目的:评估复杂先天性鼻泪管阻塞(C-CNLDO)的概况和结局。
方法:2016年1月至2019年6月,对诊断为C-CNLDO的患者进行了回顾性介入病例系列研究,并在三级护理泪学研究所进行了治疗。根据探查过程中的术中发现诊断出复杂的CNLDO,并将其定义为CNLDO继发于,或者与复杂的胚胎实体相关,比如埋藏的探针,骨NLD的发育不良或不发育,额外的近端泪腺发育不全,无张力囊,或相关的颅面综合征和颅面骨发育不良。研究的参数包括患者人口统计学,临床表现,C-CNLDO的类型,管理模式,和结果。成功被定义为在荧光素染料消失测试中通过客观测量正常泪液弯月面高度和染料清除率来主观解决泪液和放电。对于接受泪囊鼻腔吻合术(DCR)的患者,DCR后最少1年的随访被认为是结局分析.
结果:在这期间治疗的2714例CNLDO病例中,482例(17.75%)被诊断为复合CNLDO。C-CNLDO对男性有好感(60.3%,291/482).相当数量的患者(40.2%,194/482)超过36个月。C-CNLDO的常见亚型为无张力囊(33.8%,163/482),埋探头(19.7%,95/482),和相关的近端泪道引流异常(11.2%,54/482)。由于C-CNLDO通常在最初的内窥镜引导探测期间被确认,根据C-CNLDO的类型,管理有所不同。硅胶插管和/或球囊骨成形术(BDCP),和/或额外的微创手术被添加到初始内窥镜引导的冲洗和基于C-CNLDO的性质的探测。这些非旁路方式的总体分辨率为72.6%(350/482)。尽管在3岁以上的C-CNLDO患者中成功率开始下降,3-5岁年龄组采用多模式(非旁路)管理的成功率显著(71.8%,79/110)和令人鼓舞的结果(38.5%,27/70)在5-10岁年龄组。接受内窥镜或外部泪囊鼻腔造口术并随访超过1年的患者的解剖和功能结局为96.4%(55/57)。
结论:C-CNLDO患者的就诊年龄延迟。多模态内窥镜引导管理有助于识别C-CNLDO的几种亚型,并在年龄较大的儿童中取得了显著的有利结果。C-CNLDO不易探查,插管和BDCP在外部或内窥镜泪囊鼻腔吻合术中取得了很高的成功。
OBJECTIVE: To assess the profiles and outcomes of complex congenital nasolacrimal duct obstruction (C-CNLDO).
METHODS: Retrospective interventional case-series was performed on patients diagnosed with C-CNLDO and managed at a tertiary care Dacryology Institute from Jan 2016 to June 2019. Complex CNLDO was diagnosed based on intraoperative findings during probing and are defined as entities where CNLDO is secondary to, or associated with complex embryonic entities like buried probe, mal-development or non-development of bony NLD, additional proximal lacrimal dysgenesis, atonic sac, or associated craniofacial syndromes and craniofacial dysostosis. The parameters studied include patient demographics, clinical presentation, types of C-CNLDO, management modalities, and outcomes. Success was defined as the subjective resolution of epiphora and discharge with objective measures of normal tear meniscus height and dye clearance on fluorescein dye disappearance test. For patients who underwent a dacryocystorhinostomy (DCR), a minimum follow-up of 1-year post-DCR was considered for outcome analysis.
RESULTS: Of the 2714 cases of CNLDO managed during this period, 482 (17.75%) were diagnosed as complex CNLDO. C-CNLDO showed predilection to the male gender (60.3%, 291/482). A significant number of patients (40.2%, 194/482) presented beyond 36 months of age. The common subtypes of C-CNLDO were atonic sacs (33.8%, 163/482), buried probes (19.7%, 95/482), and associated proximal lacrimal drainage anomalies (11.2%, 54/482). Since C-CNLDO is usually confirmed during the initial endoscopy-guided probing, the managements varied based on the type of C-CNLDO. Silicone intubation and/or balloon dacryoplasty (BDCP), and/or additional minimally invasive procedures were added to the initial endoscopy-guided irrigation and probing based on the nature of C-CNLDO. The overall resolution rate with these non-bypass modalities was 72.6% (350/482). Although the success rates start dropping in C-CNLDO patients beyond 3-years of age, significant success rates with multi-modal (non-bypass) management were noted in age-groups 3-5 years (71.8%, 79/110) and encouraging results (38.5%, 27/70) in 5-10 years age group. The anatomical and functional outcomes in those who underwent endoscopic or external dacryocystorhinostomy with a follow-up beyond 1-year was 96.4% (55/57).
CONCLUSIONS: The age at presentation is delayed in patients with C-CNLDO. Multi-modal endoscopy-guided management facilitates the identification of several sub-types of C-CNLDO, and achieves significantly high favourable outcomes in older children. C-CNLDO refractory to probing, intubation and BDCP demonstrates high success with external or endoscopic dacryocystorhinostomy.