Nasolacrimal duct obstruction is a common problem for the pediatric population. In fact, 6% of all children experience symptoms of tearing and recurrent infections. Ultimately, symptoms are resolved in 80% to 90% of children through conservative measures using massage and medical therapy. Approximately 10% of children fail to have symptom resolution and may require surgery. Various surgical options are available for treatment, but a probing and irrigation procedure is the most widely accepted first-line initial procedure.1,2 However, some patients fail to have symptom resolution after a probing and irrigation procedure and require additional and more invasive procedures to correct the problem. This poses the question: are there common factors in these patients that may have predicted whether the child was at a higher risk for initial surgical failure? If factors can be identified, a more invasive first-line surgery can be considered to increase the initial surgical success rate or prepare parents and patients for the potential need for additional surgery. Previously, predictors for failure were studied but no risk factors were found to be statistically significant in most cases.3–5 We studied possible associated patient anatomic or physiologic factors for initial failure.
Patients and Methods
A retrospective chart review was conducted at Children's Hospital and Medical Center and the University of Nebraska Medical Center in Omaha. One hundred ninety-four patients who underwent surgical management of a nasolacrimal duct obstruction between January 2015 and August 2018 were identified. The diagnosis of nasolacrimal duct obstruction necessitating surgical correction was based on symptoms of epiphora and discharge refractory to medical management and ductal massage. A physical examination with the slit lamp and/or dye disappearance test using a fluorescein strip confirmed these signs. The patient's medical history and eye examination were completed during the patient's first visit to assess anatomical abnormalities or other ocular pathologies.
A single pediatric ophthalmologist (DS) examined all identified patients and assessed the need for surgical intervention. The primary surgical procedures used to treat the symptoms were probing and irrigation, balloon dilation, and stenting procedure. After surgery, all patients were treated with a 14-day course of fluoroquinolone eye drops. Failure and success rates were based on the resolution of symptoms at follow-up or the history of previous surgeries. Parents and patients were called by clinical staff after the surgery, followed up in an eye clinic, and instructed to contact the eye clinic if symptoms returned. Being symptom free for 6 months was deemed a successful surgery as per standard current practice. The protocol was approved by the University of Nebraska Medical Center's institutional review board and the study was carried out in accordance with the principles of the Declaration of Helsinki. Because this study was a retrospective chart review, the requirement for consent was waived.
One hundred ninety-four patients were identified, but 16 of those patients were excluded from the study due to recent facial trauma resulting in ductal obstruction, a history of head and neck radiation, unobtainable initial surgical records, or symptoms that started in adolescence. Of the remaining 178 patients, 140 patients had one surgical procedure, whereas the remaining 38 required two or more surgical procedures for successful treatment. Overall, our first-time surgical success rate for the participating patients was at least 82%. The medical records of the 178 participating patients in these two groups were analyzed and compared for 8 different patient-specific factors that may contribute to the need for multiple surgeries. The patient ages varied from 2 months to 13 years at the time of surgery, with all initial surgeries before age 13 years. Of the patients, 95 (53%) were female and 83 (47%) were male. The remaining factors studied were selected based on anatomic location/development or physiologic processes occurring near the nasolacrimal system.
All 178 patients were divided into two groups based on the need for multiple surgeries versus a single surgery. The authors considered this a reasonable comparison because factors independent of the type of surgery may predispose patients to have an unsuccessful procedure.
The results of analyzed risk factors from all patients with successful initial surgeries compared to those who required multiple surgeries are presented in Figure 1. This included all 178 patients who underwent any form of nasolacrimal duct obstruction surgery, such as probing and irrigation, balloon dilation, or stenting procedures, as their first surgical treatment. Risk factors examined for surgical failure included genetic abnormalities that may play a role in anatomy development, obstructive sleep apnea due to hypertrophy within the nasopharynx, concomitant strabismus surgery, having upper respiratory tract infection symptoms within 1 month prior to surgery, prior diagnosis of allergic rhinitis/seasonal allergies, history of adenoidectomy, history of myringotomy with ear tube placement, and premature birth defined as younger than 37 weeks' gestational age.
Odds ratios of patient risk factors that required multiple surgeries were compared to those with the same factors only requiring one surgery to calculate the odds ratio. Odds ratios with P < .05 at a 95% confidence interval are marked with an asterisk (*). URI = upper respiratory tract infection; OSA = obstructive sleep apnea
Of these factors, the statistically significant findings are as follows: trisomy 21 with an odds ratio of 3.09 (P = .0495), prior diagnosis of allergic rhinitis/seasonal allergies with an odds ratio of 3.13 (P =.025), history of an upper respiratory tract infection within 1 month with an odds ratio of 3.88 (P =.010), and a prior diagnosis of obstructive sleep apnea with an odds ratio of 5.15 (P = .019). Although the history of myringotomy was not a significant factor, a history of multiple myringotomy procedures was significant, with an odds ratio of 30.67 (P = .007). The odds ratios for the remaining patient factors were 2.31, 0.73, and 2.10 for muscle surgery, adenoidectomy, and premature birth, respectively. Of note, the average time interval between surgical interventions in those with multiple surgeries was 9.7 months.
The current management of nasolacrimal duct obstruction consists first of conservative management with observation, digital massage, and a trial of antibiotics.1,2 If the patient continues to have symptoms, a probing and irrigation procedure with or without anesthesia is typically the first-line treatment.1 Although this first-line treatment has a 75% to 90% success rate, there is insufficient data for why this treatment fails to work for certain patients.2 This retrospective study investigated common factors that were present preoperatively among patients who had unsuccessful first surgeries to determine if there is a better way to predict which patients are at higher risk for failure. The risk factors selected for statistical analysis were based on prevalence within the patient population and logical estimation based on current medical knowledge of anatomy and physiology.
Factors found to be correlated with patients who required a repeat surgical intervention were presence of trisomy 21, a prior diagnosis of allergic rhinitis/seasonal allergies, and a history of an upper respiratory tract infection within the past month. This finding would suggest that patients who have trisomy 21 may benefit from having a balloon dilation procedure as their initial surgical intervention rather than a probing and irrigation procedure, because the failure rate is higher with the simple probing and irrigation. A prior diagnosis of allergic rhinitis/seasonal allergies may benefit from treating the condition prior to surgery, due to this higher success rate. Having an upper respiratory tract infection prior to surgery showed an increased risk. Therefore, due to the elective nature of surgical intervention, it may be beneficial to postpone surgery for these patients until they are fully recovered.
Other factors that were initially examined as plausible risk factors but proved to have no significant increased risk of repeat surgical intervention were premature birth and concomitant extraocular muscle surgery during the same time as the nasolacrimal duct obstruction surgery. However, only 4 patients underwent concomitant strabismus surgery. The data showed this factor had an odds ratio of 4.81 but a P value of .09. We were not able to make a definitive conclusion due to the limited number of patients in this group.
A patient's initial surgery was deemed appropriate for the level of symptoms by a surgeon based on his anecdotal experience. This is a valuable comparison because many clinicians practice in this manner, and previous research suggests that balloon dilation and stenting procedures, although more invasive, should have a high rate of success in patients with mild disease.1,6,7 Limitations of our study include relatively small population sizes and lack of standardization of nasolacrimal duct obstructions among the various clinicians prior to referral. A large standardized, prospective, randomized study would be beneficial to address these limitations.
Our study suggests that patients who have trisomy 21 or a history of recent upper respiratory tract infection may be correlated with a higher risk of failure with initial probing and irrigation surgery. Patients with trisomy 21 may benefit from an initial balloon dilation procedure due to a similar risk profile as patients without trisomy 21. Furthermore, patients with a recent upper respiratory tract infection may benefit from postponing surgery until the symptoms are resolved.
- Lueder GT. Nasolacrimal duct obstruction in children. American Academy of Ophthalmology Web site. https://www.aao.org/disease-review/nasolacrimal-duct-obstruction-4. Accessed November 9, 2017.
- Takahashi Y, Kakizaki H, Chan WO, Selva D. Management of congenital nasolacrimal duct obstruction. Acta Ophthalmol. 2009;88:506–513. doi:10.1111/j.1755-3768.2009.01592.x [CrossRef]
- Clark RA. Dilation probing as primary treatment for congenital nasolacrimal duct obstruction. J AAPOS. 2002;6:364–367. doi:10.1067/mpa.2002.128210 [CrossRef]
- Robb RM. Dilation probing as primary treatment for congenital nasolacrimal duct obstruction. Ophthalmology. 1998;105:1307–1310. doi:10.1016/S0161-6420(98)97038-5 [CrossRef]
- Honavar SG, Prakash VE, Rao GN. Outcome of probing for congenital nasolacrimal duct obstruction in older children. Am J Ophthalmol. 2000;130:42–48. doi:10.1016/S0002-9394(00)00388-3 [CrossRef]
- Repka MX, Chandler DL, Holmes JM, et al. Pediatric Eye Disease Investigator Group. Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing. Arch Ophthalmol. 2009;127:633. doi:10.1001/archophthalmol.2009.66 [CrossRef]
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