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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 2  |  Page : 93-96

Endoscopic-guided probing for the management of congenital nasolacrimal duct obstruction


Department of Ophthalmology, Ophthalmic Center, Mansoura University, Mansoura, Egypt

Date of Submission13-Jun-2015
Date of Acceptance29-Jul-2015
Date of Web Publication28-Oct-2015

Correspondence Address:
Ayman E Abd El Ghafar
Mansoura Ophthalmic Center, Faculty of Medicine, Mansoura University, Elgomhoria Street, Mansoura 35516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-9173.168539

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  Abstract 

Purpose
This study aimed to assess the value of direct visualization during probing of congenital nasolacrimal duct obstruction using nasal endoscopy and its effect on the success rate.
Patients and methods
This is a prospective interventional case series including 34 eyes of 26 patients who presented with congenital nasolacrimal duct obstruction and treated with probing under direct visualization using nasal endoscopy. Observations were recorded.
Results
This prospective interventional case series included 10 female children (38.46%) and 16 male children (61.54%), mean age 15.6 ± 2.1 months. Endoscopic-guided probing achieved a success rate of 94.12%. Endoscopy indicated a stenotic valve and membrane in 82.36%, elastic membrane in 5.88%, submucosal false passage in 5.88%, bony obstruction in 2.94%, and tight inferior turbinate in 2.94% of the patients.
Conclusion
Endoscopic-guided probing transfers probing from a blind procedure to a visualized one, diagnoses the cause of obstruction and false passage, and enables intraoperative readjustment of false passage; this in turn increases the success rate.

Keywords: nasal endoscopy, nasolacrimal duct obstruction, probing


How to cite this article:
Abd El Ghafar AE. Endoscopic-guided probing for the management of congenital nasolacrimal duct obstruction. Delta J Ophthalmol 2015;16:93-6

How to cite this URL:
Abd El Ghafar AE. Endoscopic-guided probing for the management of congenital nasolacrimal duct obstruction. Delta J Ophthalmol [serial online] 2015 [cited 2017 Dec 12];16:93-6. Available from: http://www.djo.eg.net/text.asp?2015/16/2/93/168539


  Introduction Top


Congenital nasolacrimal duct obstruction (CNLDO) is a common ocular complaint in the first year of life [1],[2] . It is usually caused by a membrane obstructing the nasolacrimal duct (NLD) orifice in the nasal cavity or by failure of canalization of the inferior tip of the NLD that normally occurs at the eighth month of gestation [3] . Nasolacrimal duct obstruction (NLDO) occurs in about 2-4% of newborns and up to 20% in some studies [4],[5] .

There is a controversy in the optimal time of probing of the NLD, but it is usually performed beyond the age of 1 year in cases with failed conservative treatment [6],[7] .

Probing, despite the debate on the optimal timing at which it could be performed, is established as an effective technique in cases of unresolved NLDO, with a success rate of up to 90% in some studies. Being a blind procedure, it has the risk of creating a false passage that may lead to worsening of the condition rather than improving it [8] .

An increase in the success rate of probing and prevention of a false passage can be achieved by converting this blind procedure into a visible one using nasal endoscopy, which enables intraoperative monitoring of the procedure and readjustment of the intraoperative false passage [8] .

In this study, the value of using nasal endoscopy during probing in the detection of the cause of obstruction, intraoperative complications, and false passage, and its effect on the success rate was evaluated.


  Patients and methods Top


This is a prospective interventional case series including 34 eyes with CNLDO in 26 children ranging in age from 12 to 25 months. It was performed at the Mansoura Ophthalmic Center, Mansoura, Egypt, from January 2014 to August 2014. All children were diagnosed with CNLDO on the basis of a history of epiphora with or without discharge dating since birth or shortly thereafter in one eye (18 cases) or both eyes (eight cases), supported by an objective evidence of reduced lacrimal outflow using a fluorescein disappearance test (FDT). Ethical approaval was taken from Mansoura Ethics Committe and a written consent was taken from all patients.

In this test (FDT), fluorescein eye drops were instilled in both eyes and the time of clearance of the dye from both eyes was calculated and both eyes were compared. Normally, most of the dye disappears after 5 min. In cases of NLDO, pooling of the dye and delayed disappearance occurred.

Examination included inspection of the lacrimal puncti to exclude punctal occlusion, inspection for anomalies of the lids that may impair tear drainage, for example, entropion, ectropion, or coloboma, and exclusion of other causes of lacrimation and discharge, for example, purulent and allergic conjunctivitis. The age of the patients ranged from 12 to 25 months in infants with failed conservative treatment during the first year.

Patients with amniotocele or those probed before were excluded.

Surgical technique

The procedure was carried out under general (inhalation) anesthesia without intubation in all cases. A nasal pack soaked in 1 : 100 000 epinephrine was inserted into the nasal cavity for 5-10 min before probing for decongestion and then removed.

After dilatation of the upper punctum with a Nettleship punctal dilator, probing was carried out using a Bowman's probe. The probe was introduced vertically into the punctum, and then rotated horizontally 90° while pulling the outer canthus laterally in the same plane to enter the canaliculus; then, the probe was advanced until it reached the nasal wall of the lacrimal sac (hard stop) and rotated vertically and guided without force (to avoid false passage) through the NLD. At this time, nasal endoscopy (Karl Storzendoscope, Berline, Germany, telecam DX II, Hopkins II, 0°, 4 mm) was applied to the nasal cavity under the inferior turbinate to assess probing by visualization in the area of the inferior meatus. Observations while advancing the probe were noted.

Topical tobramycin eye drops four times/day and xylometazoline hydrochloride 0.05% nasal drops were applied for 1 week.

Resolution was defined as the absence of watering or discharge with a normal FDT. Failure was defined as persistent watering or discharge and delayed FDT. Cases were followed for 3 months after probing.


  Results Top


This prospective interventional case series included 34 eyes in 26 children with NLDO, 10 female children (38.46%) and 16 male children (61.54%), mean age 15.6 ± 2.1 months (ranging from 12 to 25 months).

Observations during probing indicated the following:

The probe tip had protruded successfully through a stenotic Hasner's valve or obstructing membrane in 28 cases (82.36%) [Figure 1].
Figure 1: Passage of the probe through a stenotic Hasner's valve (blue arrow)

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The probe could not perforate the Hasner's valve and there was a hard stop because of bony obstruction at the end of NLD in one case (2.94%).

The probe tip tented an elastic membrane at Hasner's valve in two cases (5.88%). In these cases, the membrane was highly elastic and was thus cut down onto the probe using a No. 11 blade to disrupt this elastic membrane [Figure 2].
Figure 2: Tenting of an elastic membrane at Hasner's valve (blue arrow)

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The probe did not perforate the membrane and entered the submucosal space in two cases (5.88%). The probe passed down to the hard palate without perforation of the mucosa into the nasal cavity. In these cases, the probe was removed and redirected [Figure 3].
Figure 3: Submucosal false passage (blue arrow)

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The probe perforated the inferior turbinate (tight inferior turbinate) in one case (2.94%). Thus, a false medial passage was created. In this case, the inferior turbinate was adherent to the lateral nasal wall obscuring the inferior meatus.

In this case, the probe was removed and the inferior turbinate was out-fractured with a periosteal elevator and then the probe was again redirected carefully to the inferior meatus with successful passage.

The success rate of probing in this study was 94.12%. The two failed cases were those with bony obstruction and one case of elastic membrane. The case of bony obstruction was a female child aged 2 years. dacryocystorhinostomy (DCR) was performed with a silicone stent that was removed after 3 months without further complications.

In the case with an elastic membrane at Hasner's valve, probing with application of a silicon stent was performed and the stent was removed after 3 months, followed by improvement.

Intraoperative bleeding occurred in two cases, one of the two cases with elastic membrane, and bleeding occurred in that case during incision of the membrane. The other case was that of tight inferior turbinate and bleeding in that case occurred during out-fracture of the turbinate. In the two cases, bleeding was minimal and was controlled by application of a nasal pack.


  Discussion Top


CNLDO is one of the most common problems in infants, affecting up to 20% of newborns. However, spontaneous canalization occurs in 96% of the cases by the end of the first year [3],[4],[8] .

Probing is the surgical treatment of choice for CNLDO in nonresolving cases after 1 year of conservative treatment. However, as it is a blind procedure, it carries a risk of false passage with worsening of the condition. Moreover, the exact cause of obstruction cannot be identified [4] .

Most studies have reported a success rate of probing ranging from 55 to 90% [9],[10] . Other reports showed that the use of nasal endoscopy during probing improved the results of probing compared with blind probing. Moreover, it enabled readjustment of the position of the probe during surgery if false passage occurred [11],[12] ; in this study, a high success rate was achieved (94.12%).

Hidenori et al. [13] reported that even with experienced hands, a false passage may occur during primary probing and will have a negative impact on the results. They mentioned that bleeding during probing that meant a false passage occurred in up to 20% of blind probing.

Although metal-to-metal sensation is used by most surgeons to ensure proper passage of the probe through the NLD, a false passage may still occur and different varieties of anomalies cannot be detected except by direct visualization using nasal endoscopy [14] .

Miguel et al. [15] , in a comparative study between conventional blind probing and endoscopic-guided probing, reported a success rate of 50% in a blind procedure compared with 97.22% in an endoscopic-guided procedure, and reported that 16.67% of those cases showed tight inferior turbinate and 11.11% showed a submucosal false passage of the probe.

Choi et al. [16] reported that cases with CNLDO were mainly because of a membrane at the lower end of the NLD, a false passage of the probe in the submucosal space, and a collection of pus and mucus under the inferior turbinate.

Kashkouli et al. [17] , in a series of 138 eyes, reported that obstruction by a membrane was present in 90.2% of eyes and described it as simple NLDO, and the rest of cases (9.8%) were diagnosed with complex NLDO (e.g. bony obstruction, amniotocele).

Al-Faky [18] reported that during endoscopic-guided probing, the following variants were detected: impaction of the inferior turbinate that concealed the NLD opening, the probe may pass through a stenotic valve, perforation of the membrane may be difficult because of a thick or elastic membrane, and bony obstruction.

Hidenori et al. [13] reported that observations during endoscopic-guided probing indicated that NLDO by fibrous tissue because of chronic inflammation and chronic edema of the nasal mucosa were the most commonly encountered causes.

It is now established that CNLDO is most commonly caused by a membranous obstruction [19],[20],[21] .

In this study, an obstruction by a membrane and a stenotic valve at the lower end of the NLD were the most common findings, followed by elastic membrane and false passage in a submucosal space and to a lesser extent by bony obstruction and tight inferior turbinate to the lateral nasal wall.

Despite the described advantages of nasal endoscopic evaluation during probing, some limitations are present such as the need for an expensive nasal endoscopy compared with the blind procedure and the need for collaboration between an ear, nose, and throat (ENT) surgeon, and an ophthalmologist, leading some surgeons to use this technique only in cases of failed primary probing to assess the cause of failure and correct it if possible [22] .

From this study, it was found that the nasal endoscopic-guided probing helps to achieve a high success rate, detect different causes of obstruction and causes of failure of blind probing, and enables intraoperative correction of these causes. In this study, the procedure was entirely performed by the author because of the availability of nasal endoscopy and past experience in endoscopic DCR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ffooks OO. Dacryocystitis in infancy. Br J Ophthalmol 1962; 46:422-434.  Back to cited text no. 1
    
2.
Guerry D, Kendig EL. Congenital impatency of the nasolacrimal duct. Arch Ophthalmol 1948; 39:193-204.  Back to cited text no. 2
    
3.
Duke-Elder S. System of ophthalmology. Vol. 3, Part 3. In: Duke-Elder S, editor. Congenital deformities, the 99C. St Louis, MO: Mosby; 1963:923-941.   Back to cited text no. 3
    
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MacEwen CJ. Congenital nasolacrimal duct obstruction. Compr Ophthalmol Update 2006; 7:79-87.  Back to cited text no. 4
    
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Wallace CJ, Cox A, White CJ, et al. Endoscopic assisted probing for congenital nasolacrimal duct obstruction. Eye 2006; 20:998-1003.  Back to cited text no. 5
    
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Takahashi Y, Kakizaki H, Chan WO, Selva D. Management of congenital nasolacrimal duct obstruction. Acta Ophthalmol 2010; 88:506-513.  Back to cited text no. 6
    
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Pediatric Eye Disease Investigator Group. Resolution of congenital nasolacrimal duct obstruction with nonsurgical management. Arch Ophthalmol 2012; 130:730-734.  Back to cited text no. 7
    
8.
Orhan M, Onerci M. Intranasal endoscopic silicon intubation for congenital obstruction of the nasolacrimal duct in children. Int J Pediatr Otorhinolaryngol 1997; 41:273-278.  Back to cited text no. 8
    
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Katowitz JA, Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987; 94:698-705.  Back to cited text no. 9
    
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Robb RM. Success rates of nasolacrimal duct probing at time intervals after 1 year of age. Ophthalmology 1998; 105:1307-1310.  Back to cited text no. 10
    
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Mandeville JT, Woog JJ. Obstruction of the lacrimal drainage system. Curr Opin Ophthalmol 2002; 13:303-309.  Back to cited text no. 11
    
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Zilelioglu G, Hosal B. The results of late probing in congenital nasolacrimal duct obstruction. Orbit 2007; 26:1-3.  Back to cited text no. 12
    
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Hidenori S, Toshiyuki T, Akira M. Direct endoscopic probing for congenital lacrimal duct obstruction. Clin Exp Ophthalmol 2013; 41:729-734.  Back to cited text no. 13
    
14.
Elmorsy S, Shabana YK, Fayek HM. Endoscopic assisted probing for symptomatic congenital nasolacrimal duct obstruction after one year of age. Rhinology 2010; 47:100-103.  Back to cited text no. 14
    
15.
Miguel AA, Félix JA, Asunción MF, et al. Comparative study of primary intention lacrimal probing with and without nasal endoscopy. Acta Otorrinolaringol Esp 2014; 65:297-301.  Back to cited text no. 15
    
16.
Choi WC, Kim KS, Park TK, et al. Intranasal endoscopic diagnosis and treatment in congenital nasolacrimal duct obstruction. Ophthalmic Surg Lasers 2002; 33:288-292.  Back to cited text no. 16
    
17.
Kashkouli BM, Beigi B, Parvaresh MM, et al. Late and very late initial probing for congenital nasolacrimal duct obstruction: what is the cause of failure? Br J Ophthalmol 2003; 87:1151-1153.  Back to cited text no. 17
    
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Al-Faky YH. Nasal endoscopy in the management of congenital nasolacrimal duct obstruction. Saudi J Ophthalmol 2014; 28:6-11.  Back to cited text no. 18
    
19.
Cassady JV. Developmental anatomy of the naso-lacrimal duct. Arch Ophthalmol 1952; 47:141-158.  Back to cited text no. 19
    
20.
Schwartz M. Congenital atresia of the naso-lacrimal canal. Arch Ophthalmol 1935; 13:301-302.  Back to cited text no. 20
    
21.
Fiori R. Diseases of the lacrimal system. Textbook of ophthalmology. Vol. 5, chapter LVIII. Duke-Elder editor. London: Kimpton; 1952:331-334.   Back to cited text no. 21
    
22.
Cakmak SS, Yildirim M, Sakalar Y, et al. Is it necessary to accompany probing with endoscopy in cases of congenital nasolacrimal canal obstruction? Int J Pediatr Otorhinolaryngol 2010; 74:1013-1015.  Back to cited text no. 22
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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