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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 109  |  Issue : 1  |  Page : 1-4

Bicanalicular lacrimal intubation as a primary surgical treatment for nasolacrimal duct obstruction in children


Department of Ophthalmology, Faculty of Medicine, Minia University, Minya, Egypt

Date of Submission13-May-2015
Date of Acceptance27-Nov-2015
Date of Web Publication21-Oct-2016

Correspondence Address:
Raafat M Abdelrahman Abdallah
Department of Ophthalmology, Minia University Hospital, Minya, 61111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.192742

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  Abstract 

Purpose
The purpose of this study was to evaluate the success of bicanalicular lacrimal intubation as a primary treatment in cases of epiphora caused by congenital nasolacrimal duct obstruction in children up to 6 years of age.
Patients and methods
A prospective surgical intervention case series study was carried out in the Ophthalmology Department of Minia University Hospital. Forty-six eyes of 43 children with epiphora (dated since birth or shortly after) were enroled in this study. A bicanalicular lacrimal silicon tube was introduced through the nasolacrimal duct to the nose.
Results
In this study, the primary lacrimal intubation was successful in 40 eyes out of 46 eyes (87%). For children aged 1–2 years, primary intubation was successful in 22 eyes out of 24 (91.6%), and for those aged 2–4 years it was successful in 12 eyes out of 14 (85.7%). On the other hand, for children aged between 4 and 6 years, the procedure was less successful: six eyes out of eight (75%). Improvement of symptoms occurred in two eyes out of four (50%) when the tubes were removed early, and this rate increased to 90.9% in 20 out of 22 eyes when the tubes were retained for up to 3–6 months and to 90% in 18 out of 20 eyes when the tubes were retained for up to 6–12 months.
Conclusion
Bicanalicular lacrimal intubation is a successful treatment for children with nasolacrimal duct obstruction, and the younger the age of the children the higher the success rate.

Keywords: bicanalicular intubation, congenital epiphora, lacrimal intubation, nasolacrimal duct obstruction


How to cite this article:
Abdelrahman Abdallah RM. Bicanalicular lacrimal intubation as a primary surgical treatment for nasolacrimal duct obstruction in children. J Egypt Ophthalmol Soc 2016;109:1-4

How to cite this URL:
Abdelrahman Abdallah RM. Bicanalicular lacrimal intubation as a primary surgical treatment for nasolacrimal duct obstruction in children. J Egypt Ophthalmol Soc [serial online] 2016 [cited 2023 Jan 28];109:1-4. Available from: http://www.jeos.eg.net/text.asp?2016/109/1/1/192742


  Introduction Top


Congenital nasolacrimal duct obstruction occurs in ∼5% of normal newborn infants. The blockage occurs most commonly at the valve of Hasner at the distal end of the duct. The rate of spontaneous resolution is estimated to be 90% within the first year of life [1],[2]. Spontaneous improvement as the membrane dissolves occurs in about 90% of cases [3]. For cases in which obstruction does not resolve spontaneously, probing has been found to be successful in about 70–97% of them [4],[5].

Lacrimal intubation has become a very common surgical procedure for congenital nasolacrimal duct obstruction that does not respond to conservative medical treatment or with failed probing [6],[7]. Bicanalicular lacrimal tubes have two probes with an intervening stent. One probe is passed through the upper punctum and the other through the lower punctum. The probes are removed, and the free ends of the silicone tube are tied in the nose and sometimes secured with a suture. Monocanaliculus tubes have a plug that is seated at the upper or lower punctum, whereas the stent hangs freely in the nose [8],[9]. Lacrimal intubation as a primary treatment for cases with nasolacrimal duct obstruction is associated with a success rate of 79–96% [8].


  Patients and methods Top


A prospective surgical intervention case series study was carried out in the Ophthalmology Department of Minia University Hospital over 3 years in the period between May 2011 and May 2014. Forty-six eyes of 43 children with epiphora were enroled in this study, who presented to the Ophthalmology Department with epiphora dated since birth or shortly after. The included patients were 30 boys and 13 girls with an age range between 1 and 6 years. Their complaint was unilateral in 40 cases and bilateral in three cases in the form of epiphora (watering), mucoid or mucopurulent discharge.

The inclusion criteria were patients with epiphora dated since birth or shortly after caused by primary nasolacrimal duct obstruction. Children with a history of trauma, facial anomaly or previous surgical interference including probing or intubation were excluded from this study.

This study was approved by the ethics committee. After a written informed consent was obtained from the parents, the procedure was performed after patients’ evaluation.

The enroled children were subjected to local ophthalmological examination, which included the following:

  1. Anterior segment and fundus examination.
  2. Eye lid examination for malposition, puncti evaluation and regurge test.


Nasal evaluation was carried out to exclude nasal problems or any local causes for nasolacrimal obstruction by an ENT specialist. General paediatric evaluation was performed to exclude congenital anomalies or disease that may interfere with general anaesthesia.

Surgical procedure

Under general anaesthesia and with the use of surgical microscope or surgical loupe, the puncti were examined. Dilatation of the puncti canaliculi and probing by 0 and 00 lacrimal dilator was performed. Bicanalicular lacrimal silicon tube (FCI Opthalmics, Paris, France) ([Figure 1]) was introduced through the upper and lower puncti, canaliculi and nasolacrimal duct to the nose. Both metal ends were delivered from the nose by a small straight haemostat. After removal of the metal probes, the two silicon ends were tied over each other by three to four square knots to secure the tube in place at suitable length, not too loose not too short.
Figure 1: Bicanalicular FCI tube for epiphora.

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Local antibiotic eye drops were applied at the end of surgery. Anterior nasal pack might have been needed for a few hours postoperatively. Postoperative local antibiotic drops were prescribed for 2 weeks. Parents were instructed to keep the child’s hands away from the tube site to avoid accidental grasping and displacement of the tube. The patients were followed up for 1, 3, 6 and 12 months postoperatively. The tubes were aimed to be retained for 3–12 months according to the postoperative outcome.

The tubes were removed under sedation by pulling the silicone loop at the medial canthus from the puncti, cutting this loop and pulling one end out of the punctum. Local drops were used for 1 week after tube removal. The patients were followed up for 3 months after tube removal. The surgical outcomes were evaluated. Data were analysed using Z-test of proportion.


  Results Top


This study included 46 eyes of 43 patients with epiphora caused by nasolacrimal duct obstruction. Bicanalicular lacrimal intubation was the primary treatment for the patients in this study.

The included patients were 30 boys and 13 girls with an age range between 1 and 6 years. They were 22 patients (24 eyes) aged between 1 and 2 years, 13 patients (14 eyes) aged between 2 and 4 years and eight patients (eight eyes) aged between 4 and 6 years ([Table 1]).
Table 1: Patients’ demographic data

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The surgical procedure was considered effective and successful if the clinical manifestations such as epiphora, mucoid or mucopurulent discharge disappeared within the follow-up period. The presence of any sign and the need for further surgical interference is considered to be failure of the procedure.

In this study, the primary lacrimal intubation was successful in 40 eyes out of 46 eyes (87%). However, the success rate was variable with age and duration of lacrimal intubation.

For the children aged 1–2 years, the primary intubation was successful in 22 eyes out of 24 (91.6%, P<0.0001) and for those aged 2–4 years it was successful in 12 eyes out of 14 (85.7%, P=0.0007). For the children aged between 4 and 6 years, the procedure was less successful: six eyes out of eight (75%) ([Table 2]).
Table 2: Success rate in relation to children age and duration of tube retention

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In this study, most of the tubes, 42 out of 46 (91.3%), were removed within the follow-up period of 3–12 months. Four tubes (8.7%) were pulled by the children and laterally displaced and then removed before the third month of postoperative follow-up. Improvement of symptoms occurred in two eyes out of four (50%) when the tubes were removed early, and this rate increased to 90.9% (P<0.0001) in 20 out of 22 eyes when the tubes were retained for up to 3–6 months and 90% (P<0.0001) in 18 out of 20 eyes when the tubes were retained for up to 6–12 months ([Table 2]).

In the current study, intraoperative complications were bleeding from the nose in four eyes (8.7%), and slipping of the metal end of the probe out of silicone tube in one eye (2.17%).

Postoperative complications were lateral displacement of the tube in six eyes (13%); two of them were repositioned and four tubes were removed within the first 3 months. Granuloma out of the punctum was encountered in one case (2.17%), which was excised.


  Discussion Top


Probing of the nasolacrimal duct obstruction is effective in about 95% of cases, but this decreases with repetition or with an increased patient age of more than 2 years [10]. Intubation of the congenitally obstructed nasolacrimal duct became a popular surgery for cases with persistent symptoms [11]. Therefore, lacrimal intubation of the nasolacrimal duct became another less invasive alternate to dacryocystorhinostomy in congenital nasolacrimal duct obstruction with failed probing [12].

Primary lacrimal intubation has been endorsed as a primary treatment for children above 2 years because of the lower success rate of probing with age [13]. In this study, prospective assessment of primary intubation for children aged 1–6 years was performed. The overall success rate (87%) of the current study is similar to that of Yazici et al. [14] on 50 eyes with bicanalicular intubation, with an overall success rate of 86%.

In the age group of 1–2 years, primary intubation was successful in 22 eyes out of 24 (91.6%) and for the age 2–4 years it was successful in 12 eyes out of 14 (85.7%). For the children aged between 4 and 6 years, the procedure was less successful: six eyes out of eight (75%). In this study, the success rate varied with age, which decreased with increased children age, from 91.6% in those aged between 1 and 2 years to 85.7% in those aged between 2 and 4 years and to 75% in the older age group (4–6 years). These results are in agreement with those of Lim et al. [8] who reported a success rate of 83–100% in children between 1 and 4 years of age and 71–75% in children older than 4 years of age.

Engel et al. [15] recorded a success rate of 97% for intubation in children younger than 2 years of age, and this rate decreased to 90% in older children. Welsh and Katowitz [16] reported a decline in success rate from 100% in infants from the 6 to 13-month age group to 79.6% in children over the 24-month age group.

With regard to the time of tube removal in this study, four tubes (8.7%) were retained for less than 3 months, with premature removal between 1 and 3 months. Improvement of symptoms occurred in two eyes out of four (50%) when the tubes were removed early. The success rate increased to 90.9% in 20 out of 22 eyes when the tubes were retained for up to 3–6 months, with persistence of symptoms; the remaining tubes were retained for longer periods, with a success rate of 90% in 18 out of 20 eyes when the tubes were retained for 6–12 months.

Engel et al. [15] found in their large series of primary intubation that tube dislodgement and premature removal has no effect on their success rate. Migliori and Putterman [17] indicated that tube retention for 6 weeks can achieve good results with improvement of symptoms. Peterson et al. [18] noticed in their study that tube removal even after 1 month was associated with improvement of epiphora for children younger than 2 years of age and poor outcome for children older than 2 years of age. On the contrary, Repka et al. [19] found reduced success rate of lacrimal intubation for tubes retained less than 2 months.

Welsh and Katowitz [16] experienced good surgical outcome if the tubes were retained for 6 months or more. In the current study, 22 tubes were retained for 3–6 months, with a success rate of 90.9%, and 20 tubes were retained for 6–12 months, with a success rate of 90%. Lim et al. [8] recommended tube retention for a maximum of 12 months, which may be associated with a high success rate, which declines with longer time of tube retention with increased risk of failure after 18 months.


  Conclusion Top


Bicanalicular lacrimal intubation is a successful primary surgical treatment for children with epiphora due to nasolacrimal duct obstruction. The younger the age of the children the higher the success rate of the procedure, and the longer the duration of the tube retention the better the results, with best results between 3 and 12 months.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Paul TO. Medical management of congenital nasolacrimal duct obstruction. J Pediatr Ophthalmol Strabismus 1985; 22:68–70.  Back to cited text no. 1
[PUBMED]    
2.
Nelson LR, Calhoun JH, Menduke H. Medical management of congenital nasolacrimal duct obstruction. Ophthalmology 1985; 92:1187–1190.  Back to cited text no. 2
    
3.
Wagner RS. Lacrimal disorders. Ophthalmol Clin North Am 1996; 9:229–237.  Back to cited text no. 3
    
4.
Honavar SG, Prakash VE, Rao GN. Outcome of probing for congenital nasolacrimal duct obstruction in older children. Am J Ophthalmol 2000; 130:42–48.  Back to cited text no. 4
    
5.
Kashkouli MB, Beigi B, Parvaresh MM, Kassaee A, Tabatabaee Z. Late and very late initial probing for congenital nasolacrimal duct obstruction: what is the cause of failure? Br J Ophthalmol 2003; 87:1151–1153.  Back to cited text no. 5
    
6.
Kaufman LM, Guay-Bhatia LA. Monocanalicular intubation with Monoka tubes for the treatment of congenital nasolacrimal duct obstruction. Ophthalmology 1998; 105:336–341.  Back to cited text no. 6
    
7.
Huang YH, Liao SL, Lin LL. Balloon dacryocystoplasty and monocanalicular intubation with Monoka tubes in the treatment of congenital nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol 2009; 247:795–799.  Back to cited text no. 7
    
8.
Lim CS, Martin F, Beckenham T, Cumming RG. Nasolacrimal duct obstruction in children: outcome of intubation. J AAPOS 2004; 8:466–472.  Back to cited text no. 8
    
9.
Pediatric Eye Disease Investigator Group, Repka MX, Melia BM, Beck RW, Atkinson CS, Chandler DL, Holmes JM et al. Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age. J AAPOS 2008; 12:445–450.  Back to cited text no. 9
    
10.
Mrugacz M, Sielicka D, Bakunowicz-Lazarczyk A. Treatment of nasolacrimal duct obstruction with probing in children younger than 4 years. Klin Oczna 2010; 112:221–222.  Back to cited text no. 10
    
11.
Engel JM, Hicuje-Schmidt C, Khammar A, Ostfeld BM, Vyas A, Ticho BH. Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction. J AAPOS 2007; 11:183–186.  Back to cited text no. 11
    
12.
Komínek P, Cervenka S, Pniak T, Zeleník K, Tomášková H, Matoušek P. Monocanalicular versus bicanalicular intubation in the treatment of congenital nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol 2011; 249:1729–1733.  Back to cited text no. 12
    
13.
Paul TO, Shepherd R. Congenital nasolacrimal duct obstruction: natural history and the timing of optimal intervention. J Pediatr Ophthalmol Strabismus 1994; 31:362–367.  Back to cited text no. 13
    
14.
Yazici B, Akarsu C, Salkaya M. Silicone intubation with the Ritleng method in children with congenital nasolacrimal duct obstruction. J AAPOS 2006; 10:328–332.  Back to cited text no. 14
    
15.
Engel JM, Hichie-Schmidt C, Khammar A, Ostfeld BM, Vyas A, Ticho BH. Monocanalicular silastic intubation for the initial correction of congenital nasolacrimal duct obstruction. J AAPOS 2007; 11:183–186.  Back to cited text no. 15
    
16.
Welsh MG, Katowitz JA. Timing of Silastic tubing removal after intubation for congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg 1989; 5:43–48.  Back to cited text no. 16
    
17.
Migliori ME, Putterman AM. Silicone intubation for the treatment of congenital lacrimal duct obstruction: successful results removing the tubes after six weeks. Ophthalmology 1988; 95:792–795.  Back to cited text no. 17
    
18.
Peterson NJ, Weaver RG, Yeatts RP. Effect of short-duration silicone intubation in congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg 2008; 24:167–171.  Back to cited text no. 18
    
19.
Repka MX, Chandler DL, Holmes JM, Hoover DL, Morse CL, Schloff S et al. Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing. Arch Ophthalmol 2009; 127:633–639.  Back to cited text no. 19
    


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    Tables

  [Table 1], [Table 2]



 

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