Optimal timing for intervention in congenital nasolacrimal duct obstruction

April 13, 2019

Congenital nasolacrimal duct obstruction (CNLDO), which occurs in 1 in 9 newborns, is characterized by persistent tearing and intermittent mucopurulent discharge from one or both eyes. Standard early treatment includes hydrostatic nasolacrimal massage and topical antibiotics. While the obstruction spontaneously resolves in most infants, it does not resolve in up to 25 percent of infants affected.

Results from a retrospective study of 1,998 infants with CNLDO suggest that surgical intervention may be appropriate during a new time frame ― between ages 9 and 15 months ― that capitalizes on the condition's changing rate of resolution and the declining success rate of the initial probing.

"Although the overall rate of spontaneous resolution in CNLDO and efficacy of probing have been documented in the literature, the optimal timing of intervention remains controversial," says Brian G. Mohney, M.D., with Ophthalmology at Mayo Clinic's campus in Rochester, Minnesota, who led the research team. "In current practice, probing is generally recommended to occur after the patient reaches age 1 year. We wished to confirm whether that timing is optimal."

Using data from the Rochester Epidemiology Project, the team retrospectively reviewed the medical records of 1,998 consecutive infants (younger than 5 years) diagnosed with CNLDO from Jan. 1, 1995, through Dec. 31, 2004, while residing in Olmsted County, Minnesota. The data recorded included sex, laterality, natural history and treatment:

  • The cohort was 48 percent female and 89 percent white.
  • Among the 1,998 infants who received a diagnosis during the 10-year period, CNLDO in 1,669 (83.5 percent) spontaneously resolved, 289 (14.5 percent) required surgical treatment, and 40 (2.0 percent) were lost to follow-up.
  • The 1,669 infants whose obstructions spontaneously resolved were diagnosed at a median age of 1 month compared with 6.0 months for the 289 infants who required treatment.
  • The median age at resolution was 2.4 months for the 1,669 infants whose obstructions spontaneously resolved, while the 289 infants underwent the first surgical procedure at a median age of 14.0 months.

Findings support new time frame for intervention

"Our goal was to identify the rate of spontaneous resolution of the condition over time and by sex, as well as the optimal timing of intervention," says Dr. Mohney. Study results include:

  • The rate of spontaneous resolution was highest in the first few months of life, declining until age 9 months, when the resolution rate flattened. The rate of resolution was 35 percent faster at younger than 1 month versus 3 months; 43 percent faster at 3 months versus 6 months; 39 percent faster at 6 months versus 9 months; and 1 percent slower at 9 months versus 12 months.
  • Boys' obstructions resolved 0.5 months faster than girls', and unilateral obstructions resolved 0.2 months faster than bilateral obstructions.
  • Of the 289 infants who were treated surgically, 272 (94.1 percent) eventually underwent a probing. The obstruction resolved in 242 (89 percent) of those probed without additional treatment.
  • After adjusting for the effects of age at diagnosis, sex and laterality, infants probed at 15 months or older had decreased odds of resolution after probing relative to infants probed at ages 12 to 14 months.
  • When infants younger than 11 months were compared with infants of 12 to 14 months of age who were probed, there was no difference in their success rates. The success rate of probing was 89.5 percent (n = 68 of 76) in infants younger than 9 months; 94.5 percent (n = 52 of 55) in infants 9 to 11 months of age; 97.8 percent (n = 45 of 46) in infants 12 to 14 months of age; and 81.1 percent (n = 77 of 95) in infants 15 months or older.

"Given that the rate of spontaneous resolution appears to plateau after age 9 months and a successful probing outcome declines beyond age 15 months, surgical intervention between these time intervals appears to be a reasonable treatment strategy for infants with CNLDO," Dr. Mohney says. "This time frame establishes both an earlier and narrower range of ages for intervention compared with the current general practice of probing after age 1 year.

"An additional argument for earlier probing may be that by delaying procedures, older children could develop more-complicated obstructions and ultimately require additional surgical procedures and increased exposure to general anesthesia."

Study results were published in JAMA Ophthalmology in 2018.

For more information

Mayo Clinic. Rochester Epidemiology Project.

Sathiamoorthi S, et al. Spontaneous resolution and timing of intervention in congenital nasolacrimal duct obstruction. JAMA Ophthalmology. 2018;136:1281.