Comparison of monocanalicular stenting and balloon dacryoplasty in secondary treatment of congenital nasolacrimal duct obstruction after failed primary probing

PURPOSE: To determine the success of monocanalicular stenting and balloon dacryoplasty as secondary treatment options for congenital nasolacrimal duct obstruction after failed probing surgery. METHODS: An interventional case series of consecutive secondary balloon dacryoplasty and monocanalicular stenting for congenital nasolacrimal duct obstruction was reviewed. These secondary treatments were used in cases in which a bicanalicular stent would have been used in the past. Seventy-seven nasolacrimal systems in children with epiphora after probing and irrigation surgery were treated with a monocanalicular stent or balloon dacryoplasty. The patients were then evaluated at least 3 months after surgery or after stent removal by using a dye disappearance test. Cases in which there was no significant dye at 5 minutes were considered a success. Cases with residual dye or history of persistent tearing were considered failures. RESULTS: The monocanalicular stent was used in 35 nasolacrimal systems, whereas balloon dacryoplasty was used in 42 nasolacrimal ducts. The mean age of treatment was 25.2 months for the monocanalicular stent group and 25.8 months for the balloon group. Overall, 32 of 35 (91%) nasolacrimal ducts responded to monocanalicular stenting, whereas 36 of 42 (86%) responded to balloon treatment. When the patient group was further stratified by age, the monocanalicular stenting was 94% successful in children younger than age 2 years and 89% successful for children older than 2 years. The balloon treatment had a success rate of 91% in the younger group and 79% in the older group. Chi-square statistical analysis showed no significant difference between the two treatments or on the basis of age stratification within each treatment group. CONCLUSIONS: Monocanalicular stenting and balloon dacryoplasty are excellent secondary therapies for congenital nasolacrimal duct obstruction after initial probing and irrigation surgery has failed. These two treatment options are now our procedures of choice for secondary surgery.     

Efficacy of endoscopic guided anterograde 3 mm balloon dacryoplasty with silicone intubation in treatment of acquired partial nasolacrimal duct obstruction in adults

Aim

To report the outcomes of endoscopic guided anterograde 3 mm balloon dacryoplasty with silicone intubation in patients with acquired partial nasolacrimal duct obstructions in adults.

Methods

Retrospective case series, included 21 eyes with partially obstructed nasolacrimal ducts of 12 patients. All the 21 ducts were initially probed and the probe confirmed with an endoscope in the inferior meatus. After confirming the presence of probe in the inferior meatus, a 3 mm balloon was used for dilating the distal and proximal portions of nasolacrimal duct, followed by stenting of ducts with Crawford tubes. Main outcome measures were anatomical patency of the passage and resolution of epiphora.

Results

Of the 12 patients, 9 had bilateral and 3 had unilateral acquired partial nasolacrimal duct obstructions. All the patients underwent bicanalicular stenting under endoscopic guidance which were retained for a period of 12 weeks. A minimum follow up of 6 months following stent removal was considered for final analysis. 15 of the 21 ducts (71%) were freely patent on irrigation but 13 of the 21 reported improvement of epiphora. Two nasolacrimal ducts showed similar partial regurgitation and partial patency on syringing as before with no improvement of symptoms. Four nasolacrimal ducts were completely obstructed with complete regurgitation of fluid on syringing with worsening of the epiphora. Two eyes persisted with symptoms of epiphora despite patent nasolacrimal duct with grade 2 dye retention on dye disappearance test.

Conclusions

3 mm balloon dacryoplasty is an alternative and safe way to manage partial nasolacrimal duct obstructions with an anatomical success in 71% and functional success in 62% of the patients. Further studies with a large sample size and longer follow-up are required to ascertain the long term benefits.     

Balloon catheter dilation for treatment of adults with partial nasolacrimal duct obstruction: a preliminary report

PURPOSE: The purpose of this study is to determine the efficacy and morbidity of balloon catheter dilation for treatment of partial acquired nasolacrimal duct obstruction in adults with epiphora.METHODS: We performed balloon dacryocystoplasty prospectively on a series of 15 partial nasolacrimal duct obstructions in 13 adults with epiphora. Partial obstruction was diagnosed by a negative Jones-1 test and canalicular irrigation revealing simultaneous reflux through the opposing punctum and drainage into the nose. Balloon dacryocystoplasty was performed under local anesthesia using an antegrade insertion technique. Silicone intubation of the nasolacrimal system was performed immediately after balloon catheter dilation, and the tubes were removed 2 months postoperatively.RESULTS: Success was measured objectively and subjectively at follow-up examinations 2 months and 6 months after the procedure. At 2 months, 11 (73%) of 15 obstructions were open on irrigation, with subjective success (Munk, grade 0 or grade 1) reported in 13 (87%) of 15 obstructions. At 6 months, 11 (73%) of 15 obstructions were open on irrigation, with subjective success (Munk, grade 0 or grade 1) reported in 9 (60%) of 15 obstructions.CONCLUSIONS: Balloon dacryocystoplasty may be a satisfactory primary treatment for adults with acquired partial nasolacrimal duct obstruction who exhibit no clinical signs of chronic infection. Additional long-term observations following balloon dacryocystoplasty are required.     

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.     

Four-year experience with intranasal transilluminating dacryocystorhinostomy using ultrasound

BACKGROUND: The aim of this study was to investigate the results obtained by intranasal dacryocystorhinostomy. METHODS: This was a prospective, non-randomised, non-comparative case series study of 150 patients with epiphora due to nasolacrimal duct obstruction. The same team of ophthalmic and otorhinologic surgeons performed the transilluminating intranasal dacryocystorhinostomy using ultrasound. The main outcome measures were subjective improvement of epiphora, dye testing, lacrimal probing, lacrimal irrigation, and endoscopic nasal examination. RESULTS: Symptomatic relief and patency of the lacrimal apparatus was achieved in 92% (138) of the patients at the 3-month follow-up and 89% (134) at the 6-month follow-up. At 1 year, only 2 patients of the 134 initial successes showed obstruction of the nasolacrimal duct. All 16 successful patients that we have followed for 4 years have sustained their improvement. INTERPRETATION: Transilluminating intranasal dacryocystorhinostomy is a quick and safe option for the treatment of nasolacrimal duct obstruction. The main advantages over external dacryocystorhinostomy are avoidance of skin incision, reduced haemorrhage, shorter duration of the operation, and quicker recovery of the patient.     

球囊管扩张术治疗儿童先天性泪道阻塞的临床观察

目的 观察球囊管扩张术治疗儿童先天性泪道阻塞的手术方法、疗效与并发症.方法 前瞻性研究.2008年5月至2009年10月,对就诊于首都医科大学附属北京儿童医院眼科的31例(50只眼)泪道探通、插管和激光术后失败的先天性鼻泪管阻塞患儿进行全身麻醉下鼻泪管球囊管扩张术,探针经泪小管探通直至鼻泪管,顺行插入尾端带有球囊的导管探针,进行鼻泪道球囊管扩张.手术前后进行症状评估、荧光染料消失试验以及泪道冲洗检查,同时对术中出血、水肿、假道形成等并发症进行观察与分析.随访时间为术后4～17个月.结果 50只眼中44只眼治愈,总成功率为88.0%(95%CI 85.5%～96.9%),荧光染料消失试验40只眼(80.0%)显示为1级或0级.主要术中并发症有10只眼(20.0%)鼻腔少量出血,有2只眼(4.0%)出现泪小点裂伤.结论 球囊管扩张术是一种便捷、安全、有效,不破坏局部解剖结构的新型儿童泪道手术方法,可用于泪道探通、插管或泪道激光手术失败后的儿童先天性泪道阻塞治疗.

Abstract：

Objective To introduce the procedure of balloon dacryocystoplasty and to evaluate its effectiveness and complications as the treatment of congenital nasolacrimal duct obstruction after a previous unsuccessful surgery. Methods Prospective case series. Balloon dacryocystoplasty was performed under general anesthesia in 50 eyes of 31 children with congenital nasolacrimal duct obstruction following previous unsuccessful surgery in Beijing Children's Hospital between May 2008 and October 2009. A probe was introduced through the punctum into the inferior meatus of the nasal cavity. A deflated balloon catheter was introduced anterogradely and the balloon was inflated several times to perform the dilation of the nasolacrimal duct. Treatment success was defined as absence of epiphora and mucous discharge,negative results of fluorescein dye disappearance test(FDDT) and the unobstructed irrigation of the lacrimal system during the follow-up period of 4 - 17 months after tube removal. Results Successful operation was reported in 44 of 50 eyes ( 88.0%;95% confidence interval 85.5% - 96. 9% ). Forty of 50 eyes were FDDT 0 - 1(80. 0% ). Major complications included epistaxis (10 eyes,20. 0% ) and lacrimal duct laceration (2 eyes,4. 0% ). Conclusion Balloon dacryocystoplasty is a safe,simple and effective procedure for congenital nasolacrimal duct obstruction following previous unsuccessful surgery without disturbing the anatomy of normal lacrimal drainage system.     

The histopathologic effects of balloon dacryoplasty on the rabbit nasolacrimal duct.

PURPOSE: To examine the histopathologic effects of balloon dacryoplasty on the nasolacrimal duct of the rabbit. METHODS: Sixteen nasolacrimal ducts of 8 infant white New Zealand rabbits were divided into 3 treatment groups: a control group, a 2 mm balloon dilation group, and a 3 mm balloon dilation group. The LacriCath balloon catheter (Quest, Medical, Allen, TX) was used for nasolacrimal duct dilation according to the manufacturer's recommended human protocol. The rabbits were euthanized at 1, 3, and 7 days after treatment and the nasolacrimal ducts were harvested for histological examination. RESULTS: There were no significant differences between treatment groups in the number of neutrophils in the lumen, epithelium, and stroma of the duct; the number of monocytes in the stroma of the duct; or in the number of red blood cells in the stroma of the duct. No differences were found in overall cellularity of any type in the nasolacrimal ducts of treated and untreated rabbits. Finally, no histopathologic signs of crush injury were evident. CONCLUSION: Balloon dacryoplasty does not induce significant inflammation or crush injury in the nasolacrimal duct of a rabbit model.     

Antegrade balloon dilatation of nasolacrimal duct obstruction in adults

AIMS: To determine the efficacy of antegrade balloon dilatation of postsaccal lacrimal stenosis in adults. METHODS: Balloon dilatation was performed in a series of 30 patients with complete nasolacrimal duct obstructions and epiphora. Obstruction was diagnosed by canalicular irrigation and transcanalicular endoscopic examination of the lacrimal pathway. Except for four cases in which general anaesthesia was applied, the procedure was performed under local anaesthesia. The Lacricath balloon catheter set was used. Silicone intubation was performed simultaneously. The time at which the tubes were removed depended on the findings at postoperative follow up but was, at the earliest, 3 months postoperatively. RESULTS: Success was objectified by irrigation and was evaluated subjectively at each follow up examination according to Munk's scale. In all cases the procedure could be performed with subsequent silicone intubation. Three months postoperatively 89.9% of all cases were positive on simple irrigation, and subjective success was also registered (Munk's grade 0 or 1). At 6 months 70% of all cases were positive on irrigation, again with subjective success (Munk's grade 0 or 1). One year postoperatively 73.3% of all procedures showed subjective success (two successful redilatations would raise the success rate to 79.9%). CONCLUSION: Retrograde as well as antegrade dilatation has been reported to be more or less successful in partial nasolacrimal obstruction. Although the procedure is used as primary treatment in cases of complete obstruction, it can still be performed under local anaesthesia on an outpatient basis. Long term observation will be required to prove the sustained effect of this procedure.     

Balloon dilation of the nasolacrimal duct.

PURPOSE: Our purpose is to report our experience with balloon catheter dilation of the nasolacrimal duct after failed probing for congenital nasolacrimal duct obstruction. METHODS: We undertook a retrospective chart review. Patients who were enrolled had symptoms of persistent nasolacrimal duct obstruction after simple probing and irrigation. Balloon nasolacrimal ductoplasty was performed using the LacriCATH system (Quest Medical, Inc. An Atrion Company, Allen, TX). Outcomes were determined by postoperative examination and telephone follow-up. RESULTS: Thirty-nine lacrimal systems of 26 patients (age range, 10 months to 84 months) were treated. Of the obstructed ducts treated, 82% (32/39) showed resolution of epiphora. There were 9 children older than the age of 2, with 15 nasolacrimal systems studied. These had 11 of 15 successes for a success rate of 73%. There were 17 children between the ages of 10 months and 2 years with 24 nasolacrimal systems studied. These had 21 of 24 successes for a success rate of approximately 88%. The difference was not statistically significant (P = 0.28). CONCLUSION: Balloon dilation of the nasolacrimal duct is an alternative to silicone intubation in the treatment of congenital nasolacrimal duct obstruction after failed simple probing. Although our success rate was slightly lower than some published reports of nasolacrimal system intubation, this simple and atraumatic procedure was successful in 82% of cases for this specific situation.     

Assessment of functional nasolacrimal duct obstruction--a survey of ophthalmologists in the southwest

The term 'functional nasolacrimal duct obstruction' describes patients with epiphora where the tear duct is partially or completely patent to syringing. Delayed tear drainage is demonstrated with a fluorescein dye disappearance test (FDDT) or lacrimal scintigraphy. A dacrocystogram is also frequently abnormal.Studies show that selected patients with epiphora because of functional nasolacrimal duct obstruction have an 80-90% success rate with open or endonasal dacryocystorhinostomy. To find out if such patients were being considered for surgery, we sent a questionnaire to all ophthalmologists in the southwest. Of the 198 questionnaires, 163 were completed and returned (82%). In the assessment of epiphora, fewer than half those questioned (41%) regularly used an FDDT and only 51% syringe patients themselves. Most did not use lacrimal scintigraphy or dacrocystography if the drainage system was patent on syringing. This survey shows that many patients with epiphora who are patent to syringing are being incompletely assessed, and hence not considered for dacrocystorhinostomy. We recommend that an FDDT is performed on all patients, syringing is carried out by experienced staff, and more radiological investigations are undertaken, so patients with a highly treatable cause of epiphora can be offered dacrocystorhinostomy.     

Trephination and silicone stent intubation for the treatment of canalicular obstruction: effect of the level of obstruction

PURPOSE: To investigate the efficacy of canalicular trephination and silicone stent intubation procedure for relief of epiphora according to the level of obstruction within the canaliculus. METHODS: The medical records of 32 patients (41 eyes) who underwent canalicular trephination followed by silicone stent intubation of the nasolacrimal system for the treatment of canalicular obstruction were retrospectively reviewed. Canalicular obstruction was diagnosed on preoperative irrigation and probing. Level of obstruction was confirmed by intraoperative probing. Proximal obstruction was classified as those within 4 mm of the punctum, distal obstruction as those 5 mm or greater from the punctum, and common canalicular obstruction as those 10 mm or greater from the punctum. Silicone stents were kept in for a minimum of 5 months, and outcome was based on symptomatic relief of epiphora at the end of follow-up (minimum of 6 months). Partial relief of epiphora was defined as improved symptoms and at least a fair clearance on fluorescein dye disappearance testing. RESULTS: On average, 49% of eyes had complete relief of epiphora, 38% had partial relief, and 13% had no relief. Eighty percent of eyes with distal lower canalicular obstructions had complete relief of epiphora and 20% had partial relief of epiphora. Eyes with distal bicanalicular obstructions had 66% complete and 33% partial relief. Patients with common canalicular obstructions had 59% complete, 29% partial, and 12% no relief. Proximal bicanalicular obstructions were the least successful, with 55% partial relief and 45% no relief. CONCLUSIONS: Success of canalicular trephination and silicone stent intubation for treatment of canalicular obstruction is based on the site of obstruction. Distal monocanalicular obstructions have the highest degree of symptomatic epiphora relief, followed by distal bicanalicular, common, and proximal obstructions.     

Is dacryocystectomy effective in reducing epiphora?

Purpose:To study the efficacy of dacryocystectomy (DCT) in reducing epiphora in cases of primary acquired nasolacrimal duct obstruction.Methods:This was a prospective, nonrandomized, interventional study conducted over a period of 12 months. All cases who either opted or satisfied our criteria for DCT in primary acquired nasolacrimal duct obstruction (age above 70 years) were included in the study. Patients with secondary nasolacrimal duct obstruction and those undergoing revision surgeries were excluded. Patients were asked to report the percentage improvement in postoperative watering subjectively. Munk score and fluorescein dye disappearance test (FDDT) were recorded pre- and postoperatively. Wilcoxon signed ranked test was used for analysis.Results:Eighty-two eyes of 65 patients were included. Most of the patients (46, 70.8%) were females. The mean age was 68.46 ± 5.7 years (range: 60–85 years). The mean subjective improvement in watering was 86.8%. The P value for preoperative and postoperative difference in Munk score and FDDT score was highly significant (P = 0.00001).Conclusion:Apart from providing relief from ocular discharge, DCT also provides significant improvement in watering. Patients can be preoperatively counseled regarding chances of reduction in epiphora following surgery.     

Efficacy of probing the nasolacrimal duct with adjunctive Mitomycin-C for epiphora in adults.

PURPOSE: To investigate the efficacy and safety of adjunctive low-dose mitomycin-C during lacrimal probing for adults with blocked nasolacrimal ducts. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: From January 1998 to December 2000, a total of 32 adult patients (36 eyes) seen with epiphora caused by primary nasolacrimal duct obstruction was treated and evaluated. INTERVENTION: Lacrimal probing with adjunctive mitomycin-C (0.2 mg/ml). MAIN OUTCOME MEASURES: Objective evaluation of patency with irrigation, as well as patients' subjective assessment of improvement. RESULTS: For 32 of the treated eyes (89%), the nasolacrimal duct remained open 9 months after treatment. Repeat procedure was successful for two of the remaining four eyes with recurrent obstruction during follow-up, yielding an overall patency rate of 94%. Patient satisfaction was assessed after 9 months and indicated that the epiphora was at least mildly improved for 30 (83%) of the treated eyes. Watering was completely absent for nine eyes (25%), rated as moderately improved for 17 (47%), and mildly improved for 4 (11%). No complications were encountered over the 9-month follow-up period. CONCLUSIONS: Our experience suggests good long-term results for probing with adjunctive, topical Mitomycin-C for cases of adult epiphora caused by obstruction of the nasolacrimal duct followed by repeat procedure if necessary. It can be recommended as a simple, effective, and minimally invasive technique, with no significant complications resulting from low-dose use in our study.     

Nasolacrimal obstruction secondary to I(131) therapy

PURPOSE: To report the finding of nasolacrimal drainage system obstruction associated with I(131) therapy for thyroid carcinoma from an updated and expanded cohort. METHODS: Patients with a history of epithelial derived thyroid carcinoma who had tearing were offered referral for evaluation by an oculoplastic surgeon. Patients underwent nasolacrimal probing and irrigation procedures with localization of their nasolacrimal obstruction. Therapy for the site of obstruction was instituted. RESULTS: Clinically significant tearing was identified in 26 patients, all of whom had previously undergone I(131) therapy (n = 563). Nineteen patients were evaluated and confirmed to have nasolacrimal drainage system obstruction; 7 have yet to be formally evaluated. Areas of obstruction included nasolacrimal duct, common canaliculus, and, rarely, distal upper and lower canaliculi. Patients were treated with a variety of modalities including silicone intubation, balloon dacryoplasty, dacryocystorhinostomy, and conjunctival dacryocystorhinostomy. CONCLUSIONS: The use of I(131) for thyroid carcinoma is associated with a 3.4% incidence of documented nasolacrimal drainage obstruction and an overall 4.6% incidence of documented or suspected obstruction. The true incidence may be higher, since - I(131) treated individuals were neither systematically evaluated nor questioned about tearing. It has yet to be established if the obstructions result from local toxicity caused by the passive flow of radioactive iodine containing tears through these tissues or the active uptake and concentration of I(131) in lacrimal drainage system tissues through the sodium/iodide supporter.     

The management of nasolacrimal duct obstruction in children between 18 months and 4 years old.

PURPOSE: Success with nasolacrimal duct probing has been shown to be inversely correlated with age. Consequently, several authors have suggested that the older child with a previously untreated nasolacrimal duct obstruction should undergo silicone intubation or a balloon catheterization as the primary surgical procedure because older children are more likely to have complicated obstructions that will not respond to simple probing. The purpose of this study was to investigate the hypothesis that older children with uncomplicated nasolacrimal duct obstruction can be successfully managed with simple probing. METHODS: A 14-year prospective study was conducted of consecutive patients older than age 18 months with nasolacrimal duct obstruction. All were treated (subject to certain exclusion criteria) with a simple nasolacrimal duct probing. Careful attention was paid to the type of obstruction encountered at surgery. Outcome evaluation included a standard ophthalmologic examination plus a dye disappearance test at 6 weeks after surgery. A follow-up examination or telephone interview was conducted 1 year after surgery. RESULTS: Of 378 children undergoing nasolacrimal duct probing, 23 met the inclusion criteria of being older than age 18 months (18 to 48 months). Seventy percent of the 23 children had a good outcome from the probing procedure. When analyzed by the type of obstruction, 12 of the 12 children (100%) with a simple membrane at the valve of Hasner had a good outcome. This contrasted with a success rate of 4 of 11 children (36%) who had complicated obstructions (p < 0.01). Complicated nasolacrimal duct obstructions were more prevalent in older children. CONCLUSION: A simple probing of the nasolacrimal duct has an excellent success rate in children up to 4 years old if an uncomplicated obstruction is found at the valve of Hasner.     

Inaccuracy of diagnosis in a cohort of patients on the waiting list for dacryocystorhinostomy when the diagnosis was made by only syringing the lacrimal system

PURPOSE: Accurate identification of the factors contributing to epiphora is essential in directing appropriate management and treatment strategies. The authors applied a methodical strategy of assessment for epiphora to patients who were already on the waiting list for dacryocystorhinostomy (DCR). The findings were compared to the original findings. METHODS: Forty-four eyes of 35 patients listed for DCR were re-examined. All canaliculi were examined using four tests: dye disappearance, Jones 1 (dye retrieval), probing using Bowman probes, and syringing of the nasolacrimal duct (NLD) under local anesthesia. Some patients were examined using an endocanalicular mini-endoscope. Patients with NLD obstruction underwent DCR and those with canalicular and NLD stenosis underwent intubation of the lacrimal system-canaliculus, lacrimal sac, and nasolacrimal duct-using silicone stents. The authors refer to this as canaliculodacryocystoplasty (CDCP). The patients were assessed for symptoms of epiphora at 12 months. Forty-four eyes had been listed for DCR. They had been originally diagnosed, by means of lacrimal syringing, as NLD obstruction (24 eyes) or stenosis (12 eyes), and functional blocks (8 eyes). RESULTS: Four out of the original 44 planned DCR surgeries were performed after re-evaluation. After re-examination, 28 lacrimal systems were found to have canalicular stenosis, 4 NLD stenosis, 4 NLD obstruction, 4 punctal phimosis, 3 ocular surface disease, and 1 patient was asymptomatic. Twenty-eight lacrimal systems underwent CDCP, 4 underwent DCR, 4 had punctoplasty, and 4 had probing alone. Three had treatment for ocular surface disease and one patient required no treatment. After a follow-up of 12 months, 41 (93%) systems had improvement or were free of their CONCLUSIONS: Syringing of the lacrimal apparatus may result in a high false positive diagnosis of NLD obstruction. Canalicular pathology is not uncommon in this cohort of patients and may be underdiagnosed.     

Treatment of nasolacrimal duct obstruction in adults with polyurethane stent

PURPOSE: To evaluate the efficacy of polyurethane nasolacrimal duct stents in the treatment of epiphora resulting from primary acquired nasolacrimal duct obstruction in adults. MATERIALS AND METHODS: In 25 patients (21 women and four men with mean age of 44 years, range 20 to 74 years) with nasolacrimal duct obstruction, 28 hollow polyurethane stents designed by Song and associates were placed under fluoroscopic guidance. The obstruction was complete in 20 lacrimal drainage systems and partial in eight. The lacrimal sac size was normal or large on dacryocystogram in all lacrimal drainage systems. A Ritleng probe was introduced through the upper punctum and advanced past the obstruction. A guide wire with a flexible tip was then introduced through the probe, over which the stent was advanced in retrograde fashion and placed into the lacrimal sac and nasolacrimal duct. Clinical success was defined by the demonstration of a completely patent lacrimal drainage pathway through saline irrigation and no or minimal complaint of epiphora. RESULTS: Stent placement was technically successful in 26 of 28 lacrimal drainage systems (93%). The mean time of fluoroscopy screening was 3.2 minutes (range, 1.4 to 5.8 minutes). The overall success rate was 82% (23 of 28 lacrimal drainage systems). Two stents were completely occluded. In one lacrimal drainage system with minimal epiphora, the stented drainage pathway was partially occluded. The patients were followed up from 4 to 22 months (mean, 7.2 months). CONCLUSIONS: Retrograde placement of a hollow polyurethane nasolacrimal duct stent is a technique that is simple and well tolerated by patients. This method achieves a high success rate and may be suggested as a nonsurgical procedure for adults with primary nasolacrimal duct obstruction and proper lacrimal sac size. The Ritleng probe facilitates the procedure.     

Balloon dilatation for treatment of congenital nasolacrimal duct obstruction

PURPOSE: To evaluate the safety and effectiveness of balloon dacryocystoplasty in the treatment of congenital nasolacrimal duct obstructions. METHODS: Balloon dacryocystoplasty was attempted in 25 eyes of 21 patients. The procedure was performed successfully in 24 eyes of 20 patients, age range 21-72 months. Nineteen eyes had no previous procedure. The mean age of this group was 43.9 months (range 36-72 months). Five eyes had failed probing of lacrimal system. The mean age of this group was 22.2 months (range 21-24 months). The authors performed balloon dacryocystoplasty under endoscopic guidance. Clinical success was defined as complete remission of epiphora within follow-up period of 7-34 months (mean 25.2 months). RESULTS: The authors performed balloon dacryocystoplasty in 24 eyes. The first procedure was successful in 20 of them and the clinic success rate was 83.3%. The technique was repeated in the one eye that recurred and as it ended successfully, the clinic success rate increased to 87.5%. In 17 of the 19 eyes (89.4%) in which balloon dacryocystoplasty was performed primarily, and in 4 of 5 eyes (80%) in which balloon dacryocystoplasty was performed secondarily after unsuccessful probing, the procedure was clinically successful. There was intermittent epiphora in 3 eyes (15%) and these were considered as recurrence. CONCLUSIONS: This experience shows that balloon dilatation is a safe and effective treatment of congenital nasolacrimal duct obstruction as a primary procedure in children over 36 months of age and as a secondary procedure after failure of lacrimal system probing. As a result, balloon dacryocystoplasty can be an alternative treatment in older children and can be preferred to silicone intubation and dacryocystorhinostomy performed after unsuccessful probing.     

Endoscopically assisted balloon dacryocystoplasty and silicone intubation versus silicone intubation alone in adults

PURPOSE: To compare the success rate of endoscopically assisted balloon dacryocystoplasty (DCP) and silicone intubation (DCP-SI) with endoscopically assisted silicone intubation alone (SI) in adults with incomplete nasolacrimal duct (NLD) obstruction. METHODS. In a retrospective nonrandomized comparative case series, 62 eyes of 55 adult patients with incomplete NLD obstruction underwent endoscopic probing and either SI (n=39 eyes) or DCP-SI (n=23 eyes) under general anesthesia. The last follow-up examination included diagnostic probing and irrigation if there was not success. Success was defined as disappearance of the symptoms and failure as partial improvement or absence of improvement at last follow-up. RESULTS: Patients ranged from 20 to 85 years of age (mean: 60.93, SD: 15.60). Tubes were removed between 6 and 20 weeks (mean: 7.49, SD: 2.25) postoperatively. Follow-up ranged from 6 to 63 months (mean: 14.60, SD: 10.33). Success rate of the eyes with SI (21/39, 53.84%) and DCP-SI (14/23, 60.86%) were not statistically different (p=0.60). Complications included slight nasal and canalicular bleeding in almost all eyes in both groups which was easily controlled, slit punctum in four eyes with bicanalicular intubation (4/50, 8%), and monocanalicular tube lost in three eyes prematurely. CONCLUSIONS: Success rate of endoscopic DCP-SI had no statistically significant difference from silicone intubation alone in treatment of incomplete NLD obstruction in adults.     

The course of epiphora after failure of silicone intubation for congenital nasolacrimal duct obstruction

Background One of the indications for dacryocystorhinostomy (DCR) in children with congenital nasolacrimal duct obstruction (CNLDO) is failure of silicone intubation. We evaluated the course of epiphora after failure of silicone intubation for CNLDO when DCR was not performed.Methods In a comparative cohort study carried out at a tertiary referral center, ten eyes of seven consecutive children who had failure of silicone intubation manifested as persistent epiphora over 2 months and whose parents refused DCR were followed up for an average of 50.4 months (range 33–70 months). Three lacrimal drainage systems of three other children who had failure of silicone intubation underwent uneventful DCR.Results In eight (80%) of the ten consecutive eyes with congenital nasolacrimal duct obstruction (six of the seven children, 86%), there was spontaneous complete resolution of the epiphora and normal dye disappearance test (DDT) at the end of the follow-up period. One child with Downs syndrome, allergic rhinitis, asthma and multiple site obstructions had improvement of symptoms but abnormal DDT. The epiphora in all three children who underwent DCR had disappeared by 6 months after surgery when the silicone tube was removed. No complications were noted during the follow-up.Conclusions Epiphora can spontaneously resolve after failure of silicone intubation in CNLDO, and DCR should no longer considered be compulsory in such cases unless complications evolve.The authors have no financial or proprietary interest in any of the products mentioned in this paper.Presented in part at the 107th American Academy of Ophthalmology Annual Meeting, Anaheim, CA, November 2003.