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Purpose: To assess the management of patients with congenital nasolacrimal duct obstruction (CNLDO) in a paediatric population and review the long-term outcomes over a 5-year interval, with particular emphasis on the difference between patients with trisomy 21 and those without trisomy 21., Methods: This single-centre, retrospective, cross-sectional, case review study included patients suffering from CNLDO at Alder Hey Children's Hospital NHS foundation Trust. Patients were divided into two groups: Non-trisomy 21 and trisomy 21. Patients were followed-up for a 60-month interval. Patients aged <12 months at the time of surgery, patients with <60 months of follow-up data and patients with acquired nasolacrimal duct obstruction were excluded. The main outcome measures were discharge rates in patients undertaking primary intervention with syringe and probe (S&P), number of patients requiring further treatment with lacrimal intubation or dacryocystorhinostomy (DCR) and overall symptom-free periods post-treatment., Results: Ninety-three patients (142 eyes) were included. The mean number of surgical interventions was 1.53 ± 0.65. The mean interval between the 1st and 2nd intervention was 15.54 ± 16.33 months. There was a trend towards greater success rates non-trisomy 21 patients versus patients with trisomy 21 ( p  = 0.1352). The average symptom-free period after the final intervention was 44.31 ± 20.68 months, significantly longer in the non-trisomy 21 group compared to the trisomy 21 group ( p  = 0.0074)., Conclusions: The overall success rate after primary S&P was 55.9%. Our results suggest that in trisomy 21 patients suffering from CNLDO, a one-stage intervention with primary monocanalicular intubation should be considered instead of sequential approach.

Objective: This study aims to assess morphometric variations in bony nasolacrimal ducts (BNLDs) and sinonasal anatomy in Asian patients with unilateral primary acquired nasolacrimal duct obstruction (PANDO) through computed tomography (CT)., Methods: We enrolled 34 patients with unilateral PANDO who underwent endoscopic dacryocystorhinostomy, alongside 34 age- and sex-matched control patients without documented epiphora complaints. We compared BNLD and sinonasal parameters on CT images between the affected and unaffected sides of PANDO patients and the control group., Results: The entrance area of the BNLD was larger on the affected side of unilateral PANDO patients compared to both the unaffected side (p = 0.012) and the control group (p = 0.046). The open angle in the coronal plane was greater on both the affected (p = 0.044) and unaffected side (p = 0.028) than in the control group. Minimal area and distal area in the axial plane showed no differences among the 3 groups. Paranasal parameters did not differ between the study and control groups. More patients in the study group had superiorly located nasal septum deviation than the control group (p = 0.048). A trend suggested that more patients in the study group had anteriorly located nasal septum deviation than the control group (p = 0.056), although not reaching statistical significance., Conclusion: The increased angular tilt in PANDO patients could impede fluid drainage from a fluidics standpoint. The larger BNLD area on the affected side reflects inflammation-induced osteolysis. Additionally, sinonasal variations, particularly nasal septum deviation at the anterior and superior half, have been identified as contributing to a higher risk of PANDO., (Copyright © 2024 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Congenital arhinia-microphthalmos syndrome or BOSMA syndrome is an exceptionally rare clinical syndrome characterized by unilateral or bilateral complete absence of the nasal cavity associated with several craniofacial, ocular, and systemic anomalies. Lacrimal drainage anomalies are secondary to absent nasolacrimal duct and usually present as dilated lacrimal sac or mucoceles. While navigation-guided dacryocystorhinostomies into the contralateral nasal cavity are described for unilateral arhinia, the way forward for the complete absence of the nose and nasal cavity is still unclear. A multidisciplinary team from the specialties of genetics, plastic surgery, ophthalmic plastics and reconstructive surgery, otorhinolaryngology, and endocrinology should get involved very early on for better continuity of care.

Purpose: Congenital epiphora can be related to anomalies of the nasolacrimal duct. This study aimed to assess the distal end of the nasolacrimal duct and the outcomes of endoscopic treatment in children older than 12 months with congenital epiphora., Methods: This retrospective analysis describes the clinical characteristics, management, and outcomes of symptomatic congenital lacrimal obstruction in 32 lacrimal systems of 23 children. Data was collected on the preoperative symptoms, age at the time of surgery, intraoperative findings, treatment modalities, and outcomes of the children in our cohort. All patients underwent a standard endoscopic lacrimal examination, including irrigation and diagnostic probing, viewed via the inferior meatus. Cases with complex anomalies characterized by obstructions in the canaliculi, nasolacrimal junction, or nasolacrimal duct were excluded., Results: The mean age at the time of surgery was 48.03 (±27.99) months. Four different types of distal nasolacrimal duct obstruction were diagnosed. These were obstructions by a membrane (n=12), ostium stenosis (n=15), impacted turbinate (n=3), and membranous residual flaps (n=2). They were all managed with inferior meatus microsurgery and nasal endoscopic probing without silicone intubation. After a mean follow-up period of 14.75 (±11.93) months, successful outcomes were achieved in all cases., Conclusion: Microsurgery to the inferior meatus, performed under nasal endoscopy, is a safe and effective treatment for isolated anomalies of the distal end of the nasolacrimal duct in children older than 12 months. We do not recommend silicone intubation in the absence of complex lacrimal system anomalies.

Congenital arhinia is a rare anomaly characterized by a syndrome called Bosma arhinia microphthalmia syndrome. A 22-year-old woman with a history of congenital arhinia presented with bilateral discharge and enlarged bilateral lacrimal sacs, with imaging consistent with bilateral dacryocystoceles and complete absence of nasal structures. This is the first case in the literature that describes surgical management of bilateral dacryocystoceles in a patient with Bosma arhinia microphthalmia syndrome., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Data supporting treatment recommendations for congenital nasolacrimal duct obstruction (CNLDO) in patients with craniofacial abnormalities is scarce. This study reports the incidence, clinical features, and outcomes of patients with concomitant craniofacial abnormalities and CNLDO., Methods: This multi-center, retrospective, population-based cohort study included all patients diagnosed with CNLDO before age 6 during a 10-year period in a single US county., Results: Of the 17,713 live births during the study period, 1998 infants were diagnosed with CNLDO, among whom 41 (2.05%) had associated congenital craniofacial abnormalities, yielding a birth prevalence of 23.1 (95% CI 16.6-31.4) per 10,000 live births. Craniofacial patients were significantly older at time of diagnosis (6.2 months) compared to uncomplicated CNLDO (3.7 months; p  = 0.035). There was no significant difference in mean age at spontaneous CNLDO resolution, but 31.7% of craniofacial patients required probing for CNLDO resolution, compared to 14.5% in the CNLDO group (OR 2.76 [95%CI 1.41-5.39] p  = 0.003). All but two patients with craniofacial abnormalities had resolution of symptoms after initial probing. Intraoperative probing findings indicated that 8 of 13 craniofacial patients had complex obstructions., Conclusions: The similar age at spontaneous resolution indicates that watchful waiting until approximately one year of age is a reasonable approach even in patients with craniofacial abnormalities, though more of these patients may require surgical intervention.

Complex congenital lacrimal drainage anomalies are known to be associated with several syndromes and present unique surgical challenges. Duplication of human body structures is uncommon and has been reported in the uterus (uterine didelphys), ureter (duplex ureter), duodenum, transverse colon, and nose. Lacrimal drainage anomalies have been reported in proboscis lateralis. To the best of the authors' knowledge, there are no prior reports on duplication of the lacrimal sac. The present case reports a complex congenital nasolacrimal duct obstruction that was associated with duplication of the lacrimal sac and the presence of 3 canaliculi., Competing Interests: M.J.A. receives royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery” and for the treatise “Atlas of Lacrimal Drainage Disorders.” Other authors have no conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To investigate whether patients with craniosynostosis exhibit higher rates of nasolacrimal duct obstruction (NLDO) and to explore potential risk factors., Methods: Retrospective review including all craniosynostosis patients treated at both the Divisions of Ophthalmology and Plastic, Reconstructive, and Oral Surgery at The Children's Hospital of Philadelphia between 2009 and 2020 was conducted. Synostosis characteristics, lacrimal disorders, and genetic data were collected. Main outcome measures were the rate of NLDO and associations with anatomical and syndromic/genetic risk factors., Results: The total of 767 participants had a mean age of 2.8 ± 3.8 years, 465 (60.6%) were males, 485 (63.2%) had no syndromic association; 631 (82.3%) had one major suture involved, 128 (17%) had involvement of 2 to 4 major sutures, and 429 (55.9%) underwent craniofacial surgery. Forty-eight (6.2%) patients had NLDO, which more prevalent in the genetic/syndromic group (11.0% vs. 3.5%, respectively, p < 0.001), with the highest prevalence observed in patients with Apert syndrome (n = 4, 30.8%). The genetic variants most associated with NLDO were EFNB1 (n = 1, 100%) and FGFR2 (n = 6, 19.4%). There was no association between NLDO and the number or types of sutures involved or a history of craniofacial surgery., Conclusions: Nasolacrimal duct obstruction is more common in patients with craniosynostosis compared to the general population. Having a putative syndrome or a putative genetic variant and female sex were risk factors for NLDO. Ophthalmic evaluations for all craniosynostosis patients and careful assessments of any symptoms of tearing are recommended., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To assess and compare the success rate (SR) of probing and intubation in patients with congenital nasolacrimal duct obstruction (CNLDO)., Methods: We conducted a literature search for identifying relevant studies published in English using PubMed, Google Scholar, Scopus, and Web of Science databases from the date of inception to Feb 2023. After extracting data, the SR was compared between the study groups: simple and complex CNLDO. To compare the treatment outcome, the mean difference of the SR was considered as the effect size. Random effects model or fixed effects model were performed for statistical inferences., Results: A total of 21 studies were eligible to be analyzed. The pooled SR of treatment was 88% in simple, and 57% in complex CNLDO. Exerting intubation in increased the SR from 87% (SR of probing) to 92% in simple CNLDO which was not significant. However, compared to probing, intubation has a significantly higher SR in complex CNLDO (46 to 82%). While the SR of probing was significantly lower in complex CNLDO, the difference between the SR of intubation was not significant between groups. Although increasing the age does not have an adverse effect on the SR in simple CNDLO, it causes a significant decrease in the SR of complex group., Conclusion: This study revealed that even though the addition of NLD intubation does not provide significant benefits beyond probing alone for patients with simple CNLDO, in children with complex CNLDO, NLD intubation should be considered as a primary treatment due to its substantial increase in surgical success rates. Delaying the treatment would increase its success in patients with complex but not the simple CNLDO., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To explore the endoscopic and histopathologic characteristics of the lacrimal sac (LS) and the nasolacrimal duct in cases with punctal agenesis presenting with LS swellings., Methods: This is a prospective, interventional study of 13 LSs of 8 patients presenting with punctal agenesis and LS swellings over a 5-year study period (June 2018-July 2023). Complete ophthalmic examination was performed along with CT scans of the orbits. The LS was exposed with an anterior lacrimal crest incision and explored. The exterior and interior of the sac swelling were examined and LS flaps were sent for histopathological analysis., Results: The mean age of the patients was 23 years with a male:female ratio of 5:3. All patients presented with swelling in the LS region. Occasional epiphora was the presenting feature in 6 patients. All patients had both upper and lower punctal agenesis on the affected side with associated LS swelling. CT scans showed a hypodense cystic swelling with expansion of the LS fossa and bony nasolacrimal duct ending abruptly short of the inferior meatus. Intraoperatively, the LS had thin, translucent walls with mucoid secretion and an absence of common canalicular opening. Histopathological analysis showed epithelium consistent with LS with less robust development of the sac walls and poorly structured lacrimal drainage-associated lymphoid tissue with scanty stromal inflammation., Conclusions: The development of LS and the nasolacrimal duct is structurally affected in patients with punctal agenesis. Retrograde approaches for epiphora resolution are not logical in such cases but conjunctivodacryocystorhinostomy with Jones tube can be a feasible option., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To report the incidence, clinical characteristics, and outcomes of acute dacryocystitis among a large, population-based cohort of children born with congenital nasolacrimal duct obstruction (CNLDO) over a 10-year period., Methods: This multicenter retrospective, population-based cohort study included all patients diagnosed with acute dacryocystitis in a cohort of patients diagnosed with CNLDO before age 5 years in Olmsted County, Minnesota, United States of America from January 1, 1995, through December 31, 2004., Results: Of 1,998 patients with CNLDO, there were 70 cases (36 female [(51%)]) of acute dacryocystitis during the study, yielding an incidence rate of 243 per 100,000 children (95% CI, 170-316). Mean age at diagnosis was 9.0 months. Patients who developed dacryocystitis were significantly less likely to be born via C-section (OR = 0.29, P = 0.009). Less than half of patients with dacryocystitis were treated with oral/intravenous antibiotics (46%), but whose who were had a significantly higher odds of requiring probing (OR = 8.50, P = 0.004). Spontaneous CNLDO resolution was significantly less likely to occur in patients diagnosed with acute dacryocystitis compared with those without (OR = 2.46, P = 0.001). The median age of spontaneous resolution in the dacryocystitis group (6.0 months) was significantly older than the uncomplicated CNLDO group (P = 0.012)., Conclusions: Pediatric acute dacryocystitis is an uncommon complication of CNLDO and is associated with both a lower likelihood of and older age at spontaneous resolution of CNLDO symptoms., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Pierre-Robin sequence consists of a classical triad of micrognathia, glossoptosis, and upper airway obstruction. The common ocular manifestations include congenital glaucoma, high myopia, maculopathy, and retinal detachment. Except for a mention of a nasolacrimal duct obstruction without many details, lacrimal drainage anomalies have not been reported earlier to the best of the authors' knowledge. The present case describes several lacrimal drainage anomalies including supernumerary puncta, canalicular wall hypoplasia, grossly dilated nasolacrimal duct, and complex congenital nasolacrimal duct obstruction in a patient of Pierre Robin sequence. The patient was successfully managed with endoscopic guided probing and marsupialization of the large intranasal cyst resulting in a complete resolution of epiphora.

Purpose: The objective of this study was to analyze the impact of different factors on the success rate of probing for congenital nasolacrimal duct obstruction (CNLDO)., Methods: A retrospective analysis was conducted on 239 eyes of 202 patients who underwent probing for CNLDO between 2014 and 2019. Patients were divided into three age groups (12-24 months, 25-36 months, and over 36 months) and two groups based on the type of membranous obstruction (MO) and incomplete complex obstruction (ICO), with complete complex obstruction (CCO) cases being excluded. The study involved administering general anesthesia (GA) to all participants during the probing procedure. The patients were then monitored at scheduled intervals for up to 6 months after the surgery. Success was defined as an improvement in symptoms and signs, and logistic regression and Fisher's exact test were used for statistical analysis., Results: The mean age of the patients was 25.48 ± 13.38 months, and the total success rate was 86.61%. The success rate for MO was 92.8%, 95.87%, and 97% in age groups 1, 2, and 3, respectively. The success rate for ICO was 91.17%, 80%, and 23.52% in age groups 1, 2, and 3, respectively. The success rate for MO was significantly higher than ICO in all age groups. The success rate for ICO was significantly lower in age group 3 (p = 0.009)., Conclusion: The study found that probing performed within the first 36 months had high success rates regardless of age and type of obstruction. However, the success rate significantly decreased in patients undergoing probing for ICO at 36 months or later., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: Aplasia of lacrimal and salivary glands (ALSG) is a syndromic disorder characterized by aplasia of lacrimal and salivary systems. Reported ophthalmic manifestations of ALSG include aplasia of lacrimal glands, punctal agenesis, lacrimal sac mucocele, and membranous congenital nasolacrimal duct obstruction (CNLDO). Bony CNLDO, a rare clinical entity, has not been associated with any syndromic disorder. This study investigated the relationship between genetic mutations and bony CNLDO in 3 Chinese families with ALSG., Design: Single-center observational case study., Participants: Three Chinese families with bony CNLDO, including 7 affected and 9 healthy family members., Methods: Slit-lamp ophthalmic examination, comprehensive physical examination, orbital computed tomography (CT) imaging, cervicofacial magnetic resonance imaging, audiometry, and whole exome sequencing on periphery blood were performed. Variants were cross-referenced with 1000 control genomes and various population databases. Pathologic variants were identified using bioinformatic tools., Main Outcome Measures: Clinical examination, diagnostic imaging, whole exome sequencing, and bioinformatic analysis findings., Results: Affected patients showed decreased tear production on the Schimer I test and reduced tear breakup time. Bony CNLDO was observed on CT, showing unilateral or bilateral bony termination at the middle or terminal segment of the nasolacrimal canal. Magnetic resonance imaging showed aplasia or absence of lacrimal, parotid, and submandibular glands. Physical examination revealed normal ears, digits, and facial morphology. Audiometry and dental assessment were conducted on the pediatric patients and yielded normal results. The clinical characteristics of patients aligned with a diagnosis of ALSG. Genomic analysis revealed 3 novel heterozygous missense mutations of the Fgf10 gene: c.316T→C, c.327C→G, and c.332T→G. The inheritance pattern was autosomal dominant with variable penetrance. These variants were not observed in 1000 control genomes and population databases. These variant positions also were shown to be highly conserved across various animal species. Mutated genes and proteins were predicted as deleterious with most computational models, with a few suggesting they may be benign., Conclusions: Bony CNLDO was identified as a novel phenotype of ALSG implicated by missense mutations of highly conserved residues in the Fgf10 gene. These cases broadened our knowledge of Fgf10-related phenotypes and prompted clinicians to consider syndromic associations in patients with bony CNLDO., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2023 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Congenital nasolacrimal duct obstruction is a known risk factor for amblyopia and anisometropia. The purpose of this study was to investigate whether the rate of anisometropia and amblyopia development differed based on the age at CNLDO resolution in older infants., Methods: This retrospective chart review at a single tertiary children's hospital from 2007 to 2017 compared early versus late spontaneous resolution (cutoff 12 months) and intervention (cutoff 15 months) groups presenting at ≥9 months of age, comparing visual outcomes, including anisometropia (≥1 D of sphere or cylinder) and amblyopia (≥2 levels difference in Teller acuity or optotype testing). Parents/guardians were contacted by phone for missing data on spontaneous resolution or intervention status., Results: A total of 462 patients were included (152 early; 310 late group). The early group presented at a median age of 12.0 (interquartile range: 10.0, 13.0) months, while the late group presented at 21.0 (interquartile range: 15.0, 32.0) months. Unilateral disease occurred in 62% and 59%, respectively. Anisometropia was seen in (12/102) 12% of early versus (25/243) 10% of late patients (p = 0.686, 95% CI: -0.059, 0.088), and amblyopia in (4/131) 3% of early versus (14/286) 5% of late patients (p = 0.322, 95% CI: -0.061, 0.018). In patients presenting <24 months without undergoing surgery, spontaneous resolution occurred in 76% between 12 and 24 months (n = 41)., Conclusions: Anisometropia and amblyopia rates did not significantly differ between early and delayed intervention for congenital nasolacrimal duct obstruction in this retrospective cohort presenting beyond 9 months of age to a children's hospital. This study found frequent late spontaneous resolution., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: Congenital nasolacrimal duct obstruction (CNLDO) is the most common cause of epiphora in infants. It usually resolves completely by the end of 1 st year with conservative management in most cases. Many studies have confirmed high frequency (80%-90%) of spontaneous resolution of symptoms during the 1 st year of life. The aim of this study is to determine the effectiveness of the lacrimal sac massage in the treatment of CNLDO., Methods: The study was done in a tertiary care hospital in eastern Asia over 5 years. Each infant presenting with epiphora and diagnosed as CNLDO was treated with lacrimal sac massage and reviewed after every 1 month. The resolution of CNLDO was judged by the improvement of epiphora and from the fluorescein dye disappearance test., Results: Following conservative management, 740 (86.75%) infants recovered completely after 3 months of continuous lacrimal sac massvage. One hundred and five (12.31%) infants did not recover with sac massage even at 12 months, in which cases probing was done. Repeat probing was needed in six patients (0.07%). Two patients did not recover, and a dacrocystorhinostomy was carried out. About 70.6% of infants recovered within 6 months of age. Earlier the age of presentation, the lesser the morbidity., Conclusion: The incidence of CNLDO is about 6%-20% among infants. Several studies showed spontaneous resolution within 1 st year of life. In this study, the success rate of resolution of symptoms in CNLDO with sac massage is 86.75%. Conservative management should be the first line of treatment till 12 months of age in CNLDO., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Middle East African Journal of Ophthalmology.)

Purpose: This study introduces a method for Crawford bicanalicular stent placement for congenital nasolacrimal duct obstruction by looping the ends to themselves which are tied together with dissolvable sutures to ease in-office removal., Methods: This is a single institution, retrospective study that evaluates outcomes of patients aged 5 years and under who underwent bicanalicular stenting for congenital nasolacrimal duct obstruction by a single surgeon (G.S.E.) between 2004 and 2020. Only primary surgeries were included in the analysis. Stenting could be accompanied by balloon dilatation and/or turbinate infracture. Age, sex, follow-up time, complications, type of intervention, extrusion, recurrence, and operative room removal were recorded., Results: This study included 56 eyes from 54 patients with a mean age of 19.0 ± 9.5 months (range, 8-50 months). There was a 30.3% extrusion rate, a 5.4% rate of recurrence of disease, and a 3.6% rate of operative room removal. The average follow-up time was 25.1 ± 39.8 months (range, 1-132 months). For patients with or without extrusion, there were no significant differences between age, sex, laterality, type of intervention, follow-up time, or rate of recurrence. Each eye that had recurrence (3 total) or needed operative room removal (2 total) underwent only bicanalicular stenting without accompanying procedures, although the difference in rates between procedures was also not statistically significant., Conclusions: This method had a low recurrence and operative room removal rate, with similar extrusion and complication rates to other bicanalicular stent and intubation methods for the treatment of congenital nasolacrimal duct obstruction., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Background: We describe the ocular findings in two infants who were found to have unusual internal eyelid folds during routine probing for nasolacrimal duct (NLD) obstruction., Materials and Methods: Medical records review of two patients with similar eyelid folds., Results: Both children had unusual eyelid folds that began on the inner eyelid adjacent to the lacrimal canaliculi and extended to a position near the caruncle. Both children had resolution of NLDO following routine surgery, suggesting that the eyelid anomalies were an incidental finding at the time of NLDO surgery., Conclusion: The etiology of these unusual inner eyelid folds is not certain but may represent schisis or incomplete separation of the inner eyelid margin.

A 23-year-old patient with Williams-Beuren syndrome presented with ocular irritation and bilateral persistent tearing. Despite probing as an infant which showed bilateral nasolacrimal duct obstruction, dacryocystorhinostomy had been avoided due to the patient's syndromic supravalvular stenosis and related anesthesia risk. As the known diminished production of elastin in Williams-Beuren syndrome causes an array of associated vascular diseases, this case report hypothesizes that the lacrimal duct becomes obstructed through a similar mechanism. This case presents the unique findings of bilateral congenital nasolacrimal duct stenosis in a Williams-Beuren syndrome patient., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: To compare the clinical outcomes of primary nasolacrimal duct probing and primary bicanalicular intubations with endoscopic assistance for congenital nasolacrimal duct obstruction (CNLDO) in children aged 4 to 7 years., Methods: Forty-three eyes of 43 children (25 boys and 18 girls) with congenital epiphora who underwent primary unilateral probing and bicanalicular intubation were evaluated retrospectively. The tubes were removed 3 to 4 months after their placement, and the children were followed up for another 6 months after their removal. Treatment success was defined as the normal result of the fluorescein dye disappearance test and complete resolution of the lacrimal symptoms and signs of patients. The success rates were compared between the two groups (bicanalicular intubation vs probing). Type of CNLDO (membranous, incomplete complex, and complete complex) was determined with an endonasal endoscope., Results: The mean age was 63.3 ± 11.1 months (range: 48 to 84 months) for the probing group and 64.4 ± 12.1 months (range: 48 to 84 months) for the bicanalicular intubation group ( P = .915). The bicanalicular intubation group showed significantly greater treatment success (21 of 24, 87.5%) compared to the probing group (11 of 19, 57.9%; P = .038). Bicanalicular intubation provided higher treatment success among patients with complex CNLDO compared to probing (80.0% vs 11.1%, P = .002). There was no difference in mean age between the patients with successful and failed treatment in both groups ( P = .631 and .137, respectively)., Conclusions: Bicanalicular intubation was associated with a higher success rate than probing under nasal endoscopic visualization for the treatment of CNLDO in children aged 4 to 7 years. The type of CNLDO might be the primary factor for the treatment success. [ J Pediatr Ophthalmol Strabismus . 2023;60(2):101-107.] .

Aim: To evaluate the occurrence of co-existing congenital nasolacrimal duct obstruction (CNLDO) and other lacrimal anomalies in eyes with congenital glaucoma (CG)., Methods: Retrospective analysis of children aged ≤1-year with co-existing CG and CNLDO seen between 1998 and 2019, treatment interventions and outcomes., Results: During the study period, 1993 children had CG and 6203 children had CNLDO, among the children aged 1-year or less. Of these, 51 children (73 eyes) had co-existing CG and CNLDO. The prevalence of CNLDO in CG was 2.5% (51/1993) and the prevalence of CG among CNLDO was 0.8% (51/6203). Median age (Interquartile range, IQR) was 53 days (IQR: 8, 155), when they were diagnosed with CG. Among the children with CNLDO, 68 eyes (93.1%) had simple CNLDO, and 5 eyes (6.9%) had complex CNLDO. Associated lacrimal anomalies were present in 7/73 eyes, including congenital lacrimal fistula in two eyes, upper punctal agenesis and upper mid-canalicular obstruction in two eyes each, and upper single canalicular-wall hypoplasia in one eye. Lacrimal syringing and probing were successful in 69/72 eyes (95.8%), and failed in 3 eyes (4.2%). These 3 eyes had complex CNLDO and underwent Dacryocystorhinostomy (DCR) with Mitomycin-C and intubation. Sixty-two eyes underwent combined trabeculotomy and trabeculectomy, and two eyes underwent trabeculectomy. Median age at glaucoma surgery was 87 days (IQR: 54, 193). Median time delay for glaucoma surgery after probing was 18 days (IQR: 12, 35)., Conclusion: Among children aged ≤1-year presenting with congenital glaucoma coexisting lacrimal drainage anomalies was noted in 2.5% and simple CNLDO was the commonest. Early intervention is of paramount importance to prevent sight-threatening intraocular infection with CNLDO, and to minimize the delay of glaucoma surgery. The outcomes of lacrimal probing were excellent, however complex CNLDO required DCR.

Background/aims: To determine if nasolacrimal massage or topical antibiotics are associated with higher rates of resolution compared with observation alone in a population-based cohort of infants with congenital nasolacrimal duct obstruction (CNLDO)., Methods: The medical records of all children <5 years diagnosed with CNLDO while residing in Olmsted County, Minnesota from 1 January 1995 through 31 December 2004 were retrospectively reviewed for type of management and non-surgical resolution of tearing., Results: Among 1958 infants diagnosed and followed for CNLDO, 516 (26.4%) were merely observed, 506 (25.8%) were prescribed massage alone, 485 (24.8%) were prescribed at least one course of topical antibiotics, 397 (20.3%) were prescribed both topical antibiotics and massage, and 54 (2.8%) had no documented therapy. Non-surgical resolution, occurring in 1669 (85.2%) during a median follow-up of 3.1 months (range: 1 week-248 months), was 74.6% for the merely observed, 89.7% for those prescribed digital massage, 87.0% for those prescribed antibiotics and 90.7% for those treated with both. This comparison was significant in unadjusted (p<0.001) and multivariable comparisons (p<0.001)., Conclusion: Prescribing topical antibiotics or digital massage for infants with CNLDO in this cohort, individually or in combination, was associated with a higher rate of spontaneous resolution than observation alone., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To study the clinical profile, associated lacrimal disorders, and long-term outcomes following a membranotomy, in patients with incomplete punctal canalization (IPC)., Methods: Retrospective interventional study was performed of all the patients diagnosed with IPC during the study period over 5 years from January 2015 to December 2020. The diagnosis of IPC was made based on the earlier published guidelines. A combination of rapid and slow taper Nettleship's punctal dilators were used for an effective membranotomy, followed by further assessment of the lacrimal drainage passage. Appropriate interventions for associated lacrimal disorders were performed. Data collected on chart reviews include demographics, clinical presentation, laterality, type of IPC, associated lacrimal anomalies, management modalities, and long-term outcomes., Results: Ninety-eight puncta of 62 eyes of 46 patients with IPC were examined in the clinic. Incomplete punctal canalization-external membrane variant was seen in 62% (61/98) and internal membrane variant in 38% (37/98). Seventy-eight puncta (78/98, 79.5%) in 39 patients underwent membranotomy using Nettleship's punctal dilator. Associated lacrimal drainage pathway deformities were seen in 31% of patients (12/39). Three puncta had mini-monoka insertion for associated canalicular stenosis and canalicular obstruction. Five patients with associated congenital nasolacrimal duct obstruction underwent probing, of which 3 patients needed dacryocystorhinostomy for complex congenital nasolacrimal duct obstruction. Associated punctal agenesis was noted in 3 patients involving the other punctum of the same eye. Canalicular wall hypoplasia involving 3 walls of the canaliculus was seen in 1 patient. At a mean follow up of 28 months, the anatomical and functional outcomes were noted in 100% and 97.4%, respectively., Conclusions: The long-term outcomes of membranotomy for IPC are excellent. Associated congenital lacrimal drainage anomalies are common with IPC., (Copyright © 2021 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Purpose: The aim of reporting this case is to describe a rare combination of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction. A variety of lacrimal anomalies have been seen in blepharophimosis-ptosis-epicanthus inversus syndrome but the occurrence of nasolacrimal duct obstruction is rare., Method: The blepharophimosis-ptosis-epicanthus inversus syndrome is an autosomal dominant rare genetic defect with clinical manifestation of dysplasia of the eyelids, palpebral fissures, flat nasal bridge, and ptosis. A 20-month-old boy was referred with the complaints of watering and discharge from his right eyes since birth. On examination, the child had all the features of blepharophimosis-ptosis-epicanthus inversus syndrome with right congenital nasolacrimal duct obstruction in line with the published reports., Result: On endoscopic probing and irrigation, the probe could not be visualized into the inferior meatus. On dacryoendoscopy, the membranous part of the nasolacrimal duct was found to be completely obliterated with no light transmission into the nose indicating a malformed nasolacrimal duct. The child was managed by endoscopic dacryocystorhinostomy. We could find only one case report published so far on the combination of congenital nasolacrimal duct obstruction with blepharophimosis-ptosis-epicanthus inversus syndrome. This study adds one more case of blepharophimosis-ptosis-epicanthus inversus syndrome with congenital nasolacrimal duct obstruction and adjuvant use of dacryoendoscopy.

Bilateral Tessier cleft types 3 and 4 are rare and commonly involve the lacrimal drainage system owing to their anatomical location. Such clefts commonly present with associated ocular anomalies and include colobomatous eyelids, hypertelorism, microphthalmia, punctal or canalicular agenesis, and nasolacrimal duct obstruction or exstrophy. The current report presents an 18-month-old baby with bilateral Tessier cleft 3 with a unilateral anophthalmos, symmetrical eyelid colobomas, and lacrimal drainage anomalies. The lacrimal anomalies noted include small lacrimal sac with inferior canaliculus on the right side and upper and lower punctal and canalicular agenesis on the left side. Computed tomographic dacryocystography demonstrated unilateral lacrimal sac and bilateral maldevelopment of the bony nasolacrimal duct.

Purpose: The aim of this study is to report the outcome of balloon catheter dilation as the primary treatment of congenital nasolacrimal duct obstruction in children of all ages., Methods: A 10-year retrospective study of 148 children (270 eyes), aged 9 to 159 months (mean age: 29.6 ± 17.7 months), who previously had not undergone a nasolacrimal surgical procedure and who presented with clinical signs of nasolacrimal duct obstruction, was conducted. All children underwent balloon catheter dilation of the nasolacrimal duct., Results: Treatment success, defined as complete resolution of nasolacrimal duct obstruction symptoms present at follow-up visits at 1 week and up to 6 months after surgery, was 87% (234 of 270 eyes). Partial success was defined as occasional tearing which was acceptable to parents and present in 3% (nine eyes). Only 10% of the children underwent a second procedure due to complete failure. In a sub-analysis by age groups-under 18 months, between 18 and 36 months, and above 36 months-complete resolution rates were 85%, 93%, and 77%, and partial success rates were 3%, 3%, and 4%, respectively. There was a statistically significant difference between the age groups ( p  = .007)., Conclusion: In this large cohort of patients with nasolacrimal duct obstruction, balloon catheter dilation was successful as a primary treatment for congenital nasolacrimal duct obstruction, particularly under the age of 36 months.

Purpose: The aim of this study was to research the relationship between types of birth and congenital nasolacrimal duct obstruction., Method: The study enrolled 665 infantile patients with prediagnosis of congenital nasolacrimal duct obstruction due to associated ophthalmic symptoms. Age, gender, family history, delivery type, and patient medical records were investigated. Patients were grouped and compared according to their birth type and whether it was the first birth., Results: The number of the infants with and without congenital nasolacrimal duct obstruction was 227 (34.1%) and 438 (65.9%), respectively. Comparison of the congenital nasolacrimal duct obstruction and non-congenital nasolacrimal duct obstruction groups according to the first births showed that ratio of cesarean section was significantly higher in the congenital nasolacrimal duct obstruction group than the non- congenital nasolacrimal duct obstruction group (58.7% and 20.7%, respectively). Number with positive family history also was significantly higher in the congenital nasolacrimal duct obstruction group., Conclusion: Cesarean section in first birth and positive family history of congenital nasolacrimal duct obstruction appear to be important risk factors in the etiopathogenesis of congenital nasolacrimal duct obstruction.

Purpose: To investigate spontaneous resolution of congenital nasolacrimal duct obstruction (CNLDO) beyond 12 months of age in Japanese infants., Methods: Retrospective, observational case series. We retrospectively reviewed the clinical records of patients diagnosed with CNLDO beyond 12 months of age at Kyoto Prefectural University Hospital, Kyoto, Japan. This study involved 155 cases of CNLDO in 133 Japanese infants diagnosed with CNLDO. All patients chose intervention with either dacryoendoscopic guided probing and stenting or conservative management. The proportion and age of patients who had spontaneous CLNDO resolution were analysed., Results: The patients were divided into two groups: (1) 62 patients with 70 obstructed nasolacrimal ducts (45%) in whom spontaneous resolution occurred and (2) 71 patients with 85 obstructed nasolacrimal ducts (55%) who underwent dacryoendoscopic guided probing and stenting. The mean age of spontaneous resolution was 17.8±5.3 months (range: 12.0-35.4 months). Dacryoendoscopic guided probing and stenting were successful in 83/85 (97.6%) of cases., Conclusions: Spontaneous resolution of CNLDO can occur in 45% of infants over the age of 12 months. Dacryoendoscopic guided stenting also has high success rates in this patient group, and both treatment options can be proposed to caregivers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To investigate the presence of amblyopia risk factors in newborns with congenital nasolacrimal duct obstruction (CNLDO) and age-matched healthy control subjects., Methods: This retrospective case-control study involved newborns aged 30 to 60 days with CNLDO and age-matched healthy control subjects. Amblyopia risk factors were identified in accordance with the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee recommendations. The prevalence of amblyopia risk factors was compared in newborns with CNLDO and age-matched healthy control subjects, newborns with unilateral and bilateral CNLDO, and the affected eye and fellow eye of newborns with unilateral CNLDO., Results: Amblyopia risk factors were found in 18 patients (11.9%) with CNLDO and 19 control subjects (8.7%) (P = .314). Eyes with CNLDO showed a significantly lower spherical equivalent compared to control eyes (2.01 ± 1.21 vs 2.79 ± 1.14 diopters, P < .001). No difference in amblyopia risk factors was found in eyes with unilateral and bilateral CNLDO (11.5% vs 12.1%; P = .908) or in eyes with unilateral CNLDO and fellow eyes (9.8% vs 12.3%; P = .540)., Conclusions: CNLDO does not seem to be associated with amblyopia risk factors in newborns. Because anisometropia might develop later on, all patients with CNLDO should be monitored for amblyopia. [J Pediatr Ophthalmol Strabismus. 2020;57(1):39-43.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To report outcomes of nasolacrimal duct (NLD) probing in children 4 years and older with simple membranous NLD obstruction., Methods: The records of all patients 4 years and older with congenital NLD obstruction who underwent surgery from 1997 to 2015 at Washington University School of Medicine were retrospectively reviewed. Of 47 patients reviewed, 18 (38.3%) were found to have simple membranous obstructions and were included in this study. Simple membranous obstruction was present at the distal duct and was relieved with passage of the probes in all patients. Children with canalicular or diffuse distal NLD stenosis (as defined by a tight, gritty feeling or multiple obstructions when passing the probe through the bony portion of the NLD), trisomy 21, lacrimal trauma, or craniofacial abnormalities were excluded. A successful outcome was determined by resolution of epiphora and periocular crusting., Results: Eighteen patients with ages ranging from 4.1 to 10.6 years with simple membranous NLD obstruction were treated. Sixteen of 18 (88.9%) patients had good outcomes following NLD probing. Two patients had persistent symptoms that resolved following balloon dilation and stent placement., Conclusions: This study found that the success rate of probing in older patients with simple membranous NLD obstruction was comparable to that of younger patients. NLD probing alone is a good treatment option for older children with simple membranous NLD obstruction. Additional procedures such as balloon catheter dilation or stent placement may not be necessary at the time of initial probing. [J Pediatr Ophthalmol Strabismus. 2020;57(1):44-47.]., (Copyright 2020, SLACK Incorporated.)

Background: To investigate the therapeutic effectiveness and safety of endoscopic dacryocystorhinostomy (EN-DCR) to treat congenital nasolacrimal canal dysplasia (CNCD)., Methods: Forty children (50 eyes) with congenital nasolacrimal duct obstruction (CNLDO) and lacrimal bony dysplasia, including 8 children with bony atresia (10 eyes) and 32 with bony stenosis (40 eyes), were recruited in this retrospective study. Standardized EN-DCR was performed in all cases. The postoperative observations included relief of symptoms, fluorescein dye disappearance test (FDDT), syringing of lacrimal passages and anastomotic patency under nasal endoscopy. Patients were followed up for 8-18 months., Results: Standardized EN-DCR surgery had a success (cure and improvement) rate of 100%, including a cure rate of 82% and an improvement rate of 18%. The cure rate among 40 cases of bony nasolacrimal duct stenosis was 82.5%, while that of 10 cases of bony nasolacrimal duct atresia was 80%. Statistical analysis showed that nether the receipt of other treatments before surgery nor the type of bony nasolacrimal duct dysplasia affected the cure rate. No significant complications were observed during postoperative follow-up except for four cases (4 eyes) that suffered middle turbinate and nasal mucosal adhesion and two cases with sinusitis., Conclusions: CNCD is a type of CNLDO that does not respond to conservative and conventional treatment. EN-DCR represents a safe and effective treatment for children with CNCD. In addition, the combination of EN-DCR with lacrimal CT scanning provides advantages over traditional lacrimal surgery in that it has a high success rate with a low incidence of complications.

Purpose: To investigate the success rate of probing for young children with nasolacrimal duct obstructions and the risk factors involved., Methods: The medical records of 3,143 patients (3,928 eyes) who received nasolacrimal duct probing in southwest China were collected. These included delivery method, age and gender, preoperative treatments, anesthesia methods, probing procedure, and follow-up clinical records. Then the relationship between the success rates of the probing and a few probable risk factors were analyzed., Results: Children delivered by eutocia were more likely than those delivered by cesarean section to have nasolacrimal duct obstruction. The total success rate of the probing was 85.2%. Patients older than 19 months had a lower completion rate compared with those younger than 1 year (P < .01). In the follow-up observations, the younger age groups were more likely to have higher success rates than the older ones (P < .05) using pairwise comparison. The success rates also had a significant relationship with the type of obstruction and older patients were more likely to have complex obstruction (odds ratio: 1.13, 95% confidence interval: 1.08 to 1.19, P < .001)., Conclusions: This large-scale study proved several factors affect the success rate of nasolacrimal duct probing, and confirmed children delivered by eutocia were more likely to have nasolacrimal duct obstruction. [J Pediatr Ophthalmol Strabismus. 2019;56(6):365-372.]., (Copyright 2019, SLACK Incorporated.)

Purpose: To study the CT appearance of the nasolacrimal canal (NLC) in cases of congenital nasolacrimal duct obstruction (CNLDO) where there is a tactile sensation of a hard contact (HC) stop in the duct preventing stent intubation., Methods: The authors retrospectively reviewed all consecutive cases of chronic CNLDO observed between 2003 and 2018 in which an apparent HC obstruction prevented nasolacrimal intubation. CT scans were reviewed to determine the cause of probing failure: distal stenosis, loss of parallelism of the NLC walls, abnormal angulations or an adjacent obstacle blocking tear outflow., Results: Nine patients (12 sides) met the following criteria: CNLDO + HC + probing failure. The mean age at the time of the first HC was 3.9 years (range: 0.8-8.1 years) and at the time of a second confirmation of HC with subsequent dacryocystorhinostomy was 7.8 years (range: 4.1-9.2 years). Nasolacrimal duct opacification was noted in 33% of cases (4/12). Abnormalities of the NLC occurred in 8 of the 12 cases of CNLDO (8/12 = 66.6%) and on the asymptomatic side in 1 case (1/6 = 16.6%). A canine tooth bud situated in the same plane as the NLC was observed in 9 cases of CNLDO (9/12 = 75%) and on the asymptomatic side in 2 cases (2/6 = 33.3%)., Conclusions: HC noted during probing is a sensitive but relatively nonspecific sign which, nevertheless, does indicate either a complex obstruction or at least potential intubation difficulties. As confirmed by CT imaging, a significant anatomical variant is not necessarily predictive of epiphora, but nevertheless may complicate the intubation procedure.The authors describe hard contact palpation during probing for CLNDO and its relationship to anatomic location and etiologies of obstruction in the nasolacrimal canal by CT imaging.

Purpose of Review: After failed conservative management, most clinicians treat congenital nasolacrimal duct obstruction (CNLDO) in a conventional stepwise fashion: starting with probing, then repeat probing, next silicone intubation and/or balloon dilatation, and finally dacryocystorhinostomy. This approach is based on the patient's age and previously failed procedures and recruits 'one procedure for all' CNLDO. A newly introduced approach is based on the type of obstruction and recruits 'all procedures for one' CNLDO. The aim of this review is to examine the best available evidence regarding CNLDO management., Recent Findings: Recent articles support the concept that through intraoperative evaluation of obstruction in CNLDO, clinicians may predict probing failure and instantaneously employ more appropriate treatment modalities. This review addresses whether an age-based approach should be changed into a one-stage obstruction-based approach., Summary: An age-based approach treats CNLDO as a homogeneous disease and thus treats all patients with one predetermined procedure. A one-stage obstruction-based approach, however, considers CNLDO to be a heterogeneous disease, and therefore allows recruitment of all procedures simultaneously and selects the best intraoperatively. It may allow replacement of the conventional stepwise approach to CNLDO treatment provided that randomized trials verify its efficacy, safety, and cost-effectiveness.Video abstract http://links.lww.com/COOP/A30.

Rubinstein-Taybi syndrome is a rare multisystem disorder characterized by broad thumbs and first toes, short stature, microcephaly, delayed milestones, beak nose, and hypertelorism. Lacrimal drainage anomalies are not uncommon in this syndrome. We present a patient with Rubinstein-Taybi syndrome with bilateral congenital nasolacrimal duct obstruction and left-sided grossly dilated nasolacrimal duct.

Purpose: To assess the success rate of external dacryocystorhinostomy (DCR) with silicone intubation for recurrent lacrimal abscess in children younger than 6 years., Methods: A single-center retrospective analysis of 46 eyes of 40 children who underwent DCR with silicone tube intubation for recurrent lacrimal abscess was done. Probing done previously in these cases was unsuccessful. Only those children who underwent incision and drainage of the abscess at least once with antibiotic treatment were included in the study. In all cases, silicone tube removal was done after 3 months. A successful outcome was defined as the absence of subjective complaints of pain and swelling over the medial canthal area and watering and discharge at 6 months postoperatively. Objective assessment of patency of the lacrimal apparatus was done by sac syringing at 6 months postoperatively., Results: The mean age at surgery was 4.93 ± 0.93 years (range: 3 to 6 years) and the mean follow-up duration was 11.80 ± 11.87 months (range: 6 to 84 months). Intra-operative difficulties encountered were excessive perisac adhesion (n = 28) and severe bleeding/hemorrhage (n = 24). A total of 82.61% cases had a successful outcome after DCR with silicon tube intubation. One child had granuloma formation at the wound. Spontaneous tube extrusion occurred in three children., Conclusions: DCR with silicone tube intubation is a safe and effective surgical approach with satisfactory outcomes for treating recurrent lacrimal abscess with congenital nasolacrimal duct obstruction in children younger than 6 years. [J Pediatr Ophthalmol Strabismus. 2019;56(3):188-193.]., (Copyright 2019, SLACK Incorporated.)

Purpose: To determine the effect of probing for congenital nasolacrimal duct obstruction in children older than 2 years., Methods: A prospective interventional case series included 110 eyes of 94 patients with congenital nasolacrimal duct obstruction (CNLDO) aged 2 years or older, with no previous intervention. The diagnosis was based on clinical findings (epiphora, discharge, regurgitation test, and fluorescein dye disappearance test). The children were divided into two groups: 2 to 5 years and 6 to 8 years. Probing of the nasolacrimal duct under general anesthesia was done. Success was predefined as resolution of symptoms and signs that persisted 3 months postoperatively. Another probing was done at 4 to 6 weeks when necessary before considering the final outcome as a failure. The chi-square test was used to analyze the result., Results: Patients' ages ranged from 2 to 8 years (average age: 55 months). Twenty-six (28%) patients needed a second probing. The overall success rate was 80%: 85% in the 2 to 5 years group and 73% in the 6 to 8 years group. The success rate was significantly lower in patients with complex obstruction (33.3%). The outcome of probing was not affected by the age of the patients (P = .2305)., Conclusions: Probing is a viable primary surgical option in CNLDO in older children and hence should not be withheld in children who are referred late. [J Pediatr Ophthalmol Strabismus. 2019;56(3):141-145.]., (Copyright 2019, SLACK Incorporated.)

A 16-year-old girl diagnosed with velocardiofacial syndrome complained of occasional bilateral ocular discharge. Examination revealed an agenesia of the inferior puncti and canaliculi, while the irrigation through the superior puncta was patent on both sides. Dacryocystorhinostomy with insertion of Lester Jones tubes is not considered for the time being because of the absence of epiphora. To the best of the authors' knowledge, this is the second reported case of lacrimal system agenesia in velocardiofacial syndrome.

The authors conducted a 10-year retrospective review of all patients within one physician's practice to determine the frequency of spontaneous resolution of congenital nasolacrimal duct obstruction in children older than 1 year during the interval between scheduling and date of probing. This review found 4.4% of eyes resolved within an average interval period of 39 days. [J Pediatr Ophthalmol Strabismus. 2019;56:e31-e33.]., (Copyright 2019, SLACK Incorporated.)

Background/aims: The literature on the prevalence and demographics of congenital nasolacrimal duct obstruction (CNLDO) is 30-70 years old and largely comprises small sample sizes. This study provides epidemiological findings of this common disorder from the largest cohort reported to date., Methods: The medical records of all children (<5 years of age) residing in Olmsted County, Minnesota, when diagnosed with CNLDO from 1 January 1995 through 31 December 2004, were reviewed., Results: Of 17 713 newborns born during the 10-year study period, 1998 were diagnosed with CNLDO, yielding a birth prevalence of one in nine live births. The diagnosis was made in approximately 90% by a primary care physician, at a median age of 5 weeks, with no gender predilection. Compared with the reference population, CNLDO was associated with premature birth (p=0.005) and was more prevalent among Caucasians (p<0.001). Two-thirds of patients initially presented with discharge alone, 18% with tearing alone and 15% with both discharge and tearing., Conclusions: In this large population-based cohort, CNLDO occurred in one in nine live births with no gender predilection. Prematurity and Caucasian race were associated with the development of CNLDO. Mucopurulent discharge was a much more common feature than tearing at initial presentation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Objective: To evaluate the effectiveness and safety of autologous fibroblasts combined with keratin gel for tear trough deformity rectification as injectable soft tissue filler., Materials and Methods: The new injectable soft tissue filler was derived from autologous fibroblasts and keratin gel. A total of 35 patients received treatment of this filler injection for tear trough deformity rectification. All the patients were followed up, and the clinical features including photographs and satisfaction were collected and assessed at 1, 3, 6, 12 and 24 months after injection. The efficacy of each patient was evaluated independently by blinded evaluators at different time points. All patients consented to publish identifiable photographs in this study., Results: Tear trough deformity was improved even at 18-24 months post-injection. No severe adverse effects were observed resulting from the filler injection., Conclusion: Combination of autologous fibroblasts and keratin is efficient and safe for correction of the tear trough deformity with long-term satisfaction and desirable result., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Importance: Although the overall rate of spontaneous resolution in congenital nasolacrimal duct obstruction (CNLDO) and efficacy of probing have been documented in the literature, the optimal timing of intervention has not been established., Objective: To report new findings regarding spontaneous resolution in a large cohort of children with CNLDO., Design, Setting, and Participants: The medical records of 1998 consecutive infants diagnosed with CNLDO from January 1, 1995, through December 31, 2004, while residing in Olmsted County, Minnesota, were retrospectively reviewed. Data were analyzed between January 1, 2015, and January 2017., Main Outcomes and Measures: Rate of spontaneous resolution over time and by sex., Results: The cohort, diagnosed at a median age of 1.2 months (interquartile range, 0.4-3.6), was 48% girls (n = 959) and 89% white (n = 1626; 173 were unreported). Among the 1998 cases, 1669 (83.5%) spontaneously resolved, 289 (14.5%) underwent treatment, and the remaining 40 (2.0%) were lost to follow-up. Of the 1958 infants followed up, CNLDO in 925 (47.3%) spontaneously resolved by age 3 months, in 1300 (66.4%) by 6 months, in 1472 (75.7%) by 9 months, and in 1516 (78.4%) by 12 months. The rate of resolution was 35% faster (95% CI, 23%-47%; P < .001) at less than 1 month vs 3 months, 43% faster (95% CI, 27%-64%; P < .001) at 3 months vs 6 months, 39% faster (95% CI, 16%-64%; P < .001) at 6 months vs 9 months, and 1% slower at 9 months vs 12 months (hazard ratio, 0.99; 95% CI, 0.80-1.22; P = .78). Congenital nasolacrimal duct obstruction resolved in boys 0.5 months (95% CI, 0.2-0.8; P < .001) faster than girls (median, 2.9 vs 3.4 months), and unilateral obstructions resolved 0.2 months (95% CI, 0.1-0.4; P = .002) faster than bilateral (median, 3.1 vs 3.3 months) ones. Children probed at 15 months or older had decreased odds of resolution after probing (odds ratio, 0.11; 95% CI, 0.01-0.89; P = .04) compared with children probed at age 12 to 14 months., Conclusions and Relevance: Based on this large cohort of children with CNLDO, probing between age 9 and 15 months may be reasonable given that the rate of spontaneous resolution plateaued after 9 months and initial probing success declined after 15 months. This time frame supports both an earlier and narrower range of ages for intervention compared with the current practice of probing after age 1 year.

Objective: The acellular dermal matrix (ADM) used in correcting the tear trough deformity has been reported, but there were only a few cases. The long-term effectiveness of ADM was not clear. We aim to discuss the technique and the effect of using ADM to correct the tear trough deformity through more cases., Methods: A retrospective study was conducted from January 2012 to January 2017. Twenty-six patients who showed obvious tear trough deformity with moderate or severe orbital fat bulging and excess of lower eyelid skin were treated with ADM to improve the appearance of the midface. Follow-up was performed for 2-12 months in 26 cases. The level of postoperative satisfaction was assessed by interview during the follow-up and rated as very satisfied, satisfied, acceptable, or unacceptable., Result: Twenty patients were very satisfied for having achieved complete correction. Three patients were satisfied for having achieved obvious improvement. Three patients felt the results were just acceptable and were refilled because of the insufficiency of the filler. No one was unacceptable. There were no complications such as rapid resorption, rejection, or inflammation., Conclusion: The method of using ADM for the correction of tear trough deformity has the advantages of low absorption rate, good appearance, and high security. It provides a new choice for the treatment of tear trough deformity., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Purpose: To identify the efficacy and adverse event rates of balloon dacryoplasty in cases of congenital nasolacrimal duct obstruction in children who fail to respond to an initial nasolacrimal duct probing., Methods: A literature search was last performed in September 2017 in the PubMed database to identify all reports of balloon dacryoplasty. All searches up to and including the last search were limited to the English language, and they yielded 104 articles that were assessed for relevancy. Thirty-six articles were selected for full review, and 8 of these were selected for inclusion in this assessment and assigned a quality of evidence rating by the panel methodologist., Results: Three of the 8 studies included in this assessment were rated level II, and 5 were rated level III. Success rates varied from 75% to 100%. Only 2 complications were identified, and these were cases of self-limited postoperative emesis. The 2 studies that compared balloon dacryoplasty with lacrimal stenting reported that outcomes were comparable between the 2 techniques., Conclusions: Although level I evidence was not available, the studies that were uncovered in the literature review indicate that balloon dacryoplasty is a safe, effective procedure to address congenital nasolacrimal duct obstruction that persists after standard probings. The outcomes of this intervention are similar to those of lacrimal stenting, and the absence of an implanted stent theoretically reduces the risk of complications., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Congenital nasolacrimal duct obstruction (CNLDO) remains the most common cause of epiphora in infants. This retrospective study compares the success rate of nasal endoscopic-assisted probing between younger (3 years and below) and older (above 3 years) children with membranous CNLDO and its correlation with the thickness of the membrane at the valve of Hasner. Case records of a total of 38 eyes in 34 children with membranous CNLDO who underwent endoscopic nasolacrimal duct probing and irrigation under general anesthesia were analyzed. The cases were divided into two groups, Group Y (20 cases of children 3 years and below) and Group O (18 cases of children above 3 years). The success of the procedure was defined as complete remission of symptoms and a clinical examination of eye to rule out the presence for discharge or watering after three months of the procedure. Overall, 35 cases (92.1%) were successfully treated with a success rate of 95% in Group Y and 88.9% in Group O. The mid-P exact test p value for the success rate between the two cohorts was not statistically significant (p = 0.59). The thick membrane was observed in 50% cases in Group Y and 33.33% cases in Group O (p = 0.34). There is no age related decline in the overall success rate for nasal endoscopic-assisted probing and irrigation in cases of membranous CNLDO. The thickness of the membrane may be a factor for failed blind probing, but it has no correlation with the success rate if probing is done under endoscopic guidance.