Nasolacrimal Duct Obstruction in Children: Outcome of Intubation Charmaine S. Lim, MB BS (Hons), a Frank Martin, FRACS, FRANZCO, a Ted Beckenham, FRACS, FRCS (ed), a and Robert G. Cumming, MB, BS, MPH, PhD b Background: Nasolacrimal silicone intubation is a treatment for congenital nasolacrimal duct obstruction (NLDO) after failed probing and irrigation. Functional outcome has been previously reported as poorer in children with Down syndrome. Method: The outcome of 122 cases of silicone bicanalicular nasolacrimal intubation, performed between 1988 and 2002 on 97 children aged 11 months to 9.5 years, was retrospectively reviewed. In all children, intubation was performed under direct vision using nasal endoscopy. Statistical analysis, including multiple logistic regression analysis, was used to assess the effects of duration of intubation, and age at surgery, on treatment outcome, and to determine potential predictors of treatment failure. Results: The overall success rate was 85%, with 89% success for eyes in children with Down syndrome and 85% success for eyes in children without Down syndrome. Success rates were consistently high (83% to 100%) for children who underwent surgery between 1 and 4 years of age. The average duration of intubation was 5.5 months. Increasing duration of intubation was not associated with increasing chance of success, but with a significantly higher risk of failure if greater than 18 months (P = 0.03). Retention of stents for longer than 12 months was associated with a significantly lower success rate (67%). The presence of Down syndrome, increasing age at surgery, or gender were not predictive factors for treatment failure. Unplanned removal of tubes because of dislodgement was the most common complication, occurring in 25% of eyes, but did not affect functional outcome. Conclusions: Nasolacrimal silicone intubation, under direct nasal endoscopic visualization, is a consistently successful procedure for the treatment of NLDO among children aged older than 12 months of age. Tubing should be left in place for a maximum of 12 months because the success rate declines after this period and the risk of failure is significantly increased after 18 months of intubation. Prematurely dislodged tubes need not be replaced unless symptoms of nasolacrimal obstruction occur, because this does not lead to an increased risk of treatment failure. (J AAPOS 2004;8: 466-472) N asolacrimal silicone intubation is a treatment for congenital nasolacrimal duct obstruction (NLDO) after failed probing and irrigation. Functional out- come has been previously reported as poorer in children with Down syndrome. 1 Congenital NLDO is prevalent in approx- imately 6% of newborns. 2,3 In as many as 90%, the mem- brane that obstructs Hasner’s valve at the end of the naso- lacrimal duct dissolves spontaneously in the first 6 months with conservative treatment alone. 4 Conservative treatment includes lacrimal sac compression and massage, lid hygiene, and topical antibiotics. 5,6 Failing this, probing with irrigation of the duct often is the next line of treatment. Controversy surrounds the timing of this procedure with some advocating early, office-based probing, and others preferring to wait until the child is older to allow resolution of the membrane spontaneously and better control of probing with general anesthesia. Silicone nasolacrimal intubation often is reserved for cases in which probing has failed, although some recom- mend it as the primary surgical option to avoid a potential second operation under general anesthesia. Previously, sim- ple probing with or without silicone intubation for treatment of Down syndrome-associated congenital NLDO has been associated with poor outcomes. 1 Balloon catheter dilation has been proposed as an alternative first-line treatment for older children with craniofacial abnormalities, including children with Down syndrome. 7 Nasolacrimal duct obstruction is more common (present in approximately 20% of all cases) among children with Down syndrome. It is generally be- lieved to be more difficult to treat in these cases than in the general pediatric population because of the complex anatom- ical abnormalities found in their lacrimal drainage systems, including extremely tight bony nasolacrimal ducts (as op- From a The Children’s Hospital at Westmead, Sydney, Australia and b The University of Sydney, Sydney, Australia Submitted June 3, 2004. Revision accepted June 28, 2004. Reprint requests: Dr Charmaine Lim, c/o Department of Ophthalmology, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Sydney, Australia (e-mail: charmainelim@optusnet.com.au) Copyright © 2004 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2004/$35.00 + 0 doi:10.1016/j.jaapos.2004.04.013 Journal of AAPOS 466 October 2004