Lecture: Congenital Lacrimal Disorders and Management

DR. FREITAG: Welcome to this Cybersight webinar, today we’re talking about Congenital Lacrimal Disorders and Management. I’m Dr. Suzanne Freitag, I’m at Massachusetts eye and ear infirmary and Harvard Medical school in Boston. DR. BOTHRA: Hi, I’m Dr. Nandini Bothra, and I practice at the Govindram Seksaria Institute in Hyderabad, India. DR. FREITAG: Congenital nasolacrimal duct obstruction is common. Approximately 6% of full term newborns have this condition. But a number of about 6% is often quoted. Higher in children with craniofacial disorders and other anomalies. If persistent, it can lead to chronic problems in childhood and adulthood with epiphora, infection, dacryocystitis, orbital cellulitis or conjunctivitis. Next. A brief look at the lacrimal system is in this slide. There’s the medial part of each eyelid. Forming an upper and lower canaliculus. Which extends in 90% of individuals to form the common canaliculus, and some people lack this before entering the sac. It goes downward through the maxillary bone in the section called the lacrimal duct, and into the nose under the inferior turbinate, where there’s a structure called the valve of Hasner. The development of the lacrimal outflow system begins with a thickened ridge of surface ectoderm cells at the naso optic fissure. At 12 weeks, these cells divide into surrounding mesoderm forming solid cord of cells on the next slide. This elongates from the direction from the future medial canthus to the nasal cavity and forms a hollow tube. This should be complete by about 6 months of gestation, and the canaliculate just before the lids separate. Next. And here’s the diagram on the eye and the nose on B and C, and the cord of future lacrimal tissue, and extending towards the nose and towards the lids. And eventually, everything joins up and canalizes. Next. DR. BOTHRA: So, as Dr. Freitag was saying, what happens when the canalization occurs? If you look at the development of the nasolacrimal system, it begins in the lacrimal sac. As you can see in the second picture. You can see these are various vacuoles. The white chaste spaces in the lacrimal drainage passage, that begins in the sac and proceeds both proximally and distally almost together. But because the proximal passage is likely smaller, it sort of completes canalization by sixth or seventh month of intrauterine life. But in the distal portion, it’s slightly longer, and completes at birth or just after birth. That’s why in congenital lacrimal duct obstructions, the most common membrane that you see which is imperforate is the distal duct. When we say congenital nasolacrimal duct as we saw in the embryology, the lower part has a membrane. Now for that membrane to break, it either automatically breaks at birth, or breaks after a few days after the birth. So, how does that happen? So, when the child is actually sucking in and taking and increasing the intranasal pressure, at that time, this membrane automatically bursts open. Which usually happens at about birth or just a few days after that. So, if it does not break, that is when we get congenital nasal lacrimal duct obstructions. Next. So, when you see a child with NLDO, what do you ask the parents? The first thing is, when did you first observe watering? As we know, that it can be immediately at birth or a few days after. Usually the parents say that the watering started maybe a month or so after the birth of the kid. Now, it can be unilateral or bilateral, and the most common presentation is watering from the eye. And the second most common would be mucoid discharge which is forming on the surface of the eyelid. A very characteristic phenomenon is that this discharge generally forms when the child is sleeping. And therefore when the child wakes up, it forms like a thick crust on the eyelids and makes it impossible for the child to open the eyes until you actually clean the discharge away. And sometimes when this discharge starts collecting into the sac, you press the sac and get the typical mucoid discharge which comes out from the nose. Next. So, now look at this picture. So, look at the right eye. It looks absolutely normal. But when you look at the left eye, you see that the tear meniscus height is visibly raised. You will see that the lashes are actually sticking to each other, which is what we call the matted lashes. And then the excess of the epiphora, overflowing on to the skin of the eyelid. Right. Next. So, the first step when you evaluate is to evaluate whether it’s because of overproduction or outflow obstruction. Can you press next three times, please? And three. Yeah. So, if there is overproduction, when would that happen? When there is reflex watering from the eye. When does reflex watering happen? When there is an infection in the eye. Or if you look at the first picture in the below panel on the left you will see that on the left-hand side there is an entropion, an epiblepharon. When you have an epiblepharon, the lashes are turned inwards and touch the surface of the eye. And that is when you can have watering. The second picture shows an acute glaucoma child. In a case where the intraocular pressure is so elevated, even that can cause watering. And if you look at third picture in the right eye, you see that the cornea has a keratitis, and therefore that can cause reflex watering. First we need to recommend whether it is because of overproduction or whether it is because of outflow obstruction. Next. So, your history will play a very, very important role as we discussed earlier, the first thing you should ask is when did it start? It should be a few months or days after birth. Then it should be constant if it is because of obstruction. If it is not because of obstruction, it will not be constant. So, if there is an obstruction, there has to be a constant outflow of tears. Second, the third important thing that you should ask is: Is it associated only when the child has upper respiratory tract infection? Because upper respiratory tract infection can cause reflex secretion and overproduction if it’s in the epiphora. If it’s only during the episodes, wait until the infection subsides and re-evaluate the child. If there is a history of discharge or epiphora, we will come to why that’s important later in the presentation. And the last is whether the eyelids stick after waking up from the sleep in the morning. That is because of excess accumulation of discharge. Next. So, when we evaluate, the most important step is in a kid, we cannot do a syringe. How do you know if it’s because of an obstruction? You do a fluorescein dye disappearance test. Okay. Go to the next slide, please. So, you mix fluorescein — you just put about one drop of fluorescein stain saline in the inferior fornix and leave it there. And always put it in both the eyes. You wait for about five minutes. After five minutes, use the blue or the cobalt filter on the indirect thermoscope and look at the kid. Look at the picture, which is a beautiful picture thanks to Dr. Freitag, you look at the right eye. You see a nice, elevated tear meniscus height. In the left eye, there is absolutely no fluorescein. But what do you see in the nose? That all the fluorescein from the left eye has actually drained into the nose and you can see the fluorescein shining in the left nose. Whereas in the right nostril, you cannot see anything, it’s not drained because of an obstruction. This is a very important test in children. Okay. Next. So, again, just reiterating all the signs that we spoke about: Matted lashes, elevated tear meniscus height, you can see mucoid discharge there. And if the sac is dilated, press in the area of the sac, you will see regurgitation of discharge. Next. So, what are the causes? The main causes that membrane at the lower distal-most end at the valve of Hasner did not break at birth. When it does not break, it leads to congenital nasolacrimal duct obstructions. Next. When you have a congenital nasolacrimal obstruction, it’s a simple or complex obstruction. I want you to look at the first picture on the top panel. So, that one is called a simple obstruction because there is just a small membraneous obstruction at the end of the nasolacrimal duct. What you see in the picture is the core structure is your inferior turbinate. The larger curve, which is like this, is your lateral wall of the nose. And in between the space is your inferior meatus where is where your nasolacrimal duct opens. Look at the first picture, there is a small membraneous obstruction. But look at B, C, D, E, and F, all of these are complex varieties. In B, what do you see? Look at the nasolacrimal duct, it reaches all the way up to the floor of the nose. Here, if you don’t have an endoscope, there is going to be a problem because you will hit the floor. You will think that you opened it. But actually, it will not open. You have to medialize your probe, get into the inferior meatus and break that membrane as part of the nasolacrimal duct. All the others, that is C, D, E, and F, the membrane is part of the nasolacrimal duct is not formed at all. Here in the C, it is opening into the inferior turbinate. In B, it is opening again into the inferior turbinate. In E, it’s opening into the lateral wall of the nose. And in F, the lower part of the nasolacrimal duct is not formed at all. All of these varieties starting from B to F are complex variations whereas a membraneous obstruction is a simple variation. Next. So, a simple obstruction, as I told you, if you see the bottom picture, you see on the left-hand side, the bulge that you’re seeing is actually your dilated nasolacrimal duct. And then when you come in from the probe, the picture on the right, you will perforate through this membrane. You use your periostial elevator to raise the probe and break in that area and enlarge the opening. This is an example of a simple congenital nasolacrimal obstruction. Next. Whereas if you look here, where do you see the probe coming out from? You see that the probe is coming out from the inferior turbinate. So, this is actually a misdirected nasolacrimal duct into the inferior turbinate. If you see a picture like this, you have no other option than to go ahead with the DCR surgery. Your problem is not going to solve with just a simple probing because it’s a misdirected NLD. It’s not in the correct position and the water — or the tears are not going to flow through a bony membrane like this. Okay. Next. What is the treatment? Up to one year of age, you will do lacrimal sac compressions. Why up to one year of age? Why not 5 years of age? In 1991, they observed a few kids across the spectrum, McEven and Young, from birth up to one year of age. What they saw is up to 95% of these kids actually present within the first month of life. That’s why history is so important. When the epiphora start. And the second observation, about 96% of these resolve spontaneously. Now look at the table there, you will see about 95% resolution occurs in one month, and in 12 months as low as 0%. That is based on his observation that we suggest that dual lacrimal sac compressions to one year of age, see if there is spontaneous correction, if there is, well and good. If not, after one year of age, take the child up for probing. Next. Let us understand how to go ahead and do the compressions. Hello, everyone. Today let us understand the correct technique of lacrimal sac compressions done on a child less than a year old and suffering from continuous watering from the eyes. The first step is to hold the child firmly. Hold the head and make sure the head does not move while doing the compressions. Now use your index finger to do the compression. Make sure that your nails are trimmed. Feel for the edge of the bone next to the nose and below the eye. Using if I recall pressure, press towards the nose, directing the force slightly inwards. Continue these compressions ten times per sitting. At least four such sittings per day have to be performed. A crying child should not be a cause for concern and should not be a reason to discontinue compressions. Now let us understand this process again. It is always good to try these compressions first on yourself to understand the amount of force needed during the compressions. Using your index finger, feel for the edge of the bone as described earlier. Start the compressions by pushing towards the nose, gently inwards. Continue this for ten times per sitting. 96% of watering in kids resolve spontaneously by lacrimal sac compressions by the age of one year. So, the correct technique can go a long way to avoid any further procedures on your child. Okay. Next. Right. So, Dr. Freitag, you want to continue? DR. FREITAG: Okay. So, if you find yourself in a situation without resolution of the problem, by the time the child is about 12 months of age, you want to think about formal intervention. And so, lacrimal probing and irrigation is the most common first intervention and so, indications would be on the top picture shows a congenital dacryocystocele, called dacryocystocele and amniotocele. It’s accumulating in the sac, but you’re not able to get it out without compression because the valve of Hasner, and although the top is the valve of Rosenmuller. This can be obstructed so you can’t push the fluid up or down and it’s stuck. The middle picture shows a child who has developed dacryocystitis with a little bit of cellulitis in the lacrimal sac. He appears a little bit older and has had a while for bacteria to grow. And the bottom is the more significant lacrimal abscess. These patients all deserve intervention. Next. Do you want to narrate your video? DR. BOTHRA: Endoscopic guidance has expanded our understanding of the physiology of lacrimal disorders. The development of endoscopic techniques has contributed to the development of minimally invasive lacrimal procedures and congenital nasal duct obstruction is not an exception. Let us go through the procedure of probing under endoscopic guidance. What’s needed apart from the system is a syringe, 23 gauge cannula, short dilater, Bowman’s a lacrimal probe, elevator, and suction cannular along with the apparatus. The procedure is performed under short general anesthesia with a lacrimal mask. Nasal mucosa is decongested with cotton soaked with 0.225 metazoline. The conjunction of the medial and the middle third from the margin, sum that the — and the canaliculus is there. And use the short punctum dilater. It’s inserted perpendicular to the opening and turned to run parallel to the lid margin to enter the horizontal canaliculus. And then repeated on the affected side. Irrigation is:ed with a syringe and a straight cannula to perform the nasolacrimal duct obstruction. Bowman’s lacrimal probe, using age-appropriate size, is then used in a similar way. First inserted perpendicular to the punctum, and then turned so that it’s parallel to the lid margin and advanced until hard stop is felt. The probe is then turned perpendicular and advanced in a downward, lateral, and posterior direction. The probe is brought to a halt the moment any obstruction is felt. The cotton buds are removed from the nasal cavity. A 2 .7mm zero degree endoscope is used to visualize the nasal cavity. The inferior turbinate is medialized using the blunt edge of the periostial elevator and a view of the meatus is obtained. Probe is advanced and obstruction is overcome under direction visualization. The probe visualize the in the meatus is lifted with the help of the elevator to widen the opening. Irrigation is done to confirm the free passage of distal water. A retrospective intervention interest study at our center looked at the nasal lacrimal duct obstruction which has undergone probing elsewhere without endoscopic guidance and were referred to us for a second or third procedure. 100 eyes of 82 children failed without endoscopic guidance done elsewhere. 63 cases underwent intervention, this time under endoscopic guidance. Of interest, what 35 cases of simple lacrimal duct obstruction, which are the simple membraneous obstruction at the nasal lacrimal duct opening. post-intervention, 32 of the cases had successful probing with the endoscopic guidance. And the remaining three had developed a sac and successfully managed by the rhinostomy procedure. Of the 28 cases of complex congenital lacrimal obstruction, 20 had severe obstruction requiring rhinostomy surgery. The remaining cases were treated with probing with out without stent or ballooned sacroplasty, and using endoscopy with good outcomes. So, to conclude, endoscopic guidance helps identify a variety of congenital nasolacrimal duct obstruction sub-types and facilitates the perform of additional procedures along with probing in a single sitting to achieve optimal outcomes. Thank you. Thank you. Next, please. Yeah. So, basically, before we just move ahead, the whole point of showing that previous video in so much detail was to understand that whenever — sorry — whenever we do probing, it is very, very important to learn it the right way and to do it under endoscopic guidance. Right. Over you, Dr. Freitag. DR. FREITAG: So, there have been a number of studies looking at success rates for initial probings. And there are definitely some trends that become obvious by the child’s age. And we’ve alluded to some of that already, but presenting a little more data, looked at a large number of patients with Stager, over 2300 patients, and they found their data shift point was at 9 months. So, probing was successful in 94% of kids less than 9 months of age and decreased to 84% after 9 months. Katowitz looked at a large number of patients, 572, and success was 96% at less than 1 year of age. Decreased to 69% during that second year of age, and down to 33% over 2 years. So, that’s a very significant jump. And even Mannor et al. had a smaller number of patients, but overall very similar data trends. Next slide. So, many options exist when initial probing fails. And we, as lacrimal specialists, often find ourselves in this situation. First option is to repeat the probing. Perhaps the person who did it before wasn’t as adept with the technique. You want to check things yourself. Keep in mind that repeat probing may become less successful as children become older. Katowitz found 54% success in second probings in children 18 to 24 months and decreased to 33% in kids older than 2 years. Additional options at the time of second probing, and we always want to have additional tricks in our bag. You could place silicone tubes, infracture the inferior turbinate, do a balloon catheter procedure, or a nasal endoscopic examination, which Dr. Bothra recommends on the first probing, which is good if you have that available easily. Next. Silicone intubation, described by Quickert and Dryden in 1970, tubing helping dilate segments in the system. Performed under general anesthesia in children. And packed with vasoconstrictor. And it’s placed through lower and upper systems. There’s a trend among some doctors of using monocanalicular stents, it’s easier removal. But you only get the probes through the system, but bicanalicular, it’s larger. And brought with a metal hook or tube, can if you use another device, similar externalization techniques, the tubes are fixated and tied at the appropriate tension. Next slide. So, here is an example of a Crawford tube, which is my tube of choice. It has metal probe ends with a silicone part in between and then I use a Crawford hook to retrieve this through the inferior meatus of the nose. Next. Complications of silicone intubation. You can always create a false passage during placement. The punctum can erode or slit, especially if the tube is tied a little too tight. You can get a reaction, inflammation, pyogenic granuloma around the punctum from irritation from the tube. The tube can be too loose and come outward on the skin side with a loop exposed. The tube can cause cranial irritation or abrasion, which is fairly uncommon, or you can get an infection. Next. Silicone intubation, timing of tube removal has been the subject of much debate. Many advocate leaving the tube in place for about 3 to 6 months, but good success is reported in as little as 6 weeks of placement. Success rates report ranges from 77 to 100%. I like this procedure because it preserves a normal anatomy. You’re not creating a DCR passage. It’s just trying to work with the native anatomy. Next. Infracture of the inferior turbinate is another technique that we often use. It was described by Jones and Wobig in 1977. The goal is to simply move the inferior turbinate away from the ostium of the nasolacrimal duct. It just physically widens the area. And if you’re probing and making a new opening, hopefully it will help that opening to expand as Dr. Bothra showed with her elevator in her video. To do the infraction, a Freer elevator is great, choice, it’s flat. You place it against the nasal wall and push away from the wall medially and feel this sensation of a little crushing or movement as it gives way. And Havins and Wilkins reported 88% success rate in 24 patients doing a second probing with the infracture of the inferior turbinate. Next slide. Balloon catheter dilates was described by Becker in 1996. And although I believe it’s not used as frequently in adults anymore, it is still quite popular in many centers for children. The reported success rate by Becker was 95% in 61 eyes, including 94% success in 34 systems that had previously failed a probing or intubation. Tao reported 77% success including 75% in previously failed procedure cases. Seemed to be more successful in older patients in his study. And then Yuksel reported an overall success of 83% in 24 eyes. Many of which had not had a previous procedure. But this was promising data because the mean patient age was 44 months. A group in which primary probing often has very poor results. Next. So, here is a picture the of the placement of the balloon Kat per you can see on the right, you want that balloon in the duct and then extending through the valve of Hasner area into the inferior turbinate of the nose. And then the little picture on the left shows the inflated balloon catheter. You place it uninflated in the correct position, use a nasal endoscope to verify this and inflate several times, holding it for a number of seconds each time to allow dilation of the tissues. Next. DR. BOTHRA: Sorry. So, the balloon is inserted until same way as we insert the probe. It’s like the probe. And then inserting into the inferior meatus through the NLD. First step, do the probing. Once you’ve done the probing, opened the inferior part of the NLD, insert the balloon and then you inflate it. How much? For 8 millimeters of water, before about 90 seconds. Right? And then you deflate it. And then you re-inflate it for about 60 seconds. Again, 8 millimeter of water pressure. Okay? So, you actually deflate and inflate the balloon twice. Why do you do it twice? Because you want that opening to stay enlarged. And why do you do it for 90 seconds? Then you give it a break and do it for 60 seconds, because the vascularization around that area, you do not want it to get compromised. So, you do it for 90 seconds. You give it a break for a few seconds and again inflate it for 60 seconds. Again, if you keep un-inflating it for a longer duration of time, there is a chance that — that area can undergo vascular necrosis. You do not want that. So, this exactly is the procedure for balloon catheter dilatation. And then after the dilatation, you do an irrigation and you see free fluid coming into the inferior meatus. Next. DR. FREITAG: We’ve already talked about nasal endoscopy and how important this is. It allows for the visualization for the inferior meatus and surrounding structures. There’s interesting data that’s been published on false passages. And these can be quite common, even in experienced hands. So, Choi reported visualization of a false passage into the submucosal space in 5 of 11 probings, and resulted in successful outcome in four out of five of these children. MacEwen did endoscopy in 52 probings and found false passage in 15%. Even if you’re experienced with this, don’t underestimate the value of looking directly with an endoscope. Next. dacryocystorhinostomy. And it’s when they have failed and when off an nomogram louse passage. It’s a bypass fistula between the lacrimal sac and the nose to provide an alternate pathway for lacrimal outflow. Created adjacent to the middle meatus of the nose, and the lacrimal sac is anastomosed to the nasal mucosa. It’s through the incision or the visualization, and a silicone tube is used in either approach. Next. External DCR was first described in — by Dr. Toti in 1904. It’s a very old procedure. The overall success rate for DCR in children is about 85 to ate%, which is similar to the rate in adults. The main disadvantage of an external DCR is the cutaneous scar that’s required. Which can tough for parents to see their children have a surgical scar. Next. DR. BOTHRA: All right. Let’s go through the steps of the external DCR. Here we’re showing it on an adult. But the similar procedure can be done in a child as well. So, first thing, always confirm your syringing findings. Whether there is actually an obstruction. Here because it’s an adults, we press on the lacrimal sac and look at opposite punctum. Now mark the incision, along the interior lacrimal crest. In a kid, do it under general anesthesia. In an adult, under local anesthesia. Under local, you need to give certain nerve blocks like the infratrochlear nerve block, midway between the supra and the glabella. You inject a little bit in that area for an intraocular nerve block. And then the ethmoidal nerve block so they’re comfortable. And you have to do this block irrespective of anesthesia, under general or local. And take some jelly and anesthetize the nasal cavity. Here you can use some oxymetazoline nasal drops to get some decongestion into the nose. What is important is the direction. Always stay parallel to the face whenever you’re decongesting or inserting the nasal pack. Just stay parallel to the face. Do not go perpendicular. Because then you are actually going along the floor which is not where you need the nasal packing. Can you completely avoid the nasal pack? Yes, you can. Just use a little bit of decongestant nasal spray into the nose. Now you use a 15-number blade and you take the incision around the anterior lacrimal crest. Now, of course, the surgery is going to be a little bloody, right? You cannot do the surgery without seeing any amount of blood. Then you use your scissors and just separate the orbicularis fibers. Once the orbicularis fibers are separated, use — and do this until you see a bare bone, right? Now once you see a bare bone, use a — or just a periosteal elevator to take a periostial incision. Once you have the incision, this is retracted towards the lacrimal crest. You hold the edge and retract it inferiorly. Now the bone is the interior lacrimal crest. That’s your lacrimal sac for your sac. I tend to use gauze to separate the sac from the sac fossa. This is two, first is separation, and then a little bit of hemostasis. Now you can see clearly into the lacrimal sac. You can see the two bones, the frontal part of the maxima, and the lacrimal bone. You perforate the lacrimal bone and start the osteotomy using your bone rounders. You can make your osteotomy big enough such that your entire sac is unexposed to the nasal cavity. So, what is your anterior end point? Until you cannot insinuate your probe into the — into your in between the nasal mucosa and the bone. Inferiorly, until you see the nasolacrimal duct. It’s the retractor. You can now see your nasolacrimal duct, and you will do the osteotomy. Once it’s free of any bone, then you proceed anteriorly. You do anteriorly until you cannot insinuate your round between the mucosa and the bone anymore. That should be your end point. And what is your end point superiorly? Until your entire sac fundus is free of any bone that is in front of it. The one large piece of bone is still pending — which is right exactly in front of your sac. The mucosa you see below is why is your osmoidal mucosa. That means you’re close to completing the osteotomy. Observe the colors you see. There’s the grayish in color, the sac is light pink in color. Whereas your nasal mucosa is reddish in color. You should be able to distinguish these mucosas from each other so that your surgery is smoother and you understand the landmarks. Now, once you have done that, you dilate the puncta and put in a probe. Now, this probe will help you visualize whether or not your sac is completely exposed and whether there is any amount of bone that is lying in front of your sac. Now you insert the probe. We’ve already seen how to do that in our probing video. But here you will just direct it at parallel to the horizontal fissure. And then you see it pointing into the cavity and you see that there is absolutely no bone in front of it. That means your osteotomy is complete and large enough such that there is going to be no obstruction to the flow of tears. Now you take a 11 numbered blade and take a small incision on to the sac. You will see an egress of the discharge. And I tend to use conjunctival scissors for this to extend the incision superiorly as well as inferiorly. Now as we all read in our books, we have to take an H-shaped incision. This is the horizontal incision and now you take two vertical incisions on either side to create the edge. So, this is your anterior lacrimal flap. After you take the incisions vertically, that your anterior flap is completely free and then you see the probe coming in freely into the cavity. Now similar vertical incisions are taken on the posterior lacrimal flap. Such that it just falls behind. Your aim is to open the sac like a book such that it’s exposed to the flap entirely. And now make vertical cuts on the posterior flap. You can see now the flap is nicely falling down and the sac is completely — or the common caniculus is completely exposed to the nasal cavity. Now in a similar way, so, that is the anterior flap and then the posterior flap. Right? Now in a similar way, we will take nasal mucosal incision using an 11 numbered blade. Be careful not to take the incision on to the septum. And then once you have made that official cut, you use your conjunctival scissors to make the cut superiorly and inferior lay. And just like for the lacrimal flaps, do the incisions such that you create an H-shaped flap. Again, that is your anterior nasal flap. Right? And similarly, you will create a posterior nasal flap. Giving vertical cuts. Now the structure that you see inside is your middle turbinate. Which is where in the nose, if you’re looking beyond the nasal flap, the pink structure that you’re seeing is your middle turbinate. Now once that is done, mitomycin-C is applied. We use 0.52% mitomycin-C and leave it inside for about 3 minutes. Now, after this is done, the first step is suture both the posterior flaps. Now why you want to suture it first before putting the intubation? Because you don’t want your intubation tube to get entangled in the suture. So, the first thing is, take a single suture at the posterior flap — so, that was the suture through the nasal flap, and this is through the lacrimal flap. Such that the edge to edge of both the flaps oppose each other. Once the posterior flap is in place, we can do a bicanalicular intubation. Once you do the intubation, in a case like this, where you see flaps are nicely made with no injury to the common canaliculus. If you do not have access to intubation, it is perfectly okay to just leave it like that. Now I use a suction catheter and I feed this probe into the suction catheter and I just pull it out of the nose. The other way to pull it out through the nose is using an artery forceps, going in through the nose and holding the stylette of the intubation tube and just pulling it out. So, as you can see, the — when you use a suction catheter, there is minimal trauma to the nasal mucosa. Because it’s like a pipe and you feed it into the pipe and just take it out using your bimanual movement. So, you push it from top and you pull it from down. And your probe is secured. Now, once your intubation is in position, you will go ahead and suture the anterior flaps. Make sure that you do not include your intubation or your stent into the suture because that is going to create a problem and whenever actually removing the intubation tube. Now intubation is usually kept in for about four weeks in our setting, but you can keep it for as long as six weeks. We tend to avoid keeping the intubation in place for more than six weeks because it leads to a biofilm formation and that can cause inflammation and failure of your surgery. So, try to avoid keeping it for more than 6 weeks, right? Now once you’re done with the flap, I tend to fix it to the overlying orbicularis so it’s folded up and does not fall back down and then you close the skin. Right. So, I think we can move on to the next slide, please. Yeah. DR. FREITAG: So, another look at success rates for pediatric DCRs. This slide combines reports by a number of authors for external and endoscopic techniques. For external, these four reports have 586 patients with a success rate of 88%. And we have 66 cases combined from these studies with an 85% success rate. So, these are good numbers. Next. The earliest descriptions of endoscopic lacrimal surgery through the nose were in 1893, 1910, and ’21. Of course, there’s been a lot of improvement in endoscopic equipment that have led to a resurgence of interest in endoscopic DCRs starting about 25 years ago. Next. And so, here is an endoscopic DCR. DR. BOTHRA: Yeah. As Dr. Freitag mentioned earlier, there’s nothing worse than seeing your child with a scar. So, if you want to avoid that scar, you would actually go ahead and do an endoscopic procedure which is a far more simpler procedure as compared to your external. So, let us just understand the landmarks. So, you know see that thing hanging there, that is your middle turbinate. Now, where it attaches to the lateral wall is the axilla. Your sac lies anterior to it. Now see I’m injecting a little bit of lidocaine in the area I want to incise. This is precisely the area where it lies. It is anterior to your middle turbinate. You inject a little bit of lidocaine combination into the mucosa and pack with sponges, soaked in — this is very important so that you can have a bloodless surgery. I have given a very small injection into the septum as well just so that it decongests and is out of my way during the surgery. Right? So, these are sponges which are soaked in the same solution and kept inside the nose. Now, let us start the surgery. So, first is remove all these packs that you’ve inserted. Now you see it is a nicely decongested cavity. You can see the overhanging middle turbinate. Now use a 15-number blade. Go up until the axilla a little higher than the axilla of the middle turbinate. Take a horizontal incision for about 10 to 12 millimeters. Then you take a vertical incision for about 10 to 12 millimeters. And usually it is up to two-thirds the length of the middle turbinate, and then you join it behind. Now once you have done that, use your periostial elevator and just reflect this nasal mucosa posteriorly. Once you have done that, you will see there is an edge of the bone that you see over there. That is what is called your maxillary line. Anterior to that maxillary line is frontal process of maxilla, proximal to that is the lacrimal bone. That’s exactly the place where your lacrimal sac fossa is. And you would go in and at the inferior-most point, just break away the bone. Let us press the sac from outside, you will actually see a nice movement of the sac happening on the inside. Just have a look. Can you see the movement happening inside?S that your lacrimal sac. Go ahead and just enlarge this osteotomy. So,s in a much smarter procedure as compared to your external DCR. And is much more physiologic. Can you see that movement now on pressing on the outside you can actually see the movement of the lacrimal sac on the inside. Now you go ahead and complete your osteotomy. So, what is the end point? You put in the probe, as I showed you earlier during the external DCR, and you see directed absolutely parallel along the horizontal fistulae. And in front of that, there should be no bone. That is your end point of the surgery. So, again, remember the colors of the mucosa. You have to identify that once again. So, the mucosa is slightly grayish, sac is slightly pinkish in color. And here you won’t see the nasal mucosa which is slightly more reddish in color. You can now see that the osteotomy is nearly complete. This thin bone that is being reflected from the surface of the sac is your lacrimal bone. This bone can just be removed with the help of an alligator forceps. So, this is the alligator forceps. Be careful not to pull any mucosa. Else that will cause bleeding. If it is attached to the mucosa, you can use your periostial elevator to separate, and remove that bone. Comes off very, very easily. There. So, that is your thin lacrimal bone. Which is what you perforate when you do an external surgery. Now you can see there is a huge chunk of bone which is sitting right in front of your lacrimal sac. This bone is again separated from the mucosa on all the sites, and then using an alligator forceps, this bone is also completely removed. Now you put in a probe and then you look at where the probe is exiting. Is there any bone in front of it? Look at top-most part of your lacrimal sac. You can see the probe coming in. You can see that there is no bone in front of it. Now once you have achieved that bit, if you see a bone in front of it, you can use either your rounder or you can use a power drill like what I’m using here to smooth on the bone superiorly. Why is it important? One, superior bone is much more thicker than any other place. See? Look at the thickness of the bone. Sounds the round cannot account for the thickness of the bone. In those cases, you can use a powered instrument like a drill to just smooth out the bone and increase the osteotomy. Right? So, now there is no bone. Now we use a crescent blade and we give an incision on to the sac. So, an H-shaped incision as we spoke about. First is the vertical incision. Once you’ve given the vertical incision, with the same thing, you give back cuts. Two horizontal back cuts, superiorly and inferiorly. The posterior falls back. You see the egress of the discharge and then similarly in the — and you see the probe exiting out. You see the anterior of the sac. A similar horizontal incision is actually taken on the anterior flap as well. And then using a ball probe, you can actually turn the flaps outside such that it opens up like a book. Mitomycin-C is then applied for 3 minutes. Once that is done, a bicanalicular stent is done. Surgery is not needed, you can use the alligator to just pull out the probes. Once that is done, the flaps are put in position. So, there we suture the flaps in external DCR. Here we cannot suture the flap. It is very difficult to suture inside the nasal cavity. What we are going to do is push the flap behind, push our nasal flap which we are deflected behind again. Make sure there is an edge-to-edge apposition. Once we achieve that apposition, what we use in our practice is fibrin glue. You can see the flap set opposed to each other. And here I’m putting in some glue so that it stays opposed. So, that is the end of the surgery. Right. Next, please. Yeah. DR. FREITAG: So, now we’re going shift gears a bit and look at upper lacrimal system surgery. So, congenital anomalies of the upper system may be managed by reconstruction or bypass. A focal segment of a canalicular stenosis, for example, may be excised and the ends anastomosed over a stent. And fistulas can be excised. Look at this. Another procedure for upper system is a conjunctivodacryocystorhinostomy, or CDCR, described by Dr. Jones in 1962. This is a creation of a direct bypass between the medial canthus or ocular surface and the nose. They are not pay tent or able to be repaired. In a glass tube called a Jones tube is placed between the medial canthus ocular surface and the nose. Next. CDCRs in children, we don’t do very often. Welham and Hughes described five cases in five children with punctal and canalicular genesis, and they must have made the children sit in a chair their whole lives. They tend to fall in or out, even in highly reliable adults. And even if you sneeze, they can blow out. It requires a very high amount of compliance for patients to keep these in place. Hakin had ten of 11 successful CDCRs in children. But again, the long-term follow-up on these I would love to see. Next. CDCR complications. The most frequent complication is extrusion of the glass tube externally or migration into the nose. These, as I mentioned, are really hard to maintain in children who are active. Adults can tolerate in-office manipulations of the tube if it’s a little deep or needs to be cleaned out. Children may require anesthesia. The tubes can become blocked Debris can collect internally inside the glass. You can get a granuloma formation or an infection. Next. We’re back to a little more discussion on congenital dacryocele or dacryocystocele, same thing. And ask parents if the children are having difficulty breathing or feeding. Because you can get intranasal cysts that can be related to these obstructions. And the bottom slides are showing pictures, endoscopic view, of some cysts. So, with the treatment is irrigation and probing with endoscopic guidance, opening you have the cysts. And lacrimal sac compressions from the interim. Next. These, as I mentioned, have different names and the dacryocele, mucocele, present around birth, unilateral mostly, and blue or pink-colored beneath the skin. And they’re sterile have a dilated lacrimal sac from fluid. Next. As I mentioned earlier, you often have a proximal and distal blockage that are at the valve of Rosenmuller. Next slide. And complications can include infection. Patients can get pre-septal cellulitis. Occasionally form a fistula if this opens to the skin. They can have pressure, expending out to the nose, causing intranasal cysts. If large and untreated, they can cause astigmatism and amblyopia. Dacryocystitis occurs in a wide range of cases and warrants surgical intervention. Next. Nasal lacrimal duct obstruction associated with these cysts was described by Raflo in 1982, which is quite interesting. Because obviously these have been occurring since the beginning of time. But no one really described it until 1982. We have to remember that small children are preferential nose breathers. So, if they have large cysts obstructing their nasal passageways, this becomes quite concerning. It can lead to respiratory distress and need urgent surgical intervention. Next. Here are more examples. There’s an axial CT slice on the left with a little arrowhead showing an intranasal nasolacrimal duct cyst. And we get an endoscopic view of this patient on the right. Next. And here is a link to Dr. Bothra’s videos and information. As you can see, it’s a really remarkable collection and so I hope you’ll take note of this. Next. DR. BOTHRA: Right. So, now we’re coming to the end of our presentation. So, when you see a congenital — when you see a kid presenting with epiphora is a always congenital nasolacrimal obstruction? No, we need to rethink. What are the others? Let me go through a few of the cases. Next. So, punctal agenesis. You always need to ask the parents: Is there watering along with a lot of mucosal discharge or just minimal discharge? When you have minimal discharge and a lot of watering, that’s when you suspect there’s something going on with the puncta as such. Look at the puncta. You see on the lower eyelid, there is no punctal opening. If you look at the portion of the your eyelid, the one medial to the puncta, you can see there are hair in that area as well. That hair indicates that the development has not happened properly. The other very subtle thing, when you look at these patients under a microscope or under a slit lamp, you will see that there is a hollowness in the area where the canaliculi should be. There is are just subtle signs that you should notice and that is when you realize this is actually a punctal agenesis and not an obstruction. These can be associated with ocular and systemic diseases in 23% the cases. Thus it is very important to recognize this entity. Okay before we move on to incomplete punctal canalization. If you have punctal dysgenesis, you can — as was described, creating from the to the nose. A DCR is not going to work in those case. Coming to the second, it is incomplete punctal canalization or an IPC. Now here look at the image here. Now in the center of the image, can you see a depressed area with vessels on it? Now that is the area of your Puncta. And you see the nice member which is overlying that punctal opening. Now what happens during development, there is failure of the dehiscence epithelium over a normally formed canaliculi or there’s failure at the duct, there’s failure of the canalization of the punctal opening in these cases. What do you do? Next, please. So, it’s very, very simple. So, similarly we took an OCT through the puncta. What do you see? You see a nice vertical canaliculus where it’s opening. But there is no opening on to the surface. There is a thick membrane overlying this opening of the vertical canaliculus. Next. How do you treat this? Next. Yeah. So you know use a dilater. Now, there are two dilaters that I’ve put over here. The one on the left is your smart taper punctal dilater. And the one on the right is a rapid punctal dilater. It’s pointed. This is the dilater that you want to use. You go in and you puncture that membrane. Once you puncture the membrane, you do an irrigation and in 98% or 99% of the cases there are no associated other anomaly and the syringe is after you perforated the membrane. Next. As I said, there are no associated systemic anomalies. Sometimes that is very rarely. May be associated with a canaliculi stenosis or a congenital obstruction, in which case, you know what to do. Whether we need an intubation after we break the membrane, no, we don’t need an intubation. These membranes don’t form again.S it very similar to the one that we open in the nasolacrimal duct. We do not really need to put in a stent. Similarly over here, we do not really need to put in a stent. Next. Coming to the next is a canicular wall dysgenesis. These kids come in with complaints of epiphora, which is just water. There is no discharge. And the epiphora is minimal. There’s not too much of epiphora. If it is associated with an underlying nasolacrimal duct obstruction, they will be accessible epiphora on discharge. But why is it important to recognize this condition? Can we move on to the next slide? Yeah. So, it is important to recognize this condition because here, as you see, the caniculus is not completely covered with all the layers that it’s supposed to be covered with. The muscle layer is missing in all of these cases. When the muscle layer is missing, the lacrimal puncta function is affected, not absent, but it’s affected. Even if you go ahead and take care of the underlying nasolacrimal duct obstruction, there may be a little bit of persisting epiphora which is very important for us to explain this to the parents so they do not really get bothered that, oh, you did the procedure, but it is still watering. So, it will — it may water a little bit. But it is going to be much better than what it was. Because of the underlying nasolacrimal duct obstruction. Next. So, how do you recognize this as we already saw? You put in a probe. And then you see the probe is completely visible when you put in through the canaliculus. There is a thin membrane which is covering the probe or sometimes if it is an aplasia, you can actually see the entire wall of the canaliculus is missing. It can be associated with certain local and systemic pathologies. And implications we already discussed, weakness of Horner muscle function. Therefore, weak lacrimal pump function. And also, whenever you’re doing probing, turn the probe ventricularly, be careful in these cases because you can perforate and cause an entire caniculus to tear. That’s where you have to be very, very careful doing probing in these cases. Next. The last part where you may have some amount of epiphora because of the weakness of the lacrimal pump function. Is something called a supernumerary. You see two openings, one. And this can cause minimal epiphora and there’s no discharge and there’s no associated other anomalies. Next. DR. FREITAG: So, moving down the system a little, next we’ll talk about congenital anlage ducts and lacrimal chew large-scales. They’re well-defined, mostly-inferomedial in location and have smooth, regular edges. Next. Here is a nice picture of a congenital lacrimal fistula. You can see it inferior and medial, with a drop of fluorescein. This says there’s a connection with the lacrimal system. These occur in 1 in 2,000 live births by report. In my own personal experience, I think it’s probably more rare than that. They can be bilateral. They can have multiple openings or end in blind pouches. I had a patient recently with two of these on each side and most of them were blind pouches. If you look histologically at these structures, if you remove them, they are similar to a normal canaliculus with non-keratinized stratus squamous epithelium. If they’re connected to the system, they can result in epiphora. The fistula can become infected and it can cause focal dermatitis from chronic lacrimation. I’ve had a patient who collected a bit of keratin in these and caused some itching and irritation. Next. The condition is often sporadic, but can be autosomal dominant. And these fistula have been reported in conjunction with other anomalies such as nasal obstruction, contralateral absent punctum, total agenesis of lacrimal systems. Clearly if there’s a fistula, something is not right and there may be other lacrimal anomalies. It depends on the symptomology. It’s perfectly fine to leave these alone if they’re not causing a problem. Reports have shown the following strategies for dealing with them. Cautery, simple closure, excision of a fistula’s tract, my preferred technique, and I’ll show you on the next slide. If there’s associated NLDO, consider a DCR, silicone intubation or common canalicular dissection. Next. This is a great article by Tim Sullivan. And it shows a young person with a congenital lacrimal fistula with the arrow pointing it out. This is the procedure I use. I place a Bowman probe as far into the fistula as I can. Some are blind pouch and some connect up with the lacrimal system. I take an 11 blade followed by a small scissors and I just cut a circle of skin and fistula around that probe while the probe is in place. And then I put simple cutaneous sutures in. Next. So, mass lesions can simulate NLDO. If someone has a lump in their medial canthus, we want to consider a lacrimal obstruction. But we don’t want to miss an encephalocele. They usually have quite anomalous facial changes. You will see telecanthus or a widened nasal bridge area and some other changes. But we don’t want to miss an encephalocele. Hemangiomas can occur, you can get a dermoid cyst, glioma, a lymphangioma, local sac primary tumor, rhabdomyosarcoma, ethmoiditis, and most have atypical finding from an obstruction. And radio logic imaging can be helpful if you’re worried about other things and want to prepare for surgery. Next slide. This is the home stretch. Just a few comments about radiographic imaging. Most cases of congenital lacrimal obstruction are managed without imaging studies. You want to consider imaging if there’s an atypical presentation or anatomy, or if previous treatments have failed and you’re stumped and you want to get more information. Next. So dacryocystography, DCG, you inject into the lacrimal system with a cannula. And taken in supine and water position. Then you can show the areas of lacrimal stenosis, diverticuli, and correlate with the bony landmarks. You don’t get soft tissue formation from this study. You can do it with fluoroscopy equipment. Next. Here is an example of a dacryocystogram. On the patient’s right side, you can see in the tear film along the eyelid and the can you lay Louisiana is in the lacrimal system and dye going down through the system into the nose. Then on the patient’s left side, you can see that the lacrimal sac contains three little globs of contrast material, but then there’s an obstruction at the sac duct junction. Which is a common place for an obstruction in adults. Next. You can also inject dye and then do a CAT scan. Here you see a CT-DCG where dye is injected into the lacrimal system and axial I means are obtained. Then you can reinstruct them in three dimensions and even rotate them to look for areas of obstruction. And MRI is a similar concept. You would use MRI contrast material injected into the system. And then do your studies and reconstruction. Next slide. Dacryocystography is considered in children. It’s non-invasive. It doesn’t require cannulation of the system. And so, technetium-99 is on the surface of the globe like an eye drop is placed. And the material takes pictures as you work through the system. You need the child to cooperate for about 20 minutes, which can be challenging. But you want the child awake. A sedated child won’t be blinking and operating their lacrimal pump apparatus. This study not only looks at the anatomy, but it also considers lacrimal pump function. And you don’t get any visualization of the surrounding landmarks. It’s just looking at the dye. Next. So, a few summary slides. Congenital nasolacrimal lacrimal obstruction is common, occurring in about 6% of newborns. About 90% of cases resolve by one year of age with conservative management. The most common site is the valve of Hasner at the nasolacrimal duct junction. persistence beyond one year of age warrants intervention. Because the results of intervention decrease significantly as months and years go on. Next. Probing is a typical first intervention for congenital nasolacrimal obstruction. The success rate of probing is around 90% which performed at 1 year of age. And it gets lower as the child ages. A second probing is usually performed after a first probing. And you want to consider additional procedures if you’re doing a second probing such as intubation, infracture of the inferior turbinate, or balloon catheter dilation. Continued obstruction warrants consideration of a DCR, either external or endoscopic. Next. Obstructions at higher points in the lacrimal system are less common. Radiologic imaging such as DCG can help localize the site of atypical obstructions and guide management. Obstructions of the upper lacrimal system are treated by primary anastomosis of functional tissues or CDCR bypass. Next. So,that is the end of our presentation. We have very little time for questions. Let me see if we have anything. DR. BOTHRA: I actually answered the questions while you were speaking. DR. FREITAG: Thank you. DR. BOTHRA: So we could get through. If there are any more live questions coming in, then we can take it. DR. FREITAG: I think we have about 5 minutes or less. But if there are any questions we will try to answer them. DR. BOTHRA: So, what I’m going to do is I’m going to go back to the answered questions and if there’s anything that you want to elaborate. So, the one question was: Would there be any side effect of fluorescein during the FDDT? So, there is no. The answer is none. Because fluorescein as such does not have any side effects. Right? And Dr. Freitag with the next question is, in the newborn, do you use antibiotics several days before probe something antibiotics — DR. FREITAG: We have to question, are we talking about oral or topical antibiotics? For children who are just a little crusty on the ocular surface, without a dacryocystitis, certainly topical antibiotic can be helpful from an antibiotic ointment. If someone really has a dacryocystitis, then systemic antibiotics are indicated. And just like in adults, if someone has a very significant dacryocystitis, you want to time your DCR surgery for them to improve a little bit because the tissues can be distorted and quite friable if there’s a significant infection. But if you’re somewhere in between, with a young, young child with a congenital obstruction, I think going ahead with probing is reasonable. Any other comments on that? DR. BOTHRA: No, I think I agree with what you said. But also one more question that I’ve already answered that one. But they’re asking: If you use the antibiotics, which antibiotic would you prefer? Like in our practice, we use tobramycin eye drops if I have to give a topical. But if I have to give a systemic, amoxicillin-clavulanate acid combination. DR. FREITAG: It depends on your region and the risks of MRSA and other infections. We have had children in homeless shelters and other places who have had quite interesting flora in their periorbital infection. Knowing your region and taking a careful history of the patient to know if they’re at risk for atypical organisms. But in general, amoxicillin is good for a routine situation. DR. BOTHRA: Can you use a — stent instead of a Crawford stent in congenital? I would say Nunchaku stents are really very good. Especially if you don’t have an endoscope with you. Because with the Nunchaku stent, the advantage is it automatically goes inside your NLD into your inferior meatus. And at one point us you will get a click. When you get that click or you feel a click on your hand, that is when you think that the stent has engaged inside and you just withdraw the stylette which is inside the probe. So, it is a self-retaining stent. So, here if you don’t have an endoscope, you don’t have to pull anything from the nose. It automatically goes and sits into your NLD. If you don’t have a endoscope and you’re in the very well versed with queuing it, you can use a nunchaku instead of a Crawford stent. Any experience with Nunchaku stents? DR. FREITAG: I don’t use them often. But they’re becoming popular. Here in Boston, it’s done with frequency with better results and getting the tubes out again. Here’s a good question or comment. Do you give topical steroid after probing to prevent scarring. It’s common here in Nepal. Your thoughts on that, Nandini? DR. BOTHRA: I give for a week steroids after perforating four times a day for a week. I stop. I don’t taper it. Even if you don’t give it, it is perfectly fine. In our experience. I’ve tried both, and both works. DR. FREITAG: What is the minimum age for performing DCR in children? I mean, you do it when — if someone is badly infected and there’s no other way around it, you would have to think outside the box. But I would say probably about 1 year of age in my opinion. Nandini, what would you say for that? DR. BOTHRA: So, I’ve operated a kid as young as a 21-day-year-old child because the child had bony obstruction. The child needed an urgent corneal transplant. And if — and there was excessive discharge from the eye. So, the cornea surgeons were not ready to go ahead be the transplant, and rightly so, without us clearing the nasolacrimal — without us clearing the lacrimal passage. So, the child was 21 days old and we had to go ahead and do a DCR. But unless there are some pressing conditions like, say, repeat episode of acute dacryocystitis or an urgent need for an interocular procedure, it is better to wait up to 5 years of age so that the bone growth is complete and we take the child up for surgery then. DR. FREITAG: Another question: How to avoid the angular vein trauma during external DCR surgery. If it’s injured, how do you manage it? So, Dr. Bothra’s video was exquisitely beautiful anatomically, but angular vein are hit almost every time and you cauterize it. It’s of no consequence. That’s an expected part of DCR surgery. DR. BOTHRA: Yeah. One point to add, I think I answered one question where they asked what’s the difference between the exterior lacrimal crest versus a medial incision? That’s where it’s damaged most commonly. When you take a medial canthal incision. That’s 7 to 9 milliliters medial. That’s where the angular vein crosses. If you want to avoid it, first thing is go anterior lacrimal crest. The second part, even if it is injured, as Dr. Freitag was seeing, just hold it and cauterize it. It is of no real significance. DR. FREITAG: All right. I think we’ve kind of reached a hard stop on our time allotment today. I want to thank Orbis and Cybersight for allowing us to present this webinar. And thank you to all of the people who have attended for your attention and your excellent questions. So, thank you so much and have a great day. DR. BOTHRA: Thank you, everyone. And if there are any questions, you can always email either of us and we’ll be happy to take it.