Demystifying a confusing, controversial procedure.
David Silbert, MD Lancaster, Pa.
Of all the treatment challenges in pediatric ophthalmology, nasolacrimal obstruction may be one of the most confusing and controversial. The questions of how early to probe, what to use as a secondary procedure and what kind of anesthesia to use all remain open. In this article, I'll provide my views as an ophthalmologist with fellowship training in both pediatric ophthalmology and oculoplastic surgery. I have devised protocols that work quite well for my patients and my referring pediatricians and family doctors.
The catheter being inserted (top) and the inflation of the balloon in the dacryoplasty procedure.
The Early Stages
When pediatricians call you to report that a child is tearing
excessively, or has "sleep" in the eyes in the morning,
or has persistent discharge and a low-grade infection, you can
be fairly sure you're dealing with nasolacrimal obstruction.
In the early stages, I generally recommend proceeding conservatively. Some studies show that only 37 percent of term infants have patent nasolacrimal systems at birth. However, most spontaneously canalize by two months of age;1 only 5-6 percent of infants older than two months of age present to the primary care doctor with symptomatic congenital nasolacrimal obstruction.
If a low-grade infection is present, I recommend that the parents clean the eyelid skin with a moist face cloth followed by nasolacrimal pushdowns, 10 repetitions four times daily. I do not recommend antibiotic drops unless there is significant discharge present during the day.
Generally, I start with tobramycin drops four times daily, but will switch to ciprofloxacin, ofloxacin or polymyxin/trimethoprim drops if there is no improvement after seven days. Incidentally, I find that parents prefer drops to ointment; it is easier to instill in the child's eyes.
If two different antibiotic drops do not resolve the infection, I instruct the primary care physician to evaluate the child to make sure there is no rhinitis or otitis causing the underlying infection. If there is not, it is generally necessary to place the child on a course of oral antibiotics to clear the infection.
In most cases, the obstruction will clear without the need for surgery. Studies show that approximately 54 percent of nasolacrimal obstructions will resolve spontaneously with conservative treatment by 6 months of age, and another 17 percent will resolve by approximately one year of age.2
If the condition persists until 11 months of age, however, or if there is persistent low-grade infections that do not fully clear up with any topical antibiotics and recur once oral antibiotics are discontinued, surgery is often the best course of action.
Probing
In my practice, probing is the first line of treatment for children
under 18 months of age. A recent study showed good results for
probings even in older children.3 The success rates appear in
Table 1.
In nearly every case, I prefer to probe under general anesthesia; I find this is much more controlled and successful than doing it in the office without sedation. When I probe under general anesthesia, symptoms resolve completely more than 95 percent of the time.
After the procedure, I have parents continue nasolacrimal pushdowns for one week and use an antibiotic/steroid combination drop (tobramycin/dexamethasone) four times a day to minimize infection and scarring, which can cause failure of the procedure. If children show no significant improvement on post-op day one, I start oral antibiotics, since persistent infection (leading to scarring of the nasolacrimal duct) is a major cause of primary probing failure.
Rarely, this procedure fails to resolve the obstruction. Sometimes, the failure occurs due to infection, as mentioned above. Sometimes, the failure occurs due to a stenotic nasolacrimal duct or to bony abnormalities like those that frequently occur in Down syndrome.
When this occurs, I usually perform a balloon dacryoplasty, employing Atrion's Lacricath balloon under endoscopic guidance.
Before doing this procedure, I first make sure there is no nasolacrimal infection present. If there is, I treat with a course of a suitable oral antibiotic and also administer IV antibiotics and IV dexamethasone (Decadron) intraoperatively.
I recommend infracturing the inferior turbinate in these cases so that you can see the valve of Hasner with the endoscope. Occasionally, probings fail because the probe created a false passage; it's possible to see this endoscopically.
Particularly if there was infection present preoperatively, I prescribe a course of oral antibiotics and a taper of steroids postoperatively (Pediapred 1-2 mg/kg total daily dose for three days then 1/2-1mg/kg total daily dose for three days).
In the vast majority of cases, the symptoms resolve after this procedure.
Some surgeons prefer to place silicone Crawford tubes in these cases. I rarely use these devices. I find that the tubes are frequently a nuisance, especially when they are pulled out by the child (usually when I am out of town and my partners, who are corneal, glaucoma, retinal or neuro-ophthalmic specialists are on call) or when they cheesewire. It's also often necessary to place the child under anesthesia a third time to remove the tubes.
Rarely, children fail both their first and second procedures, whether the second procedure is balloon dacryoplasty or placement of Crawford tubes. When they do, they require a dacryocystorhinostomy.
In the past, I have used external DCR in these cases. However, I have had such good results with endoscopic balloon DCRs in adults that I am in the process of switching over to these for children as well.
In a recent case, a young child failed her initial probing. During the procedure, I had noted that the nasolacrimal system appeared tight. When I took her back to the operating room to attempt an endoscopic balloon dacryoplasty, I was able to pass a 0 Bowman probe. But what appeared to be a bony structural anomaly prevented me from passing larger probes, and I could not fit the 2-mm balloon. Crawford tubes also certainly would have failed in this case. After obtaining the parents' consent, I converted to an endoscopic Balloon DCR, using the Lacricath 5.0-mm balloon as well as the thicker stent tubes. The child is doing very well, and the parents were pleased that we could avoid a third procedure as well as visible scars on the child's face.
Intra-operative and postoperative treatment is the same for endoscopic DCR as it is for balloon dacryoplasty. After three months, you can remove the tubes under general anesthesia. You can also re-inspect the osteum endoscopically and redilate it with the balloon if necessary.
For primary probings in children over 18 months of age, I hedge my bets. I generally schedule probing, but also have the balloon catheters and endoscope ready if I need it. If the nasolacrimal system appears tight, I infracture the inferior turbinate, then dilate the nasolacrimal system under endoscopic control with a 3-mm Lacricath balloon. I believe this frequently can save the child a second trip to the operating room.
With modern technology, resolving nasolacrimal obstruction no longer has to be difficult or messy. Using the protocols I described above, I am able to achieve success in more than 95 percent of all cases with probing alone. In cases where failure occurs, I can often resolve it without the inconvenience of Crawford tubes and without creating an external scar.
Dr. Silbert's subspecialties include oculoplastics, pediatric ophthalmology and strabismus.
1. Becker BB, Berry FD, Koller H. Balloon Catheter Dilation
for Treatment of Congenital Nasolacrimal Duct Obstruction. Am
J Ophthalmol 1996;121(3): 304-309.
2. Busse H, Muller K Kroll P: Radiological and histological findings
of the Lacrimal passages of newborns. Arch Ophthalmol 98:528-532,
1980.
3. Katowitz JA, Welsh MG. Timing of initial probing and irrigation
in congenital nasolacrimal obstruction. Ophthalmology 1987;94:698
4. Manor GE, Rose GE, Frimpong-Ansah K, Ezra E. Factors affecting
the success of nasolacrimal duct probing for congenital nasolacrimal
duct obstruction. Am J Ophthalmol 1999 May; 127(5):616-7
Table 1: How Probing Fares
| Age | Success rate |
| 12 months or younger | 92 percent |
| 12-24 months | 89 percent |
| 24-36 months | 80 percent |
| 36-48 months | 71 percent |
| 48-60 months | 42 percent |