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Over the past 15 years balloon dacryoplasty has become a widely accepted treatment for nasolacrimal duct obstruction, for both primary treatment and as a secondary procedure following failed probing. In 1996 Becker et al. [1] reported on the efficacy of balloon catheter dilation in the treatment of congenital nasolacrimal duct obstruction (CNLDO) in children over 12 months of age, and those children failing probing or silicone intubation. The commercial lacricath balloon was introduced shortly thereafter.

Background: Persistent nasolacrimal duct obstruction (NLDO) often requires treatment by probing, intubation, or balloon dacryoplasty. Refractory cases have been managed by external dacryocystorhinostomy (DCR), which leaves a scar; however, this procedure is generally avoided in young children. Endoscopic DCR has been successfully performed in adults and described in children. We report the success of this procedure in a series of pediatric patients. Methods: A retrospective review of all endoscopic lacrimal procedures performed in a 3-year period was undertaken. Seventeen children (22 ducts) with persistent NLDO after at least one failed probing, with or without silicone tube placement, underwent endoscopic DCR. Follow-up ranged from 6 to 36 months, and success was defined as resolution of tearing and discharge by follow-up clinical evaluation and by parental history. Results: All but 2 patients (88%) with NLDO showed complete resolution of tearing and discharge. These 2 patients had recurrent symptoms after the Crawford tubes were removed and required revision endoscopic DCR. No complications from this procedure were noted. Conclusions: Endoscopic DCR is a safe and effective means of treating persistent NLDO in infants and young children when simple probing, intubation, or balloon procedures have failed. The team ophthalmology-otolaryngology endoscopic approach provides a highly successful alternative for patients with a persistent distal obstruction that might otherwise require an external procedure. (J AAPOS 2001;5:143-7)

Purpose To report a series of lacrimal complications associated with a specific type of lacrimal plug (Herrick Lacrimal Plug; Lacrimedics Incorporated, Rialto, CA.) Design Retrospective, noncomparative case series and survey. Methods Members of the American Society of Ophthalmic Plastic and Reconstructive Surgery were asked to submit personally treated cases of patients referred for treatment of complications after placement of a Herrick Lacrimal Plug. Main outcome measures Failure of the device to be removed by simple lacrimal irrigation. Results The clinical courses of 41 patients were analyzed. Patients ranged in age from 19 to 81 years, and all had symptomatic epiphora related to the presence of the lacrimal plug. Several interventions were used to treat lacrimal obstruction. Nasolacrimal duct probing with irrigation was used in 15 lacrimal systems, whereas six systems were probed and subsequently stented with silicone tubing. Eyelid margin cutdown was used in eight cases. Balloon dacryoplasty was performed in three systems, dacryocystorhinostomy in 18 instances, and conjunctivodacryocystorhinostomy in two patients. Conclusions The Herrick lacrimal occlusion device sometimes cannot be removed by simple irrigation and is capable of inducing permanent, irreversible, symptomatic lacrimal drainage system obstruction.

In recent years, there has been an emerging interest in the development and application of alternative therapeutic approaches for the treatment of complete and incomplete nasolacrimal duct (NLD) obstructions (NLDOs). For complete NLDOs, it is generally accepted that an incisional dacryocystorhinostomy (DCR), because of its high rate of success (more than 90%), is the treatment of choice. Despite such effi cacy, controversies around anesthetic choices and rare, cosmetically signifi cant scarring have aroused interest in alternative treatment modalities. Increasing attention has recently focused on balloon dacryocystoplasty, a technique based on dilation of a completely or incompletely stenotic aperture along the NLD using a balloon catheter device similar to those used in vascular dilation. Balloon dacryocystoplasty initially emerged as a fl uoroscopicassisted retrograde technique aimed at dilating the stenotic NLD. This involved the use of a guide wire that cannulated the NLD and, subsequently, placed a balloon catheter through the area of stenosis. Over the past decade, the technique has undergone signifi cant innovations. Most notable is the transition from a retrograde to anterograde approach using specially designed lacrimal system balloon catheters. Balloon dacryoplasty has also been used in association with temporary silicone tube stenting of the NLD to increase the success rate. Lastly, a recent report also describes signifi cant effi cacy in combination with endoscopy. Despite these advances, varying degrees of success have been reported using this technique for complete or incomplete NLDO. In this chapter, the authors examine the effi cacy of balloon dacryocystoplasty for complete and incomplete NLDOs.

Purpose: To examine the histopathologic effects of balloon dacryoplasty on the nasolacrimal duct of the rabbit. Methods: Sixteen nasolacrimal ducts of 8 infant white New Zealand rabbits were divided into 3 treatment groups: a control group, a 2 mm balloon dilation group, and a 3 mm balloon dilation group. The LacriCath balloon catheter (Quest, Medical, Allen, TX) was used for nasolacrimal duct dilation according to the manufacturer’s recommended human protocol. The rabbits were euthanized at 1, 3, and 7 days after treatment and the nasolacrimal ducts were harvested for histological examination. Results: There were no significant differences between treatment groups in the number of neutrophils in the lumen, epithelium, and stroma of the duct; the number of monocytes in the stroma of the duct; or in the number of red blood cells in the stroma of the duct. No differences were found in overall cellularity of any type in the nasolacrimal ducts of treated and untreated rabbits. Finally, no histopathologic signs of crush injury were evident. Conclusion: Balloon dacryoplasty does not induce significant inflammation or crush injury in the nasolacrimal duct of a rabbit model.

Purpose To determine the success of monocanalicular stenting and balloon dacryoplasty as secondary treatment options for congenital nasolacrimal duct obstruction after failed probing surgery. Methods An interventional case series of consecutive secondary balloon dacryoplasty and monocanalicular stenting for congenital nasolacrimal duct obstruction was reviewed. These secondary treatments were used in cases in which a bicanalicular stent would have been used in the past. Seventy-seven nasolacrimal systems in children with epiphora after probing and irrigation surgery were treated with a monocanalicular stent or balloon dacryoplasty. The patients were then evaluated at least 3 months after surgery or after stent removal by using a dye disappearance test. Cases in which there was no significant dye at 5 minutes were considered a success. Cases with residual dye or history of persistent tearing were considered failures. Results The monocanalicular stent was used in 35 nasolacrimal systems, whereas balloon dacryoplasty was used in 42 nasolacrimal ducts. The mean age of treatment was 25.2 months for the monocanalicular stent group and 25.8 months for the balloon group. Overall, 32 of 35 (91%) nasolacrimal ducts responded to monocanalicular stenting, whereas 36 of 42 (86%) responded to balloon treatment. When the patient group was further stratified by age, the monocanalicular stenting was 94% successful in children younger than age 2 years and 89% successful for children older than 2 years. The balloon treatment had a success rate of 91% in the younger group and 79% in the older group. Chi-square statistical analysis showed no significant difference between the two treatments or on the basis of age stratification within each treatment group. Conclusions Monocanalicular stenting and balloon dacryoplasty are excellent secondary therapies for congenital nasolacrimal duct obstruction after initial probing and irrigation surgery has failed. These two treatment options are now our procedures of choice for secondary surgery.

To develop the optimal protocol for balloon dacryoplasty (DCP) through an experiment.The experiment enrolled 12 Chinchilla rabbits (24 eyes). DCP protocol for group 1 (5 rabbits, 10 eyes) implied two dilations of 90 and 60 sec followed by another two of the same duration, while in group 2 (5 rabbits, 10 eyes) all four dilations were of 90 sec. The balloon was moved proximally before the every third dilation. The remaining 2 rabbits (4 eyes) who did not receive balloon DCP constituted the control group. The animals were killed on days 1, 3, 7, and 14. In all cases nasolacrimal duct morphology was studied.By day 14 after the procedure, inflammatory changes in nasolacrimal ducts either had resolved (protocol 1) or persisted (protocol 2).Цель - разработать оптимальный режим проведения баллонной дакриопластики (БДП) в эксперименте. Материал и методы. Исследование проведено на 12 кроликах (24 глаза) породы шиншилла. Из них 5 кроликам (10 глаз) БДП была выполнена по протоколу 1 с продолжительностью воздействия 90 и 60 с и повторного воздействия в течение 90 и 60 с после проксимального смещения, 5 животным (10 глаз) - по протоколу 2 с 4-кратным воздействием на протяжении 90 с. Кролики были выведены из эксперимента на 1, 3, 7 и 14-е сутки. Контрольную группу составили 2 кролика (4 глаза), которым не проводилась БДП. Всем животным было выполнено морфологическое исследование носослезного протока. Результаты. При проведении БДП по протоколу 1 воспалительные изменения в носослезном протоке отсутствовали к 14-м суткам, по протоколу 2 - воспалительные изменения сохранялись к 14-м суткам.

The dacryocystorhinostomy (DCR) procedure in pediatric patients is especially challenging due to the smaller anatomy. This surgery, however, is often necessary in the setting of failed lesser invasive procedures, such as stenting or balloon dacryoplasty. The choice on an external versus endonasal approach for a DCR is ultimately the surgeon’s choice. With the advances in modern endonasal imaging and powered instruments, such as the ultrasonic bone aspirator and endonasal microdebrider, the endonasal endoscopic DCR can be performed with comparable rates of success to the external approach. This chapter addresses both the techniques of external and endonasal endoscopic DCR.