Dacriocistorrinostomía endonasal y endocanalicular con láser diodo. resultados preliminares

Retrospective study of success rate and associated factors of two laser dacryocystorhinostomy techniques, in a third-level hospital

BACKGROUND AND OBJECTIVE

To compare the success rate of two laser dacryocystorhinostomy (L-DCR) techniques.

MATERIALS AND METHODS

A retrospective study of patients who underwent surgery for acquired nasolacrimal duct obstruction (NLDO) between 2000 and 2021, carried out in a third level hospital, using L-DCR and modifications of this technique. Intraoperative findings, complications, and anatomical and functional success rate of the 2 techniques were analyzed. The follow-up time was 1 year.

RESULTS

We included 92 lacrimal ducts with NLDO. 66 (71.7%) were women. 78 (84.8%) underwent unilateral surgery. The mean age was 62.77 ± 13.08 years. 61 (66.3%) underwent intraoperative laser dacryocystorhinostomy with MMTC (L-DCR + MMTC) and 31 (33.6%) L-DCR associated with endoscopic ostium enlargement (L-DCRend-amp). The one-year anatomical/functional success rate of the L-DCRend-amp + MMTC was 71%/64,5%. L-DCR + MMTC obtained a lower success rate, 65.6/60,7% (p = 0.391). There were no differences throughout the follow-up between the anatomical or functional success rates of the 2 techniques, nor between the different visits (p > 0,05). Intraoperative findings rate was 3.63% in L-DCR + MMTC, and 32.26% in L-DCRend-amp + MMTC. Postoperative complication rate was 3.27% in L-DCR + MMTC, and 3.23% in L-DCRend-amp + MMTC.

CONCLUSIONS

The L-DCRend-amp + MMTC gets a higher success rate than the L-DCR + MMTC. We must consider the surgical time-cost of the L-DCRend-amp + MMTC, as well as the learning curve of endoscopy techniques, and the skill of the surgeon, without a clear benefit in the success rate.

Endocanalicular Laser Dacryocystorhinostomy and its modifications: A systematic review of techniques and success rates

OBJECTIVE

the main objective of this work is to review the articles that refer to transcanalicular diode laser dacryocystorhinostomy (TCL-DCR) in acquired nasolacrimal duct obstruction (NLDO), as well as its modifications.

MATERIAL AND METHODS

A systematic review of publications related to TCL-DCR of the lacrimal duct from 2000 to March 2021 was carried out in the MEDLINE, EMBASE and COCHRANE LIBRARY databases. The search terms in Spanish and English were: «Endocanalicular laser», dacryocystorhinostomy or «primary DCR-L» or «laser» and «tear ducts».

RESULTS

After subjecting the articles to the inclusion and exclusion criteria, we got 49 articles: 21 retrospective and 28 prospective studies. The bibliometric result obtained guaranteed, for this review, a level C recommendation according to the Scottish Intercollegiate Guidelines Network scale.

CONCLUSIONS

Currently, the classic TCL-DCR has lower success rates than its modifications, so we suggest using the latter. We prefer TCL-DCR with IS-MMC or TCDL associated with endoscopy techniques, without being able to opt for any option, since their success rates are very similar. We leave the choice to the discretion of the surgeon, depending on the management skills of endonasal techniques. More studies, with longer follow-up, and better defined criteria are necessary to clarify which is the best TCL-DCR technique.

A Comparison of Transcanalicular, Endonasal, and External Dacryocystorhinostomy in Functional Epiphora: A Minimum Two-Year Follow-Up Study

Purpose

To compare the outcomes of transcanalicular diode laser-assisted dacryocystorhinostomy (TCL-DCR), nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR), and external dacryocystorhinostomy (EXT-DCR) as first-line treatments for functional epiphora.

Methods

This multicenter, retrospective, case-control study included 135 eyes of 135 patients with functional epiphora (86 females and 49 males). Functional epiphora was diagnosed based on a patent lacrimal system with a delay in the fluorescein dye disappearance test (FDDT) or dacryoscintigraphy (DSG) and no ocular surface or eyelid abnormalities. The patients were treated with TCL-DCR (2008–2011) or Ext-DCR (2005–2008, 2011–2017) at Beyoglu Eye Research Hospital (Istanbul, Turkey) and NEN-DCR at Carrot Eye Surgery Clinic affiliated with the McMaster University (Hamilton, ON, Canada) (2010–2016). Success was defined as the absence of epiphora and the normalization of an earlier delayed FDDT after surgery.

Results

The TCL-DCR, NEN-DCR, and EXT-DCR groups consisted of 38, 47, and 50 eyes with 25.9, 44.2, and 45.9 months of follow-up. The success rate for TCL-DCR was 65.8%, 70.2% for NEN-DCR, and 84.0% for EXT-DCR. During the follow-up period, 13.2% of TCL-DCR cases and 6.4% of NEN-DCR cases developed an anatomic obstruction of the lacrimal system.

Conclusion

The EXT-DCR group had a higher success rate in the management of functional epiphora than the NEN-DCR and TCL-DCR groups and was significantly safer in terms of an iatrogenic anatomic block of the lacrimal system.

Transcanalicular laser-assisted dacryocystorhinostomy with diode laser

This article compares the efficacy of transcanalicular laser assisted dacryocystorhinostomy (TL DCR) with conventional external dacryocystorhinostomy (Ex DCR). All patients were randomly divided into two groups - Group A included patients who underwent TL DCR and Group B included patients who underwent Ex DCR. 168 operations were done in a total of 163 patients; 79 patients in group A and 84 patients in group B. The overall success rate was 90.12% in group A and 95.40% in group B. The mean total surgical time was 17.41 min in group A and 49.49 min in group B. The duration of stay in hospital was about 3 hours for group A and about 48 hours for group B. Intra and post operative complications were more in group B than in group A. TL DCR can offer a minimally invasive technique with comparable results and better patient satisfaction than Ex DCR.

Outcome comparison between transcanalicular and external dacryocystorhinostomy

AIM

To compare the outcomes achieved with external dacryocystorhinostomy (EX-DCR) and transcanalicular dacryocystorhinostomy (TC-DCR) using a multidiode laser in patients with bilateral nasolacrimal duct obstruction (NLDO).

METHODS

This prospective study was conducted on 38 eyes of 19 patients with bilateral NLDO. Simultaneous bilateral surgery was performed on all patients. TC-DCR (Group 1) with a diode laser was used in the right eye, and EX-DCR (Group 2) was used in the left eye. All patients were placed under general anesthesia. Routine follow-ups were scheduled at 1wk; 1, 3, 6 and 12mo postoperative intervals. Objective (lacrimal system irrigation) and subjective [tearing, irritation, pain, discharge and visual analogue scale (VAS) score] outcomes were evaluated.

RESULTS

The overall objective success rate at 12mo was 73.7% (14/19) in Group 1 and 89.5 % (17/19) in Group 2. This difference was statistically significant. There were no significant between-group differences in the subjective results, such as tearing, pain and irritation. Only the discharge scores were found to be significantly higher in Group 1 compared to Group 2 at the 1y follow-up. The average VAS score was 6.8 in Group 1 and 8.7 in Group 2, with no statistically significant differences.

CONCLUSION

Although TC-DCR allows surgeons to perform a minimally invasive and safe procedure, EX-DCR offers better objective and subjective outcomes than TC-DCR.

The effectiveness of postoperative early ostium cleaning in transcanalicular diode laser-assisted dacryocystorhinostomy

PURPOSE

To search the effectiveness of postoperative first week ostium cleaning in transcanalicular diode laser-assisted dacryocystorhinostomy (TDL-DCR).

MATERIALS AND METHODS

A total of 123 eyes of 123 patients with acquired dacryostenosis who had surgery were retrospectively evaluated. Diode laser was used in all patients. All patients were operated under local anesthesia by a single surgeon. Intranasal endoscopic cleaning of the ostium by surgical suction under local anesthesia was performed as an extra job in the postoperative first week visit.

RESULTS

Mean age of the patients was 55 (range, 41-78 years) years. Mean follow up was 13.4 months. Successful outcomes were achieved in 117 of 123 (95.1%) patients. Reoperation was performed in 6 patients with restenosis and were free of symptoms in 1-year follow up.

CONCLUSION

Postoperative first week cleaning of the nasal ostium by surgical suction with the aiding of nasal endoscopy is a very effective method increasing the success rate of TDL-DCR.

Comparison of transcanalicular diode laser dacryocystorhinostomy and external dacryocystorhinostomy in patients with primary acquired nasolacrimal duct obstruction

BACKGROUND AND OBJECTIVE

To compare the success, complication, and patient discomfort rates of transcanalicular diode laser dacryocystorhinostomy (TCDL-DCR) and external dacryocystorhinostomy (EX-DCR) surgeries performed in patients with primary acquired nasolacrimal duct obstruction.

MATERIALS AND METHODS

Eighty consecutive patients were included in the study, and groups were assigned according to DCR technique. Thirty-four (42.5%) patients received TCDL-DCR (Group A) and 46 (57.5%) patients (Group B) received EX-DCR with temporary silicone stent intubation. The success of surgery was determined by the relief of epiphora, patient satisfaction, endoscopic evaluation of ostium patency, and lacrimal system syringing. Pearson Chi-Square test, Fisher's Exact test, and Student's t-test were used for statistical analyses.

RESULTS

Group A included 22 females and 12 males with a mean age of 49.1 ± 15.1 years, Group B included 35 females and 11 males with a mean age of 50.8 ± 11.7 years. There was no difference between groups in terms of age and gender (P = 0.905 and P = 0.167, respectively). The duration of the operation was 22.2 ± 4.8 minutes for Group A, while it was 56.3 ± 15.7 minutes for group B (P = 0.0001). In two patients in Group A, injury in the medial turbinate was recorded, and in Group B, 14 patients experienced mild to severe perioperative bleeding. The perioperative complication rate was significantly different between the groups (P = 0.004). Success in relieving symptoms was 79.4% for Group A and 89.1% for Group B. The difference in the success rates was not statistically significant (P = 0.229).

CONCLUSIONS

Although EX-DCR success rate was higher than that achieved with TCDL-DCR, the latter, with its shorter duration of surgery, lower perioperative complication rate, and a similar success rate, may be a good and acceptable surgical alternative in treatment of primary acquired nasolacrimal duct obstruction.

[Comparison between topical anaesthesia with cocaine versus lidocaine plus adrenaline for outpatient laser dacryocystorhinostomy]

OBJECTIVE

To evaluate the effectiveness of topical anaesthesia with cocaine versus lidocaine plus adrenaline for outpatient transcanalicular and endonasal dacryocystorhinostomy (TCLDCR) with diode laser under sedation.

METHODS

A double blind randomised clinical trial was designed using topical anaesthesia for outpatient TCLDCR in the treatment of adult epiphora. A total of 92 patients were enrolled, and randomly allocated to be operated on under sedation and topical anaesthesia with cocaine 4% pledgets versus sedation and topical anaesthesia with lidocaine 2% plus 1/100.000 adrenaline pledgets. Main outcome measures were postoperative comfort, evaluated by a visual analogue scale, presence of secondary effects (blood pressure, heart rate), and resolution of epiphora, evaluated by Munk's scale and endoscopic control.

RESULTS

Patients in both groups reported being comfortable during and immediately after TCLDCR. Visualization of the operative field was adequate, and surgery was successfully completed in all cases. Complications were more common in the cocaine group: Sixteen patients from the cocaine group had high blood pressures, versus 2 patients from the lidocaine group (RR=8). Mean blood loss was 6.09 ml in cocaine group, versus 2.05 ml in lidocaine group (RR=6). Both parameters were statistically significant (p=1,1×10(-9)). There were no cases of postoperative epistaxis requiring nasal packing or hospital admission in any group. Success rate was similar in the 2 groups (86.96% group 1 and 89.13% group 2), after 6 months of follow-up.

CONCLUSIONS

The combination of topical lidocaine and adrenaline is more effective for outpatient transcanalicular and endonasal dacryocystorhinostomy than topical cocaine. Patient comfort was adequate in both groups, but high blood pressure and blood loss more common after cocaine.

A novel technique to recanalize the nasolacrimal duct with endodiathermy bipolar probe

Aims:

To evaluate a new approach for recanalization (RC) of nasolacrimal duct obstruction in the treatment of the symptomatic nasolacrimal duct obstruction (NLDO).

Materials and Methods:

A prospective, interventional, comparative study in 302 eyes of 209 patients of symptomatic nontraumatic NLDO. Eyes with previous failed surgery were excluded. One hundred and fifty-one eyes underwent RC with 20 G endodiathermy bipolar probe connected to a 7 W diathermy followed by bicanalicular intubation under direct visualization. One hundred and fifty-one eyes underwent standard external dacryocystorhinostomy (DCR). Follow-up was for 24 months and evaluation was done on basis of change in symptoms and lacrimal syringing. Data was analyzed by Chi-square test and unpaired t-test. P value < 0.05 was considered statistically significant.

Results:

Success defined as an asymptomatic patient or freely patent syringing was 92.7% (140 eyes) in RC group and 83.44% (126 eyes) in DCR group. Success was significantly more (P ≤ 0.01) in RC than DCR group. Surgical time was significantly less in RC than DCR (P ≤ 0.001). In RC group, RC could not be performed in three eyes and had to be later taken up for DCR. Intubation after RC was not achieved in four eyes; however these eyes had a patent pathway till 24 months. Twenty-two eyes had a premature extrusion of the tube; but the success rate in these (20 eyes) was comparable to the others within the group (P > 0.05). Two eyes in RC and one in DCR group had complications.

Conclusions:

RC with 20 G endodiathermy bipolar probe is a quick, simple, and effective alternative to standard external DCR.

Transcanalicular laser dacryocystorhinostomy using low energy 810 nm diode laser

Background:

Hypertrophic scarring may be a cause of failure after transcanalicular laser dacryocystorhinostomy (DCR) surgery. This hypertrophic scarring results from tissue charring and excessive coagulation, which may be caused by the high laser energy. We have evaluated the use of low energy settings to prevent hypertrophic scarring, for a successful outcome.

Aims:

To perform and evaluate transcanalicular laser DCR using low energy 810 nm diode laser.

Design:

Interventional, non-comparative, case series.

Materials and Methods:

Patients with nasolacrimal duct obstruction and chronic dacryocystitis, who needed DCR, and were fit for surgery under local anesthesia, were recruited to undergo transcanalicular laser DCR using a 810 nm diode laser. The outcome was measured by the patency of the lacrimal passage, as indicated by the relief in the symptoms and the patency on syringing at the last follow-up. The surgical time and surgical complications were noted.

Statistical Analysis Used:

Descriptive analysis.

Results:

The study included 94 patients. The average age was 30.1 years (range 15 - 69 years). Seventy (74.4%) patients were female. Eight patients had failed external DCR. Per-operative patency of the passage was obtained in all the patients. Average surgical time was seven minutes (5 – 18 minutes). At the end of the study period of one year, a successful outcome was seen in 85 patients (90.5%). There were eight patients of previous failed DCR surgeries, and six of them achieved a cure at the end of follow-up.

Conclusions:

Transcanalicular Laser DCR can be safely performed using a low power 810 nm diode laser. The surgery is elegant, minimally invasive, allows fast rehabilitation, and has an excellent success rate.

[Corrective techniques of lacrimal obstruction in the vertical system]

PURPOSE

To describe current surgical techniques of dacryocystorhinostomy (DCR) and to compare their effectiveness by analysing the advantages and disadvantages between external, endonasal and transcanalicular surgery.

PATIENTS AND METHODS

A total of 91 DCRs were analysed using a retrospective, cross-sectional and multicentre study in 75 patients who had symptoms of nasolacrimal duct obstruction. Of these, 28 were operated using external DCR, 31 endonasal technic, and 32 transcanalicular DCR with diode laser. Outcomes were evaluated subjectively using patient symptoms for the grade of epiphora and the results from the syringing before and after surgery.

RESULTS

External DCR was performed in 28 cases, with 19 cases asymptomatic (67.85%), and 20 patients had a patent tract (71.42%). Endonasal DCR was performed in 31 cases, of which 19 cases were asymptomatic (61.29%), and 21 showed patency of the nasolacrimal duct (67.74%). A transcanalicular technique was performed in 32 cases, with absence of epiphora in 24 patients (75%), and the syringing was successful in 24 of them (75%).

CONCLUSIONS

Any of these 3 surgery techniques would be an adequate treatment for lacrimal obstruction, due to the significant development of endonasal and transcanalicular techniques in recent decades. With improvement, we could use either endonasal or transcanalicular techniques with diode laser with the same lever of effectiveness as the classic external approach, with the advantages of minimally invasive surgery.

Use of endocanalicular dacryocystorhinostomy with multidiode laser in children

OBJECTIVE

To evaluate the clinical outcome and efficacy of endocanalicular laser dacryocystorhinostomy using a multidiode laser in cases unresponsive to medical therapy, probing or intubation of pediatric nasolacrimal duct obstruction.

METHODS

Eight children with nasolacrimal duct obstruction were treated with a multidiode laser. The study was prospective, non-randomized, and noncomparative. The patients, 2 (25%) males and 6 (75%) females, ranged in age from 8 to 13 years (mean 11.25±2.43). Surgery was performed under general anesthesia. All procedures were performed using a multidiode laser. The nasal passage was visualized with a 30° nasal video endoscope. In all cases, silicone stents were inserted. The main outcome measure was resolution or improvement of the epiphora and no major laser damage intranasally. Patients were followed for at least 6 months.

RESULTS

The endocanalicular laser dacryocystorhinostomy failed in one of the 8 (12.5%) cases, which had been secondary to trauma. The others were due to primary nasolacrimal duct obstruction. External dacryocystorhinostomy was performed on the failed case. None of the cases with primary nasolacrimal duct obstruction had obstruction after the endocanalicular laser dacryocystorhinostomy operation.

CONCLUSIONS

Endocanalicular laser dacryocystorhinostomy using a multidiode laser appears to be an effective technique in cases unresponsive to medical therapy, probing or intubation of primary nasolacrimal duct obstruction.

Endoscopic transnasal dacryocystorhinostomy with nasal mucosal and posterior lacrimal sac flap

OBJECTIVE

To describe a new endonasal dacryocystorhinostomy technique and to assess its efficacy.

DESIGN

Prospective, non-randomised, interventional case series.

PATIENTS AND METHODS

Patients with primary nasolacrimal duct obstruction were included. A prospective series of 226 consecutive endoscopic transnasal dacryocystorhinostomies performed between January 2003 and December 2006 were entered into the study. Patients who had undergone previous lacrimal surgery were excluded. The surgical technique involved the creation of nasal mucosal and large posterior lacrimal flaps at the medial lacrimal sac wall. The two flaps were placed in close apposition. The technique also involved creation of a large bony ostium.

MAIN OUTCOME MEASURES

Success was defined as the resolution of symptoms, or unobstructed lacrimal irrigation and endoscopic visualisation of a patent rhinostomy.

RESULTS

A total of 226 consecutive endoscopic transnasal dacryocystorhinostomy procedures performed between January 2003 and December 2006 were reviewed. The main presentation was with epiphora (95 per cent) and/or mucocele (13 per cent). Septoplasty was performed in 36 per cent of cases at the time of surgery. In 18 per cent of cases, endoscopic sinus surgery was also added to the procedure. The follow-up period ranged from six months to two years. Of the 226 patients, eight were lost to follow up and were thus excluded from the series. The procedure achieved a 92 per cent success rate, in terms of symptom relief and anatomical success.

CONCLUSION

The described technique of endoscopic endonasal dacryocystorhinostomy had a success rate comparable to that of external dacryocystorhinostomy. The procedure is simple and cost-effective because it does not require sophisticated equipment such as lasers, optical fibres, silicone stents or a microdebrider.

Transcanalicular Dacryocystorhinostomy With Diode Laser: Long-term Results

PURPOSE

To evaluate the effectiveness of transcanalicular dacryocystorhinostomy with diode laser in treatment of epiphora in adults.

METHODS

A prospective, noncomparative, interventional case series of transcanalicular dacryocystorhinostomy in 25 patients presenting with epiphora due to nasolacrimal obstruction. Patient age ranged from 32 to 72 years. Patients were evaluated postoperatively at 12, 24, and 36 months. Patients were evaluated for symptom improvement through a visual analog scale, and patency of osteotomy by lacrimal system irrigation with fluorescein and direct visualization by nasal endoscopy. Success was defined as resolution of epiphora.

RESULTS

Transcanalicular dacryocystorhinostomy was able to re-establish patency of the lacrimal system in 88% of cases after 36 months of surgery. No differences were found between patients older than 65 years and younger patients (chi-square, p > 0.05). Early (12 months) and late (36 months) results were similar (chi-square, p > 0.05).

CONCLUSIONS

In this prospective series, transcanalicular dacryocystorhinostomy was effective in treatment of epiphora in adults with little morbidity.

Use of the Diode Laser With Intraoperative Mitomycin C in Endocanalicular Laser Dacryocystorhinostomy

PURPOSE

To determine the safety and efficacy of the diode laser with intraoperative mitomycin C in endocanalicular laser dacryocystorhinostomy (ECL-DCR).

METHODS

In a prospective case series of 40 ECL-DCRs using the diode laser, mitomycin C was placed intraoperatively in all cases. The main outcome measure was resolution or improvement of epiphora and no major laser damage intranasally. Patients were followed for at least 18 months.

RESULTS

Forty consecutive ECL-DCRs on 30 patients (23 females, 7 males, mean age 62 years) were performed from April 2000 to December 2001. The success rate at 12 months postoperatively was 87.5%. All failures were due to a constricted nasal osteotomy. No significant intraoperative or postoperative complications were recorded.

CONCLUSIONS

Diode laser ECL-DCR with mitomycin C appears to be a safe and effective treatment modality for primary acquired nasolacrimal duct obstruction.