Pediatric oculoplasty Update-
Congenital Dacryocystitis
Introduction

Medical science changes with reports and studies making the understanding of diseases more clear.
This review presents updated literature on pediatric oculoplastic procedures in a critical manner with
a view to  understand that the unique problems presented by childhood oculoplastic conditions
makes it appropriate to have pediatric oculoplasty as a separate speciality.


1.Congenital dacryocystitis Update

The incidence may vary from 1.2% to 30%, the disorder being commoner in children with craniofacial
disorders and Down's syndrome.


1.1        Microbiological spectrum and sensitivities

               A recent study 2 conducted at Madurai, India concluded that Gram-positive bacteria are
           the most frequent isolates with Streptococcus pneumoniae being the commonest. Among
           Gram-negative bacteria the most frequent isolate was Haemophilus influenza. Candida  
           tropicalis has emerged as a new organism. Gram-positive bacteria are sensitive to
           chloramphenicol, vancomycin, and ofloxacin and Gram-negative bacteria to ofloxacin and
            ciprofloxacin.

            
  MRSA

                  Kodsi et al have reported that MRSA may be present in cases with congenital
              dacryocystitis. Considering that MRSA may be community acquired this becomes an
              important finding and will need to be addressed if there is persistent infection in a
               particular case.


1.2         Treatment

            1.2.1        Probing

                                 Timing: The outcome of the nasolacrimal duct probing at 1 week follow up is   
                                               highly indicative of the final outcome.

          1.2.2     Endo nasal probing and retrograde irrigation of lacrimal ducts

                         When Endo nasal probing and retrograde irrigation of lacrimal ducts is done, it has
                      been reported that persistent membranes in the inferior lacrimal punctum may require
                      repetition of  the initial dilatation. In children in whom this procedure fails endo nasal
                      dacryocystorhinostomy with balloon intubations may be tried













        
   1.2.3. Balloon dilatation of nasolacrimal duct

           Balloon nasolacrimal ductoplasty is performed using the LacriCATH system (Quest Medical,
          Inc. An Atrion Company, Allen, TX).Becker et al 7 in their prospective series of 61 lacrimal
          systems reported a 95% success rate with this procedure as early as 1996.More recently tao
          et al 8 reported that as a secondary procedure it was successful in 94% of those  older than
          24 months  whereas the success rate was as lowas 59.1% in those younger than 24 months.
          Results range from 82%(tien at al 9 ) to 95%. Yuksel et al 10 proposed on the basis of their
          experience with endoscopic guided balloon dacryocystoplasty in children over 36 months of
          age that it can be an alternative treatment in older children and can be preferred to silicone
          intubation and dacryocystorhinostomy performed after unsuccessful probing
             
       
     1.2.4 Monocanalicular stenting

                         Goldstein et al 11 compared monocanalicular stenting and balloon dacryoplasty in
              secondary treatment of congenital nasolacrimal duct obstruction after failed primary and
              reported  that (91%) nasolacrimal ducts responded to monocanalicular stenting, whereas
              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.


            Step wise approach

              Cassady et al 12 have proposed a treatment paradigm prescribing probing as an initial
             procedure regardless of age. Those who fail probing should receive balloon catheter
             dilation. Those who fail probing and balloon catheterization should receive silicone
             intubation. Dacryocystorhinostomy is reserved for patients failing the above treatments