11.1 Goals

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  Achieve normal flow of tears through the nasolacrimal system and alleviate obstructions in the nasolacrimal duct causing persistent tearing.

  
  
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  Prevent dacryocystitis or recurrent conjunctivitis secondary to nasolacrimal duct obstruction (NLDO).

  
  
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  Drain dacryocystoceles in neonates and young infants.

  
  
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  Nasolacrimal duct intubation and balloon dacryoplasty are used to treat recurrent or persistent obstruction of the nasolacrimal duct.

11.2 Advantages

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  Resolve symptomatic tearing which can cause local irritation and inflammation.

  
  
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  Decrease the risk of dacryocystitis in neonates and young infants which can lead to sepsis in neonates due to an immature immune system. ⁵ In addition, bilateral dacryocystoceles may cause respiratory distress in neonates, requiring urgent surgical management.

  
  
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  Nasolacrimal duct intubation and balloon dacryoplasty are advantageous procedures in children for whom treatment with probing alone has failed, in older children, and in children with Down syndrome or craniofacial anomalies. ²

11.3 Expectations

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  Congenital nasolacrimal duct obstruction (NLDO) occurs in approximately 5% of normal newborns. ^{3 , 5}

  
  
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  Ninety percent of congenital NLDO cases resolve spontaneously within the first year of life. ¹ The patient’s family may attempt massage of the nasolacrimal duct to encourage resolution of persistent symptoms before considering surgical intervention. Proper nasolacrimal duct massage technique should be demonstrated to the family, including the appropriate amount of pressure to be used.

  
  
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  Probing alone is successful in 75 to 90% of patients 6 to 36 months old. ^{5 , 6} The success rate of probing likely declines after 36 months, and intubation may be considered as the primary procedure.

  
  
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  Dacryocystoceles may require nasal endoscopy in coordination with otorhinolaryngology to marsupialize the cyst. ⁷

  
  
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  If a stent is placed, complete resolution following stent removal occurs in approximately 90% of patients less than 4 years of age. ⁸ Persistent epiphora may occur while the stent is in place postoperatively.

  
  
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  Nasolacrimal duct intubation and balloon dacryoplasty have similar success rates. ⁹

  
  
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  Mild to moderate epistaxis may occur immediately following the procedure due to intranasal manipulation.

  
  
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  Long-term relief from tearing and irritation is expected, but sometimes it takes up to 2 weeks after surgery to achieve symptom resolution.

11.4 Key Principles

Understanding of lacrimal drainage system anatomy and use of the proper instruments improve the likelihood of uncomplicated and successful treatment in the majority of uncomplicated cases.

11.4.1 Anatomy

Tear drainage begins at the puncta (Fig. 11.1). The upper and lower eyelids each contain a punctum medially which is 5 mm from the canthal angle superiorly and 6 mm from the canthal angle inferiorly. ¹⁰ Each punctum drains into a canaliculus which travels vertically for 2 mm, then horizontally for 8 mm. The superior and inferior canaliculi fuse to create a common canaliculus in 90% of patients. The canalicular structure empties into the lacrimal sac, which is 1.2 to 1.5 cm in length in the lacrimal sac fossa. The valve of Rosenmüller is a fold of tissue that serves as a one-way valve, helping to prevent tear reflux from the lacrimal sac into the canaliculus. The lacrimal sac then transitions into the nasolacrimal duct, which travels approximately 1.2 cm through the lacrimal canal and empties into the nasal cavity via the inferior meatus. The valve of Hasner is located just at the opening to the inferior meatus, helping to prevent reflux, and is a common site of obstruction in congenital NLDO.

11.5 Indications

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  Persistent and symptomatic tearing from NLDO, especially beyond 1 year of age or if causing recurrent infections.

  
  
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  Nonresolving or recurrent dacryocystocele with or without dacryocystitis or causing respiratory distress.

  
  
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  Nasolacrimal duct probing with intubation or balloon dacryoplasty is considered in the following ^{2 , 5 , 11} :

  
  
  
  
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    Failed response to probing alone.

    
    
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    Children older than 3 to 4 years of age, as probing alone has a success rate of only 56%. ^{1 , 8}

    
    
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    Patients with suspected atypical anatomy, such as patients with Down syndrome or craniofacial anomalies, due to a higher risk of failure with probing and irrigation alone. ¹¹

    
    
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    If severe stenosis is encountered at the time of probing.

11.6 Contraindications

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  Infants and children with acute dacryocystitis are treated with antibiotics for at least 48 hours prior to surgical management.

  
  
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  Epiphora not caused by NLDO; for example, ocular surface disease, eyelid anomalies, and glaucoma.

  
  
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  Agenesis of the puncta, canaliculi, or proximal lacrimal drainage system requires an alternative approach such as eyelid cut-down and/or conjunctivodacryocystorhinostomy and should be referred to an oculoplastic surgeon.

  
  
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  Bony distal obstruction of the nasolacrimal duct may require dacryocystorhinostomy or endonasal surgery.

  
  
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  Nasolacrimal fistula to the external skin, which requires complete excision of the fistula.

11.7 Preoperative Preparation

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  A complete eye exam should be performed to rule out other causes of epiphora.

  
  
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  Evaluate the periorbital region and eyelids for any lesions or abnormalities of the puncta. The tear lake is also inspected, and a dye disappearance test can be helpful to confirm the diagnosis of NLDO.

  
  
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  The surgeon should discuss the expectations following surgery, including persistent epiphora in the early postoperative period or while a stent is in place. The risk of failure with the possible need for further surgery is also discussed.

  
  
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  Discuss management of the airway with the anesthesia team, as nasal irrigation and bleeding can cause laryngospasm or other airway obstruction. Although nasolacrimal probing and irrigation is typically brief and can be performed with mask sedation or a laryngeal mask airway, endotracheal intubation better secures the airway, especially for longer cases with stent placement or balloon dacryoplasty.

  
  
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  Nasolacrimal duct procedures are classified as clean procedures and are not sterile. Gentle pressure may be applied over the nasolacrimal sac inferior to the medial canthus to express and remove purulent material through the puncta before starting the procedure. The surgical field is then prepped with gauze and cotton-tip applicators soaked in 5% betadine to clean the eyelids and eyelashes, and sterile towels can be placed around the surgical field.

11.8 Operative Technique

11.8.1 Nasolacrimal Duct Probing with or without Irrigation

1. 
   

   Both the upper and lower puncta are examined. Occasionally, a membrane may be visualized over either or both puncta, which can be gently opened using a punctal dilator before proceeding with the remainder of the procedure.

   
   
2. 
   

   Probing through the upper punctum may result in less trauma to the proximal canalicular system with lower risk of false passage creation. ¹² However, if the patient’s anatomy precludes easy passage of the nasolacrimal probe through the upper canalicular system, the lower punctum and canalicular system are probed for the procedure.

   
   
3. 
   

   The upper eyelid is gently everted to visualize the upper punctum. The smallest available punctal dilator is inserted into the punctum, perpendicular to the eyelid margin to dilate the punctum (Fig. 11.2). Lateral traction is placed on the eyelid, and the dilator is redirected and advanced medially while rotating it along its long axis to dilate the proximal canalicular system. When performing this procedure for congenital dacryocystoceles, dilation of the canaliculus can help decompress the dacryocystocele, making the remainder of the procedure easier to perform. ¹²

   
   
4. 
   

   The punctal dilator is removed, and a #000 or #00 Bowman probe is inserted into the upper punctum perpendicular to the eyelid margin for 1 to 2 mm (Fig. 11.3a), then directed nasally into the upper canaliculus and then the lacrimal sac while simultaneously placing lateral traction on the eyelid to straighten the canaliculus. The probe should slide easily through the proximal canalicular system and then reach a firm, bony stop with no soft tissue palpable to decrease the risk of creating a false passage (Fig. 11.3b). Note that a smaller Bowman probe (#000) may be needed for probing of congenital dacryocystoceles, although Bowman probes smaller than #00 may increase the risk of false passage creation.

   
   
5. 
   

   Once the Bowman probe is confirmed to be abutting bone, it is rotated sharply 90 degrees and then advanced inferiorly, posteriorly, and slightly laterally through the lacrimal sac and nasolacrimal duct into the nasal cavity (Fig. 11.4). The tension on the eyelid is also released to prevent tearing of the punctum as the Bowman probe is advanced. In some cases, a popping sensation can be felt as the probe passes through the membrane at the valve of Hasner. In other cases, significant stenosis of the bony portion of the nasolacrimal duct may require additional gentle pressure to allow passage of the probe. Once the Bowman probe has been advanced, a second Bowman probe of any size can be held externally over the nose and lined up with the Bowman probe in the nasolacrimal system to gauge the position of the distal end of the probe in the nasal cavity. If probing for a congenital dacryocystocele in the office without sedation, elevate the infant’s head once the popping sensation is felt to allow the infant to swallow the fluid that was filling the cyst without aspirating. ¹²

   
   
6. 
   

   Larger diameter Bowman probes, up to #0 or #1, can be used to probe the lacrimal drainage system in a similar manner.

   
   
7. 
   

   A large #7 or #8 Bowman probe can then be used to verify the presence of the smaller Bowman probe in the ipsilateral nasal cavity by sliding the larger probe under the inferior turbinate and feeling for metal-on-metal contact, as well as observing movement of the smaller Bowman probe when it is in contact with the large probe (Fig. 11.5). The Bowman probe can also be directly visualized in some cases by placing a nasal speculum in the nasal cavity or by nasal endoscopy if available.

   
   
8. 
   

   The Bowman probe in the nasolacrimal system is then removed, and the above steps may be repeated for the lower punctum and canaliculus.

   
   
9. 
   

   To verify patency of the nasolacrimal system following probing, fluorescein-stained saline can be irrigated through the upper punctum with a 23-gauge cannula attached to a 3 mL syringe. The cannula is advanced and the nasolacrimal system is irrigated. The opposite punctum may simultaneously be occluded with a punctal dilator or by manual pressure using a cotton-tip applicator to prevent reflux. The fluorescein-stained saline is recovered from the naris with an 8-French suction catheter.

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