【摘要】 比较泪道探通治疗对三个年龄组的先天性鼻泪管阻塞患者的成功率。方法:共180例先天性鼻泪管阻塞患者根据年龄分为3组， I组 (4～6mo), II组 (7～12mo) 和III 组(13～24mo)，均行泪道探通治疗。症状体征均消失为治疗成功的标准。用卡方检验分析结果。结果:I组治疗成功率为100.0%, II组 治疗成功率为88.5%，III 组治疗成功率为82.3%，总的治愈率为90.7%。结论:泪道探通治疗的有效性随着年龄的增加降低。在6mo时行泪道探通治疗的孩子 成功率最高，能完全消除症状。
【关键词】 鼻泪管阻塞 泪道探通 小儿
INTRODUCTION
Congenital nasolacrimal duct obstruction is the most common abnormality of the lacrimal system in children affecting upto 20% of new borns[1], but only 1% to 6% of these children become symptomatic[2]. In Pakistan 30% of bilateral cases were found in a study conducted on 150 patients[3].
Dacryostenosis or atresia of the nasolacrimal duct is the most common cause of epiphora in paediatric population resulting from the failure of the canalization of nasolacrimal duct[4]. The commonest cause of congenital nasolacrimal duct obstruction at birth is a membranous obstruction at the distal end of the nasolacrimal duct and spontaneous resolution occurs in 95% cases during the first year of life and in 60% of remainder cases during the following year[5]. The characteristic presentation is persistent watering (epiphora) and mucopurulent discharge from the first month of life along with conjunctival hyperemia and crusting of eyelid margins[6].
Dacryostenosis should be managed conservatively whenever possible. Standard management in first few months of life includes hydrostatic massage of the lacrimal sac and topical antibiotics[7]. Probing is time proven treatment of congenital duct obstruction which includes office probing with topical anesthesia at 46 months and probing under general anesthesia at 12 months[8]. False passage formation, traumatic stenosis and unexplained failure are recognized problems of this procedure. However, the timing for initial probing has been a matter of controversy[911]. Advocates of early probing suggest that early correction avoids morbidity due to epiphora and chronic dacryocystitis and the postponement of the procedure may result in success decrease with simple probing due to chronic inflammation and fibrosis. While the advocates of late probing are of the view that spontaneous resolution of the obstruction negates the need for probing in the first place[2]. Successful outcome is defined as absence of tearing and discharge in affected eye[12].
The purpose of carrying out this study is to determine the optimal age for the successful probing of a child suffering from congenital nasolacrimal duct obstruction as there is controversy regarding the timing of probing and its outcome.
MATERIALS AND METHODS
This study was conducted from March 2005 to January 2008 at the Department of Ophthalmology Liaquat University of Medical and Health Sciences Eye Hospital Hyderabad. Children/patients coming to the Eye unit I Outpatient Depatrment (OPD) with uncomplicated congenital nasolacrimal duct obstruction were enrolled in the study. The initial examination included assessment of the lacrimal puncta, anomalies of the eyelids and face, exclusion of the conjunctivitis, allergic inflammation and other causes of epiphora in children. The diagnosis of congenital nasolacrimal duct obstruction was made on the basis of history of tearing with or without mucopurulent discharge since birth and on clinical examination as evidenced by epiphora beginning during the first few weeks of life, recurrent mucopurulent discharge and positive regurgitation test. Patients having prior history of one or more probings were excluded from the study. The eligible patients were registered and divided into three groups: Group I (aged 46 months), Group II (aged 712 months) and Group III (aged 1324 months) respectively.
All the children in the three groups were put on conservative treatment in the form of topical antibiotic drops four times daily for two days prior to the surgical intervention. The surgical procedure was carried out in the general anaesthesia. Informed consent was taken. The instruments used were punctum dilator, Bowmans probe (01 size), saline filled syringe, fluorescein dye 20g/L and cannula. Bowmans probe size 00 (0.9mm diameter) was used in all cases. After dilating the upper punctum the Bowmans probe was introduced into the upper canaliculus until the medial wall of the lacrimal fossa was felt, at which point it was turned and introduced into the nasolacrimal duct and advanced till resistance was felt. The breaking of the membrane was felt as the probe overcame the obstruction. The head of the patient was turned to the same side and normal saline stained with fluorescein dye 20g/L was injected through the lower canaliculus with a syringe and cannula. Patency was confirmed by retrieval of saline from the patients throat. Each patient was given antibiotic drops four times per day for three weeks. At first, the patient was called after one week and then followed up at the 2nd and 3rd month to observe the outcome of the procedure. Success of the probing was defined as the complete remission of the sign and symptoms at one week after procedure.
RESULTS
This quasiexperimental study was conducted on 214 eyes of 180 patients. Of these, 110 patients were male (61.1%) and 70 female (38.9%). The patients were divided into three groups according to the age at which probing was performed. The mean age of Group I (412 months) was 5.08 months, Group II (712 months) 9.1 months and Group III (1324 months) 18.7 months respectively.
In Group I (60 cases) 44 cases are unilateral and 16 cases are bilateral. In Group II (60 cases) 50 cases are unilateral and 10 cases are bilateral. In Group III (60 cases) 52 cases are unilateral and 8 cases are bilateral.
In Group I, the success rate was 100.0%. Group II showed the success rate of 88.5% while Group III had a success rate of 82.3%. The cure rate for the entire study was 90.7%(Table 1).
None of the patients had any surgery or anesthesia related complications.
Two types of obstruction were encountered during probingsimple and complex. In simple obstruction, the resistance could be easily bypassed with the help of Bowmans probe and postprobing syringing revealed a patent lacrimal system. However, in complex obstruction the probe could not be passed and there was firm resistance to its passage. Postprobing syringing was not patent in any of these patients.
Statistical Analysis It was found that at 5% level of significance the chisquare result was 13.72 with tabulated value of 5.991. It showed that the null hypothesis is rejected and the age groups and success rates and failure of the operation are not independent. Significance is also confirmed by the P value of 0.001.
We also found that at 5% level of significance the chisquare result was 6.21 with tabulated value of 5.991. It showed that the null hypothesis is rejected and the age groups and laterality are not independent. Significance is also confirmed by the P value of 0.0449.
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