Lecture: Lacrimal Duct Obstruction in Children

[Fiona] Hello everyone around the world. I’d like to welcome you to this Cybersight session on epiphora in children and the various approaches that we are able to help them with. There will be three of us talking. There is Dr. Suma Ganesh, Dr. Nishi Gupta, and myself. And I’m going to start. I’m going to talk about the intubations and DCR and their role in nasolacrimal duct obstruction in children. The learning objectives of this talk are to discuss what intubation is for, why it is used, the levels of success, when it is used, and what type of intubation are actually available. And then when do we remove the tubes, what’s the optical time, and then when is DCR indicated? Congenital lacrimal duct obstruction in children happens in about 6-20% of the pediatric population. And it has a very high rate of spontaneous resolution. Most of the time we can manage this conservatively and that involves quite a lot of education and discussion with parents. We can then treat the baby with syringing and probing and that has a success rate of somewhere between 76-94%, depending on who you talk to, without intubation. And then you may use intubation as the first intervention. The timing of this is quite controversial but I think it’s actually quite crucial. In the UK, we tend to do our syringing and probing operations under general anesthetic. And therefore we certainly would not want to intervene before the child’s at least one years old because of the higher risks of the anesthetic in these cases. And in fact in my own practice, I ask the patients to come see me at 15 months old and then expect to do the operation at 18 months old. And the reason that I delay until this time is that almost all of these patients will have resolved spontaneously. And why take the risk of a general anesthetic if you don’t have to, if the problem’s going to get better on its own. And certainly those who have syringing and probing before the age of 20 months old have a very good success rate.

I call this the disease of 90% and this is a conversation I have with the parents. If I see them maybe at 8-9 months old when they’re struggling with pus around the eye, sticky eye every morning, I tell them that they’ve got a 90% chance of this problem resolving completely on its own without having a doctor have to touch the eye. And then out of that group there are 10% who fail the first treatment and who may need to have a second procedure. Providing I can do that procedure before the age of 20 months, then I would do a syringing and probing first. But if it looks like the child’s presented late, then I would consider doing an intubation as the first procedure. The rule of thumb goes 90% resolve, 90% have a syringing and probing, 10% fail. And of those 10% that fail we do the intubation, and of those 90% are successful. And at the end of the day that leaves only about one in one hundred who present with epiphora who actually require a DCR.
There are a number of papers that look at the age of presentation of children and the success rate. And I have found, in my own work through an audit, and these are many of the parameters that we actually collected. I think the most important one for the point of this talk is to show you that there is a rate in decline with the success of straightforward syringing and probing after 18 months old. Once the child comes to see you at this age, then you should consider doing intubation as a primary procedure. That used to be quite a difficult thing to do, but we’ve got much better methods of intubation than we used to have and it makes the whole thing much more straightforward, certainly even in inexperienced hands.

How do we confirm that the patient actually has a blocked nasolacrimal duct? The history is key and it’s extremely important that the history is of continuous epiphora since birth. If the parent says, “Well, yes, they had a watery eye to start with and then they got better, and then they got worse again,” then you are not dealing with a congenital blocked nasolacrimal duct. The recurrence of the epiphora is due to some other pathology and that needs looking into. Please be very careful about taking their history.

The signs are a high tear meniscus. In this picture here, you can see a high tear meniscus, the obvious pus around the eye. And what I find a lot of my trainees miss out is this is the lacrimal lake. And in a very obvious case then this may well be full of tears as well. And if you press on this area here, you get retro-pulsion of pus and discharge. It’s also very important before you put the patient on the list to come in for surgery, that you check that a punctum is actually present. Because it’s quite a nasty surprise, having had this surprise myself, to find that you have the child under general anesthetic and there is no punctum there and you haven’t had the discussion with the family that you might have to do something a little bit different.

One of the very easy investigations that you can do in your clinic room is the dye disappearance test. You can make this very complicated, but I tend to be very simple with it. You put the drop in the eye and you wait 10 to 15 minutes and see whether the eye is still full of fluorescein and if it’s still full of fluorescein then they have a blocked duct. I actually only do these in the equivocal patients. The one shown in the picture here, I don’t think there’s any need to do any test at all, this is very obvious to me that this is a blocked nasolacrimal duct, providing the history’s appropriate. But some of them are quite subtle and you might just have this slightly raised tear meniscus, and particularly if it’s bilateral you got nothing to compare with. On those I would do the dye disappearance test and then I think it is quite helpful. It also shows the parents if they’re not too sure, is this still a problem or not that the dye has not left the eye.
There are other aids to decision making, but these tend to be for secondary blockage and we don’t tend to use them much for the primary blockage. The reason being that it’s usually quite a simple diagnosis to make in the first instance. But also the secondary blockage is much more difficult because you don’t know where that blockage is and it’s helpful information in order to decide what kind of procedure the patient should need.

You can use a dacryocystogram with CT scanning. And as you can see in this picture here, the dye has not gone down through the nasolacrimal duct where it has on the other side. And you can digitally subtract that as well which is also quite helpful sometimes. The dye is placed in the eye and then it’s syringed through. The nuclear lacrimal scintigraphy is not available to everybody, but it is a physiological test. With the DCG, you actually do an injection of dye and that’s not a physiological test, really, because it’s not looking at how the lacrimal pump is working. And sometimes that disguises a blockage whereas nuclear lacrimal scintigraphy does not. And in this picture here you can see that the dye has not gone down the nasolacrimal duct over the series of four pictures there.

Why and when to consider intubation? As I said before, I would consider as the primary procedure if the patient is over 20 months. I would consider it if the punctum is imperforate but not when the punctum is missing. And I might consider intraoperatively. If I had a patient who I thought was going to be a straightforward nasolacrimal duct syringing and probing and turned out to have either a soft stop at the common canaliculus, canalicular abnormality, or a very rough feel to the nasolacrimal duct, then I would consider intubating at that point. Even though I may have originally planned to just a syringing and probing. Did that for you. If I thought a patient who had had recurrent dacryocystitis, had a thick mucocele, and that there may be some still active inflammation going on, then I would also cannulate that patient. And perhaps even more obvious is when there’s trauma to the canaliculus. That’s when we can use things like the mini Monoka tube. And in these cases when we have secondary epiphora and the presentation is not the typical history of congenital nasolacrimal obstruction. We’d also intubate where there’s been the failing of the previous syringing and probing as a secondary procedure.

Why intubate? What do the tubes actually do? They hold open the punctum, the canaliculi, and the nasolacrimal duct. And they do allow, through capillary action, the tears to travel down the system. And they prevent a stenosis of the system structures whilst they’re healing. By virtue of having passed a probe down through the canaliculi and the nasolacrimal duct, you will cause some stretching of the epithelium and probably, in some cases, some tearing. And if you were to not intubate in some cases, you may get scar tissue formed. The actual presence of that tube in the lumen prevents that lumen closing over.
It increases the lumen diameter when it’s left for a period of time and if you remember the rule of the radius to flow then if you increase the radius just a little bit, you will increase the ratio of the flow by four.

There are now many types of intubation available. One of the easiest to use is the pushed monocular intubation. And this is particularly good for the stenosed valve of Hasner. That is the congenital type nasolacrimal duct obstruction we’ve been talking about. And it’s very good for those children who have presented over 18 months old, who you think that the chance of failure of straightforward syringing and probing is increases simply because of their age. It’s also useful for trauma to the canaliculus using the mini Monoka or the Masterka tube. And this is about 82-95% successful. Pushed monocular intubation wasn’t readily available or easy to use about 20 odd years ago. And gradually with time it’s increased in its accessibility for those who are not experienced at using it.

Then we have intranasal pulled intubation. This is where the tube has to go from the eye through into the nose and it’s pulled back out through the nare. And we would use this for all of the above, all of the things you can use pushed intubation for, but also in an abnormal canaliculus, a soft stop or an abnormal nasolacrimal duct. And if these things, if you need to progress further because your patient hasn’t had success with those, then the endoscopic DCR may require intubation again because of the abnormal upper canalicular system and the same with the external DCR.
How do you choose your intubation type? With the lowest level of skill and a patient who’s presenting late, then the pushed intubation with a Masterka tube is, I think, the procedure of choice. And as long as you’re competent to syringe and probe, it’s highly likely you’re going to be competent to push in a Masterka tube.
With patients who are difficult to syringe and probe, because they have abnormality in the canaliculus and the nasolacrimal duct, or they’ve had a dacryocystocele, this actually needs an experienced operator. And I think it’s best if you’re not experienced with these, that you refer them on to someone who is.
The types of pulled intubation are probably more accessible than the pushed. And in there we have the Ritleng probe used with the Monoka tube that can be for upper and lower tubes together or just the lower, or sometimes just the upper if the lower canaliculus is not accessible. Crawford tubes which can be joined up with Monoka tube and O’Donohue tubes. The latter being rather thicker in the metal and much more difficult to use without the DCR.

Advantages to using pushed intubation. As I’ve already mentioned, it requires a low level of skill, but it has quite reduced peri operative risks. You don’t have to enter the nose through the nare, you’re less likely to touch the turbinates, and therefore you’re less likely to cause bleeding. I do this procedure without any naso vascular constriction drugs at all. It’s just not necessary. It can be performed on the child with a fask mask, so you don’t need to intubate the child and they can be breathing spontaneously which means that they’re more likely to get in and out of hospital quickly. It has a reduced operating time. To do both sides takes me 15 minutes maximum. And the results are excellent. And even when it’s planned for later children as a primary procedure, this reduces the chance of requiring a secondary procedure. The old way of always doing syringing and probing first, I now skip that and go straight to the intubation for the older age group and this has reduced the number of procedures we do on these children.

These tubes can be removed as an office procedure without anesthetic, you simply need to hold the child in a position where you can get to the punctum and pull the tube out. Doesn’t hurt, it takes seconds provided you have the right support for holding the child still. And everybody’s parents and child are surprised at how little the thing is. But it does not need another general anesthetic. And that’s another advantage of it over the pulled intubation.

The disadvantage is that Masterka tubes and Monoka tubes can be more expensive than the Crawford tubes. Here’s the Crawford tubes, which I think we probably used mainly prior to Masterka tubes. Long pieces of metal with the tube attached, you push them through into the nose and you have to hook them. So push through the canalicula, down the nasolacrimal duct, and pulled out through the nose.

The great advantage of the Masterka tube is it sits there by itself, doesn’t need any tying. And it’s held in place in the ampulla of the punctum by its particular shape here.

The important thing about installation of the Masterka tube is getting the size right. In order to do that simply, is you put your probe in as you would usually, and go down to the hard palate. And before you withdraw, you place your finger at the level of the punctum and pull the probe back out. And that gives you the length of the punctum, the front of the punctum to the hard palate, and I’ve placed that against a ruler and that tells me that in order to ensure that I get through the valve of Hasner, I need a 35-40 millimeter Masterka tube. If I choose the 30 millimeter one it’s probably not going to go through the valve of Hasner.
Here’s a close up of the end of the tube that sits in the punctum. The flange here sits on the lid margin and this sits in the ampulla. Occasionally I’ve had a child who’s a vigorous eye rubber and they will pull this out. But the vast majority of these do stay in place and then get removed in the clinic. It’s quite a simple thing to do. And all you have to do is push this into the nasolacrimal system just as if you were probing the child. And then to withdraw it, you hold the flange with a pair of Moorefields and with a twisting motion pull the introducer back out.
This is the kit that you require. I would dilate the patient up with a Nettleship’s dilator if necessary. I never use more than the one millimeter probe, pass that down and through. But I do use a straight needle in order to syringe. The first thing I do is put this probe in and measure the length between the punctum and the hard palate. And then I go to the actual syringing to make sure that I’ve made the system patent. In order to check that, I find that if I actually push this needle through into the top of the nasolacrimal duct, then I have a much higher success rate of getting fluorescein down, sorry, got another slide later, of getting fluorescein into the nose. And I use this very fine sucker tube here, which is placed just below the valve of Hasner so that I can pick up the fluorescein. What this allows me to do is test whether the system is patent with no more than half a mL of fluorescein mixed with normal saline. And this keeps the anesthetist happy and we don’t have to intubate the child and they’re not worried about causing a problem with aspiration.

This is just going over what I’ve already spoken about but gives you an idea that you’ve placed the probe this far and your Masterka tube is just about the same length as the distance between punctum and hard palate.

In order to ensure that you get the dye back up, it’s quite important to place your suction tube in the right place. It needs to be placed along the lateral inner wall of the nose and on the floor. And providing you put the suction in the right place, you’re very likely to get a good result. But if you are not aware of your anatomy and you do not put the tube in the right place, then you might think that you’d not made patency when you have.

This diagram is off the Masterka website and it just shows that this is what happens if you get the tube too short, it doesn’t quite go through the valve of Hasner. That’s the right level and this is when it actually has gone through. That is a good website, if you haven’t used this particular method, they do have a nice little video on there that you can access to see how it’s inserted as well.

The procedure can fail and that can sometimes happen if your valve of Hasner is fibrosed across here. And what can happen is the introducer can be pushed accidentally through the bottom of the Masterka tube. And these are the cases where I would end up using pulled intubation. Because the end of the Masterka tube is fairly floppy and it will not allow being pushed through anything that’s rough or tight.

Pulled intubation. Tubes are inserted from the punctum through the canaliculus, pushed into the nasolacrimal duct and then pulled out through the nose. And my favorite of these is the Monoka tube with the Ritleng probe. The Ritleng probe is a probe just like the type that you would normally do syringing and probing with but it has a groove all the way down. And this lovely thing here is quite thick, it fits just inside that groove, and then you can see it gets thinner. Just here. And what happens is you place this into the nasolacrimal duct and you start feeding this down through into the nose to about the area of the thin area here. Now then people do what’s called metal-to-metal touch. You locate where your bottom of your tube is, your Ritleng probe here with another probe. This is called metal-to-metal touch.

The important thing to understand is where that actually is so that you don’t go fishing. And this diagram just shows you, you’re trying to go down the lateral side of the wall along the floor. And if you go along there then you will find the bottom of the Ritleng probe. In order to actually hook that plastic Monoka tube out, you need to withdraw your Ritleng probe just a little bit. Just a few millimeters. Because otherwise your hook will keep catching around the bottom of the Ritleng probe. And I’ve found that when I was first starting to do these, that even drawing on the face of the child, drawing this diagram so that I knew exactly how deep I had to go into the nose, was extremely effective in helping me get in and out very quickly.

The advantages of the Ritleng probe and using the Monoka tube is that it can be passed through canalicular narrowings or even an absence. Certainly the inperiferate punctum, it can be used through that because you can get a bit of push behind you. It can go through rough-sided nasolacrimal ducts where you think there may have been a fungal infection. And it causes less trauma than having to push metal all the way through like you would have to do with a Crawford tubes. It can be obtained in both single and double-ended types of tubing, which it can be very useful for. The double-ended, I would put a knot in, but the single end has got the same size, shaped flange as the Masterka tube I told you about, and doesn’t need to be tied. It can also be used for a traumatic disruption of the canaliculus along with the mini Monoka which doesn’t need an inserting tube.

In the really difficult cases where the system has got a number of blockages or a very fibrotic blockage, I use the trephine. And again, I think this needs quite a lot of experience to understand the exact anatomy and usual passage and angles of the canaliculus because it’s easy to make false passages. The trephine is quite sharp and it can avoid the need for a DCR. Because once you’ve made and trephined your lumen open again, and you pass your silastic tube thing through it, then you’re holding it open and it prevents a child needing a DCR later on. The disadvantage is it requires an experienced operator, it is a blind insertion, and the canaliculus really needs to be dilated up to two millimeters, which in small children causes a tearing.

For tube removal, as I’ve already explained, you can remove the Masterka tube in the clinic without anesthetic. But the pulled intubation requires GA in children, particularly if you’ve had to knot the tube because you’ve used both upper and lower cannulization. The timing of the removal. It used to be that we just removed all the tubes at three months. But it’s now known that particularly in patients who’ve had DCR, that if you delay the tube removal too much you can end up with granulomas just where you want a lumen. And so the guidance now is for about 4-6 weeks. But in cases of punctal stenosis, canalicular stenosis and obstruction, or canalicular laceration, or if you’ve trephined, then you do need to leave the tubes in for about three months.

When do we use dacrocystorhinostomy? Basically when all those other things have failed. And in my hands now, I very, very rarely have to send a child for a dacrocystorhinostomy. The options we have here are endoscopic versus surgical and I’m not going to speak about these in great detail, I’m going to leave this up to Dr. Nishi Gupta. But the main problem with DCR is that the scar may actually grow with the child.

Endoscopic approach requires a skilled operator in endoscopy and it needs the child’s nasal passages to be large enough that you can insert both the endoscope and the instrument that you’re actually using to open the valve of Halsner or the fibrosed area. It’s worth remembering that orbits grow until the fifth year of life, the nose grows into late teens, both in males and females, and the midface continues to grow into the teens with eruption of the secondary teeth. These are the periods where the scar on the side of the nose can continue to grow.

Dacrocystorhinostomy, as I said, it’s very useful in failed syringing and probing and congenital syndromes. I’m not going to go any further into that because it’s going to be discussed later. It does have complications, in particular, the scar that can grow with a patient, hemorrhage. I used to do a lot of these but got to a point where I’d seen enough blood and didn’t want to do any more. (laughs) So I copped out. And it has a very high success rate.

In our learning objectives, we’ve covered that what intubation is for? Holding up the nasolacrimal system. Why it is used, it’s enhancing the treatment and improving outcomes. The levels of success are very high, about 90%. We use it if you consider the age for the late presentations, particularly. We talked about the different types of intubation that can be used, either pushed or pulled. We’ve discussed when to remove the tubes which can be between six weeks and three months. And I’ve just touched on when DCR is indicated. For me, that’s when the intubation fails. Thank you.
[Suma] We were supposed to start with my talk on clinical diagnosis and differential diagnosis. I’m so sorry.

Going back to our introduction, that is what is congenital nasolacrimal duct obstruction? It’s basically, being a pediatric ophthalmologist, I find that it is a very common disorder. This is basically because of a failure in the nasolacrimal duct drainage system. The epidemiological prevalence is around 5-20% in the early phase of childhood. Bilaterally it is seen in 14-34% of cases.

Now seeing the high incidence of premature infants in India, we have found a high prevalence of CNLDO cases and it has been shown that anisometropic amblyopia may occur in 10-12% of children with CNLDO. We need to do a proper ophthalmic eye examination and cycloplegic refraction in cases if we find that the child has been having epiphora for three to four years and we have not done anything for it.

The embryology is that the lacrimal drainage system begins to form during the fifth week of gestation as a crease between the frontonasal and the maxillary processes which is called the nasolacrimal groove. It’s a solid cord of ectodermal tissues that separates from the surface and enters this groove. Later on this tissue canalizes and forms the lacrimal sac and the nasolacrimal duct. The lacrimal canaliculi also formed by a similar process. Canalization begins around the eighth week of gestation and continues until birth.

That’s why it’s very important, especially in pre-term babies, I think that sometimes we do find that there is a problem, there are congenital anomalies of the lacrimal apparatus also.

The pathogenesis, I think that Dr. Nishi will show you lovely videos on. I’m sure she has wonderful videos telling you all the different types of congenital nasolacrimal duct obstruction which we’ll see. A real variety, like where she sees sometimes a membrane is an abnormality, a bony abnormality with associated narrow inferior nasolacrimal canal, stenosis of the inferior meatus. And so this is basically the pathogenesis where it lies in a mechanical obstruction located distally in the nasolacrimal duct at the valve of Hasner.

When parents ask me, I always tell them that it’s a six person chance, like one is six children are born there’s a chance of epiphora and congenital nasolacrimal duct obstruction. Nothing to worry about. But there is some periocular crusting, discharge, sometimes due to the infection of the nasolacrimal system. All these symptoms are shown at 95% within one month of age. And the dacryocystitis is completely different from the other dacryocystitis as that. It is completely low grade and the organisms are usually the normal flora.

What we have to differentiate it from other sight-threatening diseases like infantile glaucoma. How will you differentiate the patient? Will have photophobia, watering of eyes, very large cornea, there might be enlarged globe, and there may be elevated intraocular pressure, or a wide corneal length.

There could also be an epiblepharon where the lashes are hurting the cornea and that is why there’s watering. Or there could be primary corneal disorders and corneal infection. And these entities, of course you can identify them by the presence of associated eyelid or corneal abnormalities. We need to look into the eye if a child has epiphora, it is not always CNLDO.

The natural history is it resolves by the age of 13 months in 95% of children. Higher spontaneous resolution occurs in the first three months of age, 68-75% in the second three months. And you’ll find as the age goes ahead, we find that it is less and less resolving in the last three months. The Pediatric Eye Disease Investigative Group compared the immediate post nasolacrimal duct probing in the office with conservative management for six months and found that 66% of the children with obstruction resolved within six months without any intervention.

In the first six months, what we practice is observation. When do we do a probing and syringing? That Dr. Nishi will cover. There are the risk factors. And certain conditions where we need to do a probing and syringing even before the age of 12 months. And also the massage is the Crigler technique, is supposed to be a very efficient method for giving a very high resolution rate rather than simple observation.

And this Crigler technique, this is a small video showing it, and thanks Dr. Nishi for this video. The massage of the lacrimal sac is what we widely adopt. And of course the parents come and it is important for us to explain how to do it. You can use the index finger and you place it over the common canaliculus to block the exit of materials through the lacrimal punctum. And then you stroke it, you do it 10 strokes per session and three to four sessions per day. And then you stroke it downwards to increase the hydrostatic pressure within the nasolacrimal sac. It is observed that with this technique alone that resolution occurs in a large amount of patients. It is important that we do the proper technique.

Do we need to give antibiotics? Many people I find that even if there’s no infection, they do give antibiotics. It is only indicated when there is a clinical evidence of any infection, not in the conservative management of CNLDO. We need to ensure that we do not give antibiotics but we do a massage thoroughly.
Primary probing and syringing. Pediatric Eye Disease Investigative Group analyzed the clinical efficacy of early probing, age 6-16 months, and revealed an overall success rate of 75%. But they found much lesser success rate with CNLDO blocks, bilateral CNLDO. Several studies report optical results in children beyond the first year of age, but they found that the success rate decreased as the years passed by.

This is clinic versus operating room probing. I used to do earlier in my first few years of practice, I used to do it in the OPD only. I was taught by Dr. Sargent to do it in the OPD in children less than six months. This is how I’m doing it in the OPD, where the child is wrapped and I did the probing. And the benefits of this was we can avoid general anesthesia. If you wrap the child, we find that in less than six months babies, it is quite not difficult to do. But the downside is the children, there’s a lot of discomfort to the child, and I felt that the child keeps crying and I think it is better to wait for it to spontaneously resolve. Or go in for a probing and syringing under anesthesia rather than making them cry and make the child very uncomfortable.

Routine probing and syringing is where you place the, this is the Bowman’s probe, and it’s one or two sizes used. And then you first place it perpendicular to the punctum and then it turn it towards the course of the canaliculus parallel to the lid margin. Then what you feel is that you hit against a nasal wall of the medial side of the lacrimal sac. Then you turn the probe 90 degrees downwards, backwards, and laterally into the nasolacrimal duct. And then you firmly engage it in the canal. In most infants you’ll find a popping sensation as soon as the probe passes through the obstruction. And then after this you can do syringing with some saline and gentamicin to confirm the patency of the draining system.

Now the next talk will be by Dr. Nishi and I’ll hand it over to her.
[Nishi] Dr. Fiona has beautifully explained a lot of points. I’ll skip the ones that are overlapping. Except that I don’t have stenting part intervention that you beautifully mentioned all types of intervention. I will be talking more on the probing part of it.

Suma explained this. I’ll just explain these figures. This is how a normal nasolacrimal duct opening is visible in the inferior meatus. If you look at this schematic diagram, this is the inferior turbinate and that’s the lateral wall of the nose on the right side. And this is the inferior meatus and that’s how we see the opening of the nasolacrimal duct. If there is membranous obstruction over this opening of the nasolacrimal duct, the secretions start getting collected under the membrane and the membrane budges into the inferior meatus like this. And it’s beautifully visible with the help of the endoscope. I am not going into the details of what CNDLO is because Dr. Suma has explained, so I will go to the next slide.

This is the clinical presentation of congenital nasolacrimal duct obstruction. Their symptoms vary from mild to troublesome epiphora. Can you see my cursor? Suma?

[Fiona] Yes.

[Nishi] Is the cursor visible?

[Fiona] Yes it is, yes.

[Nishi] The symptoms vary from mild to troublesome epiphora, persistent purulent discharge, matting of the eyelashes, skin excoriation like this of the lid margin, cellulitis, and, of course, the congenital dacryocele.

Crigler massage I’ll skip because Dr. Suma explained nicely, so I’ll go to the next slide.

And we know what a CNLDO is now from previous two talks. So straight we’ll go to probing and irrigation. There are two types of probings, one is the conventional and other is the endoscopic guided probing.

Conventional probing is usually the most commonly followed method of intervention. It’s a blind procedure that mainly depends on the surgeon’s tactile sensation during probing. And it does carry a risk of false passage and failure. Though in expert hands the results of conventional probing also are very good, but the efficacy is increased if we use the endoscopic assistance because the traumatic stenosis and unexplained failure do occur.

Unexplained is because of all these reasons. If we look at these schematic diagrams, this is the normal opening of the nasolacrimal duct and that’s the membranous obstruction. A simple membranous obstruction, which if perforated through this side, will have 100% results. But if there is any misdirected probe which gets shifted or deflected towards the lateral wall or towards the medial wall towards the turbinate are in this direction. Then this misdirected probe leads to failure and if we are doing it as a conventional procedure and not employing endoscopy in the failed cases also, we would not be able to find out the cause of failure.
And these are the findings. All of this actually we have discovered with the help of the nasal endoscope which is four millimeter, using our dacryoendoscope, which is 0.8 millimeter. And also the dual endoscope. One endoscope we pass from the superior end through the punctum and the other we pass through the inferior meatus. And we have actually seen these kinds of findings on dacryoendoscopy where the NLD stops at the wall of the inferior meatus. If there is bony obstruction here, either we’ll not be able to pass the probe, or if we pass, we’ll force it through the gonio opening. Which at the time of syringing might show some kind of fluid there. But there’s no free flow and this is likely to close.

And then we had extreme case like this where the whole bony NDL was not formed and we confounded through the probe and through the dacryoendoscope and through the help a nasal endoscope. And then we did endoscopic DCR in this case, I’ll be showing in the next slide, where we actually found that the sac size was very small. And these are some of the dacryo ETS’s. Since this seminar is not under dacryoendoscopy, so I’ve not included dacryoendoscopy videos. But we could see those concreations beautifully into the lacrimal sac lumen where we are to incise this membrane. Instead of just probing, we are to give a shot which I’ll be showing in one of the videos. And then through that you can push all the dacryoliths into the inferior meatus. And this is how we can save one DCR on this child.

The advantages of endoscopic guided probing are multiple. And that is why this is the standard of care for children with persistent epiphora. It allows direct visualization of the distal end of nasolacrimal duct. It helps in increasing the success rate of procedure as compared to the blind probing. And it has a much better outcome. The success rate, as Dr. Suma’s also mentioned, a 95.7% against 75% with the conventional probing.

How do we approach a child with epiphora? Sometimes the children are referred for endoscopic DCR after the failed probing. But we cannot strictly go ahead and do a DCR in such children. The most important step is to examine the inferior meatus first. And this is because we need to segregate and examine whether the child is less than one year or more than one year. And if this child has regurgitation test positive or the child has simple epiphora. If the regurgitation test is positive, does he have some associated abnormalities? Or are there not associated defects? If he has some associated abnormalities it could be congenital dacryocystocele. And this is the nasal cystic component of this patient which is so huge. Children are obligatory nose breathers and if the intervention is not carried out in this case and if they have bilateral dacryocele then it can lead to respiratory distress.

The other situation is congenital lacrimal sac fistula like we can see in this child with cleft lip/cleft palate and a fistula. Such children generally do not respond to probing or conservative treatment of massage and topical antibiotics and they keep getting recurrent infections. And the other is also because I work in the eye hospital as Dr. Suma and I work together and we get a lot of referrals of patient that she wants to operate for congenital cataract and she cannot wait. If the child has epiphora or positive regurgitation tests then we quickly do an endoscopic probing for such children and refer them back to her.
These are the cases where probing even less than one year of age, we should go ahead and do probing in these children. Some people do recommend conservative treatment. And I hope this is visible because it’s covered with my icon.

Some surgeons still recommend that we should try lacrimal massage in these cases, but it generally doesn’t work. And if we wait for a very long time then there is tonicity of the sac. It is better to go in for early intervention. And endoscopic intervention I’ll mention in further slides that in these cases conventional probing may not give us the advantage of removing a redundant part of the cyst wall which is seen here.

If there is no associated defect, then we can continue massage and topical antibiotics. Of course there is a controversy about that, whether we should use topical antibiotics or not.
Either there is a resolution or there is presence of simple epiphora. Some amount of epiphora is decreased with continuous massage. So that is a favorable sign. Or there may be no resolution at all. If there is resolution there is a complete follow up. But if the child remains having epiphora or turns ROPLAS positive after four weeks, then we need to endoscopic probing and irrigation.

On the other hand, if the child is more than one year and he has simple epiphora, after one year if there is no relief, we have to wait until one year in simple epiphora. If there’s no relief then the child needs intervention.
Coming to the next slide. As we all know, the CNLDO are of two types: simple and complex. But the complexity, I would say, has been demystified to a great extent with the help of these endoscopic procedures. Now we exactly know what complexity means and what is the actual defect in the NLD. Not in all the cases, but most of the cases what we have found we keep getting new findings every day. And I’m sure there is a lot that needs to be learned as of now.

In simple CNLDO this could be a thin membrane, as we can see here. This is a thin membrane for which a probe has been passed. Or there could be a very thick membrane. We can’t see the prob under the membrane. That is the definition of thick probe that we published in Orbis International and I’ll be showing later.
Or in complex CNLDO, as I mentioned, the congenital or the dacryocele falls into the category of complex CNLDO because there is double abnormality at the NLDO also and then there is secondary functional obstruction at the level of common dacrysocis which leads to this swelling in the medial canacula area.
There’s another interesting condition called buried probe. It is a condition in which the nasolacrimal duct, the membranous part goes along the lateral wall of the nose, along the floor, and it fails to open into the inferior meatus. In this condition, if we pass a probe it fails to enter into the inferior meatus. And in some cases we can maneuver it under direct endoscopic guidance to open the nasolacrimal duct opening. While in some cases the curve of the probe is such that we can’t manipulate it much into the nasal cavity so we just give a sharp nick here at the tip end, and the probe comes into the nasal cavity following which a syringing is done to see the patency.

And this is what is the bony block. This is the right nasal cavity where we see this is the inferior turbinate and that’s the lateral wall of the nose. And there is no NLD opening into the inferior meatus. We’ve seen that these cases actually end up having a bony block which then we diagnose with various techniques. And we’ve found that there is no opening, and sometimes even if you press in the medial canalical area, we can’t see the transmitted movement also. The movement of the mucosa in this area tells us the level of obstruction in the nasolacrimal duct. I think that’s probably because we’ve done quite a few cases by now so we know what kind of defect we are going to find in this. And of course, the craniofacial abnormalities.

Now if we look at the thin membrane. Let’s see a video of this. This is a membranous obstruction, as I mentioned. And here is a video in which the right eye, the punctum is dilated with the help of a nasal punctum dilator. The gradual rotating movement dilate the punctum without any trauma. And then check syringing is the first step in all cases of NLD. And once the cannula is inserted and stabilized, then that’s the inferior turbinate which is lifted gradually using a Blank periosteal dissector to examine the inferior meatus. That’s the inferior turbinate, this is septum. And as we go along, no infecture is needed, just the gentle lifting up of the inferior turbinate shows us that there is this membranous bulge over the valve of Hasner.

If we push the dye, it keeps getting collected, embedded, and in some cases if the membrane is thin we can even see the greenish colored dye getting collected under the membrane. That’s the probe that has been passed under the membrane through one of the punctum. And the probe is gently moved up and down to identify the thinnest portion of the membrane and that thinnest portion is punctured while taking care not to injure the inferior turbinate. Because nasal mucosa is very vascular and sometimes I’ve seen people in the conventional probing, when there’s reverse flow of blood there’s a lot of apprehension as to what has gone wrong. But often it is the injury to the nasal mucosa’s structure that causes bleeding. Under endoscopic guidance we can carefully puncture this membrane and this hole is widened all along the medial wall of the membranous bulge. And once we see that the hole is adequate then the irrigation is done with the fluorescein.
That’s the nasolacrimal duct. And once the syringing is done, check syringing shows free flow of fluorescein dye through the inferior. That’s the beautiful opening. And that’s the free flow of dye that we can see into the inferior meatus. This free flow of dye without any regurgitation into the eye indicates that adequate patency has been achieved. And that’s the other side of this same patient where the same membrane, it’s slightly thicker, but in most of the cases where this membrane can be perforated with a probe, we do not need to do anything further. We can add the most pressing thing we calculated to ensure that we have cleared all of this.

Which actually I have taken to just show how a sickle knife incision is given, a sharp incision. I am an ENT surgeon and rhinologist so I use what we use in here. To do that it’s a sharp sickle knife. And the indication of sharp incision is something like this. If you’ve perforated the membrane but there’s no free flow of dye, we might just feel in conventional procedure, that the dye has entered the nose in the endoscopic procedure. But we see in the eye there’s a lot of regurgitation and resistance. In that case what we do is we put a larger size probe. And when you whirl it in a little different direction to actually tent out the unaddressed portion of the membrane. This is, see the membrane looks intact so we perforated it just now and also expelled all the secretions. What we do is a sickle knife incision and the technique we use is that we go lateral to the probe so that if we go medial the probe will slip. We keep our tip of the knife laterally probe and incise the membrane over the probe. This incision clearly widens the hole into the membrane, no damage is done to the mucosa there, and you see the difference in the irrigation now. That’s the successful cannulization and we should ensure that there is no resistance during the syringing.
Coming to the next video, this is about the congenital dacryocystocele. As you can see, this child was swelling in the medial canthal area and that’s on the imaging. This is again, the left nasal cavity. That’s the inferior turbinate. And look at the cyst in the inferior meatus, it’s a huge cyst obstructing the whole of the inferior meatus and it’s a thick-walled cyst. Unless we remove a part of this cyst, the child has not responded. People have used various techniques. They can give two incisions, they can give one incision, they can use microdebrider, there has been paper on that. But the basic issue is that we have to remove the part of the redundant mucosa. That’s our basic necessity. Whatever technique we use after we perforate, you remove a part of the cyst wall and a free flow is achieved. In this case, I’m again using that sickle knife which my sickle knife which we use for ear surgery, for my prior surgery. And as soon as the membrane is perforated, we can see the thick mucopurulent charge flowing into the nasal cavity. And after the part is removed, we do a check probing and again the free flow of dye is off into the meatus.

And then another interesting situation is the buried probe as I just described. Let’s have a look at the video of this buried probe. Again this is the right nasal cavity. And this is the schematic diagram of the buried probe. And that’s actually how the buried probe looks. In the same way, as the endoscopic probing is done, the inferior turbinate is lifted as the first step. And of course, good decongestion is obtained before this procedure is attempted and that’s the inferior meatus. See, as the probe is passed, we can see it getting along the lateral wall of the nose through the floor. It is submucosal probe and it failed to enter into the inferior meatus like in normal circumstances. So we just give a nick and a tip of this probe. And as soon as we give a nick and twist, the probe is visible into the nasal cavity. And this case probably could have needed another intervention if we’d not used endoscopic technique in this. Free flow of dye can be seen.
Coming to the next slide. Importance of inferior meatus examination in CNLDO. I have put these slides specifically because there is some interesting findings. This is, of course, the normal findings in the membranous CNLDO, inferior turbinate is lifted, we can see the probe, we can see the perforating and we can see the dye and basic knife incision. These are all published articles. This is another one we published in Orbis International about the thin membrane and a thick membrane. As I described, the difference is the ability to see the probe under the membrane. And in this case, we can only see the tenting of the thick mucosa. The probe cannot be seen under the membrane so that’s how we differente.

What happens in these cases is if a thin membrane is perforated, the NLD opening looks as good as this figure. It’s a beautiful and which is seen after the restoration of the patency. And in this case, even if we perforate, if we use a thin probe it does not perforate in my experience. I’ve seen this. And if you use a thick probe then sometimes the thick probe fails to pass through the punctum. And if we are successful also, we will be just able to make a hole. I have seen that if I pass it also it’s tight here. What we do is, when we pass a probe through a sharp incision over the membrane like this and then it leads to very good results. And incidentally in this paper we published, the thicker membrane was more common in younger children. All those, there is a lot of material that we can talk about on CNLDO, but I would not like to digress from the main topic. I just want to say that this thick membrane needs to be incised for better outcome and endoscopy is important.

This is another article on buried probe, the largest study that we published again in Orbis International. See if you can see this probe, how beautiful it goes along the lateral wall into the NLD. It is coming from the punctum and it is going straight along the lateral wall. And this is a typical buried probe and similarly in this case we can see the probe submucously into the inferior meatus.

This was a case which was referred to use with persistent epiphora following one conventional probing. And this was done by a colleague. In her presence, when I flushed this dye into the nasolacrimal system, we found that there was intact intervening mucosa. Child had some resolution of symptoms but still the epiphora persisted. This is a schematic diagram that I tried to make showing this intervening intact mucosa. Probably when people do multipass procedure or metal-to-metal touch, then this intervening area remains maybe in thick membrane. Not in all the cases, because not all the cases behave like that, this was one case.
And this was another case of a two and a half year old girl. You can see the left eye is full and history. She had history of four failed probing. And that last one was done with infracture of inferior turbinate. We can see how far the inferior turbinate is from the lateral wall. It is right along the septum and such children often complain of nasal obstruction following probing. And we might ignore them saying that we haven’t done anything. But if the turbinate has been manipulated in any way, the inferior turbinate, then it does be reposited back along the lateral wall.
This is another child, a two year old boy, with history of two probing under general anesthesia. And we can see the eye is still, there is a lot of discharge and matting of the eyelid. And the child had ROPLAS positive and they, again, had referred saying that maybe you could try probing in this child. On examination we found that this inferior turbinate infracture had already been done as we can see turbinate is quite far from the lateral wall. And the checking probe when we did check probing and we could see the probe into the false passage. The child was managed with endoscopic DCR.
I added one more slide about inferior turbinate infracture. I just wanted to emphasize that inferior turbinate infracture has no role in treating the complex CNLDO situations. Because IT infection or the lateralization of the inferior turbinate is not the cause of complex CNLDO. Because quite a few cases now we have seen, we’ve recorded, we’ve published, and we know that infected inferior turbinate is not the cause of CNLDO. Even if the turbinate is butting the lateral wall of the nose, there is always adequate space in the axilla of the inferior meatus where NLD can open safely. And it keeps draining.
Infracture does not improve outcome in simple or complex CNLDO. And IT manipulation or infracture may cause nasal obstruction in children as I mentioned. Even the gentle lifting up of the inferior turbinate probing should be reposited back and I’m not again added inferior turbinate infracture aspect into it. But if I go fast and talk about the anatomy, it has a superior and inferior border and medial and lateral. Only the superior border is attached and the inferior border is free, it is spongy, it can be decongested and nicely lifted to negotiate our endoscope into the inferior meatus.
What are the indications of dacryocystorhinostomy in children and how is it different from adults? The indication specifically I have chosen CNLDO. Very few children of CNLDO now need DCR because of the advancement of technique and the minimally invasive procedures and endoscopes that we are using. And sometimes simple CNLDO is made complicated by multiple conventional procedures that becomes an indication of endoscopic DCR. In syndromic children the probing results may not be very good. And also the primary acquired nasolacrimal duct obstruction is to be differentiated from CNLDO. By history we can do it.
Here is a video on endoscopic DCR. The differences that children have in their own nasal cavity, the bones are thin. In this case we can see the flap has been lifted. That’s different in process of maxilla and the lacrimal bone. Like an adult, these steps are the same. That’s the medial turbinate and that’s the flap. The Kerrison punch is used to remove the bone of different processes of maxilla and we start seeing the sac. So that’s the sac and NLD area. The bone removal proceeds that. Since the nasal cavity is narrow, the landmarks are also crowded. We need to differentiate between the lacrimal bone and sinus process and avoid and turn to the orbit. That’s the superior part of the lacrimal sac in children. Also if the bone inclination is not such that you can easily remove from Kerrison punch, if you can’t then you need to actually drill the superior portion also. That’s the fundus of the sac that we have exposed and as the probe is passed from outside, we can see the venting of the sac.

If you look at the incision we have given a little longer incision, right up to the superior attachment of the inferior turbinate. That’s the NLD that I want to see in every child of CNLDO that I’m operating. Because there are findings that we’ve seen into the inferior meatus. We want to confirm intraoperatively as to what was the site of obstruction or the cause of obstruction in children. That’s the lacrimal sac lumen, that’s the posterior lacrimal sac flap, and this is the interior lacrimal sac flap. We can see some granulations into the nasolacrimal duct area. But the site of obstruction is a bit lower and of the bony NLD. Until here the NLD is normal and I’m trying to pass the ball pointer into the inferior meatus to see if this is fully developed.

Now if we look at the other case. Look at this picture now. That’s the left nasal cavity, this is the middle turbinate, this is the inferior turbinate, and as usual we’ve given a very long incision to expose the whole sac and the NDL. If you see in this case, this sac is very small and it can be seen ending into the bone of the frontal processes of maxilla. It is a small sac and we try to drill this area to see if there is any NDL. There is no formation of bony NDL. And as I’d shown in one of the figure, schematic diagram, where bony NDL was ending just above the inferior turbinate and this whole portion was missing. This is exactly what we saw with four mm, we saw with 0.8 mm and then intraoperatively we can form. It is a typical example of bony agenesis of the nasolacrimal duct. If in children we expose the whole portion and we’ve done endoscopy, we will be able to know the cause of why these children were not responding to probing no matter how many attempts at probing you’ll do.

Somebody asked that question. How many probings? In my view there should be only one probing. Only one probing and that should be very well-planned probing with experience. Now we have answers to many questions of what cases will do better, what cases will not improve, whether we should plan intubation in the first sitting or not, as Dr. Fiona described in detail. One probing is enough.

And the step further, this is the 0.8 mm endoscope that we use. This is from Karl Storz. We attached to the same camera unit as our 4 mm endoscope. And this is, of course, marked endoscope. And it has a side port for saline irrigation. This side port. Because you can’t use anti-fog solution, as we do with other endoscopes once you are inside the nasolacrimal system, then you cannot take it out every time to dip it into anti-fog solution. To clear this lens we have this side port to which the saline is flushed constantly which keeps the tip clear. And also keeps opening the lacrimal passage. And there’s no damage to the walls of the lacrimal passage.

This is how the lacrimal sac lumen looks with the help of this endoscope. This is the intra luminal appearance. This is a schematic diagram, this is how puncta, then canaliculi, common canaliculi, this is the lacrimal sac with holes. And that’s a beautiful nasolacrimal duct opening which is area of our interest. This is the proximal opening which we see in all membranous cases. That’s the mid part and that’s the valve of Hesner. In patent cases this is how it looks with a dacryoendoscope.

And this is the article that we published in “European Journal of Ophthalmology” on the beautiful appearance of the lacrimal canaliculi and then again the nasolacrimal duct. And this is the bony obstructions. Since I’ve not included dacryoendoscopic videos in this so you will not be able to see that clearly, but this is all NLD. You can see the secretions moving towards the blocked NLD and see beautiful dacryl into the nasolacrimal lumen. This is how a canalicular obstruction looks and that’s, again, valve of Hesner.
This is dual camera that I was talking about. You can see this nasal opening. This is how an absent opening into the inferior meatus looks. This is a typical case of nasolacrimal duct agenesis and this is the nasal endoscopic finding of this particular patient that I just described. This is how the inferior meatus look was and this was the sac.

This is some of the work that we compiled after our initial videos. We took our first book on endoscopic DCR in 2006, the second one came out in 2011, and the third one in 2020. And there is another video project that is underway that has also been published.
We have these annual hands-on training sessions in progress at Dr. Shroff’s Charity Eye and ENT Hospital for more than two decades. We have cadavers, we have models, and we have trainees. These sessions are generally in high demand because I work in Eye and ENT hospital and it is across specialty that people want to learn.

That’s all, thank you.

What is the minimum age of DCR in children? This is the first question. The answer is that there is no fixed age limit for DCR in children. I have done it as young as eight months. Also it depends on the presentation of the child. If the child has a congenital fistula of the lacrimal sac with recurrent abscess formation despite probing, then you should go ahead with DCR. And similarly there was another child that I mentioned with the false passage. He was probed at the age of six months and then at the age of nine months because he had the positive regurgitation test. When we took up there was a false passage and at that time we did an endoscopic DCR. Because the eyes keep getting smeared with that thick discharge, it’s better to relieve the obstruction. You cannot fix an age for the child. But if the child is less than one year, it is simple epiphora and not troublesome, then that is definitely not an indication for DCR.
[Fiona] I completely agree with you on that. If a simple procedure can be done, that’s absolutely fine. But certainly there are children who have problems. Certainly there are parents who struggle with the pus and muck. And in those patients they may require earlier syringing and probing even under a year. You can never have an absolute rule when you’re dealing with patients. And I think for Dr. Nishi Gupta, you have this experience of being able to do these very, very young children. This is not available all over the world, unfortunately. There will not be these fine endoscopes available everywhere. And therefore if you don’t have these things available then your methodology is going to have to be altered and changed according to what facilities you actually have. But if you do have someone with such expertise nearby then the best treatment for patient is to refer them. And refer them early so that they can plan the optimum time for the intervention.
[Nishi] Thank you, Dr. Fiona. The next question is how I can see the way of probing? I think my answer would be to have some indigenous endoscope systems. Now they are very cost-effective. For a person like me, I would be uncomfortable if I can’t see the interior meatus because probably that is how I work. I’m sure a lot of people are using good conventional technique and in expert hands the results are very good.

The other question is how common is bony obstruction in NLD? That’s a very interesting question. I would say in last 20 years I’ve seen maybe six cases or so. Or maybe we’ve become so experienced now, I should say, in terms of the equipment that we have that we’ve been able to detect it now. Just six cases in 20 years.
[Fiona] And in my 30 odd years of experience I don’t think I’ve seen more than that either. It’s quite rare, isn’t it?

[Nishi] I agree with you, it’s not very common.

Management of child with atonic sac less than one year and more than one year. I would explain what are my views and Dr. Fiona can go ahead with her views on it. In my view, child less than one year atonic sac is not often seen. And even in adults it’s very rare. And I’ve seen it with patients having associated nasal conditions like nasal polyps and others. As I mentioned, that in congenital dacryocystocele if you wait for a long time and keep doing massage over that area, it can become an atonic sac. Otherwise in children it is not that common. But wherever you find it the treatment is DCR. You agree, Dr. Fiona?
[Fiona] Yes, I would. I don’t think you have a choice on this. And the younger children do better with the endoscopic DCR for the reasons of the scarring that I mentioned earlier.

[Nishi] The next question is, they’re coming very fast, I’m losing track. Endoscopic DCR could occur in what age? We’ve answered that. The next question is endoscopic DCR again, same. The next question is do you always use a tube in dacryocystocele? Do you make early surgery in this case? Yes, as I mentioned that we should actually take the child for immediate intervention without even doing a massage. Sometimes rarely it does work but it can be an incomplete recovery. And if we are using an endoscopic assistance in this case, then we can widen the hole and remove the redundant part of the mucosa. You do not need to intubate in the endoscopic procedure. But as Dr. Fiona described that if you do not have availability of all those equipments, then preferably she would like to intube. Right, Dr. Fiona?

[Fiona] Yes, I think I would agree with that. Yes.

[Nishi] Is there any portable endoscope unit that you would recommend? Oh, there are plenty. If you are in India then you have a lot of indigenous endoscope. I can see you are, Dr. Gerkashmen, so probably. In India, if I’m sure if it was built in India it should be outside also. There are a lot of these local makes of endoscope. And they’re doing very well because we have multiple people at multiple stations. And at some stations we have those indigenous endoscopes also. It’s very easy to perform probing using that endoscopic system.

Again, the age for probing? We described in detail I think in my presentation. And tips and tricks for bypassing the probe should the probe be straight, curved, or curvilinear? Since we are doing under endoscopic guidance so we see where this is for you, Dr. Fiona. You should answer this question.

[Fiona] I prefer a straight probe because it’s easier to know where it’s going. If the probe is curved, you could twist that curve the wrong way round and end up making a false passage. Having used a straight probe for many, many years, I have a very good idea of where that is going.

The question above is what’s the minimum age for probing. There isn’t really a fixed minimum age, there’s an optimum age which I discussed in my talk. I have probed a child who was only a few days old with a massive dacryocystocele which was occluding the view from the eye. The lower lid was so much engorged that probing was the right thing to do when the baby was only a few days old. That immediately resolved the problem and reduced the risk of amblyopia. That’s the minimum age is days old.
[Nishi] The next question is two year old patient with only watering, no discharge, ROPLAS negative. FDD positive, no history of dacryocystitis. How to manage? Okay, would you like to answer that question, Dr. Fiona?

[Fiona] I would actually intubate this patient and I would use, probably, a Masterka tube on this particular patient. My only question is, so you’ve done a forced dyed disappearance test, haven’t you? Yes, I would use an intubation for this patient.

[Nishi] And I would view again the endoscopic technique to first do a checked syringing to see that the passage is patent. If not, what is the cause? And if there is a membrane, intubate it. Because sometimes in allergic rhinitis, you have these kinds of patients where the dye disappears but the patient has epiphora and check syringing is patent. Depending on the examination we’ll take a call.

[Fiona] I think that’s really important is to know whether the patient has a history of ATP. Because if they do, they might actually need some nose drops to decrease the amount of swelling within the nose. And particularly if the history says, parents say whenever the child gets a cold the eye is watery. Well yes, that’s due to nasal congestion, that’s not due to a blocked nasolacrimal duct. Again, very history taking is important in these cases. And then I send them to my friendly ENT surgeon.

[Nishi] (laughs) Next question is again for you. Do you have any educational videos of your intubation procedures?

[Fiona] Yes, yes, I do, but I couldn’t find it for the purposes of this talk. So I apologize at the moment! I maybe should make some.

[Nishi] and the next question is, is the endoscopic diagnostic, therapeutic, or both? Yes definitely it is both. Provided it’s not a bony block. You can take up the next question, Dr. Fiona. Major differences in pediatric and adult lacrimal system anatomy?

[Fiona] The anatomy it’s just size, really, from the point of view of what you do with it. The size is different but the actual anatomy itself is the same.

[Nishi] I agree. Any indications for primary intubation? Actually I do very rare intubations. I used to do some 20-25 years ago. And I realized that in CNLDO when you can see the membrane and when there is free flow of dye, why should I intubate? But I did an interesting case yesterday where there was bony obstruction of the nasolacrimal duct and the probe would not pass. It was sort of drilling that I made into the bottom of the nasolacrimal duct and then we could pass the dye. And that was one case where I stented because I literally drilled the hold into the NLD. In your view?

[Fiona] There’s one here about the role of antibiotics. And this is something I feel quite strongly about. We are guardians of our antibiotics. And willy nilly use of antibiotics is a very bad thing. The parents love the antibiotics because the problem goes away for as long as they’re putting the eye drops in. But as soon as they stop the antibiotic, the problem comes back again. And really there isn’t a role unless the lid becomes erythematous, you actually get the cellulitis, then there is a role. But if you don’t have those signs then there is no role for antibiotics in managing congenital nasolacrimal duct obstruction. And really you need to try to convince your parents through education that they should not be using antibiotics. And I know a number of you all live in parts of the world where those parents can go and buy those antibiotics over the counter, you really need to encourage them not to do that because all they’re going to do is start that baby having resistant flora on their skin. And that’s a bad thing.

[Nishi] Do you prefer simple or sedation? We always do it under general anesthesia. All the probings. The next question is, is it possible to do a punctoplasty in kids? Use punctite and not be seen readily? Well the answer is not that simple but yes I would like to say in short that all those kids with congenital absence of puncta have absence of canaliculi also, the majority of them. There is no point of doing punctoplasty if the canaliculi have not been formed. There are other options-

[Fiona] I agree.

[Nishi] There are other options but I think they’re beyond this scope of this talk. But yes, punctoplasty is not indicated in kids where they have congenital absence of puncta.
And is there a risk of closure following incision of thick membrane during probing and syringing? No, never. It doesn’t. Because if we are perforating the membrane, then with gravity the old fluid drains just with deeper fruition of the membrane. And in this case we are making an additional incision of the membrane where apoptosis has not taken place. We’ve removed that membrane, it never closes. It doesn’t, it’s separmanazation.

You can take up the next question, Dr. Fiona. What is the use of eye locks in children for obstruction in meibomian gland?

[Fiona] Don’t use it. I don’t know what eye locks is, it must be something else? What is eye locks? That’s not a product we have over here. Sorry.

[Nishi] Okay. How often should patients see the doctor after any lacrimal surgery and how to train patients with postoperative children who live with many difficulties in access and transportation? Okay. How often? In fact the answer to this is if we’ve done a probing and syringing, me and Dr. Fiona, maybe if she’s not put a stent, even if she doesn’t. Because this question is from Indonesia and they’re talking about transportation problems. I think the justified answer is if you’ve done probing and syringing you may never need to see the child at all. You can just try to give a prescription while I can do already. Do you agree, Dr. Fiona?
[Fiona] I totally agree. Yes, absolutely.

[Nishi] I think that’s all. And about training the post operative children? Even in probing, no training is needed. And exactly like that in endoscopic, we see also. Nothing, no precautions. They can wash their eye and they can put drops for a week or so and that’s all. Not much follow up is required. I think we’ve answered all the questions.