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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 551-555

Results of probing guided with soft cannula in children with nasolacrimal duct obstruction


1 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Ophthalmology, Ministry of Health, Kafr El-Sheikh Ophthalmology Center, Kafr El-Sheikh, Egypt

Date of Submission22-Jan-2019
Date of Decision03-Mar-2019
Date of Acceptance05-Mar-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Ghada M El-Halaby
Tanta, Gharbia 31733
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_17_19

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  Abstract 


Objectives
To compare between the successes of probing using soft cannula (a 22 G) versus conventional probing in children with congenital nasolacrimal duct obstruction.
Background
Congenital obstruction of the nasolacrimal duct is a common problem in the early years of life. Obstruction can occur in 6–20% of neonates. The usual cause is failure of canalization of the epithelial cells that form the nasolacrimal duct as it enters the valve of Hasner.
Patients and methods
This prospective, randomized study was conducted on 36 children (48 eyes) having congenital nasolacrimal duct obstruction presented to the outpatient clinic of Menoufia University Hospital and Kafer El-Sheikh Ophthalmology Center from November 2016 to July 2018. The children were divided into two groups: group A, 18 children (24 eyes) operated by conventional probing and group B, 18 children (24 eyes) operated by probing using soft cannula. The patients were monitored for 6 months postoperatively.
Results
Clinically successful results were achieved in 20 eyes (83.4%) for conventional probing group and 19 eyes (79.2%) for soft cannula group. No significant complication occurred intraoperatively or postoperatively.
Conclusion
Soft cannula probing is an effective and simple method with no significant complication for the treatment of congenital nasolacrimal duct obstruction. This method allows probing in a more controlled way. However, there was no statistical difference between it and conventional probing.

Keywords: congenital nasolacrimal duct obstruction, conventional probing, epiphora, probing, soft cannula


How to cite this article:
El Saadani AE, Marey HM, Mandour SS, El-Halaby GM. Results of probing guided with soft cannula in children with nasolacrimal duct obstruction. Menoufia Med J 2020;33:551-5

How to cite this URL:
El Saadani AE, Marey HM, Mandour SS, El-Halaby GM. Results of probing guided with soft cannula in children with nasolacrimal duct obstruction. Menoufia Med J [serial online] 2020 [cited 2020 Jul 14];33:551-5. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/551/287752




  Introduction Top


Congenital obstruction of the nasolacrimal duct (CNLDO) is a common problem in the early years of life. Obstruction can occur in 6–20% of newly born infants[1]. Failure of canalization of the epithelial cells that form the nasolacrimal duct as it enters the valve of Hasner is the usual cause of CNLDO[2]. Spontaneous resolution occurs in 80–96% of affected infants[3].

Conventional probing is a blind procedure that has not changed significantly in the past century[4]. Early office probing yields good results[5],[6]. Most studies conclude that the success rate of probing decreases with increasing age[7]. The most common problems recognized of this procedure are false passage formation, traumatic stenosis, and unexplained failure[4].

In this study, we used an alternative technique of probing in CNLDO, which can be practiced more safely with fewer traumas to the nasolacrimal passage.

This work aimed to study the results of probing guided with soft cannula compared with the classical probing technique in children with congenital nasolacrimal duct obstruction.


  Patients and Methods Top


This prospective, randomized study included 48 eyes of 36 patients with congenital epiphora presented to the outpatient clinic of Ophthalmology Department Menoufia University and Kafr El-Sheikh Ophthalmology Center from November 2016 to July 2018. These patients were divided into two groups: group A, 18 children (24 eyes) operated by conventional probing and group B, 18 children (24 eyes) operated by soft cannula probing.

All cases were classified as moderate and severe, then in each category, cases with odd numbers were included in group A and cases with even numbers were included in group B. Approval by the Ethics Committee of Menoufia University was obtained before initiating this study. Written informed consents were taken from parents of children included in the study. All measures were in accordance with the tenets of the Declaration of Helsinki.

Preoperatively, all patients underwent certain examinations that included medical history and specific ophthalmic examination that included examination of the eyelids to detect punctal malposition due to ectropion, large caruncle displacing the punctum, and congenital punctal agenesis. The lacrimal sac was palpated over the medial canthal area to exclude the lacrimal mass. Evaluation of the lacrimal sac and nasolacrimal duct was made by regurgitation test. Punctual reflux of the mucopurulent material or aqueous on compression indicates patent canalicular system with obstruction at the lacrimal sac or nasolacrimal duct.

Inclusion criteria

Children aged 1–4 years suffering from epiphora since birth due to congenital nasolacrimal duct obstruction who did not respond to conservative treatment.

Exclusion criteria

Children suffering from epiphora due to conjunctivitis such as ophthalmia neonatorum, congenital glaucoma, entropion, trichiasis, ectropion which causes malposition of the lacrimal puncta, large caruncle displacing the puncta away from the globe, and children who had a history of previous lacrimal system intervention.

Surgical technique

In group A, dilatation of the punctum and syringing were performed from the inferior punctum and then probing was done through the upper canaliculus by inserting the Bowman's probe perpendicular to the eyelid margin until it reached the ampulla of the punctum. Then it is rotated to the horizontal portion of tie canaliculus and is inserted toward the lacrimal sac. Sequential NLD probing was done with larger diameter probes which vary in size from size 00 to size 4. Lateral traction to the eyelid was performed to facilitate the maneuver. When a hard stop is felt, we rotate the probe 90° to be directed downwards toward the nasolacrimal duct. The right direction into the NLD is a critical step for the success of probing. No excessive movements or force should be applied to avoid any false passage. When the probe is positioned into the NLD, we pushed the probe gently downward and stopped when it came across some resistance.

The probe could not be passed into the lacrimal sac if a 'soft stop' was felt. This spongy feeling suggested that the obstruction was probably within the common canaliculus and the lacrimal probe pressed the common canaliculus and the lateral wall against the medial wall of the sac. After completing the maneuver and removing the probe, syringing with saline is repeated to confirm the patency of the drainage system.

In group B, after dilatation of the puncta as the previous group, a 22 G intravenous catheter sheath and straight metal probe size 00 were used for this procedure [Figure 1].
Figure 1: Intravenous catheter sheath and metal probe used in probing.

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The intravenous catheter sheath supported intraluminally with a guiding metal probe [Figure 2] was introduced through the superior canaliculus into the lacrimal system. The plastic catheter sheath was manipulated while retracting the metal probe; the soft tip of the sheath was gently manipulated to pass the obstruction site [Figure 3].
Figure 2: Intravenous catheter sheath with metal probe inserted in it.

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Figure 3: Intubing the nasolacrimal canal with 22 G intravenous catheter sheath supported intraluminally with the metal probe.

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Sterile saline was injected under high pressure through the sheath after complete removal of the metal probe to clear the obstruction. During irrigation, total nasal aspiration was performed. If a resistance against forced lavage was observed, the tip of the catheter sheath was thought to have kinked at the obstruction site and the passage was managed by retraction of the soft tip of the sheath and forward–backward manipulation. The lacrimal drainage system was completely intubated by the catheter sheath to the inferior meatus. Probing of all cases was performed carefully by reinserting the metal probe with a thickness of 0.6 mm into the catheter sheath.

The plastic cannula was withdrawn after complete clearance of the obstruction and a patent passage was observed. The procedure was completed with concurrent nasolacrimal lavage by a combination of gentamycin and dexamethasone.

Postoperative assessment

Postoperative examinations were performed at first month, third month, and sixth month after probing. At each visit, the parents were asked for the presence of symptoms and the child was examined for epiphora, crusting, swelling in the lacrimal sac, and regurgitation on pressure over the sac. Clinical success was assessed using the Munk score: 0–1, complete success; 2, partial success; and 3–4, failure.

Munk score

0: no epiphora

1: occasional epiphora requiring drying or dabbing less than twice a day

2: epiphora requiring dabbing two to four times per day

3: epiphora requiring dabbing five to ten times per day

4: epiphora requiring dabbing more than 10 times daily or constant tearing.

Statistical analysis

The results were collected, tabulated, and statistically analyzed by an IBM-compatible personal computer with SPSS statistical package version 23 (SPSS Inc. Released 2015, IBM SPSS statistics for Windows, version 23.0; IBM Corp., Armonk, New York, USA).

Two types of statistical analysis were done:

  1. Descriptive statistics, for example, was expressed in: number, percentage (%), mean, and SD
  2. Analytic statistics, for example:


Student's t test is a test of significance used for the comparison of quantitative variables between two groups of normally distributed data.

χ2 was used to study the association between qualitative variables; whenever any of the expected cells were less than five, Fischer's exact test was used.

Two-sided P value of less than 0.05 was considered statistically significant.

Based on the hospital records of the year prior to the study, where 53 patients in the age of 1–4 years were subjected to NLD probing, sample size calculation rendered 47 patients to the subjects of this study (power 95%, 95% confidence interval). The number was then rounded to 48 to be evenly randomized into two groups. The patients were divided equally into two groups by using computer-assisted block randomization with concealment allocation and blinding was applied by using consecutively numbered envelopes that contained the treatment assignments.


  Results Top


This study was conducted on 48 eyes of 36 patients who were divided into two groups: group A (24 eyes operated by conventional probing) and group B (24 eyes operated by soft cannula probing). There were no statistically significant differences between the two groups as regards age (mean age in group A 1.87 ± 0.88 and in group B 1.60 ± 0.56 with P = 0.21) and there were no statistically significant differences between the two groups as regards sex [males in group A were 11 (45.8%) and in group B were nine (37.5%) and women in group A were 13 (54.2%) and in group B were 15 (62.5%) with P = 0.77] [Table 1].
Table 1: Comparison between conventional probing and soft cannula probing of children with congenital nasolacrimal duct obstruction regarding age and sex

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There were no statistically significant differences between the two groups as regards the success rate [complete success in group A 16 (66.7%) and in group B 16 (66.7%) and partial success in group A four (16.7%) and in group B three (12.5%) with P = 1.00] [Table 2].
Table 2: Comparison between conventional probing and soft cannula probing in children with congenital nasolacrimal duct obstruction regarding the success rate

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  Discussion Top


Our study reported full success rate [83.4% was divided into complete and partial success (66.7% complete success and 16.7% partial success) in group A and 79.2% was divided into complete and partial success (66.7% complete success and 12.5% partial success) in group B].

Studies of primary surgical management have found probing to be also successful in 70–97% of cases, with many reports at around 90%[8].

The success rate in group A was comparable to those of Kashkouli et al.[9], prospective uncontrolled interventional case series on 180 eyes from 139 patients which reported a success rate of 83.9%. The results of group B (79.2%) was less than those of Kashkouli et al.[9] and this difference in success rate could be attributed to the larger number of cases and wide age group in the Kashkouli study.

The results are higher than that of Casady et al.[10], a retrospective interventional case series study that included 127 patients, ranging in age from 1 to 81 months, with 173 lacrimal systems diagnosed with CNLDO which were treated with initial probing showed a success rate of 76.9%.

Our results are higher than Ismailandcolleagues, a randomized interventional case controlled study that included 60 eyes (of 53 patients), 30 eyes underwent probing and 30 eyes intubation using Masterka tube as a primary treatment for congenital nasolacrimal duct obstruction. Children were aged 6 to less than 36 months at the time of surgery, with no prior nasolacrimal surgical procedure[11]. Ismail's study reported full success: 80% divided into complete and partial success (63.3% complete success and 16.7% partial success) as we done in our study. Results of our current study are higher than the results reported by Eshragiet al.[12], a prospective noncomparative interventional case series, 96 eyes of 82 consecutive patients between 2- and 5-year old with CNLDO which were probed under general anesthesia and showed a success rate of 79% which was divided into 54% for complete success and 25% for partial success.

In the current study, the successful probing with soft cannula technique (79.2%) and with conventional technique (83.4%) were less than 89.8% that reported by Yuksel and Oze[4]. The prospective, nonrandomized interventional study included 158 eyes of 122 children aged 2 months–5 years with CNLDO, as this study did not mention anything about partial success and did not divide the results into grades to evaluate the degree of success. This difference in success rate could be attributed to the larger number of cases and wide age group in Dilek Yuksel.

In the current study, regarding the success rate between men and women [complete success in group A eight (72.7%) men, eight (61.5%) women and in group B six (66.7%) men, 10 (66.7%) women and partial success in group A 0 (0.0%) male, four (30.8%) females and in group B one (11.1%) male, two (13.3%) females]. The success rate among women was higher than the success rate among men in the two groups and this correlated with the increase in the percentage of women more than men in the two groups. However, the difference in the success rates between the two groups was not statistically significant.

Our results are similar to the results in Manneret al.[13], which is a retrospective study of 142 infants and children (73 women and 69 men) who underwent nasolacrimal duct probing for congenital nasolacrimal duct obstruction. The success rate in women was more than men and this correlates with an increase in the percentage of women more than men in the two groups.

However, in Medghalchi et al.'s[14] study which was a retrospective noncomparative interventional case series on 100 eyes of 92 consecutive patients between the age of 9 and 48 months with CNLDO were probed from 2000 to 2012, most samples were women (51%) but the success rate was higher in men (83.4%) than women (63.9%) and this did not correlate with the percentage of men to women in this study. In this study, there was statistically nonsignificant difference between the success rates of women and men. In Thongthony et al.'s[15] study the rate of success in men was more than that of women, but these differences also were statistically insignificant[15].


  Conclusion Top


Using soft cannula and the high pressure fluid in the management of obstruction eliminates the risk of false passage formation and enables it to be practiced more safely.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Olitsky SE, Nelson LB. Disorders of the eye. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 16th ed. Philedelphia, PA: W.B. Saunders; 2000. 1911.  Back to cited text no. 1
    
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Piest KL, Katowitz JA. Treatment of congenital nasolacrimal duct obstruction. OphthalmolClin North Am 1991; 4 :201–209.  Back to cited text no. 2
    
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Ceylan K, Yuksel D, Duman S, Samim E. Comparison of two endoscopically assisted procedures in primary surgical treatment of congenital nasolacrimal duct obstruction in children older than 3 years: balloon dilatation and bicanalicular silicone tube intubation. Int J PedOtorhinolaryngol 2007; 71 :11–17.  Back to cited text no. 3
    
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Yuksel D, Oze PA. Long-term results of probing guided with soft cannula in children with congenital nasolacrimal duct obstruction Jpn J Ophthalmol 2014; 58 :94–99.  Back to cited text no. 4
    
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Baker JD. Treatment of congenital nasolacrimal system obstruction. J PediatrOphthalmol Strabismus 1985; 22 :34–35.  Back to cited text no. 7
    
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Skuta G, Cantour L, Weiss J. Pediatric ophthalmology and strabismus, American Academy of Ophthalmology B.C.S.C., section 6. 2011.  Back to cited text no. 8
    
9.
Kashkouli MB, Kassaee A, Tabatabaee Z. Initial nasolacrimal duct probing in children under age 5: cure rate and factors affecting success. J AAPOS 2002; 6 :360–363.  Back to cited text no. 9
    
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Casady DR, Meyer DR, Simon JW. Stepwise treatment paradigm for congenital nasolacrimal duct obstruction. Ophthalmic Plast Reconstr Surg 2006; 22 :243–247.  Back to cited text no. 10
    
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Ismail Y, Abd El Baky S, El-Essawy R, El-Sawaby E. Pushed monocanalicular intubation versus probing for management of congenital nasolacrimal duct obstruction. Med J Cairo Univ 2015; 83 :425–433.  Back to cited text no. 11
    
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Eshragi B, Aghsaei M, Akabri M, Masomian B. Probing for CNLDO in older children. Middle East Afr J Ophthalmol 2013; 20 :349–352.  Back to cited text no. 12
    
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Manner GE, Rose GE, Frimpong-Ansah K, Ezra E. Factors affecting the success of nasolacrimal duct probing for congenital nasolacrimal duct obstruction. Am J Ophthalmol 1999; 127 :616–617.  Back to cited text no. 13
    
14.
Medghalchi A, Mohammadi MJ, Moghadam R, Dalili H. Results of nasolacrimal duct probing in children between 9-48 months Acta Medica Iranica 2014; 52 :545–551.  Back to cited text no. 14
    
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Thongthony K, Singha P, Liabsuetral T. Success of probing for congenital nasolacrimal duct obstruction in children under 10 years of age. J Med Assoc Thai 2009; 92 :1646–1650.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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