Primary Monocanalicular Stent Intubation for Children With Congenital Nasolacrimal Duct Obstruction: Surgical Outcome and Risk Factors

Abstract

To determine the risk factors impacting the surgical success of primary monocanalicular stent intubation for congenital nasolacrimal duct obstruction (CNLDO).Methods: This is a retrospective interventional case series of patients 18 years and younger treated more than a 12-year period with monocanalicular stent intubation with inferior turbinate fracture for CNLDO by a single surgeon. Patients with dacryocystoceles, dacryocystitis, Down syndrome and previous tear duct surgery were excluded. An intraoperative grading scale of tear duct stenosis, date of stent removal, stent length, and postoperative symptoms were recorded. Surgical success was defined as the complete resolution of symptoms.Results: One thousand four hundred sixty-nine stents were placed in 1,001 pediatric participants (533 unilateral, 468 bilateral). The mean age at surgery was 1.86 years (0.1-18.07). The mean follow up was 34.99 months (0.43-134.3) with mean in-office stent removal at 3.41 months (0.63-36.9). Early stent loss occurred in 14.8% intubations (217/1,469). The overall success rate was 92.4% (1,357/1,469 eyes). Subjects less than the age of 4 years had a success rate of 92.8% (1,296/1,397) compared with 84.7% (61/72) in children more than 4. In multivariable analysis, bilateral surgery, severe tear duct stenosis, and early stent loss were significantly associated with higher risk of surgical failure.Conclusions: Severe tear duct stenosis, early stent loss, and bilateral surgery were significant risk factors for surgical failure. While the success rate stratified by age at surgery suggested a lower success after the age of 4. Primary monocanalicular stent intubation is an effective and safe treatment for CNLDO sparing a child the need for multiple staged surgeries.

Re: Pupil Abnormalities in Orbital Cavernomas: The Pupil Matters Both Preoperatively and Postoperatively

“…Nevertheless, the overall success rate of 92.4% (1,357/1,469 eyes) in our non-Down syndrome series with a complication rate of 0.4% and the success of 57.1% in the current Down syndrome series is a strong argument that primary stent placement in membranous and stenotic nasolacrimal duct obstructions is a worthy treatment when appropriately chose. 1,4 In conclusion, we agree with the authors' comments on our study, emphasizing the importance for a lacrimal surgeon to be prepared to perform all lacrimal procedures as necessary for both congenital and acquired nasolacrimal duct obstruction. These options should be thoroughly discussed with the families in advance.…”

Re: “Outcome of Primary Monocanalicular Stent Placement in Pediatric Down Syndrome Patients with Congenital Nasolacrimal Obstruction”

“…We read with great interest the article by Landau Prat et al 1 entitled “Outcome of Primary Monocanalicular Stent Placement in Pediatric Down Syndrome Patients with Congenital Nasolacrimal Obstruction.” The authors retrospectively compared the results of primary monocanalicular intubation for congenital nasolacrimal duct obstruction (CNLDO) in patients with and without Down syndrome (DS). They 1,2 follow the “age-based approach” in which the type of procedure is preoperatively determined based on the patient’s age and previously failed procedures and consists of probing and irrigation, followed by monocanalicular stenting, balloon dacryoplasty, or dacryocystorhinostomy for failed procedures. Because of the high failure rate of almost 70% 3 for probing and irrigation in DS-associated CNLDO, they advocate primary monocanalicular stent placement as a first-line treatment.…”

“…4–6 This led us to the concept of an “obstruction-based approach,” in which all surgical options are on the table (all procedures for one) and the procedure of choice is determined intra- rather than preoperatively based on each patient’s type of CNLDO. 4,5 While the success rate of one procedure for all 1–3 is significantly different in children with different types of obstruction, the success rate of all procedures for one 5 was not different simply because each type of CNLDO receives the procedure of choice based on the intraoperative type of obstruction. Furthermore, such an obstruction-based one-stage surgical approach to any type of CNLDO (including DS) avoids unnecessary failure of simple probing in patients with complex CNLDO, avoids unnecessary invasive procedures (intubation, ballooning, or dacryocystorhinostomy) for membranous CNLDO, avoids re-treatment sessions and repeat anesthesia, and therefore is more cost-effective.…”

Reply Re: “Outcome of Primary Monocanalicular Stent Placement in Pediatric Down Syndrome Patients With Congenital Nasolacrimal Obstruction”

“…Nevertheless, the overall success rate of 92.4% (1,357/1,469 eyes) in our non-Down syndrome series with a complication rate of 0.4% and the success of 57.1% in the current Down syndrome series is a strong argument that primary stent placement in membranous and stenotic nasolacrimal duct obstructions is a worthy treatment when appropriately chose. 1,4…”