Endoscopy can aid treatment of pediatric nasolacrimal duct obstruction

Reviewed by Rona Z. Silkiss, MD, FACS

San Francisco-Adding endoscopy to one’s skills set can dramatically improve the treatment of pediatric nasolacrimal duct obstruction (PNLDO).

Ophthalmologists tasked with clearing blocked tear ducts in infants traditionally probe until the duct is cleared or the probe is palpated with the suction leading to a “metal on metal” feel. Using an endoscope allows the clinician to visualize the tip of the probe and remove the obstruction more easily, quickly, and accurately, said Rona Z. Silkiss, MD, FACS.

“You cannot adequately manage what you cannot visualize,” said Dr. Silkiss, chief of ophthalmic plastic, reconstructive and orbital surgery, California Pacific Medical Center, San Francisco.

“With an endoscope, PNLDO suddenly changes from blocked/not blocked to defining anatomically where the nasolacrimal duct is obstructed, whether you are in the correct location and whether you have opened the closed valve of Hasner adequately,” she said. “Using an endoscope is transforming our ability to define and solve specific causes of PNLDO much more effectively than in the past.”

Advantages of endoscopy

PNLDO is the single most common cause of persistent epiphora in childhood, Dr. Silkiss noted.

Between 5% and 6% of newborns present with PNLDO, but more than 90% of cases resolve spontaneously within the first year of life.

“Everyone who practices ophthalmology, every pediatrician and every family physician doctor is going to be asked how to manage these children,” Dr. Silkiss said. “It is a fairly ubiquitous problem that has a well-defined approach to resolution.”

PNLDO is a congenital condition, she continued.

The tear duct develops as a solid cord of cells in utero, then transforms into a canal during the final weeks of pregnancy. The canalization process is not completed at birth in a small but significant percentage of neonates, leading to persistent epiphora.

The first question to ask is whether the infant has PNLDO or another condition, such as conjunctivitis, blepharitis, congenital glaucoma, entropion, epiblepharon or trichiasis leading to the epiphora. The traditional therapeutic paradigm calls for Crigler massage for the first year unless the infant has repeated infections.

If the blockage does not clear by the child’s first birthday, probing can be used in the office to attempt to clear the blockage. But in-office is difficult for patient, parent, and ophthalmologist and can lead to the creation of a false passage.

Symptom-based treatment

Symptom-based treatment

The latest data suggest symptom-based treatment. If the child has a weepy eye without infection, wait for the blockage to clear spontaneously during the first year. If the child has repeated infections and requires repeated courses of antibiotics, early intervention may be recommended. If the blockage persists beyond the first birthday, it is time to intervene.

“Once you make the decision to intervene, the question is how and where you do it,” Dr. Silkiss said. “The data show that if you probe every child with PNLDO at 6 months in the office, you have 92% success at 18 months. The results are great, but two-thirds of those children didn’t need to be probed because they would have resolved on their own.”

Primary probing with intubation can also produce good results. Reported success rates range from 90% to 96% depending on the study and age at treatment. Primary balloon dacryoplasty has a success rate of 80% and is significantly more costly than intubation, $350 for the balloon compared to $80 for a silicone tube.

While NLD probing and intubation are more successful and less costly than balloon dacroplasty, primary probing is not always successful.

Probing is blind and the probe may go astray. Some ducts fail to open through the nasal mucosa and some ducts extend lateral to the nasal mucosa or to the floor. Some children have no duct at all or have a bony obstruction. The anterior end of the inferior turbinate may be impacted or there may be craniofacial anomalies leading to obstruction.

“You can’t clear what you can’t visualize in these complex situations,” Dr. Silkiss said. “Baby noses are very tiny and when you try to look into the nose using traditional approaches, you can’t see very much. Leveraging new technologies such as endoscopy has dramatically improved outcomes for these children, especially those previously considered difficult to treat.”

Endoscopic surgery success rate

The current literature shows an over a 94% success rate for endoscopic surgery in the treatment of PNLDO, Dr. Silkiss added.

Importantly as well, PNLDO is associated with higher rates of anisometropia (8.6% versus 0.66% in the general population) and amblyopia (5.8% versus 1.6% to 3.6%). All children treated for PNLDO therefore should undergo a cycloplegic refraction at the initial and follow-up exams.

“Endoscopic surgery for PNLDO has come into its own in the past few years,” she said. “I would highly encourage other ophthalmologists to use endoscopy. It is wonderful to be able to see anatomy that you have never been able to visualize before with such clarity and deal with difficult blockages with greater precision.”

Rona Z. Silkiss, MD, FACS

E: drsilkiss@silkisseyesurgery.com

This article was adapted from Dr. Silkiss’ presentation at the 2015 meeting of the American Academy of Ophthalmology. She did not indicate any proprietary interest in the subject matter.