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Prof. Nan Xiang: Interpretation of "Expert Consensus on Diagnosis and Treatment of Congenital Nasolacrimal Duct Obstruction in China (2021)"

Posting time:2023-01-31 14:32:07

Prof. Nan Xiang: Interpretation of "Expert Consensus on Diagnosis and Treatment of Congenital Nasolacrimal Duct Obstruction in China (2021)"

Editor's note Congenital nasolacrimalduct obstruction (CNLDO) is the leading cause of epiphora in neonates. Children were born with unilateral or bilateral nasolacrimal duct hypoplasia, most of which were not open at the lower end of the nasolacrimal duct, including membranous obstruction and bony occlusion. The incidence of CNLDO is high, accounting for about 5% to 20% of neonates. The main clinical manifestations are epiphora soon after birth, which may be accompanied by purulent secretions. When symptoms persist, conjunctivitis, skin eczema, and blepharitis may be combined. The first diagnosis of epiphora in infants and young children is mostly in child health care, pediatrics, or referral to a professional ophthalmologist. The diagnosis and treatment of the disease are more difficult because the newborns cry and cry easily, cannot express themselves, and do not cooperate with examination and treatment. At present, the level of diagnosis and treatment in various regions in China varies. Improper or delayed treatment may lead to serious consequences such as acute dacryocystitis, orbital cellulitis, dacryocyst fistula, and even corneal infection and intracranial infection, or cause irreversible damage to the lacrimal duct. Difficulties in later treatment. At present, there are many reports of congenital lacrimal duct-related diseases in infants and young children, but the diagnosis of such diseases in the domestic ophthalmology community is not standardized, the timing of treatment is controversial, and the treatment methods are messy. In response to the current status of diagnosis and treatment of lacrimal duct-related diseases in infants and young children in my country, at the Vision China 2022 conference, Professor Xiang Nan from Eiger Eye Hospital elaborated on the issues related to the standardized diagnosis and treatment of CNLDO according to the "Expert Consensus on Diagnosis and Treatment of Congenital Nasolacrimal Duct Obstruction in China (2021)". Overview of CNLDO: Clinical manifestations and diagnosis From the analysis of anatomical structure, except for a few CNLDO caused by nasolacrimal duct bone stenosis or nasal deformity, most of the children are membranous obstruction caused by Hasner valve atresia. The Hasner valve at the lower end of the nasolacrimal duct is a remnant of the embryonic period, and more than 90% of the children open naturally at 4-6 weeks after birth. Therefore, CNLDO is caused by the atresia of the Hasner valve, which has the characteristics of self-healing. In the early stage, the lacrimal punctum and lacrimal canaliculi are not fully developed, the operation is difficult, and it is easy to cause lacrimal duct injury; repeated irrigation or lacrimal duct probing may lead to edema of the nasolacrimal duct tissue, formation of false ducts, or tissue adhesion and scarring. The difficulty increases and the success rate of the operation decreases significantly. Clinical manifestations: The children have epiphora and increased ocular secretions, which may be accompanied by conjunctivitis and eczema of the eyelid skin; if secondary infection occurs, chronic dacryocystitis may develop, and mucous or purulent secretions overflow from the punctum; In acute infection, eyelid cellulitis, abscesses in the lacrimal sac, and even abscesses rupture to form skin fistulas. Diagnosis: After excluding acute conjunctivitis, glaucoma, congenital anomalies of the upper lacrimal duct system (puncta, lacrimal atresia or hypoplasia), entropion, trichiasis and other diseases that can cause epiphora in children with long-term epiphora, CNLDO should be considered. Lacrimal duct irrigation can confirm the diagnosis, and FDDT can assist in the diagnosis. Treatment focus: lacrimal duct irrigation; first probing operation time & probing times According to the development of lacrimal duct, CNLDO has a certain self-healing property, so it should be fully observed, and conservative treatment should be performed at the same time to accelerate valve opening. In principle, a step-by-step treatment plan should be adopted from conservative to surgery, from simple to complex, from non-invasive to minimally invasive, from single to combined, and gradually, in order to achieve the best therapeutic effect with the least trauma. The treatment of CNLDO includes conservative treatment (massage of the lacrimal sac area, lacrimal duct irrigation) and surgical treatment (lacrimal duct probing, lacrimal canal placement, dacryocystorhinostomy (DCR), etc.), among which lacrimal duct probing It is a commonly used surgical treatment method in clinical practice. 1. Lacrimal duct irrigation: Since the lacrimal punctum and lacrimal canaliculus are relatively small in children, punctum expansion is often required during flushing, which is easy to damage the lacrimal duct mucosa. Mucous membrane accidental injury of the lacrimal canaliculus; there is no evidence to prove that lacrimal duct irrigation has a significant cure rate than conservative lacrimal sac massage and other treatments. Therefore, lacrimal duct irrigation is only one of the diagnostic methods, or when a large amount of secretions cannot be drained When cleaning the tear ducts. Repeated lacrimal duct irrigation is not recommended as a routine treatment. 2. Time of the first operation: It has been reported in the literature that 95% of children with epiphora can resolve their symptoms of CNLDO within 1 year after birth. The cure rate is the highest in children under 3 months of age, higher in children at 6 months of age, and significantly lower in children over 9 months of age. . For children who fail conservative treatment, the timing of the first lacrimal duct probing is still controversial. Since the self-healing rate of children within 6 months of age is high, the self-healing rate gradually decreases with the increase of the age of the children, and the chances of accompanying dacryocystitis, facial eczema, and secondary changes in the lacrimal duct mucosa increase. Based on the research results at home and abroad, combined with the clinical practice in my country, the time of the first probing operation is recommended to be after 6 months of age. For children with obvious complications, lacrimal duct probing can be performed in advance according to the wishes of the parents without damaging the lacrimal duct mucosa. 3. Number of probing times: If there is a need for a second probing after the first lacrimal duct probing fails, it is recommended that the second lacrimal duct probing or probing should be at least 1 month apart from the first operation. It is confirmed that the probe does not form a false duct in the lacrimal duct, and the front end of the probe encounters a bony obstruction. Further CT lacrimal angiography should be performed to determine the nature of the obstruction. Appropriate treatment methods such as lacrimal canal placement, balloon duct dilation or DCR should be selected according to the etiology and location. Repeated blind lacrimal probing is not recommended. Consensus on diagnosis and treatment of CNLDO: A comprehensive treatment plan is recommended. Clinical treatment should be selected according to the developmental stage of children with CNLDO and the cause of obstruction. The following comprehensive treatment plan is recommended: 1. For children under 6 months of age, first perform lacrimal sac massage, if there is purulent secretion Or in children with conjunctivitis, topical antibiotic eye drops can be used as an adjunct. Surgical treatment can be performed for children with obvious ocular complications or combined with dacryocystocele and acute dacryocystitis. 2. For children older than 6 months and ineffective conservative treatment, lacrimal duct probing can be performed under local anesthesia or general anesthesia. For children with failed probing (except those with definite bony obstruction), if reoperation is required, an interval of 1 month is recommended. 3. For children who have failed secondary lacrimal duct probing, CT lacrimal angiography is recommended to clarify the cause, and then repeat lacrimal duct probing, probing, balloon dilation or nasolacrimal duct rupture under nasal endoscopy. Membrane surgery (Hasner valvuloplasty), and whether or not to perform lacrimal canal placement was determined according to the intraoperative situation. 4. For children with multiple failures of lacrimal duct probing, complicated nasolacrimal duct obstruction, especially those with upper lacrimal duct obstruction, and older children, it is recommended to perform lacrimal duct placement under general anesthesia. The indwelling time of the lacrimal support tube is generally recommended not to exceed 1 month, and the time can be appropriately extended to a maximum of 3 months according to the recovery situation. 5. Children who fail the above treatments, those with nasolacrimal duct bony obstruction or other developmental abnormalities who cannot implement the above treatments, elective DCR, and minimally invasive nasal endoscopy is recommended when conditions permit. Finally, Professor Xiang summarized the main points of diagnosis and treatment of CNLDO: it is self-healing and is the most common congenital lacrimal duct disease in children. The clinical manifestations are epiphora and increased ocular secretions in children; For children under age, lacrimal sac massage is performed first, and lacrimal duct irrigation is not a routine and repeated treatment method; for children older than 6 months and conservative treatment is ineffective, lacrimal duct probing can be performed; Mature doctors or institutions should be referred to a lacrimal specialist for further specialist treatment. The choice of CNLDO intervention and the consideration of the timing of surgery require comprehensive judgment, and the joint participation of doctors and parents can achieve good therapeutic effects. Expert Profile Xiang Nan, Chief Physician, Deputy Chief Medical Officer of Iger Eye Hospital Group, Former Deputy Director of Ophthalmology Department, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology The concept of personalized, precise and minimally invasive diagnosis and treatment of tract diseases. Good at adult and pediatric lacrimal duct disease surgical treatment; rich experience in eye plastic and cosmetic surgery. Academic part-time job: Lifetime member of the Asia-Pacific Society of Ophthalmoplasty, member of the Ophthalmology Group of the Ophthalmology Branch of the Chinese Medical Association, member of the Standing Committee of the Ophthalmology Specialized Committee of the China Non-public Association, member of the Ophthalmology Specialized Committee of the Chinese Women's Physician Association, and deputy head of the ophthalmology and lacrimal duct group. Member of the Standing Committee of the Ophthalmology Branch of the Society, Deputy Head of the Orbital Lacrimal Pathology Group of Ophthalmoplasty, Executive Director of the Wuhan Medical Association, Standing Committee of the Ophthalmology Branch of the Wuhan Medical Association, Editorial Board of the Chinese Journal of Ophthalmology References: [1] Aldahash FD, AlMubarak MF, Alenizi SH , et al. Risk factors for developing congenital nasolacrimal ductobstruction[J]. Saudi J Ophthalmol, 2014, 28(1): 58-60.DOI: 10.1016/j.sjopt.2013.09.007.[2] Dotan G, Nelson LB . Congenital nasolacrimal ductobstruction: common management policies among pediatric ophthalmologists[J]. J Pediatr Ophthalmol Strabismus, 2015, 52(1): 14-19. DOI: 10.3928/01913913-20141028-01.[3]Petris C, Liu D. Probing for congenital nasolacrimal duct obstruction[J]. Cochrane Database Syst Rev, 2017, 7(7):CD011109. DOI: 10.1002/14651858.CD011109.pub2.[9] Rajabi MT, Abrishami Y, Hosseini SS, et al. Success rate of late primary probing in congenital nasolacrimal duct obstruction[J]. J Pediatr Ophthalmol Strabismus, 2014,51(6): 360-362. DOI: 10.3928/01913913-20140909-02.

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