The management of congenital nasolacrimal duct obstruction: an international perspective.

There is significant variation in how ophthalmologists treat children with congenital obstructions of the nasolacrimal ducts. In the United States, some perform an in-office probing procedure on infants, whereas many prefer to wait until after 1 year of age when more than 90% of the obstructions will have resolved spontaneously. Whether or not to instruct parents to massage the lacrimal sac and how to do it is another issue where there is not universal agreement. It is helpful to hear what physicians in other countries are doing to manage this condition. There should be no difference in the presentation and natural history of nasolacrimal duct obstruction in countries with similar demographics and healthcare delivery systems. In this issue, Puvanchandra et al. surveyed 100 ophthalmologists in the United Kingdom regarding their management of nasolacrimal duct obstruction. Of those surveyed, 49% use the dye disappearance test for diagnosis. Eighty-four percent suggest lacrimal sac massage to parents. No surveyed ophthalmologists perform “office” probing or balloon dilation. Seventy-four percent perform initial probing after 1 year, with 25% using nasal endoscopy. If symptoms persist, 64.5% repeat the probing, whereas 35.5% intubate the lacrimal system. The use of nasal endoscopy increases to 50.5%. By the third intervention, 77.6% perform lacrimal intubation, with 72.4% using nasal endoscopy. In total, 65% use tubes at some stage of management, and 33% make some use of nasal endoscopy involving ear, nose, and throat surgeons. In the United States, many surgeons have opted to augment initial probings with balloon dilatation or intubation, either monocanalicularly or bicanalicularly. We need to revisit the probing studies that have shown a more than 90% success rate with a simple probing performed between 13 to 15 months of age. Is the added morbidity and expense from adding a balloon catheterization or intubation in an initial probing procedure justified? I’m not convinced.