One Procedure for All vs. All Procedures for One in Congenital Nasolacrimal Duct Obstruction

Purpose: After a failed conservative management, most clinicians treat congenital nasolacrimal duct obstruction (CNLDO) in a conventional stepwise fashion; starting with probing, then repeat probing, next silicone intubation and/or balloon dilatation, and finally dacryocystorhinostomy. It is based on the patient’s age and previously failed procedure and recruits One Procedure for All CNLDO at a time. A newly introduced approach is based on the type of obstruction and recruits All Procedures for One CNLDO at a time. The aim is to revisit the best available evidence about CNLDO management seeking a preferred therapeutic approach. Methods: The authors provide a review of the best evidence available (51 articles) in the field of CNLDO treatment in order to firstly address the time to commence the surgery and then show if this is the time to changethe age-based to one-stage obstruction-based approach. Results: Recent articles support the idea that through intraoperative evaluation of obstruction complexity features,clinicians may predict probing failure and instantaneously hire more appropriate treatment modalities. This review addresses if age-based approach should be changed into one-stage obstruction-based approach. Conclusion: One-stage obstruction-based (preferably endoscopic) approach (All procedures for one) has the potential to provide a more individualized problem-oriented answer to different types of CNLDO. Regardless of age and previously failed procedure, such an approach targets the main problem (type of obstruction) and has proved to result in a high success rate on unselected CNLDO patients in different situations. It avoids unnecessary failure of simple probing in patients with complex CNLDO, avoids unnecessary invasive procedures (intubation, ballooning) for membranous CNLDO, avoids retreatment sessions and repeat anesthesia, and therefore is more cost-effective. Lacrimal surgeons are recommended to avoid a pre-determining specific intervention when counseling the parents preoperatively. All options should be on table until intraoperative assessment guides which option is the best.