Unilateral Nasolacrimal Duct Obstruction Research Articles

A Randomized Trial Comparing the Cost-effectiveness of 2 Approaches for Treating Unilateral Nasolacrimal Duct Obstruction

To compare the cost-effectiveness of 2 approaches for treating unilateral nasolacrimal duct obstruction (NLDO).One hundred sixty-three infants aged 6 to less than 10 months with unilateral NLDO were randomly assigned to receive immediate office-based nasolacrimal duct probing (n = 82) or 6 months of observation/nonsurgical management (n = 81) followed by probing in a facility for persistent symptoms.Treatment success was defined as the absence of clinical signs of NLDO (epiphora, increased tear lake, mucous discharge) on masked examination at age 18 months. Cost of treatment between randomization and age 18 months included costs for all surgical procedures and medications.In the observation/deferred facility-probing group, NLDO resolved within 6 months without surgery in 44 of the 67 patients (66%; 95% CI, 54% to 76%) who completed the 6-month visit. Twenty-two (27%) of the 81 patients in the observation/deferred facility-probing group underwent surgery, 4 of whom were operated on within the initial 6 months. At age 18 months, 69 of 75 patients (92%) in the immediate office-probing group were treatment successes, compared with 58 of 71 observation/deferred facility-probing group patients (82%) (10% difference in success; 95% CI, -1% to 21%). The mean cost of treatment was $562 in the immediate office-probing group compared with $701 in the observation/deferred facility-probing group (difference, -$139; 95% CI, -$377 to $94). The immediate office-probing group experienced 3.0 fewer months of symptoms (95% CI, -1.8 to -4.0).The immediate office-probing approach is likely more cost-effective than observation followed by deferred facility probing if needed. Adoption of the immediate office-probing approach would result in probing in approximately two-thirds of infants whose obstruction would have resolved within 6 months of nonsurgical management, but would largely avoid the need for probing under general anesthesia.Although unilateral NLDO often resolves without surgery, immediate office probing is an effective and potentially cost-saving treatment option.clinicaltrials.gov Identifier: NCT00780741.

Facial Asymmetry and Nasal Septal Deviation in Acquired Nasolacrimal Duct Obstruction

Introduction: Acquired nasolacrimal duct obstruction is a common disorder affecting adults. Its pathogenesis is not known. We hypothesize that facial and bony asymmetry can contribute to the unilaterality of the nasolacrimal duct obstruction.Materials and Methods: Retrospective study was done on all patients with acquired nasolacrimal duct obstruction who presented to our practice from January through June 2010. External photographs were obtained. Lacrimal probing and irrigation was used to confirm blockage of the nasolacrimal duct. Nasal endoscopy was performed to visualize the intranasal anatomy and location of the nasal septum.Results: There were 23 patients who underwent endoscopic dacryocystorhinostomy (11 males, 12 females) for acquired nasolacrimal duct obstruction. Average age was 58 years old (range, 27 to 84 years). Facial photos analysis showed facial asymmetry in 17 patients, with one side being smaller than the other side. This corresponded to the side of the nasolacrimal duct obstruction in 12 out of these 17 patients (p-value 0.03). Nasal endoscopy revealed septal deviation to the side of the nasolacrimal duct obstruction in 21 of the 23 patients, with one having twisted septal deviation. Septoplasty was performed in 10 cases in addition to endoscopic dacryocystorhinostomy.Conclusions: Unilateral nasolacrimal duct obstruction appears to occur on the side in which the nasal septum is deviated. There is a trend of nasal septal deviation toward the smaller side of the face. Further prospective studies are needed to clarify the above relationships.

High prevalence of amblyopia risk factors in preverbal children with nasolacrimal duct obstruction

To report the percentage of children under the age of 3 with nasolacrimal duct obstruction (NLDO) and amblyopia risk factors who develop clinical evidence of amblyopia over time. Records of children under 3 years of age presenting to a pediatric oculoplastic specialist with NLDO between January 1, 2001, and August 8, 2009, were retrospectively reviewed to identify those who also had amblyopia risk factors. Amblyopia was diagnosed based on visual acuity and treatment history. A total of 375 children under the age of 3 had NLDO. Of these, 82 (22%) had amblyopia risk factors, and 70 received a follow-up examination. Average age at first visit was 12 months (1-27 months). In all patients with anisometropia and unilateral NLDO, the side with the NLDO had higher hyperopia. Of the 70 with risk factors, 44 (63%) were later treated for amblyopia: 29 with spectacles alone, 2 with occlusion therapy, 13 with spectacles and occlusion therapy. Six patients required strabismus surgery. In all patients with anisometropia and unilateral NLDO, the side with the NLDO had higher hyperopia. The percentage of children identified with amblyopia risk factors who later develop clinical amblyopia was much higher than the 1.6% to 3.6% expected in a cohort of normal children.

A Symptom Survey and Quality of Life Questionnaire for Nasolacrimal Duct Obstruction in Children

To develop and validate a new parental questionnaire addressing symptoms and health-related quality of life (HRQL) in childhood nasolacrimal duct obstruction (NLDO). Cross-sectional study. Children ages 6 to younger than 48 months with and without clinical signs of NLDO. A new questionnaire was developed using semistructured interviews with parents of children with NLDO and through discussions with expert clinicians. Questionnaires were completed by parents of children with and without NLDO. Cronbach's alpha was calculated as a measure of internal-consistency reliability. Factor analysis was used to evaluate a priori subscales: symptoms and HRQL. Discriminant construct validity was assessed by comparing questionnaire scores between children with and without NLDO and between affected and unaffected eyes of children with unilateral NLDO. Instrument responsiveness was determined by comparing presurgical and postsurgical intervention scores in a subset of NLDO patients who underwent surgical treatment. The NLDO questionnaire score. Eighty-seven children were enrolled, 56 with and 31 without NLDO. All but 2 questions on the questionnaire showed a good distribution of responses, a high correlation with the rest of the questionnaire, and excellent discrimination between patients with and without NLDO. Cronbach's alpha values were good for the overall questionnaire (0.95), and for 2 predetermined subscales: symptoms (0.95) and HRQL (0.85). On a 0 to 4 scale, NLDO patients had worse scores compared with non-NLDO patients for both symptoms (mean difference, 2.1; 95% confidence interval [CI], 1.9-2.3) and HRQL (mean difference, 1.2; 95% CI, 0.9-1.5) subscales. The NLDO patients had worse scores before intervention compared with after intervention for both the symptoms (mean difference, 2.2; 95% CI, 1.6-2.9) and HRQL (mean difference, 1.4; 95% CI, 0.8-2.1) subscales. Finally, NLDO patients had worse symptom scores for affected eyes compared with unaffected eyes (mean difference, 2.3; 95% CI, 1.9-2.6). This novel NLDO questionnaire is useful in quantifying parental perception of symptoms and HRQL in childhood NLDO. The questionnaire may have a role in future clinical studies of NLDO.

CLINICAL RESEARCH, Endoscopic Radiofrequency-Assisted Dacryocystorhinostomy with Double Stent: A Personal Experience

Aim: To report the success rate of endoscopic radiofrequency-assisted dacryocystorhinostomy with double stent and the use of a Griffiths collar button. Method: A prospective, single surgeon, uncontrolled, interventional case series study was designed to include 112 patients with nasolacrimal duct obstruction. Endoscopic radiofrequency-assisted dacryocystorhinostomy (ERA-DCR) with insertion of a Griffiths collar button was done on 102 patients with unilateral nasolacrimal duct obstruction and 10 patients with bilateral nasolacrimal duct obstruction. The operation was defined as a success if: a) preoperative epiphora was resolved; b) nasolacrimal patency was achieved as confirmed by lacrimal irrigation as well as by endoscopic observation of fluorescein dye flowing through the surgical ostium on lacrimal irrigation. Results: A total of 122 ERA-DCR procedures was done, of which 117 procedures involved cases of primary acquired nasolacrimal duct obstruction (PANDO) and five procedures involved cases of previously failed endonasal DCR. Two failures were observed in this study out of the 117 procedures done on PANDO cases. The success rate is computed at 98% (115/117). The postoperative follow-up period was 28.08 ± 14.7 months. Conclusion: Endoscopic radiofrequency-assisted dacryocystorhinostomy with double stent and the use of a Griffiths collar button shows a success rate of 98% in the long-term patency of the intranasal ostium.

Balloon catheter dilation for treatment of persistent nasolacrimal duct obstruction

PURPOSE: To report the outcome of balloon catheter dilation of the lacrimal duct for treatment of children with persistent nasolacrimal duct obstruction after previous surgery. DESIGN: Interventional case series. METHODS: Thirty-two consecutive children with a history of persistent nasolacrimal duct obstruction following previous surgery were treated with nasolacrimal duct probing with balloon catheter dilation of the distal nasolacrimal duct. Patients were excluded from this study if they had a history of facial trauma, systemic disorders that involved the lacrimal system, or nasolacrimal duct cysts. Outcomes were considered excellent if the patient had complete symptomatic resolution of epiphora and dacryocystitis and normal tear drainage on examination, good if the patient had only minimal residual symptoms or a minimally delayed dye disappearance test, fair if the patient had moderate residual symptoms or delayed tear drainage, and poor if there was no improvement. RESULTS: Thirty-two children (20 with bilateral nasolacrimal duct obstruction and 12 with unilateral nasolacrimal duct obstruction) underwent balloon catheter dilation. Overall results were excellent in 9 (28%) patients, good in 15 (47%) patients, fair in 7 (22%) patients, and poor in 1 (3%) patient. Seven patients had undergone more than one previous procedure. Of these patients, 3 had excellent outcomes, 2 had good outcomes, 1 had a fair outcome, and 1 had a poor outcome following balloon catheter dilation. CONCLUSIONS: Balloon catheter dilation is a safe and generally effective treatment for children with persistent symptoms of nasolacrimal duct obstruction following previous surgery.