Probing for congenital nasolacrimal duct obstruction: a systematic review and meta-analysis of randomized clinical trials / Sondagem no tratamento da obstrução lacrimonasal congênita: revisão sistemática de ensaios clínicos randomizados e metanálise

ABSTRACT Purpose: Lacrimal probing is the treatment of choice for congenital nasolacrimal duct obstruction that does not have a spontaneous resolution; however, there is no consensus about the best time for probing and if it is superior to other therapies. The present study aimed to evaluate the effectiveness of lacrimal probing compared with other treatments/no intervention to treat congenital nasolacrimal duct obstruction. Methods: A systematic review of literature in PubMed, EMBASE, CENTRAL, clinicaltrials.gov, and LILACS databases up to December 2019 was performed. Randomized clinical trials that enrolled children diagnosed with congenital nasolacrimal duct obstruction and undergoing lacrimal probing were considered. Data extraction and a risk of bias assessment were conducted independently and in duplicate. The overall quality of evidence for each outcome was conducted using the Grading of Recommendations, Assessment, Development, and Evaluation classification system. Results: Four randomized clinical trials involving 423 participants were eligible. No statistically significant differences were observed in resolution rates between early probing and observation/late probing (two studies; risk ratio 1.00 [95% confidence interval 0.76-1.33]; p=0.99; low certainty evidence). One study reported better resolution rates with bicanalicular silicone stent intubation compared with late probing in the complex congenital nasolacrimal duct obstruction cases subgroup (risk ratio 0.56 [95% confidence interval 0.34-0.92]; p=0.02; moderate certainty evidence). Conclusions: Low certainty evidence suggests that early probing has the same success rate as late probing. Evidence of moderate certainty suggests that late probing has a lower success rate than bicanalicular silastic intubation in patients with complex congenital nasolacrimal duct obstructione.

RESUMO Objetivo: A sondagem lacrimal tem sido o tratamento de escolha para a obstrução lacrimonasal congênita que não apresenta resolução espontânea. Contudo, não há consenso sobre qual é a melhor época para a realização da sondagem e se ela é melhor do que outras terapias. O objetivo foi avaliar a efetividade da sondagem lacrimal no tratamento da obstrução lacrimonasal congênita. Método: Uma revisão sistemática da literatura foi realizada usando as plataformas eletrônicas PubMed, EMBASE, CENTRAL, clinicaltrials.gov e LILACS até o período de dezembro de 2019. Foram considerados ensaios clínicos randomizados envolvendo crianças com obstrução lacrimonasal congênita submetidas a sondagem lacrimal. A extração dos dados e avaliação do risco de viés foram feitas por dois autores independentemente. A análise da qualidade da evidência para cada desfecho foi realizada por meio do sistema GRADE (Grading of Recommendations Assessment, Development and Evaluation). Resultados: Quatro ensaios clínicos randomizados foram incluídos, envolvendo 423 participantes. A metanálise mostrou que não houve diferença estatística na resolução da obstrução lacrimonasal congênita entre o grupo submetido à sondagem lacrimal precoce e o submetido à observação/sondagem tardia (2 estudos; risco médio 1.00 [intervalo de confiança de 95% 0.76, 1.33] p=0,99, I2=79%, baixa certeza de evidência). Um estudo evidenciou melhores resultados da intubação bicanalicular com silicone em comparação a sondagem tardia no subgrupo das obstruções lacrimonasais congênitas complexas, (1 estudo; risco médio 0.56 [intervalo de confiança de 95% 0.34, 0.92] p=0,02, moderada certeza de evidência). Conclusões: Há evidências de baixa qualidade de que a sondagem precoce tem a mesma taxa de sucesso que a sondagem tardia. Evidências de moderada certeza sugerem que a sondagem tardia tem menor chance de sucesso do que a intubação bicanalicular com silicone em casos de obstruções lacrimonasais congênitas complexas.

A novel lacrimal duct prosthesis and its biodegradation and biocompatibility / 中华实验眼科杂志

Background The primary management for nasolacrimal duct obstruction is the combination of lacrimal duct probing with lacrimal duct stent implantation.However,conventional implant is undegradable.New degradable lacrimal duct prosthesis based on biopolymer materials is a research hotspot.Objective This study described herein a preparation method of novel degradable lacrimal duct prosthesis and its application.Methods A new degradable lacrimal tube stent was prepared with compound of poly L lactic acid (PLLA) and polycaprolactone (PCL) (6:4) and 15％ polyethylene glycol (PEG).Thirty-two Japanese rabbits aged 3-4 months were randomized into postoperative 1-week group,postoperative 4-week group,postoperative 8-week group and postoperative 16-week group.The degradable lacrimal tube stents were inserted into the lacrimal ducts of the left eyes of the rabbits.The prosthesis was removed in corresponding time points according to grouping,and the integrity and weight of the prosthesis were evaluated.The mucosal findings of the operative eyes were examined under the endoscope,and the histopathological and inflammatory reaction was observed by hematoxylin & eosin stain.The ultrastructure of the lacrimal mucosal surface was examined under the scanning electron microscope.The use and care of the rabbits complied with the Regulations for the Administration of Affair Concerning Experimental Animals by State Science and Technology Commission.Results The new degradable PLLA:PCL+15％ PEG lacrimal duct stents were smooth,flexible and hydrophilic tubes.The removed tubes were intact in the postoperative 1-week group,however,the rupture of the tubes appeared in the postoperative 4-week group,while discrete pieces of the tubes were seen in the postoperative 16-week group.The weight-loss rates of the tubes were (13.44±6.59)％,(23.96±6.33)％,(55.08-± 6.55) ％ and (78.00±8.74) ％ in the postoperative 1-week group,postoperative 4-week group,postoperative 8-week group and postoperative 16-week group,respectively,and the weight-loss rate of the tubes was significantly higher in the postoperative 16-week group than those in the postoperative 8-week group (q =4.27,P＜0.05).No significant difference was found in the weight-loss rate of the tubes between postoperative 1-week group and postoperative 4-week group (q =1.71,P＞0.05).The edema,hyperemia and mild proliferation of the lacrimal mucosal were exhibited in the eyes of the postoperative 4-and 8-week groups,and the mucosal findings were almost normal in the eyes of the postoperative 16-week group under the endoscope.Histopathological examination showed a large number of inflammatory cells in the postoperative 1-,4-and 8-week groups.However,few inflammatory cells were seen in the postoperative 16-week group.Mucosal folds,microvillus decrease and disorder were displayed in the lacrimal duct of the postoperative 8-week group,and no evident abnormality was seen in the lacrimal duct mucosal surface.No postoperative complication occurred in all the rabbits.Conclusions PLLA:PCL+15％ PEG lacrimal duct stent has an appropriate degradation speed and good biocompatibility after implant in rabbits,and its decay period of mechanical strength could match lacrimal duct healing period.

Dacriocistocele congênita: relato de caso e conduta / Congenital dacryocystocele: case report and treatment

A dacriocistocele representa uma rara anomalia congênita da região medial da órbita, causada pela obstrução distal (ao nível da válvula de Hasner) e proximal (ao nível da válvula de Rosenmüller) da via lacrimal, com subsequente dilatação do saco lacrimal. Recebe o nome de mucocele, quando seu conteúdo representa muco, ou amniocele, quando o seu conteúdo é preenchido por fluido amniótico. Acomete somente 0.1% das crianças, com obstrução do ducto lácrimonasal, sendo comumente unilateral e mais frequente no sexo feminino e com predisposição familiar. O diagnóstico é realizado pelas características clínicas: lesão cística tensa, abaixo do tendão cantal medial, de coloração azulacinzentada, rósea ou vermelha acompanhada por epífora desde o nascimento. No entanto podemos utilizar exames de imagem para diagnosticar esta anomalia congênita tais como: tomografia computadorizada, ressonância magnética e ultrassonografia.

The dacryocystocele represents a rare congenital anomaly in the medial region of the orbit caused by distal obstruction (Hasner valve) and proximal (valve Rosenmüller) of the lacrimal system causing dilation of the lacrimal sac. Mucocele is called when the content is mucus and amniocele when the content is filled with amniótico fluid. The incidence is only 0.1% in children with nasolacrimal duct obstruction. It is commonly unilateral and more frequent in women with familial predisposition. The diagnosis is made by clinical features: tense cystic lesion below the medial canthal tendon, blue-gray, pink or red color with epiphora since birth. However we can use image tests to diagnose this congenital anomaly such as tomography computerized, magnetic resonance and ultrasonography.