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- DOI 10.18231/j.ijceo.2023.093
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CrossMark
- Citation
Treatment management of congenital nasolacrimal duct atresia: A review article
- Author Details:
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Anurag Medatwal *
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Puneet Singhvi
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Ritu Medatwal
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Manoj Garg
Introduction
A atresia of nasolacrimal duct is a common condition in newborns and infants, clinically it present in the form of excessive tears, means epiphora[1] the prevalence is 05% to 20% in children according to epidemiological studies report.[2], [3] MacEwen et al. found too much lacrimation in 95% of neonatal age group and approximately 20% after the neonatal period of infants.[3] The point where the nasolacrimal duct enters into the nose is a place of obstruction[valve of Hasner] and the causes are presence of membrane, bone defect and inferior meatus stenosis.[4], [5] The nasolacrimal apparatus and drainage system develop in the last three months of pregnancy which causes higher percentage of excessive lacrimation in premature baby.[6] It presents clinically in the form of ocular mattering and tearing. Other causes of epiphora are infantile glaucoma, foreign body, corneal infections[7] and conjunctival bacterial infection[1], [8] should be ruled out. A percentage of anisometropic amblyopia found in children with CLND obstruction (10–12%) is high.[7], [9] Maximum number of congenital NLD atresia cases are naturally resolve in their first year of life[10], [11], [12], [13], [14] and, in some cases, this disorder may present after the one year of age, so, more update protocol for the treatment management of congenital nasolacrimal duct atresia are needed.
Observation
The conservative approach is wait and watch policy with proper lacrimal sac massage, and use of antibiotic eye drops topically when a bacterial infection occurs. So many studies shows by the age of 13 month spontaneous resolution from 32% to 95%.[15], [11], [12], [13], [14] Most of the studies explain spontaneous resolution rates are 80–90% in the first three months, 68–75% in second and finally 36–57% in the third[3], [12], [14] trimester of life. Nelson et al. described resolution rate of 93% with conservative management in children aged 8 months or less.[10]
Similarly, Noda et al. Japanese infants are managed with a conservative approach up to the age of nine months.[14] But, self resolution of atresia still occurred after the first year of life;[11], [16] in continuation Young et al. Stated that atresia resolve between 1 to 2 year of life in 44% of the children.[17] Bilateral atresia reported in 14–33.8% cases, which also resolved within the 3 months of age.[18]
Massage of lacrimal sac
The sac massage is a widely accepted conservative treatment method. In continuation of A randomized prospective trial of Kushner shows the efficacy of a simple massage in relation with no massage at all.[19] Though some studies have questioned the clinical effect of this method,[20], [21] a new recent study of Stolovitch et al. showed a success ratio of 56% in children upto 2 months, 46% in children between 2 to 6 month, and 28% in children above 6 months of age.[22]
IN continuation, a recent study gives a statistical difference of resolution rate in infants with lacrimal sac massage and those did not received massage (96.2% vs. 77.7%, p = 0.001.[23] These results shows the Crigler maneuver [lacrimal sac massage] importance. Ultimately, a simple observation with correct massage of sac is the first-line treatment in congenital NLD atresia up to the age of one year. The antibiotic role is not established in noninfective CNLD atresia. Several studies already states that there is no advantage of antibiotic drops with conservative treatement in simple atresia.[12], [24], [25], [26] Moreover, for controlling the local spread of an infection an use of antibiotic drop may be helpful.[27], [28]
In conclusion, most of the articles shows that the antibiotic therapy was used only when the clinical evidence of infection was present. Invasive treatment is also there in the form of NLD dilatation and surgery. The first-line of invasive treatment consists of irrigation with probing and other methods include repeated probing, silicone tube intubation and balloon dilatation of the lacrimal apparatus. The most common surgical treatment is probing in the children of congenital nasolacrimal duct atresia.[16], [17], [29], [30], [31], [32], [33], [34] Evidence shows that resolution rate of congenital nasolacrimal duct atresia in children below 12 months who underwent primary early probing under topical anesthesia, ranges from 75% to 89%, in comparison to children who are older than 12 months. It means a success rate is more in primary late probing in comparison with early probing[35], [36], [37], [38]. In continuation, several articles claims better results in affected children above one year.[39], [40], [41] In sequence, Rajabi et al. claim rewarding results in 75.8%, specifically 85% in 2 to 3 years, 63% in 3 to 4 years, and 50% in 4 to 5 years of age group.[42] Napier et al. claim A 76% of success rate in primary probing as a first-line intervention having no relation of gender, age and type of obstruction. [43].
The conservative treatment which is safe and effective in the most of the children and comparable results found in older than 12 months by late probing, so it acts as a reasonable second-line treatment strategy.
The clinical efficacy of other surgical interventions has been studied by Several studies. The placement of a silicone tube stent in canaliculi by nasolacrimal intubation in one or both nasal canaliculi is method of nasolacrimal intubation [14], [44] generally tubes are left in situ for a period of 2 to 6 months.
The nasolacrimal intubation having good results with some complications, but still, it should be regarded more in effective second-line management strategy.[45], [18], [46], [47]
For reducing the probing-induced complications[48], [49] the nasolacrimal duct dilate by the balloon catheter inflation.
If all these procedures have no results, means there are some problem in the form of bony obstruction, dacryocystitis, and dacryocystocele. Dacryocystorhinostomy is surgical procedure of choice[50], [51] but recent endoscopic technique having better success rate and decreased postoperative complications by external surgical approach.[52], [53]
Conclusions
A relatively common condition in the pediatric population (5–20% is Congenital nasolcrimal duct atresia.
Two third of children having congenital NLD atresia below the one year of age can be managed successfully by conservative medical treatment with high success rate.
Training of parents should be proper for performing a correct lacrimal sac massage [Crigler maneuver] 4-5 times a day which increases the spontaneous resolution chances. Due to the possibility of spontaneous resolution after first year, a invasive treatment should be performed after the age of 15 to 18 months age.
Conversely, due to lack of proof in support of antibiotic therapy in congenital nasolacrimal duct atresia treatment so antibiotics should be restricted only for the infective cases.
Early probing and late probing having comparable results, so it can be postponed for first year of life and considered for better results within 2-3 years of age. More specifically the first-line invasive treatment is probing. For that the conservative approach for treatment of congenital nasolacrimal duct atresia should be postponed as long as possible and invasive method should be considered when the conservative treatment method fails. In some cases where the probing methods fails second line of surgical management can be opted such as balloon catheter intubation and endoscopic dacryocystorhinostomy. These second line method are advanced surgical method.
Source of Funding
None.
Conflict of Interest
None.
References
- BM Schnall. Pediatric nasolacrimal duct obstruction. Curr Opin Ophthalmol 2013. [Google Scholar]
- D Sevel. Development and congenital abnormalities of the nasolacrimal apparatus. J Pediatr Ophthalmol Strabismus 1981. [Google Scholar]
- CJ Macewen, JD Young. Epiphora during the first year of life. Eye (Lond) 1991. [Google Scholar]
- EE Moscato, JP Kelly, A Weiss. Developmental anatomy of the nasolacrimal duct: implications for congenital obstruction. Ophthalmology 2010. [Google Scholar]
- AH Weiss, F Baran, J Kelly. Congenital nasolacrimal duct obstruction: Delineation of anatomic abnormalities with 3-dimensional reconstruction. Arch Ophthalmol 2012. [Google Scholar]
- SHT Lorena, JAF Silva, MJ Scarpi. Congenital nasolacrimal duct obstruction in premature children. J Pediatr Ophthalmol Strabismus 2013. [Google Scholar]
- NS Matta, EL Singman, DI Silbert. Prevalence of amblyopia risk factors in congenital nasolacrimal duct obstruction. J AAPOS 2010. [Google Scholar]
- MB Kashkouli, A Sadeghipour, R Kaghazkanani, A Bayat, F Pakdel, GH Aghai. Pathogenesis of primary acquired nasolacrimal duct obstruction. Orbit 2010. [Google Scholar]
- NS Matta, DI Silbert. High prevalence of amblyopia risk factors in preverbal children with nasolacrimal duct obstruction. J AAPOS 2011. [Google Scholar]
- LR Nelson, JH Calhoun, H Menduke. Medical management of congenital nasolacrimal duct obstruction. Ophthalmology 1985. [Google Scholar]
- P Nucci, C Capoferri, R Alfarano, R Brancato. Conservative management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 1989. [Google Scholar]
- H Kakizaki, Y Takahashi, S Kinoshita, K Shiraki, M Iwaki. The rate of symptomatic improvement of congenital nasolacrimal duct obstruction in Japanese infants treated with conservative management during the 1st year of age. Clin Ophthalmol 2008. [Google Scholar]
- HW Price. Dacryostenosis. J Pediatr 1947. [Google Scholar]
- TO Paul. Medical management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 1985. [Google Scholar]
- RA Petersen, RM Robb. The natural course of congenital obstruction of the nasolacrimal duct. J Pediatr Ophthalmol Strabismus 1978. [Google Scholar]
- SA Schellini, SCF Ribeiro, E Jaqueta, CR Padovani, CR Padovani. Spontaneous resolution in congenital nasolacrimal obstruction after 12 months. Semin Ophthalmol 2007. [Google Scholar]
- JD Young, CJ Macewen, SA Ogston. Congenital nasolacrimal duct obstruction in the second year of life: A multicentre trial of management. Eye (Lond) 1996. [Google Scholar]
- MX Repka, BM Melia, RW Beck, CS Atkinson, DL Chandler, J Holmes. Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age. J AAPOS 2008. [Google Scholar]
- BJ Kushner. Congenital nasolacrimal system obstruction. Arch Ophthalmol 1973. [Google Scholar]
- BA Weil. Application of clinical technics and surgery in the diagnosis and treatment of lacrimal apparatus pathology. Arch Oftalmol B Aires 1967. [Google Scholar]
- LT Jones. Anatomy of the tear system. Int Ophthalmol Clin 1973. [Google Scholar]
- C Stolovitch, A Michaeli. Hydrostatic pressure as an office procedure for congenital nasolacrimal duct obstruction. J AAPOS 2006. [Google Scholar]
- O Karti, E Karahan, D Acan, T Kusbeci. The natural process of congenital nasolacrimal duct obstruction and effect of lacrimal sac massage. Int Ophthalmol 2016. [Google Scholar]
- RM Robb. Congenital nasolacrimal duct obstruction. Ophthalmol Clin North Am 2001. [Google Scholar]
- YS Kim, SC Moon, KW Yoo. Congenital nasolacrimal duct obstruction: Irrigation or probing?. Korean J Ophthalmol 2000. [Google Scholar]
- RA Welham, SM Hughes. Lacrimal surgery in children. Am J Ophthalmol 1985. [Google Scholar]
- CJ Macewen, MG Phillips, JD Young. Value of bacterial culturing in the course of congenital nasolacrimal duct (NLD) obstruction. J Pediatr Ophthalmol Strabismus 1994. [Google Scholar]
- JD Young, CJ Macewen. Managing congenital lacrimal obstruction in general practice. BMJ 1997. [Google Scholar]
- C Petris, D Liu. Probing for congenital nasolacrimal duct obstruction. Cochrane Database Syst Rev 2017. [Google Scholar]
- JD Baker. Treatment of congenital nasolacrimal system obstruction. J Pediatr Ophthalmol Strabismus 1985. [Google Scholar]
- D Stager, JD Baker, T Frey, DR Weakley, EE Birch. Office probing of congenital nasolacrimal duct obstruction. Ophthalmic Surg 1992. [Google Scholar]
- RM Robb. Probing and irrigation for congenital nasolacrimal duct obstruction. Arch Ophthalmol 1986. [Google Scholar]
- TO Paul, R Shepherd. Congenital nasolacrimal duct obstruction: Natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 1994. [Google Scholar]
- J Kassoff, DR Meyer. Early office-based vs. late hospital-based nasolacrimal duct probing. A clinical decision analysis. Arch Ophthalmol 1995. [Google Scholar]
- K Hayashi, N Katori, H Komatsu, K Ohno-Matsui. Spontaneous resolving rate of congenital nasolacrimal duct obstruction and success rate of late probing after age 18 months: Historical cohort study. Nippon Ganka Gakkai Zasshi 2014. [Google Scholar]
- LB Nelson. Late probing success for congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 2008. [Google Scholar]
- R Maheshwari, S Maheshawri. Late probing for congenital nasolacrimal duct obstruction. J Coll Physicians Surg Pak 2007. [Google Scholar]
- S Arora, K Koushan, J Harvey. Success rates of primary probing for congenital nasolacrimal obstruction in children. J Aapos 2012. [Google Scholar]
- JA Katowitz, MG Welsh. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction. Ophthalmology 1987. [Google Scholar]
- MB Kashkouli, A Kassaee, Z Tabatabaee. Initial nasolacrimal duct probing in children under age 5: Cure rate and factors affecting success. J AAPOS 2002. [Google Scholar]
- MB Kashkouli, B Beigi, MM Parvaresh, A Kassaee, Z Tabatabaee. Late and very late initial probing for congenital nasolacrimal duct obstruction: What is the cause of failure?. Br J Ophthalmol 2003. [Google Scholar]
- MT Rajabi, Y Abrishami, SS Hosseini, SZ Tabatabaee, MB Rajabi, JJ Hurwitz. Success rate of late primary probing in congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 2014. [Google Scholar]
- ML Napier, DJ Armstrong, SF Mcloone, EM Mcloone. Congenital Nasolacrimal Duct Obstruction: Comparison of Two Different Treatment Algorithms. J Pediatr Ophthalmol Strabismus 2016. [Google Scholar]
- SM Goldstein, JB Goldstein, J Katowitz. Comparison of monocanalicular stenting and balloon dacryoplasty in secondary treatment of congenital nasolacrimal duct obstruction after failed primary probing. Ophthalmic Plast Reconstr Surg 2004. [Google Scholar]
- MK Kapadia, SK Freitag, JJ Woog. Evaluation and management of congenital nasolacrimal duct obstruction. Otolaryngol Clin North Am 2006. [Google Scholar]
- JE Marr, A Drake-Lee, HE Willshaw. Management of childhood epiphora. Br J Ophthalmol 2005. [Google Scholar]
- H Al-Hussain, A M Nasr. Silastic intubation in congenital nasolacrimal duct obstruction: A study of 129 eyes. Ophthal. Plast. Recons 1993. [Google Scholar]
- DR Casady, DR Meyer, JW Simon, GO Stasior, JL Zobal-Ratner. Stepwise treatment paradigm for congenital nasolacrimal duct obstruction. Ophthalmic Plast Reconstr Surg 2006. [Google Scholar]
- S Tao, DR Meyer, JW Simon, J Zobal-Ratner. Success of balloon catheter dilatation as a primary or secondary procedure for congenital nasolacrimal duct obstruction. Ophthalmology 2002. [Google Scholar]
- TS Nowinski, JC Flanagan, J Mauriello. Pediatric dacryocystorhinostomy. Arch Ophthalmol 1985. [Google Scholar]
- HG Struck, R Weidlich. Indications and prognosis of dacryocystorhinostomy in childhood. A clinical study 1970-2000. Ophthalmologe 1970. [Google Scholar]
- F Celenk, S Mumbuc, C Durucu, ZA Karatas, I Aytac, E Baysal. Pediatric endonasal endoscopic dacryocystorhinostomy. Int J Pediatr Otorhinolaryngol 2013. [Google Scholar]
- CE deSouza, J Nisar, RA deSouza. Pediatric endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg 2012. [Google Scholar]