A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Pediatric Ophthalmology/Strabismus Panel
David G. Morrison, MD,1 Gil Binenbaum, MD, MSCE,2 Melinda Y. Chang, MD,3 Gena Heidary, MD, PhD,4 Rupal H. Trivedi, MD, MSCR,5 Jennifer A. Galvin, MD,6 Stacy L. Pineles, MD7
Ophthalmology, In Press, © 2020 by the American Academy of Ophthalmology. Click here for free access to the OTA.
Purpose: To review the published literature assessing the efficacy and safety of in-office probing compared with facility-based probing to treat congenital nasolacrimal duct obstruction (NLDO).
Methods: Literature searches were conducted in March 2020 in the PubMed database with no date restrictions and limited to studies published in English and in the Cochrane Library database with no restrictions. The combined searches yielded 281 citations. Of these, 21 articles were deemed appropriate for inclusion in this assessment and assigned a level of evidence rating by the panel methodologist. Four articles were rated level I, 2 articles were rated level II, and 15 articles were rated level III.
Results: Treatments consisted of observation, in-office nasolacrimal probing, or facility-based nasolacrimal probing. Success rates and complications or recurrences were recorded from 1 week to 6 months after surgery. Complete resolution of symptoms after surgery ranged from 66% to 95.6% for office-based procedures versus 50% to 97.7% for facility-based procedures. Level I evidence indicated that 66% of cases spontaneously resolved after 6 months of observation in infants between 6 and 10 months of age. Success rates for in-office probing were lower for bilateral than for unilateral NLDO (67% vs. 82%), whereas success rates were high in both unilateral (83%) and bilateral (82%) patients who underwent facility-based probing after 6 months of observation. Cost data did not indicate a definitive cost savings of either treatment method ($562 for in-office vs. $701 for facility-based, depending on cost models predicting spontaneous resolution rates at different ages). No serious adverse events with treatment or anesthesia were reported for either treatment method.
Conclusions: Evidence supports the efficacy and safety of both in-office and facility-based surgery for congenital NLDO. However, treating bilateral NLDO in a facility setting may be better. Because a significant percentage of children achieved resolution spontaneously before 12 months of age, deferring treatment until 12 to 18 months of age is a reasonable option. Additional research may address symptom burden on families and the impact of anesthesia and emotional trauma of nonsedated office probings on patients and may explore further the cost of treatment for each treatment method.
1Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee
2Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
3Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
4Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts
5Storm Eye Institute, Department of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina
6Eye Physicians and Surgeons PC, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut
7Jules Stein Eye Institute, Los Angeles, California