Conjunctivodacryocystorhinostomy (CDCR) success rates and complications in endoscopic vs non-endoscopic approaches: a systematic review

The Association Between Taxane Use and Lacrimal Disorders

PURPOSE

The current study seeks to investigate the association between lacrimal disorders and the use of docetaxel and paclitaxel.

METHODS

A disproportionality analysis was conducted using the United States FDA Adverse Event Reporting System (FAERS). All adverse event reports containing the term docetaxel or paclitaxel were selected. Lacrimal adverse events were identified using the lacrimal disorders Standardized MedDRA Query (SMQ), which includes disorders that affect lacrimal gland and drainage system including blockage of nasolacrimal duct, occlusion/stenosis of punctum, lacrimal gland neoplasms, and inflammations and infections.

RESULTS

The proportionate reporting ratio (PRR) comparing lacrimal events among docetaxel to paclitaxel users was 2.47 (95% CI, 2.03-3.02). With respect to specific lacrimal events, dacryostenosis (PRR 19.54 [95% CI, 7.19-53.13]), increased lacrimation (PRR 3.2 [95% CI, 2.42-4.23]), lacrimation disorder (p = 0.02), and xeropthalmia reports (p > 0.001) were significantly more common.

CONCLUSIONS

The growing body of epidemiologic, clinical, and pathophysiologic research supports the case that docetaxel leads to adverse lacrimal events in certain patients and should be taken into consideration when oncologists consider docetaxel vs. paclitaxel.

Restrictive Strabismus Developing after Conjunctivodacryocystorhinostomy

Purpose: To report a case of diplopia caused by restrictive strabismus developing after conjunctivodacryocystorhinostomy (CDCR).Case summary: A 61-year-old female presented with persistent epiphora after failure to repair ipsilateral canalicular lacerations of the left eye caused by trauma occurred 25 years ago. CDCR was performed and the epiphora improved. Four months later, the patient presented with diplopia on the left gaze. An abduction limitation of -4 and a supraduction limitation of -3 were observed in the left eye. Therefore, Jones tube removal was performed 5 months after CDCR surgery. Two weeks later, as the limitations persisted, adhesiolysis of the conjunctiva and an amniotic membrane transplantation (AMT) were performed. This exposed a subconjunctival adhesion at the inferonasal conjunctiva; histopathological examination revealed fibrotic tissues. Three months later, the adhesions recurred and the patient was transferred to another hospital. Conjunctival adhesiolysis, AMT, and a 6.5 mm recession of medial rectus (MR) muscle were performed. One week later, exotropia occurred in the primary position, and the MR muscle of the left eye was advanced by 2 mm. Nine months after the final surgery, the primary gaze was orthotropia. The diplopia within the central 20° of visual field had disappeared. However, a levoelevation limitation of -1.5 remained in the left eye.Conclusions: CDCR is the only treatment method for patients with occlusion of both the upper and lower proximal lacrimal canaliculi. However, rare complications such as restrictive strabismus with diplopia may occur. As preventing adhesion is difficult, sufficient patient notice is required prior to surgery.

Lacrimal gland botulinum toxin injection for epiphora management

PURPOSE

Epiphora remains an often difficult to manage ocular complaint for ophthalmologists in all subspecialties. This review seeks to examine the safety and efficacy of botulinum toxin injection for management of chronic epiphora.

METHODS

The authors conducted a Pubmed search for studies on the use of lacrimal and transplanted salivary gland botulinum toxin injections for the management of epiphora within the past 20 years. Studies included had a minimum of four glandular injections.

RESULTS

The authors identified 14 studies and divided them by indication for injection; either functional epiphora, non-functional epiphora, or mixed studies. Seven studies examined injections for cases of functional epiphora, four for non-functional epiphora, and four for mixed cases. The number of glandular injections reported ranged from 4 to 65. Side effects reported were limited to diplopia, eyelid or lacrimal gland hematoma, papillary conjunctivitis, dry eye, ptosis, and bleeding.

CONCLUSIONS

Glandular botulinum toxin injection should be considered as a viable treatment strategy for both functional and nonfunctional epiphora. From the studies reviewed, botulinum toxin injection was shown to be effective in both children and adults. Injection can be performed in the outpatient setting, is minimally invasive, technically easy to administer, has a favorable side effect profile, and good efficacy. Furthermore, repeat injections can be performed with similar efficacy.

Long-Term Quality of Life in Patients Following Minimally Invasive Conjunctivodacryocystorhinostomy With StopLoss Jones Tube

PURPOSE

To assess the long-term quality of life outcomes of minimally invasive conjunctivodacryocystorhinostomy with StopLoss Jones tubes.

METHODS

A retrospective interventional case series was performed on all patients diagnosed with proximal bicanalicular obstruction who underwent a minimally invasive conjunctivodacryocystorhinostomy with StopLoss Jones tubes over a period of 5 years from October 2014 to September 2019. The procedure was performed as per standard published protocols of minimally invasive conjunctivodacryocystorhinostomy and StopLoss Jones tubes. Patients were followed for a minimum of 1 year after surgery. The tools employed to study were the "Jones tube satisfaction questionnaire" and the "Nasolacrimal duct obstruction-symptom score." These tools were employed at every step from the preoperative stage to each of the follow ups. Statistical analysis was performed using the R 4.0.4 (R Project, R Foundation).

RESULTS

A total number of 44 eyes of 42 patients were studied. Of these, 73.81% (31/42) were females. The mean age of patients was 61.81 years. Approximately 87% and 64% of the patients completed 2 and 3 years of follow up, respectively. For up to 2 months postoperative period, the outcomes were excellent, with the majority (76.74%, 33/43) reporting "moderately satisfied" outcomes on Jones tube satisfaction questionnaire. The dissatisfaction began at the 3-month follow up (4.55%, 3/44) and peaked at 6-month follow up (25%, 11/44), owing to tube-related complications. The mean ± standard deviation nasolacrimal duct obstruction-symptom score scores dipped from 19.98 ± 2.88 at baseline to 5.58 ± 2.99 at the 2-month follow up. Similar to Jones tube satisfaction questionnaire, the scores began worsening at 3-month follow up (9.8 ± 5.86) with the poorest scores at 6 months (12.34 ± 5.96), and these changes were significant as compared with the baseline (p < 0.001). The Jones tube satisfaction questionnaire and the nasolacrimal duct obstruction-symptom score scores showed significant improvements at 1-year follow up, owing to appropriate management of complications. The good outcomes were maintained for up to 3 years of postoperative period.

CONCLUSIONS

The long-term quality of life outcome following minimally invasive conjunctivodacryocystorhinostomy with StopLoss Jones tubes was good. The quality of life significantly suffers between 3 and 6 months following the surgery and improves equally well following appropriate management of complications.

Multidisciplinary approach to lacrimal system diseases

Pathologies of the lacrimal drainage system range from benign to malignant lesions. However, independently of the etiological origin, the most common presenting symptom is represented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic tools are now available, but for the most the first diagnostic approach is characterized by an ophthalmological visit, associated with nasal endoscopy, usually performed by an otolaryngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g. maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diagnosis has been made, different treatments are available in relation to the type of the disease, and commonly need close cooperation between an ENT and ophthalmic surgeon given the close anatomical structures involved. Taking into account all these aspects, the aim of this review is to highlight how a multidisciplinary approach to lacrimal pathologies is mandatory from diagnosis to treatment in order to offer the best clinical approach.

Application of a symptoms score questionnaire after conjunctivodacryocystorhinostomy: outcomes

Objective

To evaluate medium/long term outcomes and patient satisfaction through relief of symptoms and improved quality of life (QoL) after Jones tube conjunctivodacryocystorhinostomy (JT-CDCR) using the Naso Lacrimal Duct Obstruction symptom-score (NLDO-SS).

Methods

We conducted a retrospective, non-comparative, multicentric study including patients with complete obstruction of the superior and inferior proximal lacrimal drainage system. All patients underwent JT-CDCR, and the patency of the tube was evaluated with saline irrigation and endoscopic examination. We assessed patient satisfaction and quality of life administering the NLDO-SS.

Results

We enrolled 16 patients, for a total of 21 eyes operated. The success rate for procedures was 81%. The success rate for single parameters was globally 95.9%; if considered separately, ocular symptoms and nasal symptoms were respectively 94.3% and 100%.

Conclusions

JT-CDCR was a reliable procedure, able to solve symptoms in a majority of patients and guaranteed a good quality of life over a long period of time.

Long-term outcomes of StopLoss™ Jones tube (SLJT) and minimally invasive conjunctivodacryocystorhinostomy

PURPOSE

To assess the long-term outcomes of minimally invasive conjunctivodacryocystorhinostomy (MICDCR) with StopLoss™ Jones tubes.

METHODS

A retrospective interventional case series was performed on all patients who underwent a MICDCR with StopLoss™ Jones tubes (SLJT) over a period of 5 years. Patients were followed for a minimum of 1 year after surgery. The parameters studied include patient demographics, clinical presentation, indication for MICDCR, duration of surgery, SLJT length, standard Jones tube drainage classification, complications, and anatomical and functional successes. The variables influencing the outcomes were assessed. Anatomical success was defined as patent SLJT on irrigation, and functional success was defined as resolution of epiphora. Statistical analysis was performed using the R 4.0.4 (R Project, R Foundation).

RESULTS

A total number of 44 eyes of 42 patients were studied. The mean age of patients was 61.81 years. Approximately 87% and 64% of the patients completed 2 years and 3 years of follow-up, respectively. The Jones tube drainage class dipped significantly from class I to others at the 3-month follow-up. Classes III and IV dominated the follow-up period between 3 and 18 months, and class II dominated at 24 months and beyond. The anatomical and functional successes at the end of 1-year follow-up were 77.2%. The success was not affected by age, gender, length of SLJT tube, or duration of the surgery. However, the middle turbinate reduction influenced the success (P < 0.03). The common complications noted were tube occlusions (40.9%, 18/44) and inferior tube migration (38.6%, 17/44).

CONCLUSION

The long-term outcomes with SLJT were good, but the inferior migration was a significant complication. The results of this study reflect the need for continuity of care as long as the tube is in situ.