Probing for congenital nasolacrimal duct obstruction

Abstract

Background Congenital nasolacrimal duct obstruction (NLDO) is a common condition causing excessive tearing in the first year of life. Infants present with excessive tearing or mucoid discharge from the eyes due to blockage of the nasolacrimal duct system, which can result in maceration of the skin of the eyelids and local infections, such as conjunctivitis, that may require antibiotics. The incidence of nasolacrimal duct obstruction in early childhood ranges from 5% to 20% and often resolves without surgery. Treatment options for this condition are either conservative therapy, including observation (or deferred probing), massage of the lacrimal sac and antibiotics, or probing the nasolacrimal duct to open the membranous obstruction at the distal nasolacrimal duct. Probing may be performed without anesthesia in the office setting or under general anesthesia in the operating room. Probing may serve to resolve the symptoms by opening the membranous obstruction; however, it may not be successful if the obstruction is due to a bony protrusion of the inferior turbinate into the nasolacrimal duct or when the duct is edematous (swollen) due to infection such as dacryocystitis. Additionally, potential complications with probing include creation of a false passage and injury to the nasolacrimal duct, canaliculi and puncta, bleeding, laryngospasm, or aspiration. Objectives To assess the effects of probing for congenital nasolacrimal duct obstruction. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2016, Issue 8); MEDLINE Ovid (1946 to 30 August 2016); Embase.com (1947 to 30 August 2016); PubMed (1948 to 30 August 2016); LILACS (Latin American and Caribbean Health Sciences Literature Database; 1982 to 30 August 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), last searched 14 August 2014; ClinicalTrials.gov (www.clinicaltrials.gov), searched 30 August 2016; and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), searched 30 August 2016. We did not use any date or language restrictions in the electronic searches for trials. Selection criteria We included randomized controlled trials (RCTs) that compared probing (office-based or hospital-based under general anesthesia) versus no (or deferred) probing or other interventions (observation alone, antibiotic drops only, or antibiotic drops plus massage of the nasolacrimal duct). We did not include studies that compared different probing techniques or probing compared with other surgical procedures. We included studies in children aged three weeks to four years who may have presented with tearing and conjunctivitis. Data collection and analysis Two review authors independently screened studies for inclusion and independently extracted data and assessed risk of bias for the included studies. We analyzed data using Review Manager software and evaluated the certainty of the evidence using GRADE. Main...

Congenital Nasolacrimal Duct Obstruction (CNLDO): A Review

“…Probing of the nasolacrimal system is traditionally the most commonly adopted surgical procedure in the management of CLNDO [39,40,41,42]. This procedure, which requires passing a probe down to the distal portion of the nasolacrimal system in order to break the obstruction, may be performed either in office with only the administration of local anesthetics or in the operating room in a surgical facility with general anesthesia [9]. In recent years, two different philosophies have been debating about the optimal timing of intervention; the first one suggests an early primary probing (6–9 months) because even if it is technically more challenging to manage an awake and often crying child, it would allow for avoiding the risks of general anesthesia and, according to some authors, the potential development of fibrosis due to the prolonged chronic inflammation of the NLD [20,23,43].…”

“…In this regard, the authors found that early probing reduced overall symptoms of 3 months and was slightly more cost-effective in comparison with the deferred procedure; however, the possibility of resolving CLNDO in two thirds of the patients with only simple observation should be carefully taken into consideration [29]. In fact, probing is an invasive and blind procedure, which is not free from complications such as bleeding, damage of the nasolacrimal system and of the adjacent structures and inflammation with subsequent NLD fibrosis [9]. Young et al reported bleeding from the lacrimal punctum during the procedure in 20% of patients caused by the formation of a false passage [22].…”

“…The clinical presentation of the disease is mostly characterized by excessive tearing and ocular mattering. Distal obstruction at the Hasner valve is more likely to cause a mucopurulent discharge, whereas, when obstruction is near the nasolacrimal sac, (valve of Rosenmueller), it is more frequently related to a watery discharge [8,9]. While usually unilateral, CNLDO occurs bilaterally in 20% of cases [8].…”

“…Several studies have shown that CLNDO tends to naturally and spontaneously resolve itself within the first year of life in most cases [15,16,17,18,19]; however, in some cases, this disorder may persist beyond the first year of life, and for this reason, more practical guidelines for the management of CLNDO are needed. In fact, many ophthalmologists agree with a conservative approach as a first-line strategy, whereas a remarkable counterpart debate the primary importance of an early probing, the most common invasive approach treating CLNDO [9,20]. Thus, the aim of this study is to describe two different schools of thought in the management of this disorder and to better understand the role of medical and the surgical treatments, with a focus on the modality and timing of interventions.…”

Lacrimal sac bacteriology and susceptibility pattern in infants with congenital nasolacrimal duct obstruction in the 1st year of life: a cross-sectional study

“…If conservative therapy is ineffective, lacrimal duct probing would be advocated. Though controversy exists for the best timing for lacrimal probing [ 3 , 4 ], conservative treatment in the first year of life was generally recommended due the high spontaneous recovery rate of CNLDO [ 2 , 5 , 6 ].…”