Early office-based vs late hospital-based nasolacrimal duct probing. A clinical decision analysis
J. Kassoff and D. R. Meyer
Department of Ophthalmology, Albany (NY) Medical College, USA.
BACKGROUND: Controversy exists regarding the treatment of infants with
symptomatic nasolacrimal duct obstruction. One philosophy advocates "early"
nasolacrimal duct probing, generally in the office. An alternate strategy
advocates medical management until the infant is approximately 12 months
old to allow for spontaneous resolution, with those with persistent
nasolacrimal duct obstruction usually treated by "late" probing in the
hospital with the use of general anesthesia. METHODS: We used clinical
decision analysis to compare these two opposing treatment strategies. A
decision tree was constructed with the usual designations for probability
nodes and decision points, comparing early probing at 6 months of age in
the office and late probing at 12 months of age in the hospital. The
initial decision point thus addressed treatment of children who still had
symptomatic nasolacrimal duct obstruction at 6 months of age. One repeated
probing under same-strategy conditions was performed for patients in whom
initial office probing failed. Values for probability nodes were derived
from the ophthalmic literature, including a 70% rate of spontaneous
resolution of nasolacrimal duct obstruction between the ages of 6 and 12
months. RESULTS: Both the early office probing strategy and the late
hospital probing strategy yielded success rates greater than 99%. Based on
prevailing fees, the late hospital strategy cost $2,310,000 more than the
early office strategy per 10,000 patients, even though fewer procedures
were performed. CONCLUSION: Early office probing and late hospital probing
have similar high success rates, albeit at a higher cost for the late
hospital probing strategy.
