than 6 years with failed attempts on probing to avoid unnecessary frequent use of systemic and topical antibiotics and risk of serious complications.
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Success Rate of DCR
|Parameter||No. of Patients Who Had DCR||No. of Patients With DCR Failure||P|
| 3 to 4||3||0 (0%)|
| 4 to 5||12||3 (25%)|
| 5 to 6||31||5 (16.13%)|
| Total||46||8 (17.39%)|
| Male||27||5 (18.51%)|
| Female||13||3 (23.07%)|
| Total||40||8 (20%)|
| Right eye||24||4 (16.66%)|
| Left eye||22||4 (18.18%)|
| Total||46||8 (17.39%)|
|Complication||Incision & Drainage||P|
|Total (N = 46)||Twice (n = 30)||Once (n = 16)|