26 Probing, Irrigation, and Intubation in Congenital Nasolacrimal Duct Obstruction
Nasolacrimal duct probing and irrigation, as well as nasolacrimal intubation are common procedures for the management of congenital nasolacrimal duct obstruction, as well as dacryocystoceles. Both procedures have high success rates. For most patients, probe and irrigation will suffice; however, for recurrent nasolacrimal duct obstruction and complex cases the procedure of choice is nasolacrimal intubation. The salient points of each technique are reviewed, allowing ophthalmic surgeons to improve their technique and success with both procedures.
The goal of nasolacrimal probing and irrigation (P&I), as well as of intubation is to achieve normal flow of tears within the nasolacrimal system and alleviate obstructions causing epiphora. 1 For newborns presenting with a dacryocystocele, the goal, in addition to restoring normal outflow of tears is to prevent dacryocystitis. 2 Dacryocystitis in a newborn can be life threatening because of their immature immune system.
P&I can achieve resolution of symptoms in most children with a congenital nasolacrimal duct obstruction (CNLDO), while it can prevent dacryocystitis in children with a dacryocystocele. 1 , 2 , 3 Higher success can be achieved with nasolacrimal intubation for older children or following failed P&I. 4 , 5
Approximately 5% of infants are born with CNLDO and almost 90% of CNLDOs resolve spontaneously before the first year of life. 1 , 6 , 7 The success rate for P&I is approximately 80% for children of age groups 6 to 12 months, 12 to 24 months, and 24 to 36 months; however, the success rate declines to 56% for ages 36 to 48 months. 3 The success rate of P&I for managing a dacryocystocele is approximately 75%. 2 Nasolacrimal duct intubation has a success rate of approximately 90% for children with CNLDO less than 4 years of age. 8
26.4 Key Principles
For children less than 3 years of age with persistent CNLDO, a primary P&I can be performed. 3
Nasolacrimal intubation should be considered for children who have persistent epiphora following P&I. 5
Dacryocystocele requires urgent management, ideally while the child is still in the newborn nursery. P&I can be considered as first-line treatment. 2
Bilateral dacryocystocele often results in respiratory distress and requires surgical management in the operating room with assistance from an otolaryngologist. 2
Nasolacrimal P&I is indicated for persistent symptoms of epiphora and infections in the setting of nasolacrimal duct obstruction. 1 Patients whose symptoms persist beyond the first year of life can be considered for primary P&I, as by that time the likelihood of spontaneous resolution is low and general anesthesia is safer after the first year of life. 6 , 7 , 9 P&I can be considered at earlier ages if infections require frequent use of oral antibiotics or if the symptoms prevent children from attending daycare.
P&I is indicated for patients with dacryocystocele and should be performed at the earliest opportunity if digital massage of the nasolacrimal sac fails as there is high risk of dacryocystitis if left untreated. 2
Nasolacrimal intubation should be considered as a secondary procedure after a failed P&I, or as a primary procedure for patients over 3 years of life when a traditional P&I is more likely to fail. 3 , 4 , 5 , 8 In addition, nasolacrimal intubation can be considered for patients with dacryocystocele who require marsupialization of an intranasal cyst by otolaryngology.
Children with acute dacryocystitis should be placed on systemic antibiotics for at least 48 hours prior to proceeding with P&I.
While epiphora in the first year of life is most commonly caused by congenital nasolacrimal duct obstruction, it is important to rule out congenital glaucoma as a cause. In addition, lid anomalies, such as epiblepharon, and corneal disease can also present with tearing and should be ruled out prior to proceeding with P&I.
Patients with complete punctal agenesis would require a punctal cut-down to look for elements of the punctal ampulla and canaliculus in order to enable P&I or nasolacrimal intubation; if no proximal lacrimal drainage anatomy is present, a conjunctivodacryocystorhinostomy (Jones tube) would ultimately be required.
Patients with lacrimal fistulas require complete excision of the fistulous track at the time of surgical management.
26.7 Preoperative Preparation
In typical CNLDO, mask sedation can be used for P&I; however, it is important to limit irrigation as it can cause laryngospasm. If significant irrigation or nasolacrimal intubation is to be performed, then a more secure airway should be established either with a laryngeal mask airway or an endotracheal tube.
Nasolacrimal intubation can be performed with a variety of stents, including monocanalicular and bicanalicular stents utilizing the Rietleng, Crawford, or Masterka systems among others. 8 , 10 , 11 , 12 The type of stent to be used is the surgeon’s preference.
In newborns with dacryocystocele, P&I should ideally be performed prior to discharge from the nursery; alternatively, it can be done in the office without sedation. For these very young children, the combination of topical anesthesia with eye drops, use of a pacifier with sugar water, and swaddling them is usually enough to keep them comfortable and still for the procedure. However, patients with bilateral dacryocystocele will often experience respiratory distress as they are obligate nose breathers. Thus, early intervention in an operating room setting with assistance from an otolaryngologist is essential in order to safely and completely marsupialize the nasal aspect of the cyst. 2