A randomized trial comparing the cost-effectiveness of 2 approaches for treating unilateral nasolacrimal duct obstruction

Congenital nasolacrimal duct obstruction (NLDO) is estimated to occur in 1.2% to 20% of infants1-4 and often resolves without surgery.3-9 For children less than 6 months of age, surgery is usually deferred. After 6 months of age, the preferred clinical approach for treating NLDO is controversial. One approach is to probe the nasolacrimal duct to clear the blockage with the infant awake in the office using topical anesthesia and restraint. The alternative approach is to continue observation, and prescribe massage of the lacrimal sac and/or topical antibiotics, as many cases will resolve. If signs of obstruction remain after several months, a probing of the nasolacrimal duct is performed under general anesthesia in a surgical facility since by then the child is too strong to be sufficiently restrained in order for the procedure to be performed safely in the office. Because the costs of a probing in the office are about $1000 to $1600 less than the costs in a surgical facility,10 understanding the comparative cost effectiveness of the two approaches is important. Is it more cost effective to perform a probing procedure at an earlier age in the office on more patients or to defer surgery allowing many to resolve, recognizing that the procedure will need to be performed under general anesthesia in a surgical facility if the obstruction does not resolve? To address this question, we conducted a prospective randomized trial comparing the cost effectiveness of immediate office probing with that of deferral and probing in a surgical facility for unresolved cases.