Nasolacrimal Duct Obstruction, Congenital
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Nasolacrimal duct obstruction is a blockage of the lacrimal drainage system. In children the majority of nasolacrimal duct obstruction is congenital.
Congenital nasolacrimal duct obstruction occurs in approximately 5% of normal newborn infants. The blockage occurs most commonly at the valve of Hasner at the distal end of the duct. There is no sex predilection and no genetic predisposition. The blockage can be unilateral or bilateral. The rate of spontaneous resolution is estimated to be 90% within the first year of life.1,2,3
The etiology of congenital nasolacrimal duct obstruction is most commonly a membranous obstruction at the valve of Hasner at the distal end of the nasolacrimal duct. General stenosis of the duct is the second most common cause of duct obstruction. Congenital proximal lacrimal outflow dysgenesis involves maldevelopment of the punctum and canaliculus. Proximal outflow dysgenesis can occur concurrently with distal obstruction. Congenital lacrimal sac mucocele or dacryocystocele occurs when there is a membranous cyst extending from the distal end of the duct into the nose. The nasolacrimal duct sac is filled at birth with clear amniotic fluid. The fluid becomes purulent within days of birth and neonatal dacryocystitis occurs
. Acquired nasolacrimal duct or canalicular obstructions can occur following trauma, viral conjunctivitis, acute dacryocystitis, and use of topical antiviral medications.
Children with Down syndrome, craniosynostosis, Goldenhar sequence, clefting syndromes, hemifacial microsomia, or any midline facial anomaly are at an increased risk for congenital nasolacrimal duct obstruction.
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A history of tearing, mucous discharge and epiphora of one or both eyes is typical. The periocular skin may be chapped from continual exposure to tears. Regurgitation of purulent material into the eye can cause conjunctivitis and a history of recurrent "pink eye" in an infant or young child should alert the investigator to the presence of nasolacrimal duct obstruction. The signs and symptoms are usually worse with a concurrent upper respiratory infection. An associated preseptal cellulitis is rare.
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The signs of nasolacrimal duct obstruction consist of an increased tear lake, mucous or mucopurulent discharge, and epiphora. The periocular skin is sometimes chapped. The globe is usually white. When pressure is applied over the lacrimal sac there is a reflux of mucoid or mucopurulent material from the punctum. Add text here
The signs of nasolacrimal duct obstruction consist of an increased tear lake, mucous or mucopurulent discharge, and epiphora. The periocular skin is sometimes chapped. The globe is usually white. When pressure is applied over the lacrimal sac there is a reflux of mucoid or mucopurulent material from the punctum. Proximal lacrimal outflow blockage or dysgenesis tends to present with an increased tear lake and epiphora without mattering.
A congenital lacrimal sac mucocele presents as an initially clear bluish mass overlying the lacrimal sac. When the mucocele becomes infected and dacryocystitis occurs, there is swelling and erythema over the lacrimal sac with a palpable mass. The mass can sometimes be decompressed with digital pressure resulting in an egress of purulent material through the lacrimal puncta. If the dacryocystitis is severe, rupture of the abscessed sac through skin can occur. Add text here
A fluoroscein dye disappearance test can be helpful in confirming the diagnosis of nasolacrimal duct obstruction. 4 A drop of fluoroscein is instilled into the eyes or introduced on a moistened pledget. The disappearance of dye from the tear film after 5 minutes is observed. Retained dye in a thickened tear strip is diagnostic of an obstruction. The test is most useful if the disease is unilateral and the findings of the affected eye can be compared to those of the normal eye.
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The differential diagnosis of nasolacrimal duct obstruction includes acute conjunctivitis, glaucoma, congenital anomalies of the upper lacrimal drainage system (punctal or canalicular atresia or agenesis), entropion and triachiasis Add text here
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Treatment of congenital lacrimal duct obstruction consists of initial observation for resolution followed by probing of children with persistent duct obstruction. Probing failures are treated with more aggressive surgical procedures including balloon dacryoplasty and nasolacrimal duct intubation. Endoscopic dacryocystorhinostomy is generally reserved for intubation and balloon dacryoplasty failures. Add text here
Medical management of nasolacrimal duct obstruction consists primarily of observation, lacrimal massage, and treatment with topical antibiotics. The efficacy of lacrimal massage in relieving duct obstruction is not well established. Kushner reported that lacrimal massage performed with occlusion of the common canaliculus and firm downward pressure on the lacrimal sac was more effective than gentle lacrimal massage or no massage.5 Dacryocystitis in association with neonatal nasolacrimal duct obstruction should be treated with systemic antibiotics and urgent probing of the nasolacrimal duct with attention to the probablen need to marsupialize the membranous cyst at the distal end of the duct.
Medical follow up
Primary care doctors are usually the first medical providers to treat nasolacrimal duct obstruction. Frequently infants are referred to the ophthalmologist for surgical treatment only after a period of nonresolution. The age of the infant at referral depends on the preference of the primary care physician and also on his knowledge of the surgical practice of the ophthalmologist in regard to nasolacrimal duct probing. An ophthalmologist who performs in office probing procedures will often offer probing to families of infants 6 months or older. In contrast, the ophthalmologist who performs probings under general anesthesia or conscious sedation might wait until the infant is older because of the reluctance of families to have their infant "put to sleep." Add text here
Primary treatment of nasolacrimal duct obstruction consists of NASOLACRIMAL DUCT PROBING. In this procedure a probe ranging in size from 0.70 to 1.10 mm in diameter is passed through either the upper or lower punctum following dilation of the punctum. The probe is advance along the canaliculus while exerting gentle lateral traction on the lid until it reaches the nasal bone. Then the probe is rotated 90 degrees and gently introduced into the nasolacrimal duct and advanced into the nose.
During probing a gritty feeling can be felt along a stenotic duct and if there is a distal membrane, a distinct "pop" can be felt as the membrane is breached. Nasolacrimal duct patency can be confirmed several ways: 1) the distal end of the probe in the nose can be palpated with another probe 2) a small bolus of saline can be irrigated through the duct. If the infant is awake, the bolus will illicit a swallowing reflex. If the child is anesthetized the saline (colored with fluoroscein typically) can be aspirated with suction. 3) the end of the probe can sometimes be directly observed. Studies of primary surgical management have found probing to be successful in 70%–97% of cases, with many reports around 90%.6-11 The success of simple probing declines slightly with the increasing age of the child. Several investigators have reported a drop off in probing success rate with increased age, generally after 24 to 36 months.12-15 A prospective observational study of primary nasolacrimal duct probing in infants 6 to 60 months of age by the Pediatric Eye Disease Investigator Group showed an overall success rate of 78% with no decline in the efficacy of simple nasolacrimal duct probing through 36 months of age.16 Robb has reported > 90% success rates with initial probing beyond 36 months of age.17 The success of simple probing is less for bilateral obstructions. Complex obstructions in the proximal part of the duct have a poorer success rate following probing than simple membranous obstructions at the end of the duct. The location of nasolacrimal duct probing- in office versus in a facility under sedation has been controversial with some physicians strongly advocating in office probing for its ease of performance and avoidance of general anesthesia. Others tout the small but significant risk of aspiration during the in-office procedure and state that, since in-office probing is generally performed in children less than 12 months of age, children who would resolve spontaneously are treated unnecessarily. In its observational series, the PEDIG investigators found a slightly decreased success rate for in office (72%) as compared to in facility (80%) probings in children less than 12 months of age.16 Repeat nasolacrimal duct probing is generally not a successful procedure with reported success rates of 40-60%.14,18,19
NASOLACRIMAL DUCT STENT INSERTION is used as a primary procedure or following failure of simple probing. The procedure involves nasolacrimal duct probing followed by the passage of a nasolacrimal duct probe that has a stent swedged to one end. Bicanalicular stents have two probes with an intervening stent. One probe is passed through the upper punctum and the other through the lower punctum. The probes are removed and the free ends of the stent are tied in the nose and sometimes secured with a suture. Monocanalicular stents have a plug that is seated at the upper or lower puntum while the stent hangs freely in the nose. The success of nasolacrimal duct stent insertion as a primary procedure is estimated to be between 79 to 96%.20-23 There is no difference in success rate for primary stent insertions between monocanalicular and bicanalicular stents.23 Stents are left in place for a variable period time. Migliori and Putterman had 100% resolution in 38 patients whose stents were removed at 6 weeks.27 PEDIG investigators found a deceased success rate for stent removed less than 2 months after insertion.36 Nasolacrimal duct stent insertion is often performed following a failed probing procedure with reported success rates of 66-100%.24-35 In a prospective observational study of 88 eyes undergoing stent insertion following failed probing, PEDIG found a success rate of 84% in relieving all three clinical signs of duct obstruction: epiphora, mucous discharge and increased tear lake.36
BALLOON CATHETER DILATION is used as a primary procedure or following failure of a simple probing. Standard nasolacrimal duct probing is followed by the introduction of a LacriCath balloon catheter (Atrion Medical, Birmingham, Alabama) into the duct. The balloon is inflated according to the manufacturer's specifications and withdrawn. Success of balloon catheter dilation as a primary or secondary procedure has been estimated between 53 and 95%.37-41 A retrospective comparison between balloon catheter dilation and simple probing as a primary procedure for treatment of nasolacrimal duct obstruction showed no treatment advantage for balloon catheter dilation.42
NASAL ENDOSCOPY is sometimes used in conjunction with probing, stent insertion and balloon catheter dilation in the treatment of nasolacrimal duct obstruction. It is also used in the treatment of congenital dacryocystoceles to identify and marsupialize the intranasal cyst.
Surgical follow up
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1. Paul TO. Medical management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol and Strabismus. 1985; 22:68-70. 2. Nelson, LB, Calhoun, JH, Menduke, H. Medical management of congenital nasolacrimal duct obstruction.Ophthalmology. 1985; 92:1187-1190. 3. Petersen, RA, Robb, RM. The natural history of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol and Strabismus. 1978; 15:246-250. 4. MacEwen, CJ, Young, JDH. The fluorescein disappearance test (FDT): an evaluation of its use in infants. J Pediatr Ophthalmol and Strabismus. 1991; 28:302-305. 5. Kushner, Burton J. Congenital Nasolacrimal System Obstruction. Arch Ophthalmol. 1982;100:597-600.6. Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology 1998;105:1307–9.
7. Ciftci F, Akman A, Sonmez M, et al. Systematic, combinedtreatment approach to nasolacrimal duct obstruction in
different age groups. Eur J Ophthalmol 2000;10:324 –9. 8. Casady DR, Meyer DR, Simon JW, et al. Stepwise treatment
paradigm for congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg 2006;22:243–7. 9. Baker JD. Treatment of congenital nasolacrimal system obstruction. J Pediatr Ophthalmol Strabismus 1985;22:34–6. 10. Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987;94:698 –705. 11. Stager D, Baker JD, Frey T, et al. Office probing of congenital nasolacrimal duct obstruction.Ophthalmic Surg 1992;23:482–4. 12.Kashkouli MB, Beigi B, Parvaresh MM, Kassaee A, Tabatabaee Z. Late and very late initial probing for congenital nasolacrimal duct obstruction: What is the cause of failure? Br J Ophthalmol 2003;87:1151-3. 13. Honavar,SG, Prakash, VE, Rao, GN. Outcome of Probing for Congenital Nasolacrimal Duct Obstruction in Older Children. Am J Ophthalmol 2000;130:42–48. 14. Katowitz, JA, Welsh, MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology. 1987; 94:698-705. 15. Mannor, GE, Rose, GE, Frimpong-Ansah, K, Ezra, E. Factors affecting the success of nasolacrimal duct probing fro congenital nasolacrimal duct obstruction. Am J Ophthalmol. 1999;127:616-617. 16. Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years. Ophthalmology. 2008;115:577–584.17. Robb, Richard. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology. 1998; 105:1307-1310.
18. Pediatric Eye Disease Investigator Group. Repeat probing for treatment of persistent nasolacrimal duct obstruction. J AAPOS. 2009;13:306-307.
19. Stager, D, Baker, JD, Frey, T, Weakley, DR, Birch, EE. Office probing of congenital nasolacrimal duct obstruction. Ophthalmic Surgery. 1992;23: 482-484
20. Lim CS, Martin F, Beckenham T, Cumming RG. Nasolacrimal duct obstruction in children: Outcome of intubation. J AAPOS 2004;8:466-72.
21. Kaufman LM, Guay-Bhatia LA. Monocanalicular intubation with Monoka tubes for the treatment of congenital nasolacrimal duct obstruction. Ophthalmology 1998;105:336-41.
22. Engel JM, Hichie-Schmidt C, Khammar A, Ostfeld BM, Vyas A, Ticho BH. Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction. J AAPOS 2007;11:183-6.
23. Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age. J AAPOS. 2008;12:445-450.
24. Dortzbach RK, France TD, Kushner BJ, Gonnering RS. Silicone intubation for obstruction of the
nasolacrimal duct in children. Am J Ophthalmol 1982;94:585–90. [PubMed: 7148939]
25. Pashby RC, Rathbun JE. Silicone tube intubation of the lacrimal drainage system. Arch Ophthalmol
1979;97:1318–22. [PubMed: 454271]
26. Durso F, Hand SI Jr, Ellis FD, Helveston EM. Silicone intubation in children with nasolacrimal
obstruction. J Pediatr Ophthalmol Strabismus 1980;17:389–93. [PubMed: 7205521]
27. Migliori ME, Putterman AM. Silicone intubation for the treatment of congenital lacrimal duct
obstruction: successful results removing the tubes after six weeks. Ophthalmology 1988;95:792–5.
28. Leone CR Jr, Van Gemert JV. The success rate of silicone intubation in congenital lacrimal
obstruction. Ophthalmic Surg 1990;21:90–2. [PubMed: 2330203]
29. Heirbaut AM, Colla B, Missotten L. Silicone intubation for congenital obstruction of nasolacrimal
ducts. Bull Soc Belge Ophtalmol 1990;238:87–93. [PubMed: 2131128]
30. Beigi B, O’keefe M. Results of Crawford tube intubation in children. Acta Ophthalmol (Copenh)
1993;71:405–7. [PubMed: 8362644]
31. Al-Hussain H, Nasr AM. Silastic intubation in congenital nasolacrimal duct obstruction: a study of
129 eyes. Ophthal Plast Reconstr Surg 1993;9:32–7.
32. Aggarwal RK, Misson GP, Donaldson I, Willshaw HE. The role of nasolacrimal intubation in the
management of childhood epiphora. Eye 1993;7:760–2. [PubMed: 8119427]
33. Ratliff CD, Meyer DR. Silicone intubation without intranasal fixation for treatment of congenital
nasolacrimal duct obstruction. Am J Ophthalmol 1994;118:781–5. [PubMed: 7977605]
34. Lim CS, Martin F, Beckenham T, Cumming RG. Nasolacrimal duct obstruction in children: outcome
of intubation. J AAPOS 2004;8:466–72. [PubMed: 15492741]
35. Pe MR, Langford JD, Linberg JV, et al. Ritleng intubation system for treatment of congenital
nasolacrimal duct obstruction. Arch Ophthalmol 1998;116:387–91. [PubMed: 9514499]
36. Pediatric Eye Disease Investigator Group. Balloon Catheter Dilation and Nasolacrimal Intubation for Treatment of Nasolacrimal Duct Obstruction Following a Failed
Probing. Arch Ophthalmol. 2009; 127: 633–639.
37. Tao S, Meyer DR, Simon JW, Zobal-Ratner J. Success of balloon catheter dilatation as a primary or secondary procedure for congenital nasolacrimal duct obstruction. Ophthalmology 2002;109:2108–11. [PubMed: 12414423]
38. Becker BB, Berry FD, Koller H. Balloon catheter dilatation for treatment of congenital nasolacrimal duct obstruction. Am J Ophthalmol 1996;121:304–9. [PubMed: 8597274].
39. Hutcheson KA, Drack AV, Lambert SR. Balloon dilatation for treatment of resistant nasolacrimal duct obstruction. J AAPOS 1997;1:241–4. [PubMed: 10532771]
40. Tien D, Young D. Balloon dilation of the nasolacrimal duct. J AAPOS 2005;9:465–7. [PubMed:16213397]
41.Pediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with balloon catheter dilation in children younger than 4 years of age. J AAPOS. 2008;12:451-455.
42. Gunton KB, Chung CW, Schnall BM, Prieto D, Wexler A, Koller HP. Comparison of balloon dacryocystoplasty to probing as the primary treatment of congenital nasolacrimal duct obstruction. J AAPOS. 2001;5:139-142.
Journals: Slade SG. The use of the femtosecond laser in the customization of corneal flaps in laser in situ keratomileusis. Curr Opin Ophthalmol. 2007;18(4):314-317. [journal names abbreviated per PubMed; journal name in italics] Kezirian GM, Stonecipher KG. Comparison of the IntraLase femtosecond laser and mechanical microkeratomes for laser in situ keratomileusis. J Cataract Refract Surg. 2004;30(4):804-811. Tran DB, Sarayba MA, Bor Z, et al. Randomized prospective clinical study comparing induced aberrations with IntraLase and Hansatome flap creation in fellow eyes: potential impact on wavefront-guided laser in situ keratomileusis. J Cataract Refract Surg. 2005;31(1):97-105. up to 6 authors listed; if more than 6, list first 3 plus “et al”