Pakistan Journal of Ophthalmology Vol. 32, No. 3, Jul – Sep, 2016 165 Original Article Comparison between Early and Late Nasolacrimal Stents for Congenital Nasolacrimal Obstruction Muhammad Moin, Asif Mahmood Khokhar, Jamshaid Hameed Pak J Ophthalmol 2016, Vol. 32, No. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Dr. Asif Mahmood Khokhar Postgraduate Trainee Lahore General Hospital, Lahore. E-mail: drasifkhokhar@gmail.com …..……………………….. Purpose: To compare the success of silicone tube stents for treatment of congenital nasolacrimal obstruction in children between the age of 1 – 3 years and 3 – 5 years. Study Design: Quasi experimental study. Place and Duration of Study: Mayo Hospital and Lahore General Hospital from 2007 to 2016. Material and Methods: It is a retrospective review of 98 children with epiphora due to congenital nasolacrimal obstruction. All patients less than 5 years with failed probing were included in the study. Patients with traumatic nasolacrimal duct obstruction were excluded from the study. Patients were divided into 2 groups. In group 1 children between 1–3 years and In group 2 children between 3–5 years were included. Patients were seen at follow up at 1 week, 4 weeks and one year at the time of tube removal. Success was defined as resolution of epiphora completely or patients having mild epiphora. Results: Group 1 included 46 patients and group 2 included 52 patients. The success rate in group I (with younger children) was 91% while in group II (with older children) the success rate was 82%. Complications included cheese writing in 3 patients and mild nasal bleeding in 18 patients. Conclusion: Our study shows that nasolacrimal stent intubation is better option in children with persistent epiphora after failed probing between 1 – 3 years. Keywords: Epiphora, nasolacrimal stent, congenital nasolacrimal obstruction, silastic nasolacrimal intubation. he most common cause of epiphora in children is congenital nasolacrimal obstruction. It occurs in approximately 5% of newborns1. The most common cause of obstruction in congenital cases is imperforate membrane at the valve of Hasner. In 90% of the cases the obstruction resolves spontaneously with massage within first year of life2. In case of non-resolution of epiphora probing is performed between 1-2 years. Nasolacrimal stents and balloon dacroplasty are the two most commonly used modalities in cases of failed probing. These techniques are minimally invasive and help in opening the natural tear passage of the patient without any external incision. As the child gets older the success rate of nasolacrimal stents decreases and dacryocystorhinostomy is the procedure of choice after 5 years. The rationale of our study was to compare the success rates of nasolacrimal stents for the treatment of congenital nasolacrimal duct obstruction in children between the age of 1 and 5 years in case of failed probing by dividing them into two groups. MATERIALS AND METHODS It was a quasi experimental study of 98 children with T MOHAMMAD MOIN, et al 166 Vol. 32, No. 3, Jul – Sep, 2016 Pakistan Journal of Ophthalmology epiphora due to congenital nasolacrimal obstruction. We divided them into 2 groups. In group 1 the children were between 1–3 years and in group 2 the children were between 3–5 years. The patients presented in Mayo hospital and Lahore General Hospital between 2007 to 2016. All children less than 5 years of age having failed probing for congenital lacrimal duct obstruction were included in the study. Patients with traumatic nasolacrimal duct obstruction were excluded from the study. Duration of symptoms and time of previous probing was recorded. Epiphora was graded as mild (increased tear lake and occasional watering), moderate (Continuous watering) and severe (continuous watering with regurgitation positive). They were operated by a single ophthalmologist. Bicanalicular nasolacrimal stents were place and their ends secured in the nose with small piece of silicone tyre. Patients were seen at follow up at 1 week, 4 weeks and one year at the time of tube removal. Success was defined as resolution of epipora completely or patients having mild epiphora. RESULTS There were 46 patients in group 1 and 52 patients in group 2. The success rate in group was 83% while in group 2 success rate was 64%. The male to female ratio was 3:1 between the two groups. Complications included cheese wiring in 3 patients and mild nasal bleeding in 18 patients. Results are shown in table 1 and 2. DISCUSSION In most cases of nasolacrimal obstruction, spontaneous resolution occurs during the first year of life. During this period observation and conservative therapy (massage and topical antibiotics) is recommended. Zia et al2 studied that spontaneous resolution of nasolacrimal duct obstruction occurs in most cases with conservative treatment and massage. In another study Nasir et al3 showed that spontaneous resolution of nasolacrimal duct obstruction occurs in most infants. They also showed that in majority of cases not Table 1: Demographic data and outcome. Group 1(Total 54) Group 2 (Total 44) P value Gender Male 35 (65%) 30 (68%) Female 19 14 Laterality Unilateral 44 (81%) 34 (77%) Bilateral 10 10 Primary Success Successful 45 (83%) 28 (64.0%) 0.0280 Failed 9 16 Table2. Age Outcome Cross tabulation Outcome Total Failed Successful Age 12 – 18 months 2 20 22 19 – 24 months 3 4 7 25 – 30 months 1 1 2 31 – 36 months 3 20 23 37 – 42 months 2 7 9 43 – 48 months 4 12 16 55 – 60 months 10 9 19 Total 25 73 98 COMPARISON BETWEEN EARLY AND LATE NASOLACRIMAL STENTS FOR CONGENITAL NASOLACRIMAL OBSTRUCTION Pakistan Journal of Ophthalmology Vol. 32, No. 3, Jul – Sep, 2016 167 resolving spontaneously, probing and irrigation is successful. After 12 months of age probing is successful in 70% to 97% of cases4,5. Kashkouli et al6 proved that even in older children probing should be adopted as the primary procedure. It is successful even in older children with complex blockage of the nasolacrimal duct. The study conducted by Mirza et al7 and Eshragi et al8 have shown that even in significant number of adults probing can be considered as an initial treatment. When probing fails and epiphora persists different options have been recommended. Traditionally DCR (with or without intubation) is not recommended under the age of 5 years. The rationale is incomplete development of nasal bones at this age. Another useful technique is dilation of the nasolacrimal duct with a balloon catheter which is quite expensive9. Due to these reasons nasolacrimal stent intubation has been adopted as the procedure of choice. In this procedure a specially designed silicone tube is placed in the lacrimal drainage system. A loop of tube passes through the two puncti followed by passage of the long ends through canaliculi, lacrimal sac and nasolacrimal duct with creation of no new passage. The obstruction in the passage is broken with the help of guiding steel wires. Winn et al10 and some others10 have adopted this procedure as first choice even before probing. Most of the studies recommend probing as first choice and if probing fails then closed intubation as a second procedure11, 12, 13, 14. Various types of tubes for intubation have been used including Crawford15 and Retleng16.. In our study simple bicanalicular stents were used. Saeed et al17 has reported closed intubation with silicone tube as an effective treatment modality for children of age between 1 to 5 years with a follow up of 1 year. Rehman et al18 operated on 200 children and reported closed intubation with silicone tube as an effective treatment modality for children between 1 to 4 years of age. Our study included 83 children with epiphora due to congenital nasolacrimal obstruction between ages 1 to 5 years. Our success rate compares favourably with the study conducted by Migliori et al19 for intubation who reported success rate of 91% with intubation as primary procedure. Yaziciet al16 have also reported a success rate of 86%. Engel and colleagues have reported a success rate of 96%20. In our study the silicone tube was removed after 12 months. However, there is little agreement in the ophthalmic literature on the optimum length of time for removal of silicone tubes after closed intubation. Memon et al11 removed tube before 3 months in 6 eyes with resolution of symptoms in 5 eyes. They recommended at least 6 months for retention of tube. Engel et al20 reported that there is no impact on the success from premature loss of tube in their large series of cases who underwent primary intubation. Migliori et al19 recommend that only 6 weeks are sufficient for retention of tube for a satisfactory outcome. Another studyreported that in children younger than 24 months early removal was not significant but in children older than 24 months early removal resulted with poor outcome21. Pediatric Eye Disease Investigator Group9 evaluated nasolacrimal intubation after dilation with a balloon catheter in cases with failed probing. Their success rate was 74% in balloon dilation group compared to 84% in simple intubation with balloon dilation. Dortzbach et al14 reported that silicone intubation should be procedure of choice for congenital or acquired nasolacrimal duct obstructions in children after failure of medical therapy and nasolacrimal duct probings. This has been shown in different studies from Pakistan22, 23. CONCLUSION Our study shows that nasolacrimal stent intubation is better option in children with persistent epiphora after probing. Nasolacrimal stents should be procedure of choice for congenital nasolacrimal duct obstructions in children after failure nasolacrimal duct probing. Early stents are more favourable as very few cases (9%) need to repeat the procedure. Authors Affiliation Prof. Muhammad Moin MBBS, FRCS, FRCOphth Postgraduate Medical Institute, Lahore Lahore General Hospital Dr. Asif Mahmood Khokhar MBBS, MCPS Lahore General Hospital, Lahore Dr. Jamshaid Hameed MBBS Lahore General Hospital, Lahore Role of Authors Prof. Muhammad Moin Study Design, Data Collection, Review. MOHAMMAD MOIN, et al 168 Vol. 32, No. 3, Jul – Sep, 2016 Pakistan Journal of Ophthalmology Dr. Asif Mahmood Khokhar Manuscript Writing. Dr. Jamshaid Hameed Data Analysis. REFERENCES 1. Okumuş S, Öner V, Durucu C, Coşkun E, Aksoy Ü, Durucu E, Şahin L, Erbağcı I. Nasolacrimal duct intubation in the treatment of congenital nasolacrimal duct obstruction in older children. Eye (Lond) 2106; 301(1): 85-8. 2. Muhammad Z, Tariq M, Shoaib kk, Islam ZU. Timing of Probing for Congenital Nasolacrimal Duct Obstruction. Pak J Ophthalmol. 2012; 28(1): 43-46. 3. Nasir J, Mohyuddin M, Bhatti SA. Non Massaging Management of Congenital and Infantile Nasolacrimal Duct Obstruction. Pak J Ophthalmol. 2007; 23(2): 84-6. 4. Khan N, Khan MN, Jan S, Mohammad S. Congenital Nasolacrimal Duct Obstruction: Presentation and Management. Pak J Ophthalmol. 2006; 22(2): 74-8 5. Stager D, Baker JD, Frey T, et al. Office probing of congenital nasolacrimal duct obstruction. Ophthalmic Surg 1992; 23 (7): 482–484. 6. 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 (9): 1151– 1153. 7. Mirza SA, Siyal NA, Memon A, Khanzada MA, Aqi AEM, Mirza AA, Mirza SA. Efficacy of probing in young adult in nasolacrimal duct obstruction. Pak J Surg. 2012; 28 (4): 301-4. 8. Eshragi B, Fard MA, Masomian B and Akbari MR. Probing for Congenital Nasolacrimal Duct Obstruction in Older Children. Middle East Afr J Ophthalmol. 2013; 20 (4): 349–352. 9. 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 (5): 633-9. 10. Winn BJ, Smith SD, Garcia DD, Jian–Amadi A, Sires BS. Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation. Br J Ophthalmol. 2009; 93(9): 1220-2. 11. Memon MN, Siddiqui SN, Arshad M, Altaf S. Nasolacrimal duct obstruction in children: outcome of primary intubation. JPMA, 2012; 62(12): 1329. 12. Mocan MC, Gulmez-Sevim, Kocabeyoglu S, Irkec M. Prognostic value of metal-metal contact during nasolacrimal duct probing. Can J Ophthalmol 2015; 50(4):314-7. 13. Mauffray RO, Hassan AS, Elner VM. Double silicone intubation as treatment for persistent congenital nasolacrimal duct obstruction. Ophthal Plast Reconstr Surg. 2004; 20 (1): 44-9. 14. Dortzbach RK, France TD, Kushner BJ, Gonnering, RS. Silicone Intubation for Obstruction of the Nasolacrimal Duct in Children. Am J Ophth 1982; 94(5): 585-90. 15. Al-Faky YH, Mousa A, Kalantan H, Al-Otaibi A, Alodan H, Alsuhaibani AH. A prospective, randomized comparison of probing versus bicanalicular cy6silastic intubation for congenital nasolacrimal duct obstruction. Br J Ophthalmol 2015; 99(2):246-50. 16. Yazici B, Akarsu C, Salkaya M. Silicone intubation with Ritleng method in children with congenital nasolacrimal duct obstruction. JAAPOS, 2006; 10(4): 328-32. 17. Saeed M, Ghaffar Z, Farhat F, Ahme N. Nasolacrimal duct obstruction in infants: a simple technique of silicon intubation. J Sheikh Zayed Med Coll 2011; 2 (1): 144-7. 18. Rehman A, Qayyum I, Zain-ul-Abidin A, Iqbal N, Iqbal J, Hussain M. Timing of Closed Intubation in Recurrent Epiphoric Children. Pak J Ophthalmol. 2014; 30 (1): 42-44. 19. 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(6): 792-5. 20. 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. JAAPOS, 2007; 11(2): 183- 6. 21. Zafar SN, Khan A, Azad N. Treatment outcome of intubation in congenital nasolacrimal duct obstruction. Al-Shifa J Ophthalmol 2007; 3 (1): 31-4. 22. Mehmood T. Watery eyes (Editorial). Pak J Ophthalmol. 2006; 22: 58-9. 23. Maheshwari R, Maheshwari S. Late Probing For Congenital Nasolacrimal Duct Obstruction. JCPSP, 2007, 17 (1): 41-43.