1. Paediatric External Dacryocystorhinostomy, in the management of childhood epiphora. I. S. Sian 1, B. Gupta 1, K. N. Hakin 2. Musgrove Park Hospital NHS Trust, Taunton. 1.SpR Ophthalmology, South West Peninsula Deanery, U.K Consultant Ophthalmologist, Musgrove Park Hospital, Taunton, U.K. Correspondence to Dr Indy Sian – Design courtesy of Mr M. Small.
INTRODUCTION
Congenital nasolacrimal duct obstruction is in the main caused by a membranous obstruction at the distal end of the nasolacrimal duct. Rarely, associated midline deformities in soft tissue and bony structures of the face are present in patients with craniofacial anomalies or genetic syndromes.
% of patients respond by €the first year of life with observation, massage and antibiotics. 1
For unresolved cases, probing is a successful procedure2–4 with a high cure rate, although with increasing age that success rate may be reduced. 2  Nasal endoscopy at the time of probing provides improved information on the site of obstruction, minimises false passages, and reduces the need for repeat procedures. 5,6
Children who do not respond positively to probing/ intubation may require a Dacryocystorhinostomy (DCR). This study audits the outcome in 48 (52 eyes) paediatric external DCR cases.
What is an external DCR?
A small incision is made on the side of the nose to access the tear sac. A piece of bone between the tear sac and nose is removed in order to reach the inside of the nose. The tear sac is opened and stitched to the lining of the nose so a direct passage is formed between the sac and the nose. A soft silicone “tube“ or thread may be put into the tear passage to keep it open during healing. Thus allowing tears to drain normally again.
DISCUSSION
Epiphora due to NLD obstruction has been reported to occur in up to % of infants. In the first year of life, more than 90% of cases resolve spontaneously. For infants who are still symptomatic at 12 months of life, the likelihood of spontaneous resolution by the second year of life is still 60%.1
Probing will cure most unresolved cases, but its success does fall with an increasing number of attempts and with age, being rarely successful after the third attempt or after three years of age.3
Intubation/ NLD stents are advocated by many as the procedure of choice following failed probing. Studies of primary surgical management have found probing to be successful in 70%–97% of cases, with many reports around 90%.6-11 The success of simple probing declines slightly with the increasing age of the child. Several investigators have reported a drop off in probing success rate with increased age, generally after 24 to 36 months
A prospective observational study of primary nasolacrimal duct probing in infants 6 to 60 months of age by the Paediatric Eye Disease Investigator Group showed an overall success rate of 78% with no decline in the efficacy of simple nasolacrimal duct probing up to 36 months of age.16 The success of simple probing is less for bilateral obstructions. Complex obstructions in the proximal part of the duct have a poorer success rates following probing than simple membranous obstructions at the end of the duct.14,15 The success rates for intubation is reduced in patients with dacryocystitis and the procedure may not be possible where a bony obstruction of the NLD is present.
The main disadvantage of intubation is the potential for canalicular trauma and subsequent stenosis leading to a reduced chance of a successful outcome should further surgery such as DCR be required.17-19
Prospective studies by Hakin et al (258 eyes )2 and later Rose et al (134 eyes ) demonstrated a 96% and 92% surgical success rate in external DCR without intubation.4 This success was in cases of NLD obstruction in the absence of canalicular disease, with a fall in success if canalicular abnormalities were present.
External DCR however allows inspection of the lacrimal sac and of any canalicular tissue, enabling a decision to be made on the need for either adjunctive canalicular intubation or by-pass tube. The timing of surgery depends on the presenting complaint. To prevent recurrence of dacryocystitis, DCR should ideally be performed once an acute episode has resolved. Persistent watering without discharge requires less urgency, and surgery is preferably delayed until the teenage years, as a number may have canalicular obstruction and require a bypass tube. The watering may become more troublesome as the child grows, as the ability to produce tears increases with age.11
CONCLUSION
The ideal outcome of D.C.R surgery is to achieve an asymptomatic dry eye without need for prosthesis or long-term follow-up.
Our series demonstrated consistently good results in the management of obstruction beyond the common canaliculus, without the need for canalicular intubation in the main. Thus decreasing the number of intervention a child is required to undergo.
In those children with canalicular disease External DCR surgery allowed access to the canaliculi in a retrograde fashion improving outcomes.
We conclude therefore, that in experienced surgical hands there are few children with symptoms attributable to lacrimal obstruction who cannot be permanently and safely relieved of their symptoms by external D.C.R surgery.
METHOD
This was a retrospective study, Jan 2003 – Jan Electronic coding databases and use of theatre logbook allowed for data collection of all Paediatric patients undergoing External DCR for treatment of Epiphora (15 years of age or below).
Parameters noted:
Patient age at presentation, diagnosis, results of syringing & probing and whether intubation was conducted at this point, the surgical procedure conducted, whether a bilateral procedure was conducted, the surgical outcome, complications, surgeon profile, follow up details and whether there has been a reported reoccurrence.
RESULTS
A predominance of male patients was found in this study (26/48).
The age ranged being yrs at operation, with a mean age of 5 years.
44/48 patients had prior syringing and probing, of those patients 32 eyes were found to have bony obstruction within the common canaliculus and 8 were found to have mucoid reflux.
The remaining 12 eyes were found to have no obstruction and free flow on syringing.
8/52 eyes had previously undergone fracture of the inferior turbinate and intubation.
Despite initial improvement in symptoms in these patients went on to have External DCR surgery.
Indications for surgery were:
48 eyes underwent external DCR operation using anterior sac and nasal flaps anastomosis with no intubation while the remaining 4 had additional silicone intubation.
The operations were all performed by the same Oculoplastic Consultant.
All patients were given Oral Augmentin post operatively for 7 days with no infective complications.
Follow up times ranged between 1-2 weeks.
In those patients who underwent silicone intubation, the tube removal time varied from 3-4 months from date of surgery.
One tube removal required ENT assistance.
Symptomatic relief was achieved in 49/52 eyes at 1st follow up.
The remaining 3 eyes required further surgery with resolution of their symptoms following this.
No reported reoccurrence of symptoms have been documented.
Complications:
1 post op DCR bleed,managed by nasal packing.
One patient required further surgery to insert Lester Jones tubes.
Altered anatomy in a further 2 Trisomy 21 patients were found requiring tube insertion.
Wound gape in 1 case, which responded well to conservative management.
There were no G.A. complications documented.
Chronic discharge with or without mucocoele
(n = 27)
Watering in the absence of mucocoele or discharge
(n = 18)
Acute recurrent dacryocystitis
(n=4)
Post inflammatory obstruction
(n=3)
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