Pediatric Epiphora. Lacrimal drainage system begins to develop at the. Pediatric Ophthalmology. Saurbhi Khurana MD, FICO

Transcription

1 Pediatric Ophthalmology Pediatric Epiphora Saurbhi Khurana MD, FICO Saurbhi Khurana MD, FICO, A.K Grover MD, MNAMS, FRCS (Glasgow) FIMSA, FICO Vision Eye Centre, Siri Fort Road, New Delhi Lacrimal drainage system begins to develop at the 10mm stage from a solid column of ectoderm which later canalizes. Canalization starts at about 3 months of few weeks after birth (Figure 1). Causes of watering eyes in an infant are: Eyelid problems: Surface Abnormalities: Congenital Glaucoma All other causes must be ruled out before making a diagnosis of congenital nasolacrimal duct obstruction. Congenital nasolacrimal duct obstruction 2-4% of infants present with obstructed NLD at birth which may manifest by 2 to 4 weeks of age % of these resolve spontaneously by 2-4 months of age. Figure 1: Lacrimal drainage system Figure 2: www. dosonline.org l 41

2 Figure 3: Child with matted eyelids and Causes of NLDO in a child are: Clinically the child will present with: On examination, positive regurgitation on pressure over and sensitivity may rarely be done for cases with purulent discharge not responding to antibiotics. Management of CNLDO should be done upto 9 months to 1 year of age % of congenital nasolacrimal duct obstructions will resolve with conservative management. It includes: it is important to educate the mother about the proper technique of sac massage. The childs head needs to be stabilized and adequate pressure should be applied over the sac area directed inferiorly. The common canalicular opening must be blocked at time of massage to prevent regurgitation. Proper massage done 2-3 times a day (4-5 times each time) is adequate. If done too frequently, there may not be enough secretions in the sac to provide an adequate pressure to help open the obstruction. Probing for congenital NLD Obstruction If the obstruction is not relieved by conservative management, a therapeutic probing should be done by 9 months to 1 year of age. However, a proper massage must be attempted for 4-6 weeks before decision to probe is taken. There are studies advocating early probing (<6months) in is usually recommended and practiced is a late probing (around 1 year of age) under general anaesthesia. Technique for probing success rate of probing Figure 4(a): punctual dilatation Figure 4(b): 42 l DOS Times - Vol. 19, No. 8 February, 2014

3 (c) (d) (e) (f) Figure 4(c):Figure 4(d):Figure 4(e): Figure 4(f): pressure syringing from the lower puncta while occluding the upper puncta and to check the patency of the canaliculus (Figure 4b). After feeling for the hard stop, the probe is passes inferiorly along the nasolacrimal duct. Patency of the Post operatively, the child is given topical antibiotic drops/ along with mild steroid drops and nasal decongestant nasal drops. Sac massage should be continued post operatively. The success rate decreases with increasing age and number of probings. Complications of probing are: Failed probing Older children and history of previous probing are factors for probe failure. Moreover, in around 2% of patients, anatomical variations can cause probe resistance. Causes of probe failure are: Management of failed probing with probing helps to maintain patency of the duct in cases of failed probing. In our experience, this technique works very well in cases of failed probing and majority of these children do not need any additional procedure. However, it is not recommended along with primary probing (Figure 5). It should be done under general anaesthesia after nasal packing. www. dosonline.org l 43

4 Figure 5: (a) (b) (c) Figure 6: Other options in cases of failed probing are: Silicone Intubation Success rates of upto 70-85% have been described for intubation in congenital nasolacrimal obstructions. However, most of these are described in younger children and in primary/ previously once probed cases. It can be done in cases where repeat probing has failed/ older children where stenosis or scarring is more. The tubes are left in place for 6 months. Types of intubations described are: Figure 7: inferior end of nasolacrimal duct after Problems of Silicone Intubation: Balloon Dacryoplasty The procedure has been described for: 44 l DOS Times - Vol. 19, No. 8 February, 2014

5 months of age intubation has failed It allows greater dilatation of the lacrimal duct. It is less invasive than silicone intubation and less likely to produce tears/scarring of the lacrimal system. It can be repeated if necessary. Role of Nasal Endoscopy in probing Wherever available, nasal endoscopy should be used during probing. the Nasolacrimal duct (Figure 7). and avoid false passages Dacryocystorhinostomy (DCR) For unresolved nasolacrimal duct obstructions. DCR in a child should not be done before the age of 3 years. External/endonasal route can be selected. However, poorly scarring makes the surgery more challenging in pediatric cases. Intubation though described for pediatric DCRs does Suggested reading rate of symptomatic improvement of congenital nasolacrimal duct obstruction in Japanese infants treated with conservative 5. Schnall BM. Pediatric nasolacrimal duct obstruction. Curr Opin nasolacrimal duct obstruction with nonsurgical management. Arch intubation for treatment of nasolacrimal duct obstruction after failed RATAN JYOTI NETRALAYA PVT. LTD. Ophthalmic Institute & Research Centre & Ratan Jyoti Charitable Foundation Gwalior (M.P.) Invites Dedicated Opthalmologists in Compréhensive Ophthalmology / Cornea / Vitreo-Retina / Glaucoma and Paediatric Ophthalmology. For a super speciality fully Equipped Eye hospital and its forthcoming centres. Eligibility: Salary will be the best in industry. Vacant Posts- Senior Consultants: Associate Consultants: Fellowship After P.G. Ophth. In : Dr. Priyamvada Bhasin, RATAN JYOTI NETRALAYA PVT. LTD. www. dosonline.org l 45