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    Endoscopy can aid treatment of pediatric nasolacrimal duct obstruction

    Cycloplegic refraction beneficial for patients at initial, follow-up exams

    San Francisco—Adding endoscopy to one’s skills set can dramatically improve the treatment of pediatric nasolacrimal duct obstruction (PNLDO).

    Ophthalmologists tasked with clearing blocked tear ducts in infants traditionally probe until the duct is cleared or the probe is palpated with the suction leading to a “metal on metal” feel. Using an endoscope allows the clinician to visualize the tip of the probe and remove the obstruction more easily, quickly, and accurately, said Rona Z. Silkiss, MD, FACS.

    “You cannot adequately manage what you cannot visualize,” said Dr. Silkiss, chief of ophthalmic plastic, reconstructive and orbital surgery, California Pacific Medical Center, San Francisco.

    “With an endoscope, PNLDO suddenly changes from blocked/not blocked to defining anatomically where the nasolacrimal duct is obstructed, whether you are in the correct location and whether you have opened the closed valve of Hasner adequately,” she said. “Using an endoscope is transforming our ability to define and solve specific causes of PNLDO much more effectively than in the past.”

    Advantages of endoscopy

    PNLDO is the single most common cause of persistent epiphora in childhood, Dr. Silkiss noted.

    Between 5% and 6% of newborns present with PNLDO, but more than 90% of cases resolve spontaneously within the first year of life.

    “Everyone who practices ophthalmology, every pediatrician and every family physician doctor is going to be asked how to manage these children,” Dr. Silkiss said. “It is a fairly ubiquitous problem that has a well-defined approach to resolution.”

    PNLDO is a congenital condition, she continued.

    The tear duct develops as a solid cord of cells in utero, then transforms into a canal during the final weeks of pregnancy. The canalization process is not completed at birth in a small but significant percentage of neonates, leading to persistent epiphora.

    The first question to ask is whether the infant has PNLDO or another condition, such as conjunctivitis, blepharitis, congenital glaucoma, entropion, epiblepharon or trichiasis leading to the epiphora. The traditional therapeutic paradigm calls for Crigler massage for the first year unless the infant has repeated infections.

    If the blockage does not clear by the child’s first birthday, probing can be used in the office to attempt to clear the blockage. But in-office is difficult for patient, parent, and ophthalmologist and can lead to the creation of a false passage.

    Symptom-based treatment

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