Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Outcome of Primary Probing for Simple Membraneous Congenital Nasolacrimal Duct Obstruction in Children Older Than 4 Years

Margaret Reynolds, MD; Gregg Lueder, MD

Abstract

Purpose:

To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction.

Methods:

The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting.

Results:

Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement.

Conclusions:

This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing.

[J Pediatr Ophthalmol Strabismus. 2020;57(1):44–47.]

Abstract

Purpose:

To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction.

Methods:

The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting.

Results:

Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement.

Conclusions:

This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing.

[J Pediatr Ophthalmol Strabismus. 2020;57(1):44–47.]

Introduction

Congenital nasolacrimal duct (NLD) obstruction is a common condition, occurring in 20% to 30% of full-term newborn infants.1,2 It resolves with medical management in approximately 90% of affected children.1,3–5 For children with NLD obstruction that does not resolve, surgical intervention is typically undertaken, which includes office probing at 6 to 12 months or probing under general anesthesia between 12 months and 9 years.6 The success rates of both procedures is high (between 77% and 97% in children younger than 18 months).4,7–10 Previous reports have suggested that the success rate of NLD probing decreases with increasing age,10–12 prompting some clinicians to suggest stent placement or other procedures at the time of initial probing in older patients.13 Other studies have reported good outcomes in older children.7,14

Kushner14 recognized the importance of distinguishing simple membranous from more complicated forms of NLD obstruction; the latter typically manifests by diffuse stenosis of the distal NLD. He reported resolution of symptoms after probing in 12 of 12 children between 18 months and 4 years old who had simple membranous obstruction.14 Although other studies have suggested similarly good outcomes of NLD probing in older children with simple membranous obstruction,7,15,16 few have included children older than 4 years. In addition, many reports have not distinguished between simple membranous obstruction and diffuse stenosis, and the outcomes cannot be differentiated by age in some reports.

The aim of the current study was to determine the success of NLD probing in a cohort of patients older than 4 years with simple membranous obstruction.

Patients and Methods

The medical records of all patients older than 4 years who were diagnosed as having simple membranous NLD obstruction and underwent surgery from January 1, 1997, to December 31, 2015, were retrospectively reviewed. The study was approved by the Institutional Review Board at Washington University School of Medicine and was compliant with the Health Insurance Portability and Accountability Act. None of the patients had previous NLD probing. Patients with diffuse stenosis of the distal NLD (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), punctal or canalicular stenosis, craniofacial abnormalities, trisomy 21, or lacrimal trauma were excluded.

The procedure for NLD probing was as follows. After induction of general anesthesia with laryngeal mask or endotracheal intubation, an oxymetazoline-soaked pledget was placed beneath the inferior turbinate. The lacrimal puncta were dilated. Successively larger Bowman's probes (sizes 00 through 2) were passed through the NLD. The inferior turbinate was infractured with a periosteal elevator. Fluid was irrigated through the puncta and recovered beneath the inferior turbinate using a suction catheter. In all patients in this study, simple membranous obstruction was present at the distal duct. A simple membranous obstruction was defined as an obstruction where a single pop was felt as the probe entered the nose.14 This was relieved with the passage of one probe, and resistance was not felt with subsequent passes of probes. Resolution of the obstruction was evidenced by feeling metal-on-metal contact with the second probe that passed into the nose, with normal irrigation following probing.

Patients were treated postoperatively with neomycin and polymyxin B sulfates and instructed to use dexamethasone ophthalmic ointment at bedtime for 1 week. Follow-up information was obtained by an office visit or via phone interview with the patient's caregivers 2 or more weeks after the procedure. A successful outcome was defined as the absence of epiphora, increased tear lake, and periocular crusting and discharge. Outcomes and need for additional surgeries were recorded.

Results

Eighteen patients 4 years or older (mean: 5.6 years; range: 4.1 to 10.6 years) were diagnosed as having simple membranous NLD obstruction during the 19-year study period and underwent NLD probing. Patients were observed for a mean of 30.36 ± 44.53 months (range: 0.21 to 177.9 months). Fifteen patients were 4 to 5 years old, 1 patient was 7 years old (86 months), 1 patient was 8 years old (104 months), and 1 patient was 10 years old (126 months) at the time of NLD probing. Sixteen of 18 patients (89%) had successful outcomes (Table 1). The two patients who had persistent symptoms were 5.9 and 8.7 years old at the time of initial probing. The first patient's symptoms resolved after balloon catheter dilation. The second patient underwent balloon catheter dilation and subsequent NLD stent placement, which resolved the symptoms.

Success Rate of Patients Older Than 4 Years Who Underwent Simple Probing for Membranous NLD Obstruction

Table 1:

Success Rate of Patients Older Than 4 Years Who Underwent Simple Probing for Membranous NLD Obstruction

Discussion

NLD obstruction is a common problem in infants. It resolves spontaneously in most children. When it persists, NLD probing is usually performed in the first year or so of life, with a high rate of success. When treatment is delayed, reported outcomes have been contradictory. Some have suggested that the success rate of surgery decreases with increased age,10–12 whereas others have found little difference.7,14 Much of this discrepancy is likely due to the type of NLD obstruction, with the outcomes for simple membranous obstruction being significantly better than those with diffuse stenosis. This distinction has not been consistently reported. Few studies have included children older than 4 years and few children are reported in these studies.

In 1994, Paul and Shepherd11 reviewed the literature on NLD obstruction in children younger than 4 years and reported that probe failure increased with age, doubling every 6 months. They hypothesized that the decreased success rate was caused by diffuse stenosis in older children, which prompted some surgeons to perform additional procedures, such as stent placement, at the time of initial NLD probing in older patients. Kushner14 recognized the importance of distinguishing simple membranous obstruction from diffuse stenosis. He reported that 16 of 23 children older than 18 months had resolution of symptoms after one probing. Twelve of 12 children (100%) with simple membranous obstruction had resolution versus 36% (4 of 11) of children with diffuse stenosis. Of note, none of Kushner's patients were older than 4 years.14

A review of the literature found 7 studies on NLD probing that included children older than 4 years (Table 2). Of these studies, three did not distinguish between simple membranous obstruction and diffuse stenosis,8,16,17 and two had data that could not be differentiated according to age.7,8

Summary of Studies Including Simple NLD Obstruction in Children Older Than 4 Years

Table 2:

Summary of Studies Including Simple NLD Obstruction in Children Older Than 4 Years

Analysis of the outcomes of children older than 4 years supports Kushner14 and Paul and Shepherd's11 hypotheses regarding the importance of the type of NLD obstruction. Honavar et al.15 found that success correlated with age when all types of NLD obstruction were included. With NLD probing, approximately 100% of patients younger than 3 years had resolution, which dropped to 75% resolution in patients between 3 and 4 years and 43% resolution in patients older than 4 years (6 of 14 patients). Among all of their patients, when only simple membranous obstructions were included (similar to our study), 9 of 10 patients had resolution of symptoms after one probing. When including patients older than 48 months, 5 of 6 patients with simple membranous obstruction had resolution of symptoms after one or two probings, but the authors did not report how many patients required two probings. Al-Faky et al.16 included patients older than 4 years. Seven of 9 patients older than 48 months had resolution with probing. Like Honavar et al.,15 Al-Faky et al. found that 2 of 7 (29%) patients younger than 12 months with “tight” obstructions had resolution after probing versus 149 of 181 of all patients older than 12 months with simple membranous obstructions (82%).16 Finally, Kashkouli et al.17 reported that 3 of 7 patients older than 4 years with diffuse stenosis had resolution in 1 of 3 patients after simple probing.

Other studies have reported differing outcomes of patients older than 48 months without discussing the nature of the obstruction (ie, simple membranous obstruction versus diffuse stenosis). Of 27 patients older than 48 months described by Arora et al.,18 12 (71%) had symptom resolution with one probing alone, but the authors did not differentiate between simple membranous obstruction and diffuse stenosis.

Robb7 also found a 90% and higher success rate for simple NLD obstruction resolution after probing in 27 patients between 3 and 9.3 years old. This study included 280 patients older than 12 months who underwent probing. The oldest subgroup of patients was between 3 and 9.3 years, with a mean and median age of 4.4 and 3.7 years, respectively. A subset analysis for patients older than 4 years was not included.7

Ciftçi et al.8 reported a 69% success rate in patients between 25 and 72 months. Thirty-six eyes of 31 patients were included in this group, with a mean age of 37.2 ± 12 months. Further analysis according to children older than 4 years was not specified. Simple membranous obstruction versus diffuse stenosis were also not differentiated.

Finally, Rajabi et al.13 used a study design similar to the current study. They reviewed 28 patients older than 4 years. Similar to our study, they excluded patients with craniofacial abnormalities, facial deformities, Down syndrome, and history of trauma to the orbit or nose. Unlike our study, only 50% of patients had resolution of symptoms with probing. They excluded patients in whom the probe could not be advanced easily through the NLD and patients with canalicular obstruction. However, it is possible that some patients who were included in their study would have been excluded based on our criteria.13

Limitations of our study include the small number of patients and its retrospective nature. Additionally, the procedure included infracture of the inferior turbinate in all patients, and it is unknown whether this procedure contributes to success.

There are few published reports on the results of NLD probing in children older than 4 years. We found 89% of children with simple membranous NLD obstruction had resolution of symptoms with probing, an outcome similar to the youngest age groups studied. Therefore, for children 4 years or older with simple membranous NLD obstruction, probing alone is an appropriate choice for treatment, with a high likelihood of success. For older children with diffuse stenosis, balloon catheter dilation or placement of NLD stents should be considered.

References

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  6. Lee KA, Chandler DL, Repka MX, et al. PEDIG. A comparison of treatment approaches for bilateral congenital nasolacrimal duct obstruction. Am J Ophthalmol. 2013;156(5):1045–1050. doi:10.1016/j.ajo.2013.06.014 [CrossRef]
  7. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology. 1998;105(7):1307–1309. doi:10.1016/S0161-6420(98)97038-5 [CrossRef]
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  13. Rajabi MT, Abrishami Y, Hosseini SS, Tabatabaee SZ, Rajabi MB, Hurwitz JJ. Success rate of late primary probing in congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus. 2014;51(6):360–362. doi:10.3928/01913913-20140909-02 [CrossRef]
  14. Kushner BJ. The management of nasolacrimal duct obstruction in children between 18 months and 4 years old. J AAPOS. 1998;2(1):57–60. doi:10.1016/S1091-8531(98)90112-4 [CrossRef]
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Success Rate of Patients Older Than 4 Years Who Underwent Simple Probing for Membranous NLD Obstruction

Age GroupNo. of PatientsSuccessful Resolution After One Probing
4 to 5 years (range: 48 to 71 months)1514 of 15
6 to 7 years (range: 72 to 95 months)11 of 1
8 to 9 years (range: 96 to 121 months)10 of 1
10 to 11 years (range: 122 to 143 months)11 of 1

Summary of Studies Including Simple NLD Obstruction in Children Older Than 4 Years

StudyPatient Age (> 48 Months)SimpleComplicatedResolution After One Probing
Honavar et al.1514686 of 14 (42.9%)a
Rajabi et al.132828014 of 28 (50%)
Arora et al.1827UnknownUnknown12 of 27 (70.5%)
Al-Faky et al.16b9UnknownUnknown7 of 9 (77.8%)
Robb73 to 9.3 yearsc (n = 27)27025 of 27 (92.6%)
Ciftçi et al.825 to 72 (n = 36)UnknownUnknown25 of 36 (69.4%)
Kashkouli et al.17743d
Current study1818016 of 18 (89.9%)
Authors

From the Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Missouri.

Supported by an unrestricted grant from Research to Prevent Blindness, New York, NY.

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

Correspondence: Gregg Lueder, MD, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail: lueder@wustl.edu

Received: September 05, 2019
Accepted: November 18, 2019

10.3928/01913913-20191125-01

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