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Surgery
have spontaneously improved.
8,29
There is only one prospective, quoted success rate of between 80 and 97%.
34–37
A retrospective
controlled study into the success rate of probing during the second analysis of two groups of children – one that underwent probing
year of life; this identified that probing and syringing between 12 and the other that was intubated for continued epiphora after one
and 14 months of age was more successful than the spontaneous probing – found no difference in the outcomes of each group.
38
Intubation has also been promoted as a primary procedure, mainly
in older children with persistent symptoms.
39–43
The results of these
Endoscopic probing was introduced
retrospective studies indicate that more than 90% are cured by
this intervention; however, these results do not differ from those of
because standard probing is a blind
late probings.
12,13,22,27
procedure that makes it liable to
An alternative to intubation in cases of failed probings is balloon
complication, particularly in systems
dacryocystoplasty (DCP).
44–46
This process involves passing a
that are already anatomically abnormal.
balloon catheter into the NLD to dilate a stenosed passage and
is successful in between 74 and 94% of cases in retrospective
studies.
44–46
This is an expensive procedure,
47
but despite this,
resolution rate in a control group at 15 months, but by two years of and the lack of any concrete evidence of its benefits compared
age there was no statistical difference in the outcome between with probing,
12,13,22,27
it has been advocated as a primary procedure
those probed and those not probed due to continued spontaneous instead of probing.
48,49
One prospective non-controlled study
resolution in the control group.
29
This study indicates that identified a success rate of 79%,
48
with this result being
observation is as effective as probing in children up to two years of unaffected by either the age of the child or the extent of the NLD
age, but that probing provides a more rapid result if performed at, obstruction. A retrospective review comparing balloon DCP with
or just after, 12 months of age. It also indicates that early and late probing as a primary procedure for CNLDO found that both were
probing are equally effective and that there is no disadvantage in equally successful.
50
terms of eventual outcome by delaying probing.
A recent prospective randomised trial comparing transnasal
Endoscopic Probing endoscopic assisted balloon dilatation with bicanalicular silicone
Endoscopic probing was introduced because standard probing is a intubation for the primary surgical treatment of congenital
blind procedure that makes it liable to complication, particularly in nasolacrimal duct obstruction in children over three years of age
systems that are already anatomically abnormal. This involves identified that balloon dilatation was more effective (90%) than
direct visualisation of the distal end of the NLD and provides intubation (62.5%).
51
Although statistically significant, this study has
information in terms of the nature of the obstruction (stenosis or small groups of 20–24 patients in each arm of treatment.
atresia). It also either observes the passage of the probe directly
into the inferior meatus or identifies the development of a false Dacryocystorhinostomy
passage and provides an opportunity to rectify this.
30,31
Endonasal External DCR achieves a good success rate in large case series
studies have identified that the result was converted from failure to ranging from 83 to 96% in cases of CNLDO with chronic
success due to an intranasal manipulation when the result was dacryocystitis when medical therapy, probing and silicone
between 11 and 36%.
31–33
Is this justified? There have been no intubation have been unsuccessful.
52–54
The complication rate is low
prospective randomised studies comparing blind versus endonasal (3%) and the procedure is well-tolerated in children.
53
In expert
probing as either a primary or a secondary procedure; these are
required to evaluate this development properly, especially in older
children who are more likely to benefit.
Currently, there is no evidence to
What to Do If Probing Fails
determine the effectiveness of probing in
Studies into the management of persistent epiphora following
probing are generally limited due to a lack of consensus regarding
children less than one year of age
what a ‘failed probing’ means in anatomical terms. Lack of success
compared with simple observation.
is usually due to physiological (functional) epiphora, failure to
create a patent passage between the NLD and the inferior meatus
or complex abnormalities of the upper outflow system. Each of
these requires a different management plan varying from hands, DCR is a successful treatment for appropriately selected
observation to re-probing – preferably using endoscopy to aid paediatric cases with complex lacrimal outflow obstruction in the
diagnosis – to a variety of procedures to rectify complicated absence of cannalicular disease.
abnormalities. These include intubation of the lacrimal system with
silastic or silicone tubes, balloon dilation and DCR. Evaluation of the With the advent of endoscopic techniques and small-diameter
role for these other techniques in ‘probing failure’ is problematic endoscopes with wide-angled fields of view, intranasal
due to the poor definition of this entity. visualisation has improved and hence allowed DCR to be
performed endoscopically. Endoscopic DCR takes much less time
Intubation and Balloon Dacryocystoplasty and therefore can be carried out safely as an outpatient
Intubation of the lacrimal system is usually recommended for cases procedure. The overall success rate of endoscopic DCR ranges
where conservative treatment and probing have failed, with a from 82 to 88%.
55–57
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