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Round table: management of lacrimal drainage problems in children
An international panel of pediatric ophthalmologists discusses the timing of treatment, preferred techniques and anesthesia strategies.
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Introduction
The lacrimal drainage system is made up of a succession of rivers, holes and lakes. First are the palpebral rivers, which run along the palpebral margins. These superficial rivers end at the inner canthus, draining into the lacrimal lake (first lake), where tears in excess are aspirated by the superior and inferior meatus (first holes).
Then begin the second rivers, the palpebral canaliculi, where the lacrimal pump is particularly active (antagonism between elastic wall of the canaliculus and contraction of the Horner muscles).
The two rivers join in a common mouth, the common canaliculus, which is actually an expansion of the tear sac (second lake). This lake is a sort of a dam; almost 100% of the tears are reabsorbed here under normal conditions.
If the flow is too strong, it ends up in the third river, an underground river embedded in the nasal bones, the nasolacrimal canal. This third river empties into an ocean, the nose, through a last hole, the Hasner valve. The Venturi phenomenon explains how the tear flow is sucked by air movements into the nasal cavities.
In young children, this complex hydraulic system is frequently impaired by congenital impatency of the Hasner valve. This fragile dam is spontaneously ruptured in most cases within the first few weeks of life. Also, malformations may occur: other narrowing of the common canaliculus (15% to 20% of tearing in children), dilation of the tear sac or absence of canaliculi.
Jean-Antoine Bernard, MD
Ocular Surgery News: If a pediatric patient has a congenital obstruction of the nasolacrimal duct, how long do you believe a medical treatment should be continued and until what age, and why?
Jean-Paul Adenis, MD: I usually wait until the age of 3 months for probing, and during that period I use antibiotic eye drops, except if the baby has a purulent mucocele.
Jean-Antoine Bernard, MD: In case of congenital obstruction, I believe that medical treatment should be tried until age of 5 to 6 months, except in cases of dilation of the lacrimal sac, if massages are not effective within a month or so, to reduce the size of the sac and reflux of pus or mucus. In this instance, I do perform an early probing (at 2 to 3 months).
Dominique Bremond-Gignac, MD, PhD: Medical treatment should be followed at least 15 days in congenital cases. Treatment should be continued at least until 3 months old, varying with the age of the first probing.
Albert Hornblass, MD: Twelve months; the majority of obstructions of the nasolacrimal duct open spontaneously.
Jesus Montero-Iruzbieta, MD: At least for 5 or 6 months. Most cases resolve by themselves in this period of time. Early probing of the lacrimal duct is not usually efficient.
OSN: If a pediatric patient has a congenital obstruction of the nasolacrimal duct, at what age do you perform the first probing, and why?
Dr. Adenis: I perform probing at the age of 3 months to 9 months in my office, as an outpatient visit without syringing.
Dr. Bernard: I perform first probing at 5 to 6 months. Before 6 months, the rate of spontaneous repatency is high. At 6 to 9 months, probing without anesthesia is easy and has a high percentage of success. After 10 to 12 months, success of probing decreases dramatically.
Dr. Bremond-Gignac: In France we prefer to probe between 3 and 6 months old. I modulate with the weight of the patient and in the case of prematurity. Studies have showed that more than 50% of congenital obstruction resolves before 3 months and less than 10% after 6 months.
Dr. Hornblass: At 12 months I try compression of the sac first.
Dr. Montero-Iruzbieta: The age must be between 6 and 9 months, after a reasonable period of time in which the problem has not resolved by itself, and when probing is more effective.
OSN: If probing is performed, what technique and what type of anesthesia do you use, and why?
Dr. Adenis: At this age there is no need for anesthesia. The procedure is quick and the baby is sooner relieved than waiting with a medical treatment.
Dr. Bernard: No anesthesia is necessary in my hands before 6 to 9 months. Topical anesthesia, for instance, is ineffective and should be avoided in small children. I use a single-use probe with conic blunt head, diameter 0.7 mm, which I designed (made by France Chirurgie Instrumentation).
Dr. Bremond-Gignac: The first probing is performed in the consultation clinic using topical anesthetic with the largest probe as 1 or 0. The choice is guided by the short time of probing (less than 1 minute) and because of the risks of general anesthesia.
Dr. Hornblass: General anesthesia.
Dr. Montero-Iruzbieta: Probing through the superior canaliculus, under general anesthesia and in the office.
OSN: How many probings are performed, and why?
Dr. Adenis: I usually perform no more than two probings, as a third probing will not improve the prognosis.
Dr. Bernard: If the first probing fails, I try a second one after a delay of 4 weeks. If two probings are ineffective, the chance of success for a third one is low and there is possibility of psychological effects on parents and child.
Dr. Bremond-Gignac: Two probings (by a specialist).
Dr. Hornblass: Usually two probings are an adequate trial of perforation of the membrane.
Dr. Montero-Iruzbieta: Three times maximum. We think that more probings will not improve the results of this technique.
OSN: If probing fails, do you perform bicanalicular nasolacrimal intubation or dacryocystorhinostomy, and why?
Dr. Adenis: I perform monocanalicular intubation at the age of 1 under general anesthesia and remove the tube 2 weeks after. In case of failure I perform a DCR at the age of 18 months.
Dr. Bernard: I perform monocanalicular intubation under general anesthesia. The Mono-KA (FCI) is left in place for 3 weeks. DCR is only indicated in cases of permanent dilation of the sac, recurrent dacryocystitis or failures of intubation.
Dr. Bremond-Gignac: I prefer bicanalicular intubation, which has about a 98% success rate and is a simple and safe procedure.
Dr. Hornblass: I perform bicanalicular nasolacrimal intubation because it is noninvasive and it retains normal anatomy.
Dr. Montero-Iruzbieta: We should perform bicanalicular intubation at the age of 2 or 3. DCR should be reserved as the last-resort technique from the age of 12 on.