Factors Augmenting the Success Rate of Probing for Congenital Nasolacrimal Duct Obstruction (CNLDO) in Children

Factors Augmenting the Success Rate of Probing for Congenital Nasolacrimal Duct Obstruction (CNLDO) in Children

Dr. Md. Nasimul Gani Chowdhury¹, Dr. Afrina Khanam²*, Dr. Farzana Akter Chowdhury³, Dr. Tasmin Akter⁴, Dr. Musharrat Alam Tarin⁵, Dr Sabina Yeasmin⁶

¹Chief Consultant, Chittagong Eye Infirmary & Training Complex (CEITC), Chattogram, Bangladesh

²Resident, Institute of Community Ophthalmology (ICO), Chittagong Eye Infirmary & Training Complex campus, Chattogram, Bangladesh

³Consultant, Chittagong Eye Infirmary & Training Complex (CEITC), Chattogram, Bangladesh

^4,5Assistant Surgeon, Chittagong Eye Infirmary & Training Complex (CEITC), Chattogram, Bangladesh

⁶Resident Medical Officer, Chittagong Eye Infirmary & Training Complex (CEITC), Chattogram, Bangladesh

*Corresponding Author

DOI: https://doi.org/10.51244/IJRSI.2025.12010041

Received: 25 December 2024; Accepted: 04 January 2025; Published: 09 February 2025

ABSTRACT

Purpose: To determine the pre-operative, intra-operative and post-operative factors influencing the success rate of probing for Congenital Nasolacrimal Duct Obstruction in children.

Methods: It is a retrospective review of 200 eyes of 100 patients with Bilateral Congenital Nasolacrimal Duct Obstruction who underwent probing under General Anaesthesia. Data were recorded on age, sex, pre-operative, intra-operative and post-operative factors. All the patients were reviewed on one week, one month and three months interval. Success was defined as complete resolution of watering after 3 months of probing.

Results: Age range was 1-3 years. Average age was 2.0±0.3 years. Complete resolution of watering took place in 180 eyes (90%) of 90 patients. Watering persists after probing due to canalicular fibrosis (3 eyes, 1.5%), bony deformity (2 eyes, 1%), chronic dacryocystitis (12 eyes, 6%) and mucocele (3 eyes, 1.5%).

Conclusion: By evaluating and managing the pre-operative, intra-operative and post-operative factors properly success rate of probing can be increased.

Keywords: Nasolacrimal duct, Congenital, Probing, Children, CNLDO.

INTRODUCTION

CNLDO is a common condition in infants, affecting the tear ducts and causing epiphora^[1][2]. About 6% to 20% of neonates have this significant ocular condition ^[3][4][5][6], which is more common among prematurely born Caucasian children ^[7].  Typically, infants with CNLDO present within the first month of life with symptoms such as epiphora, mucous discharge, recurrent periocular crusting, or a combination of these ^[8]. In about 90% of cases, the primary care physician makes the diagnosis ^[3][9]. The nasolacrimal duct, which drains tears from the eye to the nose, can become partially or totally clogged, causing this condition. There are different opinions on whether cesarean delivery increases the risk of CNLDO ^[10][11].

In the naso-optic fissure, the caudal extremity of an epithelial cord derived from the ectoderm is canalized to form the nasolacrimal duct. At the end of the six months of intrauterine life, this process often occurs. However, it may be delayed for few weeks to months after birth. The membrane of Hasner, where the lacrimal duct empties into the nasal cavity, is where the obstruction is most frequently seen ^[12][9]. It has been reported that chronic inflammation in the nasolacrimal duct (NLD), nasal cavity, and sinuses can cause primary acquired nasolacrimal duct obstruction (PANDO) ^[13][14].

Spontaneous canalization of the nasolacrimal duct is observed in 51.9–83.5% of children  ^[1][7] or with conservative methods, such as lacrimal sac massage (Crigler’s manoeuvre) during the first year of life ^[9][8] . Probing is a surgical procedure to open the blocked nasolacrimal duct. It’s a minimally invasive procedure that is usually performed under general anaesthesia. Success of primary probing has got paramount importance to avoid unwanted failed probing with epiphora, re-probing, intubation and dacryocystorhinostomy later on.

Therefore, the purpose of the study was to evaluate the factors contributing the success of primary probing in children.

METHODS

200 eyes of 100 patients suffering from bilateral CNLDO were evaluated. All the patients underwent probing under general anaesthesia between January 2020 to December 2023 in Chittagong Eye Infirmary and Training Complex (CEITC), Chattogram. Data were recorded on age, sex, pre-operative antibiotic use and lacrimal massage, chronic dacryocystitis and mucocele, intra-operative canalicular fibrosis, bony deformity, soft and hard resistance, post-operative lacrimal massage and medication. All the patients underwent probing after proper counselling having topical antibiotic use and lacrimal massage.

The Fluorescein dye disappearance test was performed when the diagnosis of CNLDO was in doubt. Acute dacryocystitis, lacrimal fistula, punctal anomalies, epiblepharon, Down’s syndrome and craniofacial abnormality were not included in the study. Informed written consent was taken from all the parents. The procedure was performed under general anaesthesia using laryngeal mask airway (LMA).

Firstly, lacrimal sac area was pressed with swab stick to remove the discharge, if present. Then each punctum was dilated with Nettleship punctum dilator. Initial probing was performed by Bowman’s probe size 00 (0.90mm diameter) followed by probe size 0 (1.00 mm). The procedure was performed through upper punctum. Bowman’s probe (number 0 or 00) was introduced vertically into the punctum 2 mm and then rotated upwards as long as coincide with the line of upper canalicular system and then press medially to reach the medial wall of lacrimal sac creating the hard stop with adequate digital traction. Then the probe rotated upwards touching the upper eyebrow with lateral traction. At 70-80° probe was tried to press downwards to reach the NLD and overcome its resistance. Probe was twisted 21 times and kept for 3 minutes in the NLD before removing. Irrigation with fluorescein coloured saline was performed after probing to evaluate the patency of the system. After probing, patients received topical antibiotics and steroid combination for 2 weeks, nasal decongestant for 1 week and advised to start and continue lacrimal sac massage after 1 week to 1 months. The patients were followed up at 1 week, 1 month, and 3 months post operatively. All the probing were done by single pediatric ophthalmologist. Success of probing was defined as complete resolution of pre-operative symptoms and signs.

Statistical analysis was done by using SPSS software version 16.0. Normality of data was estimated from P-value. A value of P <0.05 was defined as statistically significant.

RESULTS

200 eyes of 100 patients were enrolled in this study. Age range was 1-3 years. Average age was 2.0±0.3 years. 46 patients (46%) are male, and 54 patients (54%) are female.

Table 01: Gender distribution (by case)

Complete resolution of watering took place in 180 eyes (90%) of 90 patients. In 20 eyes watering persist due to canalicular fibrosis (3 eyes, 1.5%) and bony deformity (2 eyes, 1%), chronic dacryocystitis (12 eyes, 6%) and mucocele (3 eyes, 1.5%).

Table 02: Findings on probing (by eye)

Table 03: Outcome of probing (by eye)

In canalicular fibrosis (3 eyes, 1.5%) and bony deformity (2 eyes,1%), probe could not pass to overcome the resistance of nasolacrimal duct. In remaining 195 eyes probe was passed overcoming the simple (120 eyes, 60%) and hard (75 eyes, 37.5%) obstruction. Regarding success rate, no significant difference was seen in simple and complex obstruction (p>0.05).

In syringing, dye was passed freely in 180 eyes (90%) and rest of the eyes, dye was not passed freely.

In canalicular fibrosis, hard stop was not found. In bony deformity, hard stop was found but probe could not pass NLD and overcome the resistance. In both cases syringing was ended with regurgitation which was an irreversible intra-operative factor for unsuccessful probing.

DISCUSSION

Spontaneous canalization and resolution of CNLDO occurs in most children before one year of age. But before resolution continuous watering and discharge from eye may create a series of complications like chronic dacryocystitis, Mucocele or atony of the sac, lacrimal fistula, acute dacryocystitis & lacrimal abscess. These unwanted troublesome complications decrease the success rate of probing. To avoid these complications and increase the success rate of probing topical antibiotic use and digital lacrimal massage has got paramount importance.

Probing is the primary choice for surgical treatment in patients with CNLDO ^[5][15]. A metal bougie is inserted into the lacrimal pathway between the punctum and the distal end of the NLD, which is usually where an obstruction is found, to make a perforation. Therefore, the success of probing depends on an understanding of the lacrimal pathway’s anatomy.

The timing of probing, the standard therapeutic procedure used for treating CNLDO, remains a matter of debate ^[16][17]. Zor et al.^[18]  found the success rate of probing to be 93.7% in patients aged 12 to 84 months. Another study concluded that the ideal probing time was between 6 and 12 months ^[19][20]. We choose to perform conservative approaches for spontaneous recovery for up to 12 months.

Different studies showed that success rate of probing decreases with increasing age ^[16][21][22]. We performed probing in between age 1-3 years. Increasing age was not a factor for decreased success rate of probing in our study. Similarly, some reports have found no age-related reductions in success rate^[15][23]. Rather it was chronic dacryocystitis, prolonged inflammation and fibrosis in the lacrimal drainage system, which decrease the success rate of probing ^{[16][19][21][24]}. Mucocele or atony of the sac was another risk factor for decreased success of probing rather than age. So appropriate treatment with topical antibiotic & digital lacrimal massage is a very important factor to prevent this unwanted occurrence.

All the cases underwent probing under general anesthesia using Laryngeal mask airway (LMA). LMA is increasingly used in children during probing as it is less invasive than endotracheal intubation and causes less laryngospasm and bronchospasm. Moreover, it does not require muscle relaxation.

Hard resistance was encounted for increased failure rate of probing in children in different studies ^[25][26][27]. We noticed only bony deformity rather than hard resistance was a bad prognostic factor for probing in children.

During probing, understanding the normal anatomy of nasolacrimal duct system and avoidance of false passage play important role to increase the success rate of probing. Skillness and surgical expertise augment the success of probing. Post-operative topical use of steroids & antibiotics combination, nasal decongestant, digital lacrimal massage augments the success rate of probing. As it is an invasive procedure systemic antibiotic and mild analgesic should be applied.

CONCLUSION

Success of primary probing is very important to ensure the quality of children’s life. Appropriate topical antibiotic use and consistent digital lacrimal massage are very important to prevent chronicity and atony of the sac which play important role for augmentation of success rate of probing. Unwanted false passage, failed probing, troublesome intubation decreases the success rate of subsequent procedure and creates a series of hazardous complications.

Conflict of interest: None.

Financial support: None.

ACKNOWLEDGMENTS

Ahmedur Rahman Research Center of Chittagong Eye Infirmary and Training Complex.

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