Reply

Abstract

To the Editor: In our 3 papers on the initial management of congenital nasolacrimal duct obstruction (NLDO), we reported the results of the treatment of 1288 eyes of infants and children with onset of symptoms prior to 6 months of age.1Pediatric Eye Disease Investigator GroupPrimary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years.Ophthalmology. 2008; 115: 577-584Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 2Pediatric Eye Disease Investigator GroupPrimary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age.J AAPOS. 2008; 12: 445-450Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 3Pediatric Eye Disease Investigator GroupPrimary treatment of nasolacrimal duct obstruction with balloon catheter dilation in children younger than 4 years of age.J AAPOS. 2009; 12: 451-455Google Scholar Exclusion criteria included Down syndrome, craniosynostosis, Goldenhar sequence, clefting syndromes, hemifacial microsomia, or any midline facial anomaly. Dr. Rumelt suggests some of our cases might have been acquired, which is possible, but onset would still have had to occur prior to age 6 months. The significance of this semantic dispute—congenital onset versus onset during the first 6 months of life—is not clear from the correspondence. If the implication is that later-onset disease during infancy may have a poorer outcome, we are unaware of support for this hypothesis. Our study addresses the more clinically relevant question regarding outcome of surgical procedures performed between 6 and 48 months of age in children whose NLDO symptoms appeared before 6 months of age. We required visualization of at least 1 patent punctum for enrollment. We did not require an examination of the nose prior to enrollment because of the practical limitation of performing a quality nasal exam in an infant or small child. We did collect data on any nasal abnormalities encountered. Dr. Rumelt points out that not all patients had an abnormal dye disappearance test at baseline. However, only 32 patients (2%) had a normal dye disappearance test so this low rate could not have had a meaningful effect on the results. Our protocol required that patency be confirmed by visualization of the probe beneath the turbinate, feeling the probe in the nose, or recovering fluorescein-stained saline from the nose. Postoperative steroids and antibiotics were used at investigator discretion because there is currently no unanimity among clinicians on their value. Dr. Rumelt questioned the follow-up rate in our study. We reported a primary outcome assessment for 1195 (93%) of the 1288 eyes in the 3 trials, a rate sufficiently high to minimize bias. The issue of comfort with an office-based probing in infancy has long been a controversy among ophthalmologists in the management of NLDO. The procedure when performed properly in the office is fast and associated with only brief discomfort. This discomfort may be no different than what is experienced in the induction of general anesthesia. Proper positioning and restraint of the infant however is important to prevent trauma to the lacrimal drainage system. No instance of trauma was identified in the 239 cases treated in the office.1Pediatric Eye Disease Investigator GroupPrimary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years.Ophthalmology. 2008; 115: 577-584Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar We agree that randomized clinical trials are appropriate to answer many research questions. However, our primary goal for this study was to assess the effect of age at surgery on the success of probing, the predominant primary treatment for NLDO among our investigators. Collection of data on the outcomes of balloon catheter dilation and nasolacrimal duct intubation was a secondary objective. Because choice of surgical procedure was at investigator discretion, various patient factors could have affected which patients received which surgery. Thus, without randomization, we believe that combining the 3 cohorts into a single report would have fostered the notion that direct comparisons of the 3 procedures would be appropriate, when in fact they are not. Primary Treatment of Nasolacrimal Duct ObstructionJournal of American Association for Pediatric Ophthalmology and Strabismus {JAAPOS}Vol. 13Issue 4PreviewTo the Editor: The Pediatric Eye Disease Investigator Group published a series of 3 articles on the different techniques for the treatment of congenital nasolacrimal duct obstruction (CNLDO): probing and irrigation, silicone intubation, and balloon catheterization (dacryoplasty) in children <4 years of age.1-3 The authors included all patients with symptoms appearing under 6 months of age. Although most of the patients probably have CNLDO, acquired disorders might also be included. A better definition of CNLDO would be symptoms of chronic epiphora and/or discharge that appears 2−4 weeks after delivery that are not caused by punctal, canalicular or nasal pathologies. Full-Text PDF