Use of adjunctive mitomycin C in external dacryocystorhinostomy surgery compared with surgery alone in patients with nasolacrimal duct obstruction: A prospective, double-masked, randomized, controlled trial

Use of Mitomycin C in Dacryocystorhinostomy: A Report by the American Academy of Ophthalmology

PURPOSE

To review the literature on the adjuvant use of mitomycin C (MMC) during dacryocystorhinostomy (DCR) in adults with primary nasolacrimal duct obstructions (NLDOs) to determine the efficacy in improving functional and anatomic outcomes with an acceptable level of risk.

METHODS

A literature search conducted in November 2020 and updated in November 2022 yielded 137 articles. Twenty-four articles met the inclusion criteria and were rated for level of evidence by the panel methodologist. Inclusion criteria required controlled studies on the effect of MMC on outcomes of external, endoscopic endonasal, or diode laser-assisted transcanalicular DCR in adults with primary acquired nasolacrimal obstruction with 6 months minimum follow-up and at least 10 participants.

RESULTS

Six of the 24 articles were rated level I evidence, 15 level II , and 3 level III. In primary external DCR, MMC significantly improved functional outcomes in 3 of 9 series. In primary endoscopic endonasal DCR, MMC significantly improved functional outcomes in 1 of 9 series. In revision endoscopic endonasal DCR, MMC significantly improved functional success in 1 of 3 series. The use of MMC did not improve outcomes statistically in any diode laser-assisted transcanalicular DCR studies. Concentrations of MMC ranged from 0.05 to 1 mg/ml, with 0.2 mg/ml used most frequently in 12 series, with duration of application ranging from 2 to 30 minutes. Ostium size was significantly larger in MMC groups than in control groups at 6 months after surgery in 4 of 5 reporting studies. However, these larger ostia did not confer higher functional success rates. Reporting of adverse events related to MMC were rare, with delayed cutaneous wound healing reported in 1 of 750 patients.

CONCLUSIONS

Intraoperative use of MMC in external and endoscopic endonasal DCR has been shown to improve functional and anatomic outcomes compared with controls in some series, but there is no agreement on the recommended concentration or application time for MMC in DCR. The data support that MMC use can result in a larger ostium size, decreased granulation tissue formation, and a decreased number of postoperative nasal debridements compared with controls, but this does not translate into improved functional success.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Evaluation of lacrimal duct probing in adults with 0.02% and 0.04% mitomycin-C in primary acquired nasolacrimal duct obstruction: A randomized comparative pilot study

PURPOSE

The purpose of the study is to evaluate the safety and efficacy of adjunctive use of mitomycin-C (MMC) using two different concentrations 0.2 mg/ml and 0.4 mg/ml for lacrimal duct probing to treat the nasolacrimal duct obstruction (NLDO) in adults.

SUBJECTS AND METHODS

Prospective, an interventional comparative randomized pilot study of lacrimal duct probing conducted in the two study groups 0.02% MMC group (n = 30) and 0.04% MMC group (n = 30) in confirmed primary acquired NLDO of <1-year duration. Patency of lacrimal duct probing confirmed by syringing was compared at 1, 3, and 6-month follow-up in the two study groups, and corresponding subjective improvement of watering was appraised according to Kraft and Crawford grading.

RESULTS

Patency of lacrimal duct probing in 0.02% MMC versus 0.04% MMC group was 66.66%/73.33% (P = 0.71) at 1 month, 46.66%/66.66% (P = 0.09) at 3 months and 46.66%/66.66% (P = 0.03) at 6-month follow-up, respectively. Subjective improvement of watering (no watering and mild watering) observed in 0.02% MMC versus 0.04% MMC group was 46.66%/73.33% (P = 0.03), at 1 month, 66.66%/83.33% (P = 0.13) at 3 months and 56.66%/73.33% (P = 0.17) at 6-month follow-up.

CONCLUSION

Adult lacrimal duct probing with 0.04% MMC was associated with significant higher objective success rate than adult lacrimal duct probing with 0.02% MMC, without added concurrently side effects.

Role of anaesthesia in endoscopic and external dacryocystorhinostomy: A meta-analysis of 3282 cases

Distal acquired lacrimal obstruction is a common adulthood pathology whose primary treatment is represented by EXT-DCR and END-DCR. When considering their influencing factors, the role of the type of anaesthesia applied during these surgeries has a major role. The aim of this study is to systematically analyse the influence of general and local/regional anaesthesia on the final success rates of EXT-DCR and END-DCR. Primary EXT-DCR and END-DCR articles published later than 2000 with at least 50 single clinician procedures were selected. Exclusion criteria included acute dacryocystitis, tumours, studies focussing on revision surgeries, surgeries with adjunctive procedures, not clearly demarcated surgeons, mixed cohort study of acquired and congenital disorders. This systematic review was conducted in accordance with MOOSE guidelines; where feasible, a meta-analysis of the collected results was conducted. As a result, 11,445 articles were selected of which 2741 were examined after screening, and 16 included after full text review (0.6% of the initial papers). Among all papers included, the number of EXT-DCR was not enough to provide a solid analysis of the effect of anaesthesia; conversely, a significant difference of success rate was noted between local anaesthesia + sedation (85.1%, IC 77.8%-90.4%), and general anaesthesia (90.8%, IC 88.8%-92.4%) in END-DCR (p = 0.048). In conclusion, END-DCR performed with general anaesthesia should be considered as the solution of choice; however, local anaesthesia, eventually associated with a sedation, can be used as an alternative in selected cases. No meaningful conclusions could be drawn for EXT-DCR, due to the lack of data.

Dacriocistorrinostomía externa, conjuntivo-dacriocistorrinostomía y cirugía de la vía lagrimal en el meato inferior

Introducción y objetivo: Realizar una revisión sobre la dacriocistorrinostomía externa (DCR-ext), sondaje de la vía lagrimal y conjuntivodacriocistorrinostomía(CDCR) empleadas ante la obstrucción de la vía lagrimal. Material y métodos : Revisión bibliográfica sobre técnicas quirúrgicas mencionadas. Discusión: La obstrucción de la vía lagrimal puede dividirse según su localización en proximales y distales. Ante obstrucciones distales, la DCR ext es la técnica gold standard con porcentajes de éxito superiores al 95%, y la CDCR en caso de obstrucciones proximales.El sondaje de la vía lagrimal es la primera indicación quirúrgica en obstrucción congénita.

Impact of Post-Surgical Therapies on Endoscopic and External Dacryocystorhinostomy: Systematic Review and Meta-Analysis

Background

Epiphora is a common ophthalmologic sign that is most commonly caused by distal acquired lacrimal obstruction. Recent data have demonstrated that external dacryocystorhinostomy (EXT-DCR) and endoscopic endonasal dacryocystorhinostomy (END-DCR) can be considered the treatments of choice. However, different post-surgical medical therapies are available and are currently used to improve surgical outcomes, although no direct comparison has been performed.

Objective

To analyse the influence of post-surgical medical treatments on END-DCR and EXT-DCR outcomes.

Methods

A structured search was conducted using the U.S. National Library of Medicine (PubMed), EMBASE, SCOPUS, and Cochrane databases with a final search performed in May 2020. The research identified papers published later than 2000 with at least 50 single clinician procedures performed in EXT-DCR and END-DCR. Articles that studied acute infections, revision cases, mixed cohort studies of acquired and congenital obstruction, and tumour were excluded. The influence of systemic antibiotic/steroids, local application of mitomycin C, nasal/ocular antibiotic, nasal/ocular steroids and nasal decongestants was analysed.

Results

In total, 11,445 papers were selected, 2,741 of which were reviewed after screening, and 18 included after full text review (0.6% of the initial articles reviewed) which involved 3,590 procedures. Considering the low number of publications on EXT-DCR, statistical analysis of post-surgical therapy was not feasible. In END-DCR, the analyses were performed only for nasal steroids (p = 0.58), oral antibiotics (p = 0.45) and nasal decongestant (p = 0.27), which demonstrated no meaningful influence. Given the variable association between adjunctive medical therapies, pharmacologic molecular heterogeneity and modality/concentration of application, these results should be considered critically. Additionally, no differences were seen for application of silicone stenting, whereas, no statistical analysis was performed for mitomycin C.

Conclusions

Given the high success rate of EXT-DCR and END-DCR and the heterogeneity of literature data, the effective influence of post-surgical medical therapy is difficult to identify. Future large prospective randomized studies could help in detecting the optimal adjunctive therapy for these surgeries.

Intra-Operative Mitomycin-C as Adjuvant Therapy in External and Endonasal Dacryocystorhinostomy: Systematic Review and Meta-Analysis

PURPOSE

To evaluate the effect of mitomycin-C (MMC) on the success of external (Ex-DCR) or endoscopic dacryocystorhinostomy (En-DCR).

METHOD

A systematic review of randomized clinical trials of Ex- or En-DCR with and without the use of MMC to treat primary acquired nasolacrimal duct obstruction (NLDO) was done. Two authors independently searched six databases from 1990 to 2019, using the terms "dacryocystorhinostomy" and "mitomycin-C." Statistical and meta-analyses were performed using RevMan 5.3 software.

RESULTS

Twenty-seven studies involving 2158 surgeries were included in this systematic review. The Ex-DCR group comprised 14 studies [odds ratio (OR): 2.74; 95% confidence intervals (CI) 1.54-4.87; I² = 30%], while the En-DCR group 13 studies (OR: 1.69; 95% CI 1.21-2.37; I² = 0%). The use of MMC slightly increased the success rate of Ex- or En-DCR (OR: 2.1; 95% CI 1.52-2.9; I² = 14%).

CONCLUSION

The intraoperative use of MMC is safe and slightly improves the success rate of Ex- or En-DCR. However, the evidence was very weak.

Antimetabolites as an adjunct to dacryocystorhinostomy for nasolacrimal duct obstruction

BACKGROUND

Nasolacrimal duct obstruction (NLDO) is a condition that results in the overflow of tears (epiphora) or infection of the nasolacrimal sac (dacryocystitis). The etiology of acquired NLDO is multifactorial and is not fully understood. Dacryocystorhinostomy (DCR) is the surgical correction of NLDO, which aims to establish a new drainage pathway between the lacrimal sac and the nose. The success of DCR is variable; the most common cause of failure is fibrosis and stenosis of the surgical ostium. Antimetabolites such as mitomycin-C (MMC) and 5-fluorouracil (5-FU) have been shown to be safe and effective in reducing fibrosis and improving clinical outcomes in other ophthalmic surgery settings (e.g. glaucoma and cornea surgery). Application of antimetabolites at the time of DCR has been studied, but the utility of these treatments remains uncertain.

OBJECTIVES

Primary objective: To determine if adjuvant treatment with antimetabolites improves functional success in the setting of DCR compared to DCR alone. Secondary objectives: To determine if anatomic success of DCR is increased with the use of antimetabolites, and if the surgical ostium is larger in participants treated with antimetabolites.

SEARCH METHODS

We searched the Cochrane Register for Controlled Trials (CENTRAL) (which contains the Cochrane Eye and Vision Trials Register) (2019, Issue 9), Ovid MEDLINE, Embase.com, PubMed, LILACS (Latin American and Caribbean Health Sciences Literature database), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic searches. We last searched the electronic databases on 6 September 2019.

SELECTION CRITERIA

We only included randomized controlled trials. Eligible studies were those that compared the administration of antimetabolites of any dose and concentration versus placebo or another active treatment in participants with NLDO undergoing primary DCR and reoperation. We only included studies that had enrolled adults 18 years or older. We also included studies that used silicone intubation as part of the DCR procedure.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened the search results, assessed risk of bias, and extracted data from the included studies using an electronic data collection form.

MAIN RESULTS

We included 31 studies in the review, of which 23 (1309 participants) provided data relating to our primary and secondary outcomes. Many of the 23 studies evaluated functional success, while others also assessed our secondary outcomes of anatomic success or ostium size, or both. Study characteristics Participant characteristics varied across studies, with the age of participants ranging from 30 to 70 years. Participants were predominantly women. These demographics correspond to those most frequently affected by nasolacrimal duct obstruction. Almost all of the studies utilized MMC as the antimetabolite, with only one using 5-FU. We assessed most trials as at unclear risk of bias for most domains. Conflicts of interest were not frequently reported, although the antimetabolites used are generic medications, and studies were not likely to be conducted for financial interest. Findings Twenty studies provided data on the primary outcome of functional success, of which 7 (356 participants) provided data at 6 months and 14 (909 participants) provided data beyond 6 months. At six months, the results showed no evidence of effect of antimetabolite on functional success (risk ratio (RR) 1.12, 95% confidence interval (CI) 0.98 to 1.29; low-certainty evidence). Beyond six months, the results favored the antimetabolite group (RR 1.15, 95% CI 1.07 to 1.25; moderate-certainty evidence). Fourteen studies reported data on the secondary outcome of anatomic success, of which 4 (306 participants) reported data at 6 months and 12 (831 participants) provided data beyond 6 months. Results at six months showed no evidence of effect of antimetabolite on anatomic success (RR 1.02, 95% CI 0.95 to 1.11; low-certainty evidence). Beyond six months, participants in the antimetabolite group were more likely to achieve anatomic success than those receiving DCR alone (RR 1.09, 95% CI 1.04 to 1.15; moderate-certainty evidence). At six months and beyond six months follow-up, two studies reported mean change in ostium size. We did not conduct meta-analysis for the various follow-up periods due to clinical, methodological, and statistical heterogeneity. However, point estimates from these studies at six months consistently favored participants in the antimetabolite group (low-certainty evidence). Beyond six months, while point estimates from one study favored participants in the antimetabolite group, estimates from another study showed no evidence of a difference between the two groups. The certainty of evidence at both time points was low. Adverse events Adverse events were rare. One study reported that one participant in the MMC group experienced delayed wound healing. Other studies reported no significant adverse events related to the application of antimetabolites.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that application of antimetabolites at the time of DCR increases functional and anatomic success of DCR when patients are followed for more than six months after surgery, but no evidence of a difference at six months, low-certainty of evidence. There is low-certainty evidence that combining antimetabolite with DCR increases the size of the lacrimal ostium at six months. However, beyond six months, the evidence remain uncertain. Adverse effects of the application of antimetabolites were minimal.

Mitomycin-C in dacryocystorhinostomy: From experimentation to implementation and the road ahead: A review

Dacryocystorhinostomy (DCR) is the procedure of choice in patients with epiphora due to primary acquired nasolacrimal duct obstruction. The evolution of surgical tools, fiber-optic endoscopes, effective anesthesia techniques, and the adjunct use of antimetabolites intraoperatively; namely mitomycin-C (MMC) have significantly contributed to the advancement of DCR surgery. MMC is a systemic chemotherapeutic agent derived from Streptomyces caespitosus that inhibits the synthesis of DNA, cellular RNA, and protein by inhibiting the synthesis of collagen by fibroblasts. Even the cellular changes in the human nasal mucosal fibroblasts induced by MMC at an ultrastructural level have been documented. There, however, seems to be a lack of consensus regarding MMC: The dosage, the route of delivery/application, the time of exposure and subsequently what role each of these variables plays in the final outcome of the surgery. In this review, an attempt is made to objectively examine all the evidence regarding the role of MMC in DCR. MMC appears to improve the success rate of DCR.

Efficacy of adjunctive mitomycin C in transcanalicular diode laser dacryocystorhinostomy in different age groups

PURPOSE

To evaluate the efficacy of adjunctive mitomycin C (MMC) in transcanalicular multidiode laser dacryocystorhinostomy (TCL-DCR) in different age groups.

METHODS

Ninety-six eyes of 96 patients who underwent TCL-DCR for the treatment of nasolacrimal duct obstruction were included in this retrospective, comparative study. Patients were divided into 4 groups based on age and intraoperative use of MMC: group 1, TCL-DCR without MMC in the 20- to 44-year age group; group 2, TCL-DCR with MMC in the 20- to 44-year age group; group 3, TCL-DCR without MMC in the 45- to 76-year age group; group 4, TCL-DCR with MMC in the 45- to 76-year age group. The postoperative evaluation consisted of calculating and comparing the success rates between groups.

RESULTS

Success rates at the final visit were 50% for group 1, 66.66% for group 2, 79.16% for group 3, and 84.61% for group 4. The differences between group 1 and group 4, and group 1 and group 3, were significant (p = 0.01 and p = 0.038, respectively). Logistic regression showed that age group had significant effect on success rate (p = 0.013). However, use of MMC had no significant effect on success rate (p = 0.23).

CONCLUSIONS

The success rates of the TCL-DCR with MMC application were found to be higher than those of TCL-DCR without MMC in different age groups. However, the differences did not reach statistical significance. In addition, our study demonstrated that age may be a significant factor influencing the surgical outcome of TCL-DCR.

Eight-flap anastomosis in external dacryocystorhinostomy

AIMS

To examine the surgical outcome of external dacryocystorhinostomy (DCR) with eight-flap anastomosis (8-flap ex-DCR).

METHODS

A retrospective chart review was performed for 55 sides of 51 patients with nasolacrimal duct obstruction who underwent 8-flap ex-DCR. The patients were followed up postoperatively at 1, 2, 4, 8 and 12 weeks, and evaluations were continued with 12-week follow-ups until postoperative 12 months. Anatomical success was defined as no reflux on lacrimal irrigation at 12 months. Functional success was defined as no epiphora at postoperative 12 months. The presence of epistaxis and postoperative surgical site infections were checked in all patients. The presence of granulation tissue around the ostium, under nasal endoscopy, was also examined on 14 sides of 14 patients, at each visit.

RESULTS

Anatomical success was demonstrated on all sides, and functional success was obtained from 54 sides (98.2%) of 50 patients. One patient experienced postoperative intermittent epiphora on one side. The patients did not show granulation tissue, epistaxis or surgical site infection throughout the observation period.

CONCLUSIONS

The 8-flap ex-DCR showed complete anatomical success and favourable functional success with no postoperative complications.

Clinical outcomes of dacryocystorhinostomy with or without intraoperative use of mitomycin C: a systematic review and meta-analysis

PURPOSE

To examine the possible benefit of intraoperative use of mitomycin C (MMC) application in dacryocystorhinostomy (DCR) and to assess its potential risk.

METHODS

Systematic review and meta-analysis of randomized-controlled trials (RCTs). A comprehensive literature search was performed according to a protocol set in advance. The participants included 811 patients of which 820 eyes were sampled for 14 RCTs. Only pertinent RCTs were identified and included in this meta-analysis. The primary efficacy measure was "patency of irrigation" at follow-up end point. The subjective outcome of "symptom relief" was also extracted as a secondary efficacy measure. For each study, relative risk was extracted. Heterogeneity, publication bias, subgroup, and meta-regression analyses were performed.

RESULTS

RevMan version 5.0 software was used for statistical analysis. In the primary efficacy measure, the use of MMC can significantly increase the rate of "patency of irrigation" [risk ratio (RR), 1.10; 95% confidence interval (CI), 1.04-1.17; P=0.0006]; the outcome of "symptom relief" was also affected by the use of MMC (RR, 1.15; 95% CI, 1.05-1.26; P=0.003). Sensitivity analysis suggested that the result was comparatively reliable.

CONCLUSION

Intraoperative use of MMC can bring about a positive effect to the outcomes of "patency of irrigation" and "symptom relief," which increases the success rate of DCR surgery.

Meta-analysis of the adjunctive use of mitomycin C in primary and revision, external and endonasal dacryocystorhinostomy

PURPOSE

To determine whether application of the anti-proliferation agent, mitomycin C (MMC), to the osteotomy site during dacryocystorhinostomy (DCR) surgery increases surgical success rates.

METHOD

We conducted a comprehensive meta-analysis of randomised controlled clinical studies relating to the adjunctive use of MMC in primary and revision, as well as external (EX-DCR) and endonasal DCR (EN-DCR).

RESULTS

15 studies met our inclusion criteria with a total of 850 DCR procedures. The mean concentration of MMC used was 0.3 mg/ml (range 0.02-0.75 mg/ml) and mean duration of application 18 min (range 2-30 min). MMC significantly reduced the failure rate of primary EX-DCR (risk ratio, RR, 0.51; 95% confidence interval, CI, 0.31-0.86) and revision EN-DCR (RR 0.43; 95% CI 0.21-0.89). The adjunctive use of MMC in primary EN-DCR, however, did not confer a significant reduction in failure rate compared with control (RR 0.94; 95% CI 0.44-2.04). We found a deficiency of evidence regarding the potential benefit of MMC in revision EX-DCR. Only two cases of adverse effects relating to the use of MMC were reported among the studies, both of which related to delayed wound healing.

CONCLUSIONS

Application of MMC to the osteotomy site is a safe and effective way of increasing surgical success rate in primary EX-DCR and revision EN-DCR, but does not provide any significant benefit in primary EN-DCR. Further studies are required to evaluate the potential effect of MMC in revision EX-DCR.

Comparative study of dacryocystorhinostomy with and without intraoperative application of Mitomycin C

Aims and objectives

To compare the outcome of dacryocystorhinostomy surgery with and without the intraoperative use of Mitomycin C.

Methods

Our study is a prospective comparative case study in which 50 patients of primary acquired nasolacrimal duct obstruction were divided on the basis of random sampling into the conventional dacryocystorhinostomy group and the Mitomycin C group in which Mitomycin C 0.2 mg/ml was used intraoperatively. Patients were followed on 1st postoperative day, 1st, 3rd, 6th weeks, 3rd and 6th months. Patient symptoms and satisfaction were noted. Patency of lacrimal passage was assessed by lacrimal syringing and tear meniscus height was recorded on each follow-up.

Results

At the end of 6 months of follow-up, 96% of patients were asymptomatic in the Mitomycin C group whereas 80% patients in the conventional group were asymptomatic. On lacrimal syringing 24 (96%) eyes had patent passage in the Mitomycin C group where as only 1 (4%) patient had complete block with regurgitation of mucopurulent fluid. In the conventional group 20 (80%) eyes had patent passage, 4 (16%) eyes had complete block with regurgitation of mucopurulent fluid and 1 (4%) eye had partially patent passage on lacrimal syringing. Out of 25 eyes, 24 had normal tear meniscus height, and 1 had high tear meniscus height in the Mitomycin C group in comparison to the conventional group in which out of 25 eyes 20 eyes had normal, 1 had moderate and 4 eyes had high tear meniscus height. Intraoperative and postoperative complications in both the groups were identical.

Conclusion

Although the difference between the two groups was not statistically significant, a distinctly higher success was achieved in patients undergoing dacryocystorhinostomy with intra operative Mitomycin C as compared to conventional dacryocystorhinostomy.