CNLDO: choose endoscopy-guidance and NOT a blind procedure

Endoscopy-guidance has changed the landscape of lacrimal surgeries and enhanced our understanding of the anatomy, physiology, and pathology of lacrimal disorders. The development of endoscopic techniques paralleled and contributed to the development of minimally invasive lacrimal procedures, and the story of congenital nasolacrimal duct obstruction (CNLDO) is not an exception.

Several papers have shown the benefits of endoscopy-guided probing in patients with CNLDO, more so in the complex variants of CNLDO.^1–5 There are several instances where endoscopy plays diagnostic and therapeutic roles in variants of CNLDO, for example, buried probe, misdirected probes, and congenital dacryocele.^4–6 It also plays a crucial role in further management of a failed probing. Even simple cases of CNLDO have the potential to get complicated in the absence of direct visualization. For example, thick membranous obstruction or mild variations in the sac-duct orientation, overcoming proximal NLD obstruction and the resultant false sense of recanalization, misdirected probe, NLD trauma, and nasal floor injury are some of the several such scenarios. Any of this would entail the child to undergo repeat probing, repeat anesthesia, and enhanced morbidity. The use of endoscopy helps identify the variants of CNLDO, and facilitates additional management along with probing, in a single sitting.

Unfortunately, some oculoplastic surgeons involved in the management of CNLDO do not use endoscopy-guidance, and their patients do not enjoy the benefits of such readily available technology. This is more reflective of the practices in the developing world. A survey of India’s oculoplastic surgeons showed that only 50% of them use endoscopy-guidance in the management of CNLDO.⁷ While this can be looked at as an encouraging trend from the earlier statistics, it is far from an optimal state.

Let us first understand the significant barriers for such underutilization of endoscopy in managing CNLDO and the possible strategies for overcoming them. The first and the foremost barrier is the expensive endoscopy equipment. While this was true earlier, several recent indigenous Indian and Chinese endoscopes with good optical quality are now available at quite affordable prices. The designs are ergonomic, and most of them are also portable, hence, easy to carry to different locations in a briefcase. The second barrier is the lack of training. While this was also true earlier, several major institutes worldwide now offer endoscopy training as part of their workshops, conferences, and fellowship programs. Fortunately, the endoscopy training for CNLDO is simple, minimally invasive, and easy to learn compared to, say, for an endoscopic DCR. The third barrier is the false belief that it would not matter much or the surgeon’s reluctance to upgrade himself. The fact that CNLDO is a disorder of a nasal structure cannot be overemphasized. Visualization is an integral component while operating any area, and the nasolacrimal duct (NLD) cannot be an exception. How can a lacrimal surgeon call himself one without being aware of standard approaches to a tissue (NLD), where they plan to intervene? How is it that a lacrimal surgeon does not want to know well or see the structure where they are operating? Why would someone want to be blind when they can see?

Interestingly, to by-pass endoscopy in CNLDO, there have been attempts to assess the probe in the NLD by other means. For example, metal to metal touch, which can be fraught with several errors while performing and interpreting it. Similarly, various shaped stents for easy retrieval from the nasal cavity, ignorant of the associated trauma to the nasal mucosa. All this, when just placing a scope at the nasal entrance, can make the entire procedure quick, safe, and simple for the surgeon and the patient.

The importance of endoscopy for lacrimal drainage disorders cannot be simply overemphasized. It just helps us to see more and do more. I am sure that no physician would want their paediatric patients to be unintentional victims of their ignorance or reluctance to adapt to better techniques.

As I keep telling my fellows repeatedly that “Every once in a while, we should stop and ask ourselves – why are we doing what we are doing? and is there a better way to do the same thing? That is how science progresses.” There is an upward trend for the use of endoscopy in lacrimal surgeries, and I am very optimistic that it would be an integral part of every lacrimal surgeon’s armamentarium in the near future.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Funding

This work was supported by Hyderabad Eye Research Foundation.