Abstract
AIM
To compare the success rate of monocanalicular versus pushed monocanalicular silicone intubation (PMCI) of the nasolacrimal duct for congenital nasolacrimal duct obstruction (CNLDO).
METHODS
In a prospective randomized clinical trial 53 eyes of 49 patients with CNLDO underwent either monocanalicular silicone intubation (MCI) (n=28 eyes) or PMCI (n=25 eyes). All procedures were performed by 1 oculoplastic surgeon. Treatment success was defined as the complete resolution of epiphora at 3mo after tube removal.
RESULTS
The surgical outcome was assessed in 20 eyes with MCI and 20 eyes with PMCI. The mean age of treatment was 26.25±10.08mo (range, 13-49mo) for MCI and 26.85±12.25mo (range, 16-68mo) for PMCI. Treatment success was achieved in 18 of 20 eyes (90.0%) in the MCI group compared with 10 of 20 eyes (50%) in the PMCI group (P=0.01). In the PMCI group, the tube loss (30%) was greater than the MCI group (5%), however the differences between the 2 groups proved to be not significant (P=0.91).
CONCLUSION
Our results indicate that MCI has higher success rate in CNLDO treatment compared with PMCI in this small series of patients.
Keywords: lacrimal drainage system, congenital nasolacrimal duct obstruction, silicone intubation
INTRODUCTION
Congenital nasolacrimal duct obstruction (CNLDO) is thought to be a prenatal developmental failure to cannulate the nasolacrimal system[1]. CNLDO is a common condition in early childhood which is reported to occur in 3.5% of mature children[2]. Most cases will resolve spontaneously early in life[3]. For those children whose obstruction does not spontaneously resolve, probing is an initial procedure[4]. Nasolacrimal silicone intubation is a treatment for CNLDO after failed probing and irrigation[5],[6]. It has been recommended as the primary procedure in patients older than 24mo because of the reduced success rate of probing with age[7]. Intubation was more successful than probing in patients with Down syndrome[8].
Many intubation techniques and types of intubation sets have been described. In monocanalicular silicone intubation (MCI), the stent was retrieved in the nasal cavity with a special hook[9],[10]. More recently, pushed MCI (PMCI) has been introduced as another potential treatment option in CNLDO. In PMCI, the metallic guide is located inside a silicone tube. Therefore, there is no intranasal retrieval of the stent required with this technique[11],[12]. It seems that the latter technique is less traumatic to nasal cavity than MCI. The aim of this study was to compare the outcomes of MCI and PMCI as a treatment for CNLDO.
SUBJECTS AND METHODS
Subjects
Children with CNLDO were prospectively randomized into 2 groups for either MCI or PMCI from December 2011 to February 2013. The diagnosis of NLDO was based on symptoms of epiphora or recurrent mucopurulant discharge from birth and/or reflux from the lacrimal sac with pressure. Children with CNLDO and a history of failed probing (secondary treatment) or age of at least 24mo old at presentation (primary treatment) were included in this study. Children with Down syndrome, punctal or canalicular anomaly, previous nasolacrimal duct intubation or dacryocystorhinostomy, history of trauma to the nasolacrimal system, craniofacial abnormality, or less than 6wk of follow-up after tube removal were excluded. The study was approved by the Tabriz University of Medical Sciences Ethics Committee. Different surgical options were explained to parents, and informed consent was obtained.
Methods
All nasolacrimal intubations were performed under general anesthesia with laryngeal mask by a single oculoplastic surgeon (Andalib D).
After standard probing through the lower punctum, patency was confirmed by touching the probe under the inferior meatus in the nasal cavity with a Crawford hook (metal on metal).
In the monocanalicular technique, we placed a medium collaret Monoka Fayet tube (Guide of Crawford, FCI, Paris, France; Figure 1) through the lower punctum; the tube was retrieved in the nasal cavity with Crawford hook. The head was then fixed in the inferior punctal ampulla with a plug inserter.
Figure 1. Monoka Fayet tube (Guide of Crawford).
In the pushed monocanalicular technique, probe with marking (Figure 2) was used for initial probing and measuring the proper length of the stent (30 mm, 35 mm, 40 mm). Once the proper stent length was selected, the Masterka (FCI, Paris, France; Figure 2) was inserted into the lower canaliculus. Once the Masterka was advanced completely into nasolacrimal duct and the plug came in contact with punctum, the metal guide was removed by holding the plug firmly in contact the punctum. The head was then fixed in the inferior punctal ampulla with a plug inserter.
Figure 2. Probe with marking and Masterka.
Following the surgery, antibiotic and corticosteroid drops were prescribed 4 times daily for 1wk in all patients. The children were examined for tube loss and corneal complication within 1wk and then again after the first and third months of surgery. Tube removal was scheduled for 3mo after surgery. Tube removal was performed in the office. Treatment success was defined as the complete resolution of epiphora at 3mo after tube removal.
Statistical Analysis
The data were analyzed with the SPSS statistical package (Version 17; SPSS, Inc, Chicago, IL, USA). Descriptive statistics, including the mean and standard deviation were calculated for all variables. Study groups were compared using Chi square, Fishers exact and Mann-Whitney U test. The P value of less than 0.05 was considered to be statistically significant.
RESULTS
A total of 53 eyes of 49 children with CNLDO were included, in 2 groups: MCI (n=28 eyes) and PMCI (n=25 eyes). In the MCI group, 8 patients were unavailable for follow-up after tube removal. In the PMCI group, 5 patients were unavailable for follow-up after tube removal. Thus, we successfully evaluated the clinical results of 20 eyes of 19 patients in the MCI group and 20 eyes of 17 patients in the PMCI group. Baseline characteristics by treatment group are given in Table 1.
Table 1. Baseline characteristics of study patients.
| Variables | MCI | PMCI | P |
| Mean age at operation time (mo) | 26.25 ±10.08 (13-49) | 26.85 ±12.25 (16-68) | 0.98a |
| Probing history | |||
| N | 7/20 (35%) | 12/20 (60%) | 0.20b |
| Y | 13/20 (65%) | 8/20 (40%) |
MCI: Monocanalicular silicone intubation; PMCI: Pushed monocanalicular silicone intubation. aMann-Whitney U test; bChi-square test.
Treatment success was achieved in 18 of 20 eyes (90.0%) in the MCI group compared with 10 of 20 eyes (50%) in the PMCI group (P=0.01).
Treatment success was achieved in 7 of 12 eyes (58.3%) after PMCI as a primary treatment.
In 1 of 20 eyes in MCI, the tube was lost after1month. A successful result was achieved in this eye at 3mo after tube loss. In 6 of 20 eyes in PMCI, the tube spontaneously fell out before 1mo. A successful result was achieved only in 3 eyes at 3mo after tube loss. In the PMCI group, the tube loss (30%) was greater than the MCI group (5%), however the differences between the 2 groups proved to be not significant (P=0.91).
Slit punctum occurred in 4 eyes in PMCI. The tube was lost only in 1 of 4 eyes. No punctal complications occurred in MCI. No other complications (corneal abrasion, tube-related keratopathy, canaliculitis and punctal plug migration to canaliculus) were seen in either group.
DISCUSSION
In this study, there was a statistically significant increase in the success rate of intubation in MCI (90%) compared with PMCI (50%; P=0.01). We could not find any study that compared these procedures in the literature.
In our study, the success rate for MCI (90%) compares favorably with the previously reported success rates, which have ranged from 86.2% to 100% for MCI in treatment of CNLDO[13]–[16].
We achieved a lower success rate with PMCI (50%). Also, we achieved a lower success rate with PMCI as a primary treatment (58.3%). However, in a retrospective study by Fayet and colleagues, 110 eyes were treated as a primary procedure with PMCI, with an overall success rate of 85%[11].
In our study, tube loss was 30% in the PMCI. However, tube loss after PMCI was 15% in study by Fayet et al[11] suggested that length of intubation for the PMCI may play some role in treatment success. El-essawy[17] found that the reoperation rate was increased if the tubes were removed prior to 6wk. Also, Peterson et al[18] found that early tube removal increased the reoperation rate in children older than 24mo. It seems that the tube loss may increase failure rate in PMCI, although the small number of patients in our study was the important limitation to make any accurate determination in this regard. Furthermore, the bunching of stent within lacrimal sac during the removal of metal guide may a risk factor for intubation failure.
Monocanalicular tubes can be pulled out easily with eye rubbing, and we provided caregivers with instructions to prevent eye manipulation to minimize this complication. In our study, tube loss was uncommon in the MCI (only 1 eye) compared with tube loss after MCI of 3.4% to 22.8% reported in other studies[13]–[15]. However, there was a statistically insignificant increase in the tube loss in PMCI (6 of 20 eyes; P=0.9). Also, the tube loss after PMCI was 15% in study by Fayet et al[11]. They found that an unnecessarily long stent will contact the floor of the nasal space and may blend. This could act as a spring, placing an upward force to unstent the Masterka[11].
In our study, slit punctum occurred in 4 of 20 eyes with PMCI and the tube was lost only in 1 of 4 eyes. However, Fayet et al[11] reported no punctal complication. Also, no punctal or corneal complications occurred in MCI in our study. However, the Pediatric Eye Disease Investigator Group found corneal complications in 1 of 309 eyes with MCI[19],[20].
No other complications (tube-related keratopathy, canaliculitis and punctal plug migration to canaliculus) were seen in either group.
The most important limitation of our study was the small number of patients enrolled, precluding the firm conclusion about the treatment success and subgroup analysis based on the probing history.
In conclusion, our results indicate that MCI had higher success rate in CNLDO treatment compared with PMCI in this small series of patients.
Acknowledgments
Conflicts of Interest: Andalib D, None; Mansoori H, None.
REFERENCES
- 1.Wang JC, Cunningham MJ. Congenital dacryocystocele: is there a familial predisposition? Int J Pediatr Otorhinolaryngol. 2011;75(3):430–432. doi: 10.1016/j.ijporl.2010.11.026. [DOI] [PubMed] [Google Scholar]
- 2.Lorena SH, Silva JA, Scarpi MJ. Congenital nasolacrimal duct obstruction in premature children. J Pediatr Ophthalmol Strabismus. 2013;50:239–244. doi: 10.3928/01913913-20130423-01. [DOI] [PubMed] [Google Scholar]
- 3.Pediatric Eye Disease Investigator Group Resolution of congenital nasolacrimal duct obstruction with nonsurgical management. Arch Ophthalmol. 2012;130(6):730–734. doi: 10.1001/archophthalmol.2012.454. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Casady DR, Meyer DR, Simon JW, Stasior GO, Zobal-Ratner JL. Stepwise treatment paradigm for congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2006;22(4):243–247. doi: 10.1097/01.iop.0000225750.25592.7f. [DOI] [PubMed] [Google Scholar]
- 5.Takahashi Y, Kakizaki H, Chan WO, Selva D. Management of congenital nasolacrimal duct obstruction. Acta Ophthalmol. 2010;88(5):506–513. doi: 10.1111/j.1755-3768.2009.01592.x. [DOI] [PubMed] [Google Scholar]
- 6.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(6):795–799. doi: 10.1007/s00417-009-1071-0. [DOI] [PubMed] [Google Scholar]
- 7.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(2):183–186. doi: 10.1016/j.jaapos.2006.09.009. [DOI] [PubMed] [Google Scholar]
- 8.Al-Faky YH, Al-Sobaie N, Mousa A, Al-Odan H, Al-Huthail R, Osman E, Al-Mosallam AR. Evaluation of treatment modalities and prognostic factors in children with congenital nasolacrimal ductobstruction. J AAPOS. 2012;16(1):53–57. doi: 10.1016/j.jaapos.2011.07.020. [DOI] [PubMed] [Google Scholar]
- 9.Goldstein SM, Goldstein JB, Katowitz JA. Comparison of monocanalicular stenting and balloon dacryoplasty in secondary treatment of congenital nasolacrimal duct obstruction after failed primary probing. Ophthalmol Plast Reconstr Surg. 2004;20(5):352–357. doi: 10.1097/01.iop.0000134271.25794.96. [DOI] [PubMed] [Google Scholar]
- 10.Kashkouli MB, Kempster RC, Galloway GD, Beigi B. Monocanalicular versus bicanalicular silicone intubation for nasolacrimal duct stenosis in adults. Ophthal Plast Reconstr Surg. 2005;21:142–147. doi: 10.1097/01.iop.0000155524.04390.7b. [DOI] [PubMed] [Google Scholar]
- 11.Fayet B, Katowitz WR, Racy E, Ruban JM, Katowitz JA. Pushed monocanalicular intubation: an alternative stenting system for the management of congenital nasolacrimal duct obstructions. J AAPOS. 2012;16(5):468–472. doi: 10.1016/j.jaapos.2012.07.003. [DOI] [PubMed] [Google Scholar]
- 12.Fayet B, Racy E, Ruban JM, Katowitz J. “Pushed” monocanalicular intubation in children under general anesthesia with spontaneous ventilation. A preliminary report. J Fr Ophtalmol. 2010;33(7):455–464. doi: 10.1016/j.jfo.2010.06.003. [DOI] [PubMed] [Google Scholar]
- 13.Andalib D, Gharabaghi D, Nabai R, Abbaszadeh M. Monocanalicular versus bicanalicular silicone intubation for congenital nasolacrimal duct obstruction. J AAPOS. 2010;14(5):421–424. doi: 10.1016/j.jaapos.2010.08.003. [DOI] [PubMed] [Google Scholar]
- 14.Lee H, Ahn J, Lee JM, Park M, Baek S. Clinical effectiveness of monocanalicular and bicanalicular silicone intubation for congenital nasolacrimal duct obstruction. J Craniofac Surg. 2012;23(4):1010–1014. doi: 10.1097/SCS.0b013e31824dfc8a. [DOI] [PubMed] [Google Scholar]
- 15.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(11):1729–1733. doi: 10.1007/s00417-011-1700-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Lee H, Ahn J, Shin HH, Park M, Baek S. Effectiveness of primary monocanalicular nasal intubation with Monoka tubes and nasal endoscopic findings for congenital nasolacrimal duct obstruction with enlarged lacrimal sac and chronic dacryocystitis. J Craniofac Surg. 2012;23(6):1638–1641. doi: 10.1097/SCS.0b013e31825dad6c. [DOI] [PubMed] [Google Scholar]
- 17.El-Essawy R. Effect of timing of silicone tube removal on the result of duct intubation in children with congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2013;29(1):48–50. doi: 10.1097/IOP.0b013e318275b634. [DOI] [PubMed] [Google Scholar]
- 18.Peterson NJ, Weaver RG, Yeatts RP. Effect of short- duration silicone intubation in congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2008;24(3):167–171. doi: 10.1097/IOP.0b013e31817113f5. [DOI] [PubMed] [Google Scholar]
- 19.Pediatric Eye Disease Investigator Group Primary treatment of nasolacrimal duct obstruction with nasolacrimal duct intubation in children younger than 4 years of age. J AAPOS. 2008;12(5):445–450. doi: 10.1016/j.jaapos.2008.03.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Repka MX, Chandler DL, Holmes JM, Hoover DL, Morse CL, Schloff S, Silbert DI, Tien DR, Pediatric Eye Disease Investigator Group Balloon catheter dilation and nasolacrimal duct intubation for treatment of nasolacrimal duct obstruction after failed probing. Arch ophthalmol. 2009;127:633–639. doi: 10.1001/archophthalmol.2009.66. [DOI] [PMC free article] [PubMed] [Google Scholar]