Abstract
In this population-based retrospective cohort study, the Optum claims dataset was used to identify children <4 years of age with the diagnosis of nasolacrimal duct obstruction during the period 2003–2016. A total of 156,044 children were identified, of whom 16,538 (9.43%) underwent a surgical procedure. There was a downward trend for the frequency of all types of treatments but particularly for facility-based probings.
Congenital nasolacrimal duct obstruction (NLDO) is a common condition affecting young children.1 The majority of cases resolve spontaneously.2 Treatment options including probing in the office using topical anesthesia with physical restraint or facility probing using general anesthesia. In 2012 and 2013 the Pediatric Eye Disease Investigators Group (PEDIG) reported the results of a randomized controlled trial (NLD3) randomizing children 6–10 months of age with NLDO to either office probing or facility probing 6 months later if the NLDO did not resolve spontaneously.3,4 NLDO resolved spontaneously in 66% of patients randomized to a delayed facility probing. The success rate of office and facility probing was similar. We investigated trends in NLDO probing in the United States.
Subjects and Methods
This was a population-based retrospective cohort study using claims data from the Clinformatics Data Mart (CDM) database (OptumInsight, Eden Prairie, MN) for the period 2003–2016; this database comprises deidentified administrative health claims for members of a large national managed care company affiliated with Optum. It includes claims information from approximately 15–18 million annual covered lives, a total of around 63 million lives from a geographically diverse population spanning all 50 states. The Optum database provides demographic and medical claims data for both inpatient and outpatient services, including surgery. Data access for this project was provided by the Stanford Center for Population Health Sciences (PHS) Data Core, which is supported by a National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award and internal Stanford funding. The Stanford University School of Medicine Institutional Review Board determined that this study was exempt from approval.
We identified children <4 years of age with NLDO using the International Classification of Disease, Ninth Revision (ICD-9-CM) and Tenth Revision (ICD-10-CM) diagnosis codes 375.55 and H04.53x, respectively. Patients who underwent treatment for NLDO were identified using Current Procedure Terminology (CPT) codes for office probing, facility probing, facility probing with stent insertion, and facility balloon catheter dilation. Facility-based probing is defined as a procedure performed in an ambulatory surgical center or hospital outpatient procedure department with anesthesia. For the purpose of this study, we defined a successful NLDO surgical procedure as a single procedure event during the study period. We compared the success rate of office-based versus facility-based probing using the Fisher exact test.
Results
A total of 4,505,847,315 claims for 53,021,454 patients were analyzed. Of these, 156,044 were identified as having NLDO and 16,538 (9.43%) underwent a surgical procedure (eSupplement 1, available at jaapos.org). About one-half of the children in this cohort underwent facility-based probing without stent intubation or balloon catheter dilation (8,844 [53.52%]). The mean age of these children was 1.78 years (range, 0.62 months to 3.99 years); 4,375 (49.5%) were female, and most were white 7,095 (80.2%). See Table 1. A total of 3,371 patients (20.4%) underwent office-based probing. The mean age of these children was 1.33 years (range, 0.49 months to 3.95 years); 1,642 (48.7%) were female, and the majority were also white (n = 2,640 [78.3%]).
Table 1.
Baseline characteristics of patients by procedure type
| Characteristics | Office probing (n = 3,371) |
Facility probing (n = 8,844) |
Probing with stent placement (n = 3,436) |
Balloon stenting (n = 887) |
|---|---|---|---|---|
| Mean average age, years | 1.3 | 1.8 | 2.1 | 2.1 |
| Age range, months | 0.49 –48 | 0.62–48 | 8–48 | 2–48 |
| Female sex, no. (%) | 1642 (48.7) | 4375 (49.5) | 1692 (49.2) | 446 (50.3) |
| Race, no. (%) | ||||
| White | 2640 (78.3) | 7095 (80.2) | 2670 (77.71) | 690 (77.8) |
| Hispanic | 301 (8.9) | 510 (5.8) | 278 (8.1) | 46 (5.2) |
| African American | 144 (4.3) | 497 (5.6) | 182 (5.3) | 69 (7.7) |
| Asian | 111 (3.3) | 273 (3.1) | 110 (3.2) | 34 (3.8) |
| Unknown | 175 (5.2) | 455 (5.1) | 195 (5.8) | 47 (5.3) |
A total of 3,436 (20.8%) underwent a facility probing with Silastic stent intubation. The mean age of children undergoing facility-based probing with stent placement was 2.12 years (range, <1 month to 4 years); 1,692 (49.2%) were female, and the majority were white (n=2670, 77.7%).
A total of 887 (5.37%) underwent facility-based probing with balloon catheter dilation. The mean age of these children was 2.14 years (range, 2 months to 4 years); 446 (50.3%) were female, and the majority were white (n = 690 [77.8%]).
One or more additional probing procedure was performed on 776 patients (23%) in the office-based probing group. The probability of success was 77.0% (95% CI, 0.755–0.784). In the facility-based probing group, 1,727 (19.5%) underwent repeat probing procedures, indicating an 80.4% probability of success (95% CI 0.769–0.813). The odds ratio for the two samples was 0.813 (95% CI, 0.738–0.896).
There was a downward trend for NLDO procedures from 2003 to 2016 (Figure 1).
FIG 1.
Number of congenital nasolacrimal duct probings, 2003–2016.
Discussion
The incidence of nasolacrimal duct probing in this study was 10.6%. The majority of patients underwent facility-based probing, which declined in frequency from 2003 to 2016. This decline may in part reflect changes in practice patterns related to the findings of the PEDIG NLD3, which showed a high spontaneous resolution rate if probing is delayed.3 A recent report by the American Academy of Ophthalmology recommended that probings for congenital NLDO be delayed until children are 12–18 months of age because of the high spontaneous resolution rate before this age.5 Another factor influencing this trend may be greater awareness of the possible neurotoxicity of general anesthesia for younger children among parents and medical practitioners.6
The majority of patients in this study were white, and although ethnicity has not been identified as a risk factor for NLDO, studies with diverse patient populations are needed to investigate factors affecting NLDO treatment.
The success rate of office-based nasolacrimal duct probing in this study was 77%. Similar success rates have been reported in prospective evaluations of office based nasolacrimal duct probing.7,8 The success rates of office- versus facility-based probing were similar in our study (77% vs 81%) to those reported by the PEDIG group: 72% for office-based and 80% for facility-based probing.7 The PEDIG group also reported on success rates of stent intubation and balloon catheter intubation: 84% for stent intubation and 77% for balloon catheter dilation.8
One limitation of our study is that laterality is not documented in the Optum database. Repeat procedures on the same date were assumed to be bilateral procedures and were excluded from the analysis. If a bilateral case was treated on different dates for each eye, it would have been erroneously included in our analysis as a repeat procedure. Also, some children who failed a probing procedure may not have had a repeat procedure with the same insurance carrier and as a result would not have been included. Repeat treatment with dacryocystorhinostomy was also not assessed. Finally, because symptoms are not recorded in Optum, we were not able to use the resolution of symptoms to determine success.
Supplementary Material
Funding support:
NIH P30 EY026877 and Research to Prevent Blindness.
Footnotes
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