External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center

Post-operative Clinical Evaluation of Endoscopic Dacryocystorhinostomy: Insights from a Three-Month Follow-Up Study

A bibliometric analysis concluded that the evaluation of post-operative outcomes of endoscopic dacryocystorhinostomy in Indonesia had yet to be done. Hence, this study aims to assess the postoperative outcomes of endoscopic dacryocystorhinostomy, focusing on ostium granulation, intranasal synechiae, membranous obstruction, and ostium stenosis after a three-month follow-up in our Indonesian center. A longitudinal study (2017-2023) at our Indonesian center included cases with a minimum of three-month follow-up. Nasal endoscopy assessed ostium granulation, intranasal synechiae, membranous obstruction, and ostium stenosis. 28 cases were successfully followed up for three months. At three months, ostium granulation was present in 42.9% of cases, membranous obstruction in 14.3% of cases, with no intranasal synechiae or ostium stenosis observed. Out of 28 cases, 13 were successfully followed for six months, revealing ostium granulation in 7.7%, membranous obstruction in 38.5%, and ostium stenosis in 23.1%. Ostium granulation predominates, followed by membranous obstruction at three-month follow-up. Ostium stenosis, a minimal occurrence, manifests after six months.

Long-Term outcomes of pediatric dacryocystorhinostomy in a single medical center- a retrospective study

PURPOSE

To examine the long-term success rate of pediatric endoscopic DCR surgery via telephone questionnaires, as determined by patients and their parents.

METHODS

This is a retrospective cohort study of all patients who underwent DCR surgery at the Schneider Children's Medical Center of Israel between 2010 and 2020. We performed long-term follow-ups to assess the quality of life, surgical complications, and satisfaction with surgical outcomes.

RESULTS

Our study includes seventy-nine patients with a total of 108 eyes. The mean age at the time of DCR was 7.05 years (Std = 4, min = 0.3, max = 17.7) Mean follow-up time was 5.7 years (Std =2.5, min = 1.4, max = 11.1). Tubes were inserted for a mean of 129 days (Std = 101). Fifty-seven patients (72%) declared they had no complications after surgery, three patients (4%) reported pain after surgery, and 14 patients (17.7%) reported tube extrusion, which occurred 7-21 days after surgery. Forty-four patients (56%) reported no recurrence of symptoms, 29 (37%) complained of mild epiphora, and 18 (23%) reported some ocular discharge. Sixty-eight patients (86%) stated that they did not undergo additional surgery, while the remaining 11 (14%) reported undergoing a revision operation for symptom control. Satisfaction rate (1-7) mean score reported was 6.15 (Std = 1.6). Sixty-two (78%) reported improved quality of life, while 17 (22%) reported no improvement. Our questionnaire results have been compared with the TEARS scores with similar findings.

CONCLUSION

Regardless of its etiology, endoscopic DCR surgery in the pediatric population is safe and efficient, with a high long-term patient satisfaction rate, as reported via a telephone questionnaire.

Primary acquired nasolacrimal duct obstruction - epidemiology, clinical signs and surgical treatment

AIM

The aim of this study was to discuss the epidemiological aspects, clinical picture and the mode of surgical treatment in patients with primary acquired nasolacrimal duct obstruction (PANDO).

Regression course of ostium granulomas under topical intranasal steroids coverage after endoscopic dacryocystorhinostomy

This study aimed to elucidate the regression process of ostium granulomas under the usage of intranasal steroid after primary endoscopic dacryocystorhinostomy (DCR). The authors retrospectively reviewed 57 patients (a total of 72 ostia) who had ostium granulomas after primary endoscopic DCR between 2011 and 2015. Topical intranasal steroid spray was applied in all the patients since postoperative day 1. Adjunctive intralesional triamcinolone acetonide injections were administered for extensive and large-sized granulomas that caused impending ostium blockage. Sequential regression of the ostium granulomas and success rates of DCR were assessed using endoscopic photos. The granulomas completely disappeared in 69 (95.8%) ostia, and the average time interval from the surgery to the disappearance was 6.9 ± 2.8 months. Anatomical and functional surgical success rates were 90.3% and 84.7%, respectively. Intralesional steroid injections for ostium granulomas did not alter the outcomes compared to topical intranasal steroid usage significantly (p = 0.445). In conclusion, we observed that, by continuing the usage of intranasal steroids, ostium granulomas disappear gradually at postoperative 6 months. The intranasal surgical manipulation of granulomas, which results in more mucosal cicatricial change and impedes patient satisfaction, can be successfully avoided.

Endoscopy-assisted dacryocystorhinostomy in a dog

OBJECTIVE

To describe the use of an endoscope to assist in performing minimally invasive dacryocystorhinostomy in a dog to successfully manage a nasolacrimal duct cyst (dacryocyst).

ANIMAL STUDIED

A 4-year-old female spayed American Staffordshire Terrier with chronic epiphora and swelling ventromedial to the nasal canthus of the right eye and reverse sneezing.

PROCEDURES

Computed tomography revealed a fluid-filled cystic lesion of the right nasolacrimal duct with extensive nasal extension and secondary obstructive frontal sinusitis. Aspiration of serosanguinous fluid with no growth of microbial organisms and histopathology confirmed the cystic nature of the structure. A 2.7 mm, 30 deg, 11 cm foreward-oblique endoscope with arthroscopic cannula was passed through a mucosal stab incision in the dorsal buccal recess into the cyst to allow for exploration. A separate instrument portal was placed in the center of the cyst through the skin which allowed for transcutaneous dacryocystorhinostomy with a meniscal probe to be performed. No clear communication was evident caudodorsally into the frontal sinus on endoscope examination. A small frontal sinus trephination was performed and lavage flowed easily into the cystic cavity and out of the nostril.

RESULTS

Follow-up at 10 days and 17 months postoperatively showed complete resolution of clinical signs with an excellent cosmetic outcome.

CONCLUSION

Endoscopy-assisted dacryocystorhinostomy demonstrated an effective minimally invasive technique to treat a functionally obstructive dacryocyst of the right nasolacrimal duct in a dog.

Clinical outcomes of endoscopic dacryocystorhinostomy without preserving mucosal flaps in combination with silicone stent and steroid-soaked gelfoam

PURPOSE

To report clinical outcomes of endoscopic dacryocystorhinostomy (En-DCR) combined with stenting and without preserving the nasal and lacrimal mucosal flaps.

METHODS

In this prospective interventional case series, patients with primary acquired nasolacrimal duct obstruction who were candidates for En-DCR were enrolled. Patients with a known history of previous DCR, sinus surgery, rhinoplasty, nasal trauma, nasal anomaly, canalicular or punctal occlusion, or less than one year of follow-up were excluded. All patients underwent En-DCR and stenting followed by ostial packing using Gelfoam soaked with dexamethasone. The patients were assessed preoperatively, on the first postoperative day, after 2 weeks, 3 months, and 1 year. Postoperative outcomes were anatomical and functional success, defined as patent irrigation test and resolution of epiphora, respectively. The nasolacrimal drainage system was evaluated anatomically and functionally during the follow-up period.

RESULTS

Eighty-three patients with a mean age of 54.36±15.27 years were enrolled. Of these, 61 patients (73.5%) were women. The mean duration of follow-up was 20.7±6.9 months. Anatomical success was achieved in all patients and remained stable during the study duration and at 1 year. Functional failure leading to epiphora was observed in 1 patient 3 months after surgery and resolved after re-DCR at year 1. Preoperative tenderness and purulent reflux were observed in 12%, 33.7% of which completely resolved postoperatively. Moderate and severe hemorrhage was observed in 12 (14.5%) and 2 (2.4%) patients, respectively.

CONCLUSION

En-DCR without mucosal flap preservation in combination with silicone stent and steroid-soaked Gelfoam is a safe and highly successful procedure in patients with primary acquired nasolacrimal duct obstruction.

Success and complications of endoscopic laser dacryocystorhinostomy vs. external dacryocystorhinostomy: A systematic review and meta-analysis

A systematic review and meta-analysis were conducted to evaluate the success and complications of endoscopic laser dacryocystorhinostomy (ELDCR) vs. external dacryocystorhinostomy (ExDCR) in primarily acquired nasal duct obstruction. The search of PubMed, Embase, and Cochrane Central Register of Controlled Trials databases revealed 109 studies on ELDCR and ExDCR. Eleven studies were found to be suitable for review. The primary objective was to compare the success rate between ELDCR and ExDCR. The secondary objectives were to analyze the surgical time, overall complications, bleeding, infection, intranasal synechia, and granulation tissue. Pooled analysis of all studies revealed that ELDCR had a significantly lesser success rate compared to ExDCR (80.3% vs. 91.6%; odds ratio [OR] 0.41; 95% confidence interval [CI] [0.27, 0.62]; P < 00001; I2 = 13%). However, there were no difference in the overall complication rate (12.0% vs. 13.0%; OR 1.04; 95% CI [0.17, 6.33]; P = 0.97, I2 = 80%) and intranasal synechiae (9.5% vs. 4.3%; OR 2.22 [1.04, 4.72]; P = 0.04; I2 = 10%). The ExDCR group had significantly increased risks of bleeding (1.9% vs. 13.0%; OR 0.20; 95% CI [0.09, 0.47]; P = 0.0002; I2 = 0%) and infection (0.3% vs. 4.6%; OR 0.09; 95%CI [0.02, 0.51]; P = 0.006; I2 = 0%). Nevertheless, ELDCR needed a shorter surgical time compared to ExDCR (mean difference [MD] -28.35, 95% CI [-35.45, -21.26], P < 0.00001, I2 = 78%). Although ELDCR is associated with lesser bleeding, lesser infection, and shorter surgical duration, the success rate of ExDCR is higher.

Modified Horner-Duverney's muscle plication in the treatment of functional epiphora

BACKGROUND

The orbicularis oculi muscle, especially its part (Horner-Duverney's muscle), which is surrounded by the pericanalicular and located deep in the lacrimal sac, is of primary importance in all stages of tear fluid flow.

PURPOSE

This study aimed to demonstrate that tightening the pretarsal-preseptal orbicularis oculi and Horner-Duverney muscles may improve the function of the lacrimal pump and may be a surgical alternative for treating functional epiphora.

MATERIAL AND METHODS

This was a prospective interventional case series of 28 patients with functional epiphora. During surgery, sutures were used to perform the intervention, and these were first passed through the upper and lower eyelid pretarsal-preseptal orbicular muscles, through the Horner-Duverney's muscle, and finally, through the dacriocystorhinostomy incision and tightened. Each patient completed the Lac-Q questionnaire and Munk scale prior to surgery, as well as six weeks and six months later. Before surgery, a fluorescein dye disappearance test was performed, which was repeated at follow-up appointments. Pre- and post-operative data were analyzed and compared at the most recent visit.

RESULTS

Twenty-eight patients (10 males and 18 females) with a mean age of 59 ± 35 years were included in this study. The severity of epiphora and its tearing effect on daily life significantly improved following the operation. The fluorescein dye disappearance test result was significantly improved after 6 weeks of followup in %89.3 of eyes and at 6 months followup in 92.9% of eyes. The Lac-Q questionnaire's mean social impact scores improved significantly postoperatively, from 3.76 to 0.77 (p < 0.001). The changes in total scores (7.29 before surgery to 1.71 after 6 months) were statistically significant (p < 0.001). The Munk score success rate was 64.3% and 85.7%, respectively. No significant complications or adverse effects were observed.

CONCLUSION

Our findings suggest that a beneficial and seemingly simple, safe, and easy procedure to reduce functional epiphora is to tighten the preseptal-pretarsal orbicularis and Horner-Duverney's muscles.

Post-Operative Endonasal Debridement May Improve Outcomes of Endoscopic Dacryocystorhinostomy

Background: Endoscopic dacryocystorhinostomy (endoDCR) has proven to be an effective minimally invasive surgical procedure for treatment of nasolacrimal duct obstruction. Post-surgical endonasal debridement has not yet been independently assessed for its impact on functional success. Methods: A retrospective review was performed of all patients who underwent endoDCR by an experienced oculofacial plastic surgeon over 7 years (2012-2019). Post-operative intranasal debridement was not routinely performed from March 2012 to February 2016. From March 2016 to June 2019, all patients underwent routine ipsilateral intranasal debridement at post-operative week 2. Surgical success was determined based upon subjective assessment of epiphora resolution at the patient's final post-operative visit. Results: A total of 69 patients (88 surgeries) were included. Thirty-five patients had standard post-operative follow-up without debridement, whereas 34 underwent endonasal debridement at post-operative week 2. Demographics and follow-up were similar between the 2 groups. Functional success was achieved in 84.1% of patients without debridement, and in 97.7% with debridement (P = .058). Conclusion: This review demonstrates a trend toward improvement in the rate of surgical success of endoDCR when routine endonasal debridement was instituted 2 weeks following surgery. We believe that removal of nasal crusts, clots, and residual absorbable gelatin sponge at the osteotomy site improves tear outflow and reduces cicatricial healing enhancing patency of the surgically derived lacrimal-nasal fistula. We advocate for postoperative debridement in the perioperative management of endoDCR patients to optimize successful outcomes.

Dacryolithiasis diagnosis and treatment: a 25-year experience using nasal endoscopy

BACKGROUND

Dacryolith-induced epiphora is caused by a chronic obstruction of the nasolacrimal duct whose aetiology is often specified peroperatively. Dacryocystorhinostomy (DCR) has been often regarded as the gold standard to treat dacryolithiasis. Hasner's valve (HV) incision is a technique to evacuate lithiasis through its physiological track. The purpose of this study was to describe clinical and radiological findings associated with presence of dacryoliths in patients who underwent surgery and to assess the efficacy of these two procedures.

METHODS

This study was a comparative interventional multicentric retrospective study including patients referred for an epiphora. The primary endpoint was to determine clinical and endoscopic findings associated with dacryoliths. The secondary endpoints were to evaluate the performance of CT dacryocystography (CT-DG) in the diagnosis of dacryoliths and the success rate of the surgical treatment 6 months postoperatively.

RESULTS

4677 nasolacrimal ducts (NLDs) (78.0% female, mean age 59.2) were included in the study. 3913 underwent DCR, and 764 underwent HV incision. 291 out of 4677 NLDs (6.2%) were found to have dacryoliths. Presence of mucocele associated to a permeable lacrimal system (OR 8.17 (95% 4.62 to 14.44), p<0.01) was associated with presence of lithiasis peroperatively. Success rates at 6 months were 95.6% for endonasal DCR and 94.6% for incision of HV in dacryolithiasis group (p<0.01). CT-DG had a negative predictive value of 96.3% to detect lithiasis (p<0.01).

CONCLUSION

Strong clinical and endoscopic findings may improve the imputability of dacryoliths in epiphora. Evacuation of dacryolithiasis through its physiological track was first described in this study in adults with similar results to DCR in patients presenting with dacryolithiasis.

Idiopathic acquired dacryocystocele in an adult: case report of a rare entity

Background

Idiopathic acquired dacryocystocele in adults is a rare disorder of the lacrimal drainage pathway. Only 20 cases have been reported in the literature. It presents with a triad of epiphora, medial canthal swelling, and recurrent dacryocystitis. Patients presenting without recurrent dacryocystitis is quite uncommon. This presentation can be confused with secondary nasolacrimal duct obstruction and other non-inflammatory pathologies. Dacryocystorhinostomy with stenting is the treatment employed in most reported cases.

Case presentation

A 24-year-old male presented with epiphora and medial canthal swelling for 3 years. Examination revealed features of left nasolacrimal duct obstruction. Imaging was suggestive of a cystic, homogenous, non-enhancing lesion in the left lacrimal sac region without bone destruction. Findings were suggestive of dacryocystocele. Patient underwent endoscopic dacryocystorhinostomy without stenting. Postoperatively, the swelling and epiphora resolved. Patient is symptom-free on follow-up.

Conclusion

Idiopathic dacryocystocele must be considered in evaluation of a medial canthal mass with epiphora without dacryocystitis. Conservative treatment is ineffective. Endoscopic dacryocystorhinostomy is safe and effective.

Ostium Characteristics and Its Relevance in Successful Outcome Following Endoscopic Dacryocystorhinostomy

Study aims to assess the postoperative ostium shrinkage pattern and also attempted to evaluate various ostium parameters and their impact on surgical outcome by using DOS scoring system. Prospective study comprising 44 patients of NLD obstruction with 52 procedures performed during October 2016 to November 2018. Various dimensions of bony neo-ostium were recorded intraoperatively and during 1st, 3rd and 6th month follow up. Degree of ostium shrinkage and its correlation with anatomical and functional success was studied. DCR ostium (DOS) scoring system, comprised of ten various ostium parameters, was used to evaluate postoperative ostium. Intraoperative mean ostium height and width were 13.67 ± 2.76 mm and 7.0 ± 1.94 mm and surface area was 98.33 ± 38.46 mm2. Maximum ostium shrinkage (by 66.93%) occurred at 1 month and after which, average size of ostium was quite stable with little change. The anatomical and functional success rate was 94.23% and failure rate was 5.77%. DOS score was "excellent" in 40(75.92%), "good" in 9(17.31%) and "poor" in 3(5.77%) cases. Meticulous evaluation at regular intervals is important for surgeon to understand the characters of ostium during healing and also helps in early detection of pathologies and may facilitate early corrective intervention. We believe that DOS system provides an effective protocol to standardize the ostium evaluation. The ostium parameters with favourable surgical outcome are ostium location anterior to axilla of MT, circular/ oval shape with shallow base, size > 8 × 5 mm, clearly visualized and dynamic ICO, absence of ostium cicatrization, granulomas, synechiae and other pathologies.

Clinical Trial to Compare Success Rate of Endonasal Dacryocystorhinostomy and External Dacryocystorhinostomy for Treatment of Primary Acquired Nasolacrimal Duct Obstruction

The purpose of this study is to compare the success rates of endoscopic endonasal dacryocystorhinostomy (EN-DCR) and external DCR (EX-DCR) for the treatment of primary acquired nasolacrimal duct obstruction (PANLDO). Prospective randomized comparative study. Study was conducted for 2 years duration in a teaching hospital with 300 cases of endoscopic and 300 cases of external DCR with a follow-up of minimum 6 months. Data regarding surgical outcome and complications were analyzed and compared using χ2 test. In our study, the overall success rate of DCR for PANLDO was 92.6%, there was difference in terms of anatomical or functional success rate between EN-DCR (93.6%) and EX-DCR (91.6%). The incidence rate of post operative complication in our study was lower in Endonasal DCR (27.33%) as compared to External DCR (48%). Patients who underwent EN-DCR had shorter recovery time, less complications and higher satisfaction due to lack of external incision, although final surgical outcomes were comparable between two groups.

Medical Malpractice Trends in Dacryocystorhinostomy and Orbital Decompression

Background and Objective

This study aims to evaluate the medicolegal trends related to 2 common orbital surgeries: orbital decompression and dacryocystorhinostomy (DCR). These procedures are performed by ophthalmologists, otolaryngologists, and multidisciplinary teams of both specialists.

Methods

The Westlaw database was reviewed from 1980 to 2020 for medical malpractice cases involving orbital decompression and DCR surgeries. Data were compiled on plaintiff and defendant demographics, procedure performed, legal allegation, nature of injury, and verdict or settlement awards. The Ophthalmic Mutual Insurance Company was also queried for all malpractice cases pertaining to orbital decompression and DCR from 1995 to 2021.

Results

The Westlaw database included 60 cases (34 orbital decompression, 26 DCR); of these, 8 orbital decompression and 6 DCR cases met inclusion criteria. Of the 7 orbital decompression cases that were tried, a verdict in favor of the plaintiff occurred in 4 cases (57%). Of the 5 DCR cases that were tried, a verdict in favor of the plaintiff occurred in 2 cases (40%). A search of all claims at OMIC yielded 31 cases (15 orbital decompression, 16 DCR). 22 of 31 cases were either dismissed or resulted in no payment. The remainder was settled out of court, with only one case being tried and the verdict supporting the defendant.

Conclusion

Despite several thousand orbital decompressions and DCR surgeries being performed annually in the US, very few lawsuits involving these complex surgeries have gone to trial. However, of the cases that did go to trial, a relatively high proportion of verdicts for plaintiffs was observed.

Introduction of Steroid Absorbed Spongostan in Endoscopic Dacryocystorhinostomy Improves Success Rates

BACKGROUND

Endoscopic Dacryocystorhinostomy (DCR) has become an acceptable alternative to the open approach, with considerable data demonstrating comparable success rates and advantages such as avoiding skin incisions. Drug-eluting bio-absorbable materials are relatively new innovation in sinus surgery, the usefulness of such materials in Endoscopic DCR is yet to be described.

METHODS

A retrospective analysis of 253 endoscopic DCR procedures performed by a single surgical team from September 2011 to June 2020 was performed. At the end of 2013, a surgical modification took place with the introduction of steroid-eluting Spongostan to the intranasal surgical bed. As a result, 2 cohorts were compared before and after the modification. The first cohort consisted of 55 patients, and the second consisted of 187 patients, respectively. Patient demographics, clinical features, complications and outcomes were examined.

RESULTS

A total of 242 procedures were evaluated after exclusion. In the first cohort of 55 patients (48 adults and 7 children), the overall and adult functional success rates were 83.6% and 83.3%, respectively. In the second cohort of 187 patients (167 adults and 20 children), where steroid-eluting Spongostan was used, the overall and adult functional success rates were 92.5% and 93.4%, respectively. These differences were statistically significant.

CONCLUSION

This is a unique study presenting a single surgical team's experience over a 9-year period where a novel technique involving drug-eluted bio-absorbable material (Spongostan) was introduced midway through, creating 2 cohorts to compare. Success rates were significantly higher after applying steroid eluted Spongostan to our endoscopic DCR technique.

Haftalık endoskopik debridmanın endoskopik transkanaliküler diod lazer dakriyosistorinostominin başarı oranı üzerine etkisi

Aim: To evaluate the outcomes of transcanalicular diode laser DCR (TL-DCR) in patients with chronic dacryostenosis. Methods: In this retrospective study we included 75 eyes of 67 patients with chronic dacryostenosis who underwent TL-DCR. In 65 patients transnasal endoscopic debridement the opening and nasalacrimal syringing was performed every week for 1 month (Group 1, 65 patients). The later patients who did not have postoperative visits were defined as Group 2 (10 patients). All patients were examined at postoperative 3 months. Results: In group 1, 65 of 63 patients had complete surgical success and two had restenosis. In group 2, six of 10 patients had success however four had restenosis. In group 1 the surgical success rate was 98% whereas it was 60% in group 2 (p< 0.001). None of the patients had any serious complications including infection and bleeding. Conclusions: The surgical success rate of TL-DCR may increase by endoscopic debridement after the surgery.

Comparison of Outcomes of External Dacryocystorhinostomy and Transcanalicular Laser-Assisted Dacryocystorhinostomy in Patients with Primary Acquired Nasolacrimal Duct Obstruction

PURPOSE

This study aimed to compare anatomical and functional outcomes of external dacryocystorhinostomy (EX-DCR) and transcanalicular multidiode laser dacryocystorhinostomy (TDL-DCR) in patients with primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

This study was conducted on 60 eyes of 60 patients with PANDO. The study subjects were randomly divided into two groups. Group 1 included 30 patients who underwent EX-DCR, and group 2 included 30 patients who underwent TDL-DCR. Surgery success rates were determined by patency of the neo-ostium, with free saline flow on irrigation and the absence of epiphora.

RESULTS

There were 23 women (76.7%) and 7 men (23.3%) with a mean age of 47.33 ± 12.44 years in group 1, and 18 women (60%) and 12 men (40%) with a mean age of 46.2 ± 19.4 years in group 2. There was no significant difference between groups 1 and 2 with respect to age or gender (p = 0.801, p = 0.267, respectively). The mean duration of symptoms was 3.2 years, ranging from 1.5 to 5 years. The mean postoperative follow-up was 12.3 ± 2.44 months. At the end of the follow-up period, the surgery success rates were 96.7% (29/30 eyes) in group 1, and 90% (27/30 eyes) in group 2. There was no statistical difference in the surgery success rates between groups (p = 0.612).

CONCLUSION

TDL-DCR is a minimally invasive and safe procedure. The lack of bleeding and incision scar and shorter operation time suggest that TDL-DCR can be a good alternative in PANDO patients.

Salvage of impending rhinostomy failure after dacryocystorhinostomy with office-based microdebrider treatment

PURPOSE

This article is to introduce office-based salvage revision of impending rhinostomy failure after endoscopic dacryocystorhinostomy (EN-DCR), using a microdebrider.

METHODS

The authors conducted retrospective medical chart review of 27 eyes of 26 patients who underwent microdebrider treatment for impending rhinostomy failure in an office setting. After local anesthesia, obstructive soft tissue, interfering with ostium function (granuloma, cicatrization, synechia), was treated with a microdebrider (Osseoduo s120, Bien-Air Surgery, Le Noirmont, Switzerland) within 6 months after primary EN-DCR. Anatomical improvement and functional relief of epiphora were evaluated after revision.

RESULTS

The causes of impending rhinostomy failure were granuloma formation (17/27 eyes, 63.0%), cicatrization (8/27 eyes, 29.6%), and synechial formation (2/27 eyes, 7.4%). The surgery did not exceed 5 min in all cases, and partial damage to pre-placed silicone tubes occurred in the first two cases (7.4%). Salvage revision resulted in anatomical success in all eyes, based on patent syringing and a positive functional endoscopic dye test. All cases showed improvement of epiphora after revision surgery.

CONCLUSIONS

Office-based salvage revision using a microdebrider provided effective management of impending rhinostomy failure during early follow-up period after primary EN-DCR. It enabled prompt management of excessive wound healing interfering with ostium function, while performing the routine postoperative nasal debridement.

Results and clinical aspects of primary endonasal endoscopic dacryocystorhinostomy with silicone tube

OBJECTIVE

Endonasal endoscopic dacryocystorhinostomy (DCR) is a common treatment for saccal and post-saccal stenosis of the lacrimal pathway or chronic dacryocystitis (DC). The main symptom is chronic epiphora (tearing) and dacryocystitis (infection). The objective of this study is to assess the short-term surgical result of this treatment based on possible prognostic factors; such as gender, age, the pathogen spectrum and the histopathological result as well as the influence of these parameters on hospital stay.

METHODS

It is a retrospective analysis, which includes 197 cases in 177 patients, who received an endonasal endoscopic DCR with a silicone tube between January 2009 and December 2016, as primary procedure. The follow-up was carried out 3 months after the surgery, with the silicone tube being removed as part of the last examination including a flushing of the tear ducts with saline. This procedure is part of determining to measure the short-term success of the intervention. The definition of success of the surgery is an absence of epiphora or an acute infection of the nasolacrimal duct system, as well as an absent reflux in case of flushing the tear duct.

RESULTS

The success rate was 86.3% (N = 170). Higher incidence was seen in females (N = 146; 74.1%) and patients with a mean age of 65.4 (± 17.2). The presence of pathogens as well as the histopathological result do not have an impact on the short-term surgical success. Patients diagnosed with rheumatic diseases appear to have a worse prognosis with relation to procedure success. Also, the length of hospital stay was related to possible prognostic factors. Type II diabetes and glaucoma had a significant influence on a longer hospital stay.

CONCLUSION

The endonasal endoscopic DCR is a surgical procedure with high success rate. Patients with rheumatic diseases should be aware of increased failure rates. Patients with glaucoma and Type II diabetes might need a more intense aftercare.

Air Bubble Test Versus Endoscopic Jones I Test in Assessment of Anatomical and Functional Success After Diode Laser Transcanalicular Dacryocystorhinostomy

PURPOSE

To compare the accuracy and positive predictive values of the air bubble test (ABT) and endoscopic Jones I test for assessment of anatomical and functional success after diode laser transcanalicular dacryocystorhinostomy (T-DCR).

METHODS

This cross-sectional study included 60 eyes of 56 patients who underwent T-DCR by a single surgical team from January 2016 to December 2018. All the 56 patients (60 eyes) underwent lacrimal syringing, endoscopic Jones I test, and ABT. Anatomical success was considered as a free passage of fluid with no reflux on the irrigation test. Functional success was defined as the resolution or improvement of epiphora (Munk score of 0 or 1). The results of irrigation test, endoscopic Jones I test, and ABT were used to calculate the accuracy and positive predictive values (PPVs) of ABT and endoscopic Jones I test for assessment of anatomical and functional success (Munk score of 0 or 1) after T-DCR. A value of p < 0.05 was considered statistically significant. All statistical evaluations were performed using SPSS software.

RESULTS

There were 60 T-DCR procedures in 56 patients (82.1% women; 46 patients) with a mean age of 56.4 years (standard deviation: 15.7; range from 29 to 92). The mean follow up was 8.1 months. Overall anatomical and functional success rates were 83.3% (50/60) and 73.3% (44/60), respectively. The PPV of endoscopic Jones I test in anatomical success and functional success was 100% and 88%, respectively. The accuracy of this test in anatomical and functional success was 100% and 81.25%, respectively. The PPV of ABT in anatomical success and functional success was 100% and 90.4%, respectively. The accuracy of this test in anatomical and functional success was 92% and 80.65%, respectively.

CONCLUSIONS

In conclusion, both endoscopic Jones I test and ABT showed PPV of 100% to detect anatomical success after T-DCR; the endoscopic Jones I test and ABT had 88% and 90.4% of PPV on evaluation of functional success, respectively. Both tests showed good accuracy in the assessment of anatomical and functional success after T-DCR. These outcomes may indicate that ABT could substitute Jones I test on postoperative DCR assessment.

Optimal Timing for Primary Early Endoscopic Dacryocystorhinostomy in Acute Dacryocystitis

Purpose: To evaluate the surgical outcomes of primary early endoscopic dacryocystorhinostomy (EnDCR) in acute dacryocystitis (AD) and to determine the optimal timing for surgery. Methods: A retrospective review of medical records was performed on consecutive patients who underwent primary early EnDCR (within 1 week) for AD between May 2010 and June 2020 (AD group) and an age- and gender-matched control group of NLDO patients who underwent EnDCR (non-AD group). The primary outcome measures were the surgical outcomes at the final follow-up examination. The secondary outcome measure was the clinical course of AD patients. Subgroup analysis was performed to determine the optimal timing of surgery by comparing the outcomes of very early EnDCR (within 3 days) and those of early EnDCR (between 4 and 7 days). Results: Forty-one patients were included in the AD group and 82 patients in the non-AD group. The anatomical and functional success rates were 87.8% and 82.9% in the AD group, and 91.5% and 84.1% in the non-AD group, which were not significantly different between the two groups (p = 0.532 and p = 0.863). In the AD group, the mean times for pain relief and resolution of swelling after surgery were 2.4 and 6.5 days after surgery, respectively. In the subgroup analysis according to the timing of surgery, the time for symptom resolution after diagnosis, the length of hospital stays, and the duration of antibiotic treatments were significantly shorter after very early EnDCR (all ps < 0.05), whereas the surgical outcomes were not different between the two groups (p = 1.000). Conclusions: Primary early EnDCR is a safe and effective procedure for the treatment of AD. In particular, very early EnDCR performed within 3 days leads to faster recovery and shortens the course of antibiotic treatment.

The role of the rhinostomy ostium size on functional success in dacryocystorhinostomy

INTRODUCTION

Endonasal and external dacryocystorhinostomy procedures have both been used for the treatment of post-saccular obstruction of the lacrimal system. Functional success of these surgeries depends on several factors.

OBJECTIVE

To evaluate the status of the rhinostomy ostium with endonasal and external approaches in dacryocystorhinostomy operations and to determine the effect of ostium size on postoperative functional success.

METHODS

The charts of the patients operated in our hospital between May 2017 and January 2019 were analyzed retrospectively (ethical approval number: 2018-12.04). The patients that were operated in the ophthalmology and otolaryngology departments were included in the study. Endoscopic rhinostomy ostium measurements, punctum lavage findings and complications were recorded at 8 weeks postoperative at the earliest.

RESULTS

When the 64 patient charts were reviewed (76 operations), the mean ostium width was 1.85±1.11mm in the endonasal approach group and 3.60±2.24mm in the external approach group. The mean ostium areas in endonasal and external group were 14.61±16.66mm² and 56.05±60.41mm², respectively. The ostium was anatomically patent and punctum lavages were negative in 11 patients (6 patients in the endonasal approach group and 5 patients in the external approach group) and these cases were considered as functional failures. The rhinostomy ostium was significantly wider in the external approach group, but this was considered ineffective on functional outcomes.

CONCLUSION

Lacrimal duct stenosis can be successfully treated with endonasal and external methods. Tear drainage may be insufficient even in the presence of a patent ostium. Therefore, functional success should also be considered when evaluating the overall success of dacryocystorhinostomy. An anatomically patent ostium is definitely required, while it is believed that ostium size does not affect functional surgical success.

[Method of endonasal endoscopic dacryocystorhinostomy with plastic stoma formation]

The article presents modern methods of surgical treatment of chronic dacryocystitis, a brief historical review of various options for endonasal endoscopic dacryocystorhinostomy is carried out. The method of plastic seamless formation of dacryocystostomy, which does not require intubation of the lacrimal passages and/or using of silicone stoma dilators, is described. Between 2010 and 2019 at The State Budgetary Healthcare Institution of Moscow Area Moscow regional research clinical institute n.a. M.F. Vladimirskiy, according to the developed technique, 32 patients (32 eyes) with chronic dacryocystitis were operated on. According to the results of observation 1 year after surgical treatment, all 100% of patients recorded a positive result (absence or significant decrease in lacrimation, good anatomical visualization of dacryocystostomy with a good tear passage, both passive and during washing the lacrimal passages).

Meet the Lacrimal Sac: Endoscopic Surgeons' Road Map

Knowledge of lateral nasal wall landmarks in relation to lacrimal apparatus is essential for successful endoscopic dacryocystorhinostomy. This descriptive study of right and left sagittally sectioned ten adult cadaver head specimens was done measuring various lateral nasal wall anatomical landmarks including lacrimal apparatus with digital calipers. Maxillary line was identified in 75%, majority overlapping lacrimal sac. Genu of middle turbinate was at or posterior to nasolacrimal duct. Mean distance of superior end of sac was 8.88 mm above axilla, between its anterior edge and axilla was 10.58 mm and its length was 11.72 mm. Considering above measurements, 'Rule of 10' can be applied for nasal mucosal incision. A "Three Tier Approach" to overcome mucosal (nasal), bony (lacrimal and frontal process of maxilla) and mucosal (sac) boundaries exposes lacrimal sac up to its inferior limit ensuring successful endonasal endoscopic dacryocystorhinostomy.

Simultaneous bilateral or sequential DCR? What to choose?

BACKGROUND

Dacryocystorhinostomy is used to treat nasolacrimal duct obstruction when conservative measures fail. It may be performed via an external or endoscopic-endonasal approach. The aim of this study was to compare the outcomes of patients with nasolacrimal duct obstruction treated with simultaneous bilateral or unilateral dacryocystorhinostomy.

METHODS

The database of a tertiary medical center was retrospectively reviewed for all patients treated for nasolacrimal duct obstruction in 2012-2017. The study sample was divided into six groups by surgery type and approach: adults (>18 years) - external or endoscopic-endonasal sequential unilateral or simultaneous bilateral dacryocystorhinostomy (four subgroups); children (18 years) - endoscopic-endonasal unilateral or simultaneous bilateral dacryocystorhinostomy (two subgroups). Data were collected on patient age and sex, surgery and anesthesia type and duration, and complications.

RESULTS

The cohort included 95 adults and 27 children who underwent 111 and 41 surgical procedures, respectively. Among the adults, the durations of anesthesia and surgery were significantly longer in the external bilateral dacryocystorhinostomy group than the others, but no such differences were found between simultaneous bilateral endonasal dacryocystorhinostomy and unilateral dacryocystorhinostomy by either approach. Among the children, there was no significant between-group difference in surgery duration.In neither age population was bilateral endoscopic surgery associated with an excess of intraoperative or postoperative complications of hemorrhage, infection, and epiphora.

CONCLUSION

The lack of intergroup differences in clinical, surgical, and outcome parameters suggests that in cases of bilateral nasolacrimal duct obstruction in adults and children, simultaneous bilateral endoscopic-endonasal dacryocystorhinostomy may yield excellent therapeutic results.

Dacryops with extensive lacrimal and maxillary bone defects in four dogs

OBJECTIVE

To describe and discuss ventromedial orbital lacrimal gland or duct cysts (dacryops) in dogs with extensive bone defects based on their symptoms, results of diagnostic imaging and histopathological examination, and therapy and discuss their potential origin based on the morphology.

ANIMALS STUDIED

Four dogs of different breeds, age, and sex were presented with a unilateral round, slow growing, indolent, and non-tender process ventromedial to the nasal canthus of the eye.

PROCEDURES

Transverse computed tomography showed a low-density, non-contrast-enhancing cystic process ventromedial to the globe with extensive defects in the lacrimal and maxillary bones in all cases. The cystic character of the structure was confirmed by the aspiration of the brownish fluid without cellular and microbiological contents. For treatment, the cystic fluid was aspirated, and the sclerosing agent polidocanol was injected in three cases. Cystorhinostomy (nasal marsupialisation) was performed in one case as the first choice and in another case following failure of sclerotherapy. Histopathological examination of the cyst walls was performed in two cases and confirmed the diagnosis of dacryops.

RESULTS

Follow-up between 2 and 18 months showed no recurrence and very good to excellent cosmetic results.

CONCLUSIONS

Aberrant lacrimal gland or duct tissue with secondary development of dacryops should be included in the differential diagnoses of ventromedial orbital cysts. Large cysts near the lacrimal drainage system with extensive bone defects in dogs should be treated by nasal marsupialization. Treatments such as evacuation of the cyst and inducing sclerosis (sclerotherapy) should be reserved for exceptional cases.

Comparison of success between external and endonasal dacryocystorhinostomy in primary acquired nasolacrimal duct obstruction in Turkish cohort

OBJECTIVE:

To evaluate the results and recurrence rates of external and endonasal dacryocystorhinostomy (DCR) surgery in patients with primary acquired nasolacrimal duct obstruction (PANDO) in Turkish Cohort.

METHODS:

Medical records were reviewed in all patients who underwent surgery for PANDO between January 2010 and September 2014 in a tertiary university hospital retrospectively. The patients were followed up on the first day, first month, third month and sixth month postoperatively. Lacrimal drainage system and recurrence rates were recorded.

RESULTS:

This study was conducted in 81 patients, 27 of whom were men (33.3%) and 54 were women (66.7%). The mean follow-up time was 30.13±16.42 months (range 6–62 months). The mean age was 50.51±12.47 years (range 16 to 77 years). External DCR was used in 44 (66.7%) of the cases and endonasal DCR was used in 37 (45.7%) of the cases. Surgical results of DCR were divided into three groups based on the integrity and openness of the lacrimal drainage pathway in all PANDO patients. Operation success rates of these data revealed that 45 (55.6%) cases were recorded as successful, 20 (24.7%) of the cases were accepted as partially successful and 16 (19.8%) of the cases were deemed as unsuccessful. Based on these data, surgical success rates were found in 38 (86.4%) patients in external DCR and 27 (73%) patients in endonasal DCR. Surgical failure rates were six (13.6%) in external DCR and 10 (27%) in endonasal DCR. There was no statistically significant difference between success rates and recurrences in both groups (p>0.05).

CONCLUSION:

Endoscopic DCR produced simple, minimally invasive and preferable results compared to external DCR in the Turkish population. Although the success of external DCR is higher and the recurrence is lower than endoscopic DCR, with the outcomes of this study, endoscopic DCR can be tried as the first choice to protect the patient from major surgery and anesthesia in PANDO.

Ectopic lacrimal gland in the lacrimal sac mimicking tumour: literature review

An 80-year-old man referred with repeated episode of dacryocystitis from the left lacrimal drainage system and palpable swelling. For many years, he has being presented with epiphora unilaterally with chronic dacryocystitis. Investigations with dye-test revealed subocclusion of the natural passage of the tears, and CT and MRI scans revealed solid mass in the lacrimal sac. The lacrimal sac was opened by endonasal endoscopic approach, the sacral mass was identified and completely removed. The histopathological examination showed lacrimal gland in ectopic position. Patient followed for 18 months with complete recovery of symptoms. In our differential diagnosis, the ectopic lacrimal gland is also identified, when a mass in the lacrimal sac and duct is present. Successful surgical excision required considerable multidisciplinary teamwork between ophtalmologist-ENT (Otolaryngologist) and radiologist. Endonasal endoscopic approach is perfectly safe with direct control and ensures a smooth postoperative recovery.

One-week intubation in external dacryocystorhinostomy- a report on long-term outcome

PURPOSE

The role of silicone stent intubation in dacryocystorhinostomy (DCR) is not clear, and conclusions presented in the literature are contradictory both regarding if intubation should be recommended and if so, the appropriate duration of intubation. This paper reports on the long-term outcome of a comparatively short duration of silicone stent intubation, one week, and discusses the possibility of an optimal duration of intubation where the benefit of the silicone stent is utilized but with minimal risk of complications.

METHODS

A total of 70 cases of DCR were followed in 67 patients for four years in a descriptive case series of uncomplicated external DCR with one-week silicone stent intubation. Pre- and perioperative findings, complications, and the need for additional surgery were recorded. At end of follow-up, a questionnaire was sent to the patients asking them to grade the frequency of epiphoric problems. If graded often/constant, a follow-up visit was offered.

RESULTS

One patient received additional surgery during follow-up due to persistent epiphora caused by synechiae between the middle turbinate and lateral nasal wall. The response rate to the questionnaire was 88%, with 93% of the respondents reporting epiphora never/seldom. Four patients reported persistent problems: one declined further examination, the tear duct was anatomically patent in two, and one was referred to the ENT department due to inflamed nasal mucosa and extensive adhesions. The long-term functional or anatomical success rate was 97%.

CONCLUSIONS

This study shows that a high long-term success rate for uncomplicated DCR is possible with only one-week silicone stent intubation.

Five- and 10-Year Outcomes for Primary Endoscopic Dacryocystorhinostomy: Failure Rate and Risk Factors

INTRODUCTION

Endoscopic dacryocystorhinostomy (eDCR) is the preferred approach for nasolacrimal duct obstruction, yet quality data on long-term outcomes is lacking.

STUDY DESIGN

A retrospective study in a single, academic institution.

OBJECTIVE

To assess the 5- and 10-year success rates of eDCR, and its associated risks.

PATIENTS AND METHODS

All eDCRs conducted at Kaplan Medical Center between the years 2002-2017 were included. For long-term follow-up analysis, two subgroups with a minimum of documented 5- and 10-year follow-up after surgery were defined. Surgical success was defined by both anatomical (observed patent lacrimal flow) and functional (symptomatic relief) success. Data was collected from the hospital's electronic medical records and was completed by phone interviews. Pre-, intra-, and postoperative variables were collected and stratified by multivariate analysis.

RESULTS

After exclusions, 321, 168, and 65 patients were included for immediate, 5- and 10-year outcome analysis, respectively. Overall success rates were 92.5%, 86.3%, and 80%, respectively. The anatomical success rates were 93.8%, 89.9%, and 86.1%, respectively. Multivariate analysis revealed that older age (P < .001, P = .001) previous smoking (P = .043, P = .037), and postoperative complains of epiphora (even when a successful irrigation was observed, P < .001, P = .01) were all associated with eDCR failure 5 and 10 years following surgery. Male gender was also associated with eDCR failure (5 years, P = .045; 10 years, P = .063).

CONCLUSIONS

Despite decreased rates over time, eDCR is beneficial for the majority of patients also at 10 years following surgery. Older age, smoking, postoperative epiphora, and male gender are related to long-term failure and should be discussed with the patients before surgery.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:10-16, 2021.

Surgical outcomes of endoscopic dacryocystorhinostomy: analysis of age effect

There is limited evidence in literature determining age effect on outcomes of endoscopic dacryocystorhinostomy (EDCR) in adult patients with primary acquired nasolacrimal duct obstruction (NLDO). We aimed to analyze the outcomes of EDCR according to age in primary acquired NLDO. A retrospective study was performed on consecutive adult patients and patients were divided into two age groups; group 1 (aged to 61 years) and group 2 (aged 62 to 89 years) based on the average value. The minimum required follow-up period was 6 months. A total of 441 EDCRs performed in 342 patients were enrolled. The anatomical success rate was not significantly different between the two groups (91.8% and 88.2%, P = 0.209). However, the functional success rate was significantly lower in the group 2 (85.1% and 76.9%; P = 0.036). Functional failure was associated with old age and a history of diabetes mellitus (P  = 0.024 and P  = 0.008). In subgroup analysis of patients with anatomical success but functionally failed EDCR, group 2 had significantly more comorbid conditions such as eyelid laxity (P = 0.026). In conclusion, the comorbid conditions which increase with age may affect functional outcome, especially eyelid laxity, careful preoperative examination of the eyelid and conjunctiva should be emphasized to lacrimal surgeons before performing EDCR.

External Dacryocystorhinostomy: A Comparison Of Ultrasonic Bone Aspiration To High-Speed Drilling

Purpose

Piezosurgical tools utilize high-frequency ultrasonic oscillations to selectively cut mineralized bone and minimize damage to soft tissue and mucosa. The purpose of this study was to directly compare outcomes in external dacryocystorhinostomy (DCR) using a piezoelectric ultrasonic bone aspirator (UBA) versus a high-speed electric drill with a diamond burr.

Methods

A retrospective chart review was conducted on 145 consecutive patients who underwent external DCR by a single oculoplastic surgeon between 2012 and 2017. Collected data included baseline patient characteristics, presenting symptoms, operative details and complications, and postoperative symptoms.

Results

One hundred and seventy-three primary external DCRs performed on 145 patients were included in this study. In total, 61.3% of cases were performed with the UBA and 38.7% with the high-speed drill. Most patients were white (92.4%) and female (67.6%), with a mean age of 57.6 years (range 1–93). Surgical success was achieved in 94.3% of patients in the UBA group and 94.0% in the drill group, with no significant differences between the two arms (p=0.36). Patients who experienced persistent nasolacrimal duct obstruction after surgery underwent endoscopic revision. Operative time was shortened for cases utilizing the UBA (38.9 mins) instead of the high-speed drill (44.7 mins; p=0.01). No significant intraoperative complications occurred in either group.

Conclusion

The UBA offers comparable outcomes and complication rates to more conventional surgical tools for external DCR. Excellent outcomes, ease of adoption, and potential surgical time savings make the UBA an appealing option for both novice and experienced surgeons.

Resolving Perplexity: Comparison of Endoscopic Dacryocystorhinostomy With and Without Stent

Endoscopic dacryocystorhinostomy (DCR) is an effective surgical procedure to treat nasolacrimal duct obstruction. This study was conducted with an aim of comparing the success rate between use of stent and without use of stent in endoscopic DCR. A prospective randomized study was conducted. Total 50 cases with signs of nasolacrimal duct blockage were included. The cases were randomly divided in two groups with 25 cases in each group. Group A cases underwent endoscopic DCR with stent and group B without stent. The follow up was till 12th week. Both subjective and objective outcomes were noted. By 12th week, only 8% cases had no relief of symptoms in group A while 92% cases of group A and all cases of group B had complete relief of symptoms. In objective outcome, by the 12th week, in group A 92% cases had full patency while in group B 100% cases had full patency. Overall complications in postoperative period were seen in 28% patients in group A and 12% patients in group B. In this study the surgical results of endoscopic DCR with or without stent came almost equal with no statistical difference in the success rate between stent group and non-stent group. Now that Endoscopic DCR without stent is equally effective and reduces cost, we recommend that the endoscopic DCR without stent should be preferred.

Endoscopic dacryocystorhinostomy with and without mucosal flap-is there any difference?

BACKGROUND

The nasal mucosa is sacrificed in conventional endoscopic dacryocystorhinostomies (EDCRs). Some surgeons, however, modify the technique by elevating a mucosal flap prior to creating the osteotomy with the aim of preserving the mucosa. To our knowledge, no clear-cut benefit of a mucosal flap has been established. The aim of this study is to examine the differences in surgical techniques and success rates of EDCRs with and without mucosal flap preservation.

METHODS

We carried out a medical record review of all patients who underwent primary EDCR at the Goldschleger Eye Institute from October 2009 to October 2017. The following data were retrieved from the medical database and analyzed: patient demographics (age at diagnosis and gender), medical history, examination findings, surgical details, postoperative success, complications, and follow-up.

RESULTS

A total of 107 patients who underwent 117 EDCRs participated in the study. Fifty-one patients comprised the group without a mucosal flap and 56 patients comprised the group with mucosal flap preservation. The medical history, presenting complaints, and preoperative examination findings were similar for both groups. The surgical success rate was not significantly different between the groups (82.1% without flap vs. 86.8% with flap, P = 0.478, Chi-square).

CONCLUSION

The findings of this comparison of EDCRs with and without mucosal flap preservation in a large patient population revealed no differences in surgical success or complications rates between the two procedures and, therefore, no benefit for adding flap preservation to conventional EDCRs.

The Fibrin Glue Application Enhances Surgical Success Rate in Endonasal Endoscopic Dacryocystorhinostomy With Lacrimal Sac Preservation

The purpose of this study to compare lacrimal sac flap preserving techniques with or without fibrin glue in patients undergoing endoscopic endonasal dacryocystorhinostomy. A retrospective study included 132 patients who underwent unilateral endonasal dacryocystorhinostomy between February 2011 and March 2016. Patients were divided into 2 groups: the nonfibrin glue group (n = 66) and fibrin glue anastomosis group (n = 66). Surgical success was defined as the patients' subjective report of relief of epiphora and objective endoscopic confirmation of ostium patency confirmed by a positive functional dye test. These parameters were compared between the 2 groups. Both groups were similar, in terms of demographic and clinical characteristics. The surgical success rate was significantly higher in the fibrin glue anastomosis group (95.5%) than in the nonfibrin glue group (84.8%; P = .041). Complication rate was 6.1% in the nonfibrin glue group, whereas in the fibrin glue anastomosis group, it was 4.5%. The complication rate was similar in both groups (P = .99). Creation of an anastomosis between the lacrimal sac flaps and the nasal mucosa using fibrin glue improves the outcome of endonasal endoscopic dacryocystorhinostomy.

Use of an image-guided navigation system for routine endonasal endoscopic dacryocystorhinostomy

OBJECTIVE

This study aimed to evaluate the results of routine endonasal endoscopic dacryocystorhinostomy combined with computed tomography guided navigation in patients with nasolacrimal duct obstruction.

METHOD

This was a retrospective study of all patients with lacrimal drainage obstruction undergoing stereotactic endoscopic dacryocystorhinostomy between 1st January 2016 and 1st April 2018. Computed tomography dacryocystography was used for intra-operative navigation. Patients with a presaccal obstruction site location were excluded from the study.

RESULTS

Endoscopic dacryocystorhinostomy with computed tomography guided navigation was successfully performed in all 17 cases without complications. Early post-operative dislocation of the inserted bicanalicular silicone stent occurred in two patients. Two other patients developed post-operative bacterial infection within the lacrimal sac. Otherwise, the silicone tube was removed three months after surgery, and after further follow up of 8 weeks, 94 per cent of the study population reported complete remission of epiphora.

CONCLUSION

The use of computed tomography guidance in routine endoscopic dacryocystorhinostomy enhanced safety for the patient and avoided unnecessary damage of bone and mucosa surrounding the lacrimal drainage system. Therefore, routine endoscopic dacryocystorhinostomy with additional stereotactic guidance by computed tomography navigation can contribute to high success rates with endoscopic dacryocystorhinostomy.

Endonasal endoscopic nasolacrimal duct dissection for primary nasolacrimal duct obstruction

PURPOSE:

The purpose of this study is to describe the results of endonasal endoscopic nasolacrimal duct dissection (EE-NLDD); a surgical technique used for the treatment of primary nasolacrimal duct obstruction (NLDO).

MATERIALS AND METHODS:

Before the operation, the patency of the nasolacrimal duct (NLD) was evaluated through irrigation and probing. The EE-NLDD surgical procedure involved the removal of the bony structure covering the NLD. The NLD mucosa was dissected and marsupialized with nasal mucosa, creating a mucosa-covered ostium. The bone surrounding the lacrimal fossa and lacrimal sac mucosa was preserved throughout procedure. The postoperative anatomical and functional outcomes were evaluated through irrigation, endonasal endoscopic fluorescein dye test, and subjective descriptions of the patients.

STUDY DESIGN:

This is a retrospective chart review study which included all patients with primary NLDO treated with EE-NLDD surgical technique from February 2012 to July 2016 in Taipei Medical University Shuang Ho Hospital by a single surgeon (YD, Shen).

RESULTS:

The mean follow-up time for the 39 patients (43 eyes) was 14.7 months (range: 0.5–46 months). Anatomical patency was achieved in all patients. Under endonasal endoscopy, fluorescein dye was observed at the internal orifice after the dye was instilled into the conjunctival sac in all patients. The complete resolution of the epiphora was reported in 36 patients (39 eyes) and two patients (2 eyes) exhibited an improvement of the epiphora after surgery. However, one patient (2 eyes) reported persistent bilateral epiphora without improvement even under solid evidence of anatomical patency. No major complications were noted intraoperatively or postoperatively.

CONCLUSIONS:

The results suggested that the EE-NLDD is a safe and effective procedure and has a success rate comparable with that of conventional endonasal dacryocystorhinostomy.

Long-term outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation

OBJECTIVE

A growing body of evidence demonstrates that endonasal endoscopic dacryocystorhinostomy (eDCR) techniques provide comparable results to conventional external techniques. The purpose of this study was to evaluate long-term outcomes after powered endoscopic DCR without preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction performed by a single surgical team.

METHODS

A retrospective review was performed of patients with epiphora secondary to acquired nasolacrimal duct obstruction who underwent eDCR without mucosal flap preservation from May 2003 to April 2013 at a tertiary referral medical center. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation and endoscopic evaluation.

RESULTS

Eighty patients (69 primary and 11 revision) totaling 103 procedures (87 primary, 16 revision) were available for analysis at a mean follow-up of 28.7 (range 6-114) months. At the most recent follow-up, 92 of 103 (89.3%) procedures had complete resolution of epiphora, and 10 of 103 procedures achieved mild intermittent epiphora. Complete resolution of epiphora was noted in 93.1% (81 of 87) of primary procedures and 68.8% (11 of 16) of revision procedures. Objective anatomic patency was confirmed in 98% (101 of 103). A revision procedure was required in 5.8% (6 of 103).

CONCLUSION

Outcomes of powered eDCR without the preservation of mucosal flaps compare favorably to previously reported results in the literature. These long-term results suggest that mucosal flap preservation is not required to achieve successful outcomes with eDCR.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:12-17, 2020.

Effects of ostium granulomas and intralesional steroid injections on the surgical outcome in endoscopic dacryocystorhinostomy

PURPOSE

To determine the effect of granuloma formation in the ostium and intralesional steroid injections (ISIs) on the surgical outcome after endoscopic dacryocystorhinostomy (DCR) in patients with primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

One hundred and eighty-three cases involving 142 patients were enrolled. The ostium granulomas were classified according to their location relative to the internal common opening (superior, anterior, and posterior positions) and to the vicinity of the ostium (inner, edge, and extra types). If an ostium granuloma was observed during the follow-up and its size increased, ISIs were performed using 0.3 ml of 40 mg/ml triamcinolone acetonide. The surgical outcomes were compared between cases with and without ostium granulomas and also between each granuloma position and type.

RESULTS

Ostium granulomas occurred in 71 (38.8%) of the 183 cases, and an ISI was applied in 65 cases with a mean of 2.1 injections. All of the granulomas regressed successfully after ISIs, with the success rate not differing between the cases with (85.9%) and without (83.9%) granuloma. There was no association between granuloma location and surgical outcome. However, the functional outcome was worse (60%) for inner granulomas (which are located within the ostial base) than for extra (87.8%) and edge (98%) granulomas.

CONCLUSIONS

ISIs can be easily applied by a surgeon to help regress an ostium granuloma and improve the ostial patency after DCR. Inner ostium granulomas are associated with a worse functional outcome, and the initiation of an early corrective intervention such as an ISI should be considered.

Outcomes after Endoscopic Dacryocystorhinostomy without Mucosal Flap Preservation

Background

The purpose of this study was to evaluate outcomes of powered endoscopic dacryocystorhinostomy (DCR) without the preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction.

Methods

A retrospective review was performed of patients undergoing endoscopic DCR without mucosal flap preservation from May 2003 to October 2006 at a tertiary referral medical center. Twenty-seven procedures were performed on 20 patients with epiphora secondary to acquired nasolacrimal duct obstruction. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation.

Results

Mean follow-up was 16 months. Mild intermittent postoperative epiphora or complete resolution of epiphora was noted in 100% (27/27) of procedures; complete resolution was recorded in 93% (25/27) of procedures. Eighteen patients (25 procedures) were available for lacrimal irrigation at a mean of 16 months follow-up. Anatomic patency was confirmed in 100% (25/25) of procedures.

Conclusion

Our results with endoscopic DCR are comparable with previously published outcomes. These data suggest that successfully powered DCR may be performed without the preservation of mucosal flaps.

Species-specific characteristics of the biofilm generated in silicone tube: an in vitro study

Background

To investigate characteristics of biofilm which is usually found in silicone tube for nasolacrimal duct surgery and can be the root of chronic bacterial infections eventually resulted in surgical failure.

Methods

To form a biofilm, sterile silicone tube was placed in culture media of Staphylococcus aureus, Corynebacterium matruchotii, Pseudomonas aeruginosa, or Streptococcus pneumonia. Biofilms formed on these silicone tubes were fixed with 95% ethanol and stained with 0.1% crystal violet. After staining, the optical densities of biofilms were measured using spectrophotometer on a weekly basis for 12 weeks.

Results

Staphylococcus aureus group and Pseudomonas aeruginosa group formed significantly more amounts of biofilms compared to the control group. The maximum optical densities of the two groups were found on week 3–4 followed by a tendency of decrease afterwards. However, the amounts of biofilms formed in other groups of silicone tubes were not statistically significant from that of the control group.

Conclusions

Bacterial species that could form biofilm on silicone tube included Staphylococcus aureus (week 3) and Pseudomonas aeruginosa (Week 4). It is important to first consider that the cause of infection around 1 month after silicone tube intubation can be Staphylococcus aureus and Pseudomonas aeruginosa.

Comparison between Endoscopic and External Dacryocystorhinostomy by Using the Lacrimal Symptom Questionnaire: A Pilot Study

Background

Epiphora has a significant impact on the patient's quality of life and is commonly caused by nasolacrimal duct obstruction. Dacryocystorhinostomy (DCR) has traditionally been performed via an external approach, which involves a skin incision. With the advent of endoscopes, the endonasal approach to DCR has gained significant popularity.

Method

To prospectively compare the quality of life of adult patients who underwent either an endonasal or an external DCR for acquired nasolacrimal duct obstruction, the Lacrimal Symptom Questionnaire (Lac-Q) was administered before and after surgery. The treatment group assignment was nonrandom and performed based on patient preference. The Lac-Q is a validated questionnaire that assesses the subjective perception of one's well-being from an eye-specific symptom and social impact standpoint. Total scores range from 0 (no concerns) to 33 (maximal degree of ocular symptoms and social impact).

Results

Sixty patients (22 in the endonasal group, 38 in the external group) were recruited between January 1, 2014, and January 1, 2016. Postoperative assessment was performed at 3 and 6 months. Patients who underwent external DCR reported a median 7.0–point improvement (interquartile range [IQR], 3.0–11.0) in total Lac-Q scores. A 12.0–point improvement (IQR, 10.0–18.5) was seen in the endonasal group (p = 0.005). The median change in the social impact score was 3.0 and 4.0 in the external group and the endoscopic group, respectively (p = 0.029). Changes in the median lacrimal symptom score were 4.0 in the external group and 8.0 in the endoscopic group (p = 0.014). The anatomic patency rate was lower in the external group (60.0%) when compared with the endonasal group (90.4%). Patients in the external DCR group were significantly older (median age, 51 versus 41 years).

Conclusion

Our study indicated that both endonasal and external DCR can lead to improvement in quality of life by using a validated questionnaire. Although there are differences in age and anatomic success rates between the two groups, subgroup analyses indicated that the differences in the Lac-Q scores persisted when age and anatomic patency were removed as potential confounding factors. Further larger, randomized studies would be helpful.

Comparison of endoscopic and external dacryocystorhinostomy for treatment of primary acquired nasolacrimal duct obstruction

PURPOSE:

The purpose of this study is to compare the success rates of endoscopic endonasal dacryocystorhinostomy (EN-DCR) and external DCR (EX-DCR) for the treatment of primary acquired nasolacrimal duct obstruction (PANLDO).

DESIGN:

This was a retrospective, comparative, nonrandomized clinical study.

METHODS:

Reviewed medical records of PANLDO underwent DCR at Far-Eastern Memorial Hospital from May 2011 to June 2017. Data regarding the lacrimal passage system, comorbidities, surgical outcomes, and postoperative complications were analyzed. Anatomical success was defined as patency confirmed by intranasal endoscopic inspection of the ostium and successful lacrimal irrigation; functional success was defined as complete resolution of epiphora and positive fluorescein dye disappearance test, which were assessed at postoperative 6^th months.

RESULTS:

One hundred and seventy patients (37 males, 133 females, mean age 57 years) underwent 178 DCR surgeries for PANLDO. The overall anatomical success rate was 94.4% (93.5% in EN-DCR vs. 95.8% in EX-DCR, P = 0.511) and functional success rate was 90.4% (90.7% in EN-DCR and 90.1% in EX-DCR, P = 0.909). Surgical outcomes were comparable between two groups. Complication rate was low in both groups, including 11 cases of early canalicular stent dislodge (7 in EN-DCR, 4 in EX-DCR), one case of postoperative nasal bleeding in EN-DCR, and two skin wound dehiscence and three cutaneous keloid formation in EX-DCR. None of these cases were concluded into surgical failure at the final visit. The time to symptoms relief was statistical significantly shorter in EN-DCR group (1.7 vs. 3.7 weeks in EX-DCR, P < 0.001).

CONCLUSIONS:

Success rate of DCR for PANLDO in our study was high, and complication rate was low for both endoscopic and external approaches. There was no statistically significant difference between them. EN-DCR provided higher satisfaction due to quicker recovery and lack of external incision. Endoscopic DCR should be considered as the primary treatment of choice for PANLDO.

Transcanalicular Laser-Assisted Dacryocystorhinostomy With Endonasal Augmentation in Primary Nasolacrimal Duct Obstruction: Our Experience

PURPOSE

To evaluate and compare the success rate of transcanalicular laser-assisted dacryocystorhinostomy with endonasal augmentation, with and without intubation, in patients suffering from primary acquired nasolacrimal duct obstruction, at 1 year of follow up.

METHODS

A prospective, randomized interventional pilot study was conducted at a tertiary care center, in accordance with the guidelines of Declaration of Helsinki. Sixty eyes of 60 adult patients with primary acquired nasolacrimal duct obstruction were included. The participants were divided randomly into 2 equal groups (A and B-without and with bicanalicular intubation, respectively). An osteotomy was first created using 980 nm diode laser (set at 8W continuous mode) transcanalicularly and then enlarged intranasally using Blakesley's nasal forceps, followed by bicanalicular silicon intubation in group B patients. The tubes were removed at the end of 8 weeks. The ostium size was assessed endoscopically at 8 weeks and again at the end of follow up, at 1 year. A successful outcome was defined in terms of ostium patency at the end of 1 year. The results were analyzed at the end of a follow up of 1 year, using various statistical tests (p < 0.05).

RESULTS

The mean age of the patients was 35.3 ± 15.89 years, with 23 male and 37 female patients, the 2 groups having a similar male:female ratio. An overall success rate of 90% was achieved at the end of 1 year with no statistically significant difference between the groups. Postoperative complications like tube displacement and punctal, canalicular injury were more in the intubated group. The average osteotomy size was 8.06 ± 5.4 mm at the end of 1 year.

CONCLUSIONS

Transcanalicular laser-assisted dacryocysto rhinostomy, with endonasal augmentation, is a scarless, effective, daycare procedure, for treatment of primary acquired nasolacrimal duct obstruction with no additional advantage offered by silicone intubation.

Effectiveness of indocyanine green gel in the identification and complete removal of the medial wall of the lacrimal sac during endoscopic endonasal dacryocystorhinostomy

OBJECTIVE

We investigated the effect of using indocyanine green (ICG) gel, a mixture of ICG and Viscoat, on complete removal of the medial wall of the lacrimal sac as well as the success rate of endoscopic endonasal dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction.

METHODS

Consecutive cases of endoscopic endonasal DCR between January and December 2010 were included in a retrospective, comparative manner. A total of 91 patients with primary acquired nasolacrimal duct obstruction were enrolled. Surgical method was selected according to time period. In the ICG gel group, we used ICG gel, which is a fluorescent-colored viscoelastic substance made of ICG dye (25 mg) and Viscoat. ICG gel was injected into the lacrimal sac via the inferior canaliculus prior to lacrimal sac dissection. The anatomic and functional surgical success rates of endoscopic endonasal DCR in each group were compared.

RESULTS

Our study included 49 cases in the ICG gel group and 42 cases in the control group. The functional success rate of endoscopic endonasal DCR reached 93.9% (46 of 49) in the ICG gel group compared with 71.4% (30 of 42) in the control group (Pearson's χ² test, p value = 0.004). In contrast, there was no statistically significant correlation between use of ICG gel and anatomic success rate of endoscopic endonasal DCR.

CONCLUSIONS

Using ICG gel during lacrimal sac dissection may enhance the functional success rate of endoscopic endonasal DCR for primary acquired nasolacrimal duct obstruction by facilitating easier identification and subsequent complete removal of the medial wall of the lacrimal sac.

Comparative Evaluation of the Ostium After External and Nonendoscopic Endonasal Dacryocystorhinostomy Using Image Processing (Matlabs and Image J) Softwares

PURPOSE

The purpose of this study was to compare the characteristics of the ostium after external dacryocystorhinostomy and nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR).

METHODS

This cross-sectional study included patients who underwent a successful external dacryocystorhinostomy or NEN-DCR and had ≥1 month follow up. Pictures of the ostium were captured with a nasal endoscope (4 mm, 30°) after inserting a lacrimal probe premarked at 2 mm. Image analyses were performed using Image J and Contour softwares.

RESULTS

Of the 113 patients included, external dacryocystorhinostomy group had 53 patients and NEN-DCR group had 60 patients. The mean age of patients in the NEN-DCR group (38 years) was significantly (p < 0.05) lower than the external dacryocystorhinostomy group (50 years). There was no statistically significant difference (2 sample t test, p > 0.05) in mean follow up (6 vs. 4 months), maximum diameter of ostium (8 vs. 7 mm), perpendicular drawn to it (4 vs. 4 mm), area of ostium (43 vs. 36 mm), and the minimum distance between common internal punctum and edge of the ostium (1 vs. 1 mm) between the external and NEN-DCR groups.

CONCLUSIONS

Image processing softwares offer simple and objective method to measure the ostium. While ostia are comparable in size, their relative position differs with posteriorly placed ostia in external compared with inferior in NEN-DCR.