No additional intervention required in children undergoing nasolacrimal duct probing before 4 years of age: JAMA
Congenital nasolacrimal duct obstruction (NLDO) is the most common cause of tearing in young children. Although often resolving spontaneously, NLDO causing persistent symptoms is typically managed through probing of the nasolacrimal duct system. It is not uncommon for symptoms to recur following initial probing, in which case a repeated procedure with or without the use of additional techniques, such as silicone intubation or balloon catheter dilation, may be indicated.
Treatment failure is associated not only with increased morbidity but also with elevated risk of general anesthesia–associated complications and increased overall cost to the health care system. A greater understanding of patient and surgeon factors associated with treatment failure on the population level may help guide treatment guidelines. In this study, Isdin Oke and team assessed the risk of a repeated procedure following initial nasolacrimal duct probing among young children in the US using data from the Intelligent Research in Sight (IRIS) Registry.
This retrospective cohort study analyzed data from the Intelligent Research in Sight (IRIS) Registry for all children who underwent nasolacrimal duct probing before 4 years of age between January 1, 2013, and December 31, 2020. The Kaplan-Meier estimator was used to assess the cumulative incidence of a repeated procedure within 2 years of the initial procedure. Hazard ratios (HRs) derived from multivariable Cox proportional hazards regression models were used to evaluate the association between repeated probing and patient age, sex, race and ethnicity, geographic region, operative side, laterality of obstruction, type of initial procedure, and surgeon volume.
This study included 19,357 children (9823 [50.7%] male; mean [SD] age, 1.40 [0.74] years) undergoing nasolacrimal duct probing. The cumulative incidence of repeated nasolacrimal duct probing was 7.2% within 2 years of the initial procedure.
Among 1333 repeated procedures, the second procedure involved silicone intubation in 669 (50.2%) and balloon catheter dilation in 256 (19.2%).
Among 12008 children aged 1 year or younger, office-based simple probing was associated with a slightly higher probability of reoperation compared with facility-based simple probing (9.5% vs 7.1%; P < .001).
In the multivariable model, a greater risk of repeated probing was associated with bilateral obstruction (HR, 1.48; P < .001) and office-based simple probing (HR, 1.33; P < .001), and a lower risk was associated with primary balloon catheter dilation (HR, 0.69; P < .001) and procedures performed by high-volume surgeons (HR, 0.84; P = .02). Age, sex, race and ethnicity, geographic region, and operative side were not associated with reoperation risk in the multivariable model.
In this cohort study, approximately 1 in 14 children younger than 4 years in the IRIS Registry required a reoperation within 2 years of initial nasolacrimal duct probing. The most frequent primary procedure performed was facility-based simple probing, and repeated procedures most often involved silicone intubation. The reoperation rate of office-based simple probing was greater than that of facility-based simple probing, and the reoperation rate of primary silicone intubation was greater than that of primary balloon catheter dilation. Other factors associated with reoperation risk included the laterality of obstruction and surgeon experience with nasolacrimal duct probing. Procedures performed by high-volume surgeons (≥20 procedures per year on average) were associated with a lower risk of reoperation, which supports the importance of development and maintenance of expertise in treating this patient population.
By leveraging electronic health record data from practices across the US from the IRIS Registry, this cohort study found that 7.2% of children younger than 4 years who underwent NLDO had a reoperation within 2 years. Higher risk of reoperation was associated with bilateral obstruction and probing performed in an office, whereas lower risk was associated with primary balloon catheter dilation and procedures performed by high-volume surgeons. Many factors may contribute to the choice of the initial procedure, and surgeons should be aware of the differences in reoperation rates and the potential association with experience in performing procedures in this population. Although officebased simple probing had a slightly higher probability of reoperation compared with facility-based simple probing, most children did not require additional intervention, which should be considered when counseling patients about treatment options. The IRIS Registry may have utility for assessing practice patterns and further exploring factors associated with nasolacrimal duct probing failure to better inform practice guidelines that may improve the care of children with congenital NLDO.
Source: Isdin Oke; Tobias Elze; Joan W. Miller; JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2023.0004
