Reply

Abstract

We thank Dr. Arnold for his kind words and for bringing to our attention his monocanalicular modification of bilateral stenting.1Arnold R.W. Bilateral monocanalicular silicone loop: Predictable home removal of nasolacrimal stents.J Pediatr Ophthalmol Strabismus. 1995; 32: 200-201PubMed Google Scholar His technique appears to have the advantage of decreasing the risk of corneal abrasions. The results of our study showed a 2% incidence of corneal irritation/abrasions.2Engel J.M. Hichie-Schmidt C. Khammar A. Ostfeld B.M. Vyas A. Ticho Bh Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction.JAAPOS. 2007; 11: 183-186PubMed Scopus (51) Google Scholar However, subsequent to our study, we found that the use of an ocular antibiotic ointment twice a day, along with instructing the parents not to allow for excessive rubbing for 5 to 7 days after the probing, practically eliminates the risk of corneal irritation/abrasions from the monocanalicular tube. We also thank Dr. Arnold for reporting his experience of the ease of taking both the Monoka and his double loop modification of the bilateral tube out in the office. In his editorial, Dr. Robb stated, we feel incorrectly, that one of the disadvantages of using the monocanalicular stent is that removing it “is an unpleasant, if not painful, procedure for the patient.”3Robb R.M. Probing and intubation as primary treatment for nasolacrimal duct obstruction?.J AAPOS. 2007; 11: 113Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar We feel that Dr. Robb must be referring to the experience of removing the bilateral silastic tubing, as removing the Monoka in the office is a procedure lasting several seconds, only requiring the use of a forceps to grasp the collarette from the upper punctum. For patients who are undergoing nasolacrimal duct probings in the hospital (as opposed to those undergoing in office probings), we feel using the monocanalicular tubing in the initial probing should be considered for the following reasons. First, with the high success rate up to 24 months, the probing can safely be delayed beyond the frequent recommendation of 12 months for parents who are skittish about the hospital procedure. There is also some evidence that a significant percentage of children do clear past the age of 12 months.4Nucci P. Capoferri C. Alfarano R. Brancato R. Conservative management of congenital nasolacrimal duct obstruction.J Pediatr Ophthalmol Strabismus. 2007; 26: 39Google Scholar Second, as Dr. Robb himself pointed out in his editorial, it is “what one would expect” that combining probing and silastic tubes in the primary procedure increases the success rate to over 96%.3Robb R.M. Probing and intubation as primary treatment for nasolacrimal duct obstruction?.J AAPOS. 2007; 11: 113Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Parents are very accepting of any technique that reduces the risk of their child undergoing another anesthetic. Third, the technique adds minimal increase in operating time, particularly after mastering the nuances of placing the tube. Probing and intubation as primary treatment for nasolacrimal duct obstruction?Journal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS}Vol. 11Issue 2PreviewIn the current issue of J AAPOS, J. Mark Engel and colleagues1 report their experience using probing plus monocanalicular silicone tube intubation as the primary treatment of congenital nasolacrimal duct obstruction. They have reviewed their results in treating 635 patients with a total of 803 obstructed ducts, gleaned from the practices of three ophthalmologists working in different locations. The tubes were left in place for a median of 8 weeks, although 15% of them were found absent or dislodged before the time of planned removal. Full-Text PDF Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstructionJournal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS}Vol. 11Issue 4PreviewEngel et al1 describe the impressive merits of primary stenting as surgical treatment for nonclearing congenital nasolacrimal duct obstruction. The monocanalicular stent they used (Monoka) required office removal and had a 14.5% dislodge rate and a 2% corneal/conjunctival erosion rate. A monocanalicular modification of bilateral stenting with planned home removal after just 4 weeks has similar success, with no known corneal erosion.2 I concur with these authors on the cost-benefit of a single procedure with low reoperation rate. Full-Text PDF ReplyJournal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS}Vol. 11Issue 4PreviewIt is reassuring to hear Dr. Engel and Dr. Ticho’s comment that the use of topical antibiotic ointment and appropriate instructions to the parents reduce the risk of corneal abrasions after monocanalicular stenting. Full-Text PDF