Unblocking Tear Ducts: Pediatric Management and Complications

At the recently held 5th World Congress of Paediatric Ophthalmology and Strabismus (WCPOS V 2024), in Kuala Lumpur, Malaysia, delegates gathered to explore nasolacrimal duct obstruction management and its complications. 

The session brought together pediatric nasolacrimal duct obstruction (NLDO) experts from around the world to share their insights, from understanding the anatomical nuances and surgical options to addressing rare conditions and innovative treatment techniques. The lectures provided a comprehensive overview, equipping attendees with valuable knowledge and practical approaches. 

Simple vs. complex

Evaluating pediatric NLDO was first on the agenda. Dr. Meghal Gagrani (USA) began by explaining the embryology of the nasolacrimal duct and its closely-linked formation of the brain, the first and second branchial arches and the nasomaxillary region. “It’s very important to understand the anatomy as we’ll see how it changes our different surgical options,” she noted. 

According to Dr. Gagrani, the most common form of NLDO in children is a membranous obstruction at the distal part of the nasolacrimal duct, or simple NLDO, and probing has a 75% to 100% success rate in treating it.

However, primary probing to treat other anatomical variations of NLDO, a.k.a. complex NLDO, is associated with lower success. “You should note your findings even in those primary probing cases because it can help you in planning for the recurrent NLDOs,” advised Dr. Gagrani. “It could be an important diagnostic tool for complex cases.”

To probe or not to probe

Dr. Benjamin Ticho (USA) then took over the stage for his lecture on primary treatment for congenital nasolacrimal duct obstruction (CNLDO). He shared that the traditional approach to treating CNLDO is to wait, as most cases improve on their own, accompanied by massage. However, Dr. Ticho pointed out a common pitfall: “The problem is that the way that most pediatricians instruct the parents on how to do massage is incorrect.”

Dr. Ticho elaborated on the correct technique for massage. He advised to push down toward the valve of Hasner, creating enough pressure to open the duct. “Push hard enough to make the child cry,” he noted. In addition to downward pressure, he recommended to also push upward to clear the sac of any purulent material.

Dr. Ticho also advocated for early probing as an excellent treatment option. He stressed the importance of achieving metal-on-metal contact in the nose to confirm the success of a typical office probing.

When anesthesia is required, Dr. Ticho emphasized the benefits of silastic intubation over probing alone due to its higher success rate. For recurrent obstructions, Dr. Ticho recommended silastic intubation or balloon dacryocystoplasty for “simple” obstructions, and a combination of both for “complex” or very tight obstructions.

Probing vs. DCR

Dr. Chia Yaw Teoh (Malaysia) took the podium next with a presentation on the outcomes of probing and dacryocystorhinostomy (DCR) for CNLDO in Malaysia. His team embarked on a comprehensive retrospective study at Serdang Hospital, analyzing data spanning from January 2012 to December 2022. 

When it came to success rates, DCR emerged as the more effective procedure, boasting an 84% success rate compared to 60% for probing. But he also noted the discrepancy when compared to previous studies, which reported average success rates of 85% for probing and 91% for DCR.

Dr. Teoh then delved into the factors influencing these success rates. Age emerged as a significant variable, with success rates declining as children got older. Additionally, a history of dacryocystitis posed a considerable challenge for the probing group, with a 13-fold reduction in success rate. However, for the DCR group, the success rate remained relatively stable despite a history of dacryocystitis.

Dacryoceles 101

Next up, Dr. Katya Tambe (United Kingdom) dove deep into all things dacryoceles, a rare form of CNLDO. The fluid-filled lacrimal sac, seen within the first four to six weeks of life, stems from obstructions in the valve of Hasner and the valve of Rosenmüller, often associated with an intranasal cyst under the inferior turbinate. The affected child will present with a bluish hue under the medial canthal tendon and often with respiratory distress.

While some dacryoceles resolve on their own, others lead to more severe complications such as acute dacryocystitis, lacrimal sac abscess and preseptal cellulitis. “How we need to treat them depends on how they present to us, at what time, and how big the dacryocele is at presentation,” she noted.

For conservative management, Dr. Tambe recommended massaging and applying warm compresses. However, she emphasized that surgical intervention might be necessary in more complicated cases. “A syringe and probe just aren’t enough for these cases,” she remarked. Instead, Dr. Tambe suggested performing a marsupialization of the intranasal cyst. In instances where there is an abscess or infection, she advised an endoscopic DCR.

Ritleng intubation pearls

Dr. Manoj Parulekar (United Kingdom) then treated the audience to detailed video demonstrations of Ritleng intubation, where he offered practical tips. In the first video, Dr. Parulekar demonstrated retrieving the thread using a retina hook, though he mentioned crocodile forceps as a viable alternative. “If you’re having trouble retrieving the thread, this is where the endoscope comes in handy,” he added. “If you don’t have an endoscope, a nasal speculum with an illumination system will do.”

One of the highlights was his explanation of the Ritleng system’s unique features. “This is the beauty of the Ritleng system. You’ve got the thicker part of the nylon, and there’s a thinner part of the nylon. As you keep pulling the thread out, the thick part keeps passing through the probe then the thin part comes out, and the thin part can slip out of the slit,” he explained, emphasizing the need for the slit to face anteriorly.

In another video, Dr. Parulekar demonstrated a tube retrieval scenario where the thread had disappeared down the back of the throat. He described his innovative solution: “I decided to put a small suction tube down the nose. I used forceps to take the tube out and got the thread out of the mouth. I pulled the thread through the suction tube, and then pulled the suction tube out of the nose, and with that came the thread.”

Wrapping up his lecture, Dr. Parulekar concluded, “Ritleng intubation is just one of many systems and, to be honest, they all work. This is just one way of doing it,” he said.

Scary but simple

Ending the session, Dr. Kazi Faiyad Mahmud (Bangladesh) discussed an unusual and alarming case of bilateral congenital lid eversion in a newborn. “It looks scary, but management is simple,” he assured attendees.

Dr. Mahmud introduced his tiny patient, a two-day-old male baby whose ocular exam revealed that both upper eyelids were everted, along with severe conjunctival chemosis and congestion. “It was challenging to examine the globe due to the massive chemosis,” he recalled, adding that the cornea was clear and protected by the displaced lid.

The initial management involved a meticulous and gentle approach. “Maintaining the hydration of the exposed surface is crucial,” Dr. Mahmud emphasized. He carefully removed crusts from the exposed upper lid, rechecked the globe and cornea, and coordinated with a neonatologist to monitor the baby’s general condition.

In a video demonstration, Dr. Mahmud showed his technique for manually repositioning the patient’s lid. He then applied a pressure bandage using a roller bandage. A generous amount of ointment was applied, and the baby’s mother was instructed on how to care for the bandage.

Post-procedure care was just as critical. Dr. Mahmud advised ensuring the baby got adequate sleep, maintaining hydration, and administering oral analgesics and antihistamines to reduce pain and inflammation. At the one-day follow-up, improvements were already evident, and by the third day, the baby had fully recovered.

However, Dr. Mahmud issued a word of caution: “Eyelid manipulations can lead to autonomic effects, such as respiratory arrest in neonates.” This sobering reminder underscored the delicate nature of treating such a rare and distressing condition in such fragile children.

Editor’s Note: Reporting for this article occurred at the 5th World Congress of Paediatric Ophthalmology & Strabismus (WCPOS V 2024) from 11-13 July in Kuala Lumpur, Malaysia.