Occult Lacrimal Pathology in Young Versus Older Patients With Presumed Primary Acquired Nasolacrimal Duct Obstruction: Implications for Preoperative Imaging.

PURPOSE: Approximately 50% of ASOPRS surgeons consider young age to be an indication for imaging in patients with nasolacrimal duct obstruction. This practice is rooted in the assumption that young age confers a higher risk of clinically occult disease. This study examines whether young age is, in fact, associated with clinically occult lacrimal pathology. METHODS: A retrospective multicenter chart review was conducted at the Université de Montréal on consecutive patients with clinically presumed primary acquired nasolacrimal duct obstruction who underwent dacryocystorhinostomy with intraoperative tissue biopsy. RESULTS: A total of 457 sides from 413 patients were analyzed, including 64 sides in patients ≤50 years (group 1) and 393 in patients >50 years (group 2). Expected lacrimal histopathology (nonspecific inflammation) was observed in 90.6% of group 1 and 89.1% of group 2 (p = 0.71). No malignant or potentially malignant pathologies occurred in group 1, compared with 2.8% in group 2 (p = 0.18). On logistic regression, young age was neither a predictor of occult pathology (B = -0.002. p = 0.82) nor occult malignancy/potential malignancy (B = 0.004. p = 0.81). Preoperative imaging was obtained in a subset of 96 dacryocystorhinostomies (34 group 1, 62 group 2) and did not detect a clinically occult pathology in any case; however, 7 patients with normal imaging ultimately had unsuspected pathologies on dacryocystorhinostomy, including 4 malignant/potentially malignant lesions. CONCLUSION: Young age was not associated with an increased likelihood of clinically occult lacrimal pathology in patients presumed to have primary acquired nasolacrimal duct obstruction, and routine imaging failed to detect all clinically silent pathologies. Available evidence therefore does not support the practice of preferentially imaging young patients with clinically presumed primary acquired nasolacrimal duct obstruction.