Endoscopic transnasal dacryocystorhinostomy with nasal mucosal and posterior lacrimal sac flap

Comparison of the surgical outcomes of endoscopic dacryocystorhinostomy in chronic dacryocystitis with or without previous bicanalicular silicone tube intubation

AIMS

To compare the outcomes of endoscopic dacryocystorhinostomy (En-DCR) in chronic dacryocystitis (CD) with or without previous bicanalicular silicone tube intubation (BSTI), and investigate whether previous BSTI influenced postoperative outcomes.

METHODS

We conducted a retrospective review of medical records of CD patients (group A) who had previously undergone BSTI for nasolacrimal duct stenosis and an age- and sex-matched control group of CD patients (group B) without previous intubation receiving En-DCR from November 2017 to January 2022. Sixty-one patients (61 eyes) were included in group A and age- and sex-matched 122 patients (122 eyes) in group B. Dacryocystic parameters were measured by computed tomography-dacryocystography and surgical findings were recorded during surgeries. The surgical success rates of the two groups were compared at 12 months post-operation.

RESULTS

The mean horizontal, sagittal, and vertical lengths were 6.06 ± 1.24, 6.03 ± 1.44, and 8.05 ± 2.00 mm, respectively, in group A and 6.33 ± 1.25, 6.26 ± 1.19, and 10.40 ± 2.45 mm, respectively, in group B. There were no differences in the horizontal or sagittal parameters between the two groups. The vertical parameter in group A was significantly lower than that in group B. Scar formation in the sac was observed in 54 patients in group A but was absent in group B. At 12 months postoperatively, the anatomical and functional success rates were 88.52 % and 85.25 %, respectively, in group A and 92.62 % and 89.34 %, respectively, in group B, with no difference between the two groups.

CONCLUSION

Previous BSTI reduced dacryocyst vertical parameter and caused dacryocyst scar formation but did not affect postoperative En-DCR efficacy.

Y. Comparative Study of Endonasal Endoscopic Dacryocystorhinostomy with or without Preservation of Nasal Mucosal Flap

OBJECTIVE

To analyse the result of endoscopic endonasal dacryocystrhinostomy with or without preservation of nasal mucosal flap.

STUDY DESIGN

Randomised prospective cohort design.

SETTING

Tertiary academic centre.

SUBJECTS AND METHODS

 100 patients who presented with epiphora and diagnosed as chronic dacryocystitis after syringing by ophthalmologist, were selected and randomised into two groups. Standard surgical procedure of endoscopic endonasal dacryocystorhinostomy was carried out except for the preservation of flap in group A and without preservation of flap in group B. Additional surgeries were done according to necessity. Postoperatively, patients were followed up on OPD-basis at the end of 1st week, 2nd week, 1st month, and 3rd month. Symptomatic improvement was assessed and patency checked by syringing by the ophthalmologist.

RESULTS

Nil intraoperative complications (p < 0.05) and nil postoperative complication noted (p < 0.05). Functional and anatomical patency found to be 100% at the end of 1st week in both groups, 96% at 3rd month in case group A and 98%, 92% and 82% respectively at the end of 2nd week, 1st month and 3rd month in group B. Nasal endoscopy of all surgical failures showed restenosis in both groups and synechiae in 2 patients in group B.

CONCLUSIONS

Preservation of nasal mucosal flap with modification around stoma can be used to cover the bared bone with avoidance of granulation tissue formation reducing the risk of closure of ostium with large rhinostomy and improve success of endoscopic endonasal DCR.

Comparison of Endoscopic Dacryocystorhinostomy Outcomes With or Without Bicanalicular Silicone Tube Intubation in Acquired Lacrimal Sac Mucocele

PURPOSE

This paper was established to validate the necessity of bicanalicular silicone tube intubation (BSTI) in patients with acquired lacrimal sac mucocele (ALSM) receiving endoscopic dacryocystorhinostomy (DCR).

METHODS

In total, 92 patients (92 eyes) diagnosed with ALSM undergone endoscopic DCR from November 2016 to December 2021 were recruited for our research. Patients were allocated into 2 equal treatment groups: group A (patients undergoing BSTI) and group B (patients not receiving this procedure). The tubes were removed 2 months postoperation in group A. Surgical outcomes and related complications were evaluated 12 months postoperation.

RESULTS

Ultimately, this study included 83 patients with ALSM, consisting of 43 patients in group A and 40 patients in group B. All patients exhibited notable mass shrinkage with the opening of the lacrimal sac during the surgery and the swelling in the lacrimal sac area was completely relieved within 5 days postoperation. At the 12-month follow-up, no distinct difference was observed in the anatomic success rate between the 2 groups (group A: 93.0%; group B: 90.0%) ( t = 0.010, P > 0.05). However, patients in group A presented higher functional success rates (90.7%) in contrast to those patients in group B (72.5%) ( t = 4.635, P < 0.05). In both groups, the failure of the lacrimal passage reconstruction was attributed to granulation tissue formation or scar formation at the ostium. No sac mucocele recurrence occurred during the follow-up.

CONCLUSION

Endoscopic DCR treatment for ALSM achieves satisfactory postoperative effects without recurrence, and BSTI may improve the functional success rate.

A Prospective Longitudinal Study to Evaluate the Outcomes of Success of Endoscopic DCR in Pediatric Age Group

Children with nasolacrimal duct obstruction (NLDO) have different therapeutic approach from that used in adults. Dacryocystorhinostomy (DCR) is the most common procedure in adults but it is less frequently carried out in children, indicated in children which are refractory to probing. The objective of the study is to report a series of 30 cases of paediatric epiphora who underwent endoscopic endonasal dacryocystorhinostomy surgery, for primary obstruction of nasolacrimal duct and results, outcomes of success are evaluated. This is a prospective and non-comparative review of 30 cases of epiphora aged between 3 and 9 years from April 2018 to March 2019. The main outcome measures assessed were determined by the resolution of symptoms and the patency of the lacrimal anatomy confirmed by syringing or irrigating the nasolacrimal duct. Secondary outcomes included the presence of such complications as bleeding, scarring, and/or persistent epiphora and infection. In our study 30 patients underwent unilateral DCR surgery in NLDO. Out of 30 patients males were 17 and females were 13. The overall success rate of endoscopic DCR was 90%, and failed cases were mainly due to pre-saccal obstruction. No major complications were reported, minor complications occurred in about 60% of cases. Analysis of the results indicated that EDCR was safe and an effective therapeutic approach for treating nasolacrimal duct obstruction in pediatric age group patients having NLDO. It's considered as an alternative procedure to external dacryocystorhinostomy after a failed conservative treatment.

Ethmoid Sinus Mucosal and Lacrimal Sac Flap Anastomosing in Patients With Failed Dacryocystorhinostomy

PURPOSE

The aim of this work is to demonstrate the outcomes of endonasal dacryocystorhinostomy (En-DCR) with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing in patients with previous failed DCR.

METHODS

The clinical data of patients who suffered from recurrent epiphora after failed DCR between September 2014 and March 2018 were reviewed retrospectively. Among them, those who received the second En-DCR procedure were enrolled in this study. During the surgery, anterior ethmoidectomy was performed. Posterior lacrimal sac flap was apposed closely to the mucosal of anterior ethmoid sinus instead of nasal flap at end of the surgery. Patients were followed up more than 12 months were included, the success rate and complications were recorded.

RESULTS

Sixty-one eyes of 61 patients were enrolled in the study. The success rate of our modified En-DCR was 83.6% (51/61). Among 10 eyes with postoperative obstruction, 4 eyes caused by granuloma, 2 eyes caused by scar synechia, 2 eyes caused by membranous obstruction, and 2 eyes caused by common canalicular stenosis. No serious complications such as orbital fat prolapse, cerebrospinal fluid leak, sinusitis, or visual impairment were occurred in this study.

CONCLUSION

Endoscopic approach with anterior ethmoid sinus mucosal and posterior lacrimal sac flap anastomosing is a good choice for patients with recurrent epiphora after previous failed DCR.

Late endoscopic evaluation of the ostium size after external dacryocystorhinostomy

OBJECTIVE

To evaluate the effect of chronicity on the size of the ostium after external dacryocystorhinostomy (DCR) with intubation.

METHODS

Design: A retrospective chart review of patients who underwent external DCR with intubation over 10 years from January 2003 at a tertiary hospital. All patients were recruited and examined with rigid nasal endoscope.

RESULTS

A total number of 66 (85 eyes) patients were included. The mean age at the time of evaluation was 53.1 years with gender distribution of 54 females (81.8 %). The mean duration ±SD between the date of surgery and the date of evaluation was 33.2 ± 33.6 (6-118 months). Our study showed an overall anatomical and functional success of 98.8% and 95.3%, respectively. The mean size of the ostium (±SD) was 23.0 (±15.7) mm² (ranging from 1 to 80.4 mm²). The size of the ostium was not a significant factor for failure (p = 0.907). No statistically significant correlation was found between the long-term duration after surgery and the size of the ostium (R: 0.025, p = 0.157).

CONCLUSIONS

Nasal endoscopy after DCR is valuable in evaluating the ostium with no observed potential correlation between the long-term follow-up after surgery and the size of the ostium.

Endoscopic endonasal balloon-dacryoplasty in failed dacryocystorhinostomy

OBJECTIVE

Endoscopic endonasal balloon-assisted dacryoplasty is a minimally-invasive surgical procedure that can be used in recurrent epiphora, a common pathology in both adulthood and childhood.

STUDY DESIGN/SETTINGS

We present a retrospective case series of eight patients who underwent trans-nasal balloon-assisted dacryoplasty after a failed external or endoscopic dacryocystorhinostomy, from March 2019 to January 2020, at the Department of Otolaryngology, San Raffaele Hospital, Milan, Italy.

SUBJECTS AND METHODS

All patients underwent routine preoperative work-up including fluorescein test (Jones test I-II), probing and irrigation of the lacrimal pathway and nasal endoscopy. Because of the recurrent nature of the pathology, pre-operatory computed tomography scan or dacryocystography was not performed. The surgical procedure was based on enlargement of the stenotic neorhinostomy created by primary dacryocystorhinostomy through the use of a high-pressure balloon catheter. Anatomical success was defined as a patent ostium on irrigation, whereas functional success was defined as free lacrimal flow on functional test and resolution of epiphora.

RESULTS

Anatomic and functional success was achieved in 100% of patients. Operative time ranged from 9 to 22 min (mean 16 min). No significant complications were reported.

CONCLUSION

Our results indicate that trans-nasal balloon-assisted dacryoplasty can be considered as a safe and reliable surgical approach after a failed primary dacryocystorhinostomy. The shorter surgical time and reduced post-operative complication rates are the main advantages of this procedure.

Long-term Outcomes for Revision Endoscopic Dacryocystorhinostomy-The Effect of the Primary Approach

OBJECTIVES/HYPOTHESIS

Revision endoscopic dacryocystorhinostomy (END-DCR) is the preferred approach for failed primary surgeries, yet quality data on long-term outcomes are lacking. This study aimed to evaluate three aspects of revision END-DCR: 5-year success rates, patient satisfaction, and the primary surgical approach's possible impact on revision.

METHODS

This retrospective study included all revision END-DCRs conducted at Kaplan Medical Center between the years 2002 and 2015. For long-term follow-up analysis, two subgroups of first and second revision END-DCRs with a minimum of documented 5-year follow-up after surgery were defined. Data were analyzed according to the primary surgical approach. Surgical success was defined by either anatomical (observed patent lacrimal flow) or functional (symptoms cessation) success. Patient satisfaction was measured by a questionnaire.

RESULTS

After exclusions, a total of 45 eyes from 38 patients who underwent revision END-DCR surgeries were included in the study. The yearly success rates from immediate to 5 years following the first revision were 93.3%, 75.5%, 71.1%, 68.9%, 68.9%, and 68.9% for the entire cohort, respectively. Immediate and 5-year success rates following the second revision were 88.8% and 77.8%, respectively. Primary END-DCR showed favorable 5-year success rates and patient satisfaction over primary external dacryocystorhinostomy (EXT-DCR) in both first and second revisions, but this did not reach significance.

CONCLUSIONS

Revision END-DCR carries an excellent short-term success rate, which decreases mainly throughout the first 2 years following surgery. Postoperative follow-up should be maintained within this timeframe. Revision END-DCR following either primary endoscopic or EXT-DCR produces comparable surgical outcomes and patient-reported satisfaction.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:E682-E688, 2021.

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.

[Intraoperative prevention of dacryocystitis relapse]

The article reviews the literature devoted to modern intraoperative methods of preventing cicatricial process at the site of dacryostoma after endonasal endoscopic dacryocystorhinostomy. Despite the constant improvement of the surgery technique, complications in the postoperative period still occur. They include the formation of granulation tissue at the sites of dacryostoma, synechiae in the nasal cavity, or narrowing of the dacryostoma, which ultimately leads to a relapse of the disease. The main prevention methods are construction of flaps from the medial wall of the lacrimal sac, from mucosa of the nasal cavity, and intubation of the dacryostoma with the lacrimal implant. They are used separately and in various combinations.

Comparing Outcomes of the Standard Technique of Endoscopic DCR with Its Modifications: A Retrospective Analysis

Objective

To compare the outcomes of various techniques of endoscopic dacryocystorhinostomy (DCR).

Study Design

Retrospective case record analysis.

Settings

Tertiary care referral center.

Subject and Methods

Retrospective analysis of case records was carried out pertaining to the period from January 1996 to September 2017 with respect to patients who had undergone endoscopic DCR with either the standard technique or one of its modifications. Case notes showing well-documented preoperative evaluation, operative details, postoperative assessment, and minimum 6-month follow-up were considered. The outcomes were measured on the basis of patients’ postoperative symptoms, clinical examination, and sac-syringing results.

Results

A total of 423 patients were included in the study. Of these, 169 underwent standard endoscopic DCR; 87, endoscopic DCR with stent; 19, endoscopic DCR with mitomycin C; 62, powered DCR; 29, laser-assisted DCR; and 57, balloon DCR. There was no statistically significant difference in success rates, recurrences, or complications of various techniques at 3 or 6 months. Mean operating time was lowest for balloon DCR (mean ± SD, 27.1 ± 3.1 minutes), followed by standard endoscopic DCR (38.2 ± 3.6 minutes; P = .001).

Conclusion

Standard endoscopic DCR and its more sophisticated modifications were equally effective and safe in managing distal nasolacrimal drainage obstruction. Balloon DCR, followed by standard endoscopic DCR, was significantly faster than other techniques.

Does long-term success from endoscopic DCR correlate with early post-operative reduction in tearing?

PURPOSE

The purpose of the study was to determine the association between early post-operative improvement in tearing and the long-term success rate of endoscopic dacryocystorhinostomy (eDCR).

METHODS

A retrospective review of consecutive patients who underwent eDCR and were followed up for at least 6 months at our institution from January 2010 to December 2017 was performed.

RESULTS

47 cases(39 patients) of eDCR met the inclusion and exclusion criteria during this time period. Mean follow up after the surgery was 12.5 ± 8 months. In 45 out of 47 (96%) cases post-operative improvement in epiphora within 2 weeks of surgery, or lack thereof, correlated with long-term success or failure of the procedure. There were only 2 cases in which the patients felt improvement in tearing at the initial post-operative visit and the tearing recurred in the late post-operative period (>6 months).

CONCLUSIONS

There is a strong association between the early initial post-operative assessment of tearing resolution and the long-term result of eDCR.

Endoscopic-Powered Dacryocystorhinostomy Without Stenting: Long-term Outcomes of 120 Procedures

Background The necessity of silicone stenting in endoscopic dacryocystorhinostomy (DCR) procedures is a controversial subject in the literature. Objective The purpose of the present study is to assess the long-term anatomical and functional outcomes of endoscopic-powered DCR (EP-DCR) without stenting or mucosal flaps. Methods One hundred twenty EP-DCR procedures were performed in 107 patients. Anatomical success was defined as a patent ostium on irrigation and functional success as free flow of dye from the ostium and resolution of epiphora. Results The mean follow-up was 46.5 months (range: 24-87). Of the 120 procedures, 13 were bilateral and 94 were unilateral. Anatomical and functional success rates of 92.5% were obtained. Conclusion EP-DCR without stenting is a safe and economic technique that provides satisfactory long-term results and could be considered as the treatment of choice for patients with postsaccal nasolacrimal duct obstruction.

Revision eDCR using a superior pedicled mucosal flap

BACKGROUND

Endoscopic dacryocystorhinostomies (eDCRs) show patency rates between 81% and 94%. However, dacryocystorhinostomy (DCR) failure and the need for revision remain a significant challenge. One of the principal challenges in revision eDCR is the need to surgically identify the correct osteotomy site and maintain long-term patency in the setting of previously instrumented and potentially scarred tissue. At the same time, the surgeon must assume that the blood supply to the commonly described anterior and posteriorly pedicled flaps has been compromised.

OBJECTIVE

The objective of the study is to describe a novel flap technique for revision eDCR.

METHODS

The superior based mucosal flap is a novel technique that provides a vascularized mucosa preserving technique in revision eDCR despite previous instrumentation of the lacrimal system. This technique provides wide exposure of the revision osteotomy site while simultaneously allowing a viable mucosal flap to be replaced at the conclusion of the procedure, thereby minimizing bone exposure and cicatricial restenosis.

RESULTS

The authors have utilized this technique in 13 procedures with 100% positive identification of the lacrimal sac, a 0% complication rate, and a 100% success rate after a mean follow-up of 26.93 ± 10.33 months (range 6-35 months).

CONCLUSION

The eDCR using the superior pedicled mucosal flap provides excellent exposure of the maxillary bone and the lacrimal sac. This method preserves vascularity of the flap using a superiorly based pedicle which is typically inviolate during both open and endoscopic primary DCR. The mucosal flap can then be replaced, thereby minimizing bone exposure and optimizing patency.

Comparison of balloon dacryocystorhinostomy with conventional endonasal endoscopic dacryocystorhinostomy for relief of acquired distal nasolacrimal drainage obstruction and its impact on quality of life: A prospective, randomized, controlled study

Background

We compared balloon dacryocystorhinostomy with conventional endoscopic dacryocystorhinostomy for the management of acquired distal nasolacrimal obstruction and the quality of life post procedure.

Methods

98 patients, aged 10-73 years, were recruited and randomized into 2 groups of 49 each who underwent conventional endoscopic dacryocystorhinostomy (group 1) and 9 mm balloon assisted endoscopic dacryocystorhinostomy (group 2). Follow-up sessions were conducted at 3, 6 and 12 months post-op.

Results

Group 2 showed significantly shorter mean operative time (25.10 min versus 29.82; p < 0.001), lesser pain in the post-op evening (mean 2.12 versus 2.9 on NRS-11 pain scale; p < 0.001) as well as on first post-op day (mean 1.08 versus 1.73; p < 0.001). Success was achieved in 89.79% in group 1 and 93.87% in group 2 at 3 months (p = 0.46) which declined due to recurrences to 85.71% and 87.75% respectively at 12 months (p = 0.76). Complications occurred in 14 cases in group 1 and in 10 cases in group 2 (p = 0.34). All were minor. Mean GBI scores (for quality of life assessment) at 12 months follow-up were 27.20 and 28.38 respectively (p = 0.08).

Conclusion

The efficacy, safety and quality of life of balloon dacryocystorhinostomy and conventional endoscopic dacryocystorhinostomy were comparable. In addition, balloon dacryocystorhinostomy had significantly shorter operative time and lesser post-op pain.

Double Posterior Based Flap Technique in Primary Endoscopic Dacryocystorhinostomy With and Without Using Powered Instrument

To demonstrate the surgical technique and outcomes of double posterior based flap technique in primary endoscopic dacryocystorhinostomy (DCR) with and without use of powered instrument. 28 patients of nasolacrimal duct obstruction were included in the study from September 2012 to February 2015. All underwent endoscopic dacryocystorhinostomy with double posterior based nasal and lacrimal flap technique. In patients of group A (14 patients), bone removal was done with the help of Smith-Kerrison punch forceps and in patients of group B (14 patients), powered drill has been used for the same. Patients were visited the endoscopic clinic at 1, 3, 6 months and 1 year after the surgery for post operative evaluation. Of 28 patients, 26(92.85%) were found free of symptoms at the end of 1, 3 and at 6 months. One from each group had recurrence of symptoms. At the end of 12 months of 25 patients, 3(12%) patients were found to have recurrence of symptoms of which 1(8.33%) patients was from group A and 2(15.38%) were from group B and failures were because of granulation tissue and stomal stenosis. Patients assisted with powered drill had more postoperative complications compared to cold instrument. Double posterior based flap technique in primary endoscopic DCR without the assistance of powered drill could be an effective surgical option for the patients of chronic nasolacrimal duct obstruction enabling early epithelisation by preventing peristomal granulation tissue resulting in encouraging surgical outcome with least postoperative complication.

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.

A Modified Preserved Nasal and Lacrimal Flap Technique in Endoscopic Dacryocystorhinostomy

Here we describe a modified preserved nasal and lacrimal mucosal flap technique in endonasal endoscopic dacryocystorhinostomy (EES-DCR) for patients with epiphora secondary to primary acquired nasolacrimal duct obstruction (PANDO) and evaluate its outcomes. Twenty-five patients with PANDO were retrospectively reviewed. Modified preserved nasal and lacrimal mucosal flap technique in EES-DCR was applied in all 27 eyes of 25 patients. The patients were evaluated with objective (anatomical patency) and subjective (symptomatic cure) success rates within the duration of follow-up. In the present study, all of the patients’ surgical procedures were successful. There were 2 cases of flap dislocation from the rhinostomy site 1 week post-operation. After a mean follow-up of 4.9 ± 1.8 months, the success rate of anatomical patency was 100% (27/27) and the success rate of symptomatic cure was 92.6% (25/27). No significant complications occurred intraoperatively. We concluded that the modified preserved nasal and lacrimal mucosal flap technique in EES-DCR for treating PANDO is simple and safe, can effectively cover the bare bone around the opened sac, and provide a similar or even better clinical outcome compared with other routine treatment techniques used for this condition.

Success Rate of Conventional Dacryocystorhinostomy in Post-acute Dacryocystitis Compared to Endonasal Dacryocystorhinostomy in Acute Dacryocystitis

Purpose:

To determine the success rate of conventional dacryocystorhinostomy (DCR) and endoscopic DCR performed in patients with acute dacryocystitis.

Methods:

Records of patients with acute dacryocystitis and operated during 2007–2008 were reviewed. Patients who completed a follow-up of 60 months were included in our study. Demographic characteristics, surgery types, success rate, and follow-up periods were recorded. Success was defined as the elimination of epiphora, absence of dacryocystitis, and negative syringing test result (i.e., unrestricted flow of irrigated saline to the nose).

Results:

A total of 67 patients were operated during the period. Fifty-seven patients completed the follow-up of 60 months. The mean age in the conventional and endoscopic groups was 39.5 ± 8.5 and 39.5 ± 8.4 years, respectively. The participants included 33 female and 24 male patients. Endoscopic DCR was performed in 28 (endoscopic group) and conventional DCR (conventional group) in 29 patients. Conventional DCR was performed after subsidence of the acute attack, which took an average of 10 days (range, 9–19 days). After a period of 60 months, patency on syringing and resolution of epiphora was documented in 26 patients in the conventional group (success rate, 89.7%) and 23 patients in the endonasal group (success rate, 82.1%) (P = 0.654).

Conclusion:

The success rates of conventional and endonasal DCR during a follow-up period of five years in patients with acute dacryocystitis are almost similar.

Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review

BACKGROUND

Historically dacryocystorhinostomy (DCR) has been performed externally with very good outcomes. Current literature shows comparable success rates between endonasal and external approaches. A common reason for the failure of a DCR is the reclosure of the nasolacrimal stoma by granulation tissue and synechiae.

OBJECTIVE OF REVIEW

A systematic review and critical evaluation of the evidence relating to the preservation of nasal mucosal flaps in DCR surgery.

TYPE OF REVIEW AND EVALUATION METHOD

A systematic review using the consort guidance for review of randomised control trials.

SEARCH STRATEGY

A search of the following evidence-based medicine databases was performed: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, Ovid, Medline, EMBASE and PubMed. The search was limited to English language articles, and the following key words were used: Endonasal, Endoscopic, Dacryocystorhinostomy, DCR, Mucosal Flaps, between years 1970 and 2015.

RESULTS

The best available evidence was level 1B, comprising two randomised control trials and three comparative studies included in the review. The main outcome measures used were lacrimal irrigation and absence of epiphora. Two of the studies demonstrated a statistically significant benefit of mucosal sparing either with nasal mucosal flaps or with lacrimal flaps. More debridement was needed, and granulation tissue was also seen in the groups without mucosal preservation. There was no difference in surgical complications between a mucosal and non-mucosal-sparing technique.

CONCLUSIONS

The overall quality of current evidence is poor, and there does however appear to be a trend towards improved outcomes and reduced granulation in groups where nasal mucosal and lacrimal flaps were preserved, but this is not clear-cut. There was no evidence of increased complication rates with mucosal-sparing techniques. We recommend that until further good quality research is available we should be performing a mucosal-sparing technique when performing DCR routinely.

Anatomical and subjective success rates of endonasal dacryocystorhinostomy over a seven-year period

PurposeEndonasal dacryocystorhinostomy (END-DCR) is a relatively novel approach that has recently been shown in some studies to provide similar success rates to the more traditional external approach for the treatment of nasolacrimal duct obstruction (NLDO). However, a range of success rates using this approach are reported within the literature and the majority of oculoplastic surgeons are still favouring the external approach. The purpose of this study was to review the anatomical and subjective success rates of END-DCRs performed over a 7-year period.Patients and methodsWe provide a review of the success rates of 288 END-DCRs for the treatment of acquired NLDO performed over a 7-year period by a single oculoplastic surgeon in Sydney, Australia. We describe the operative technique used and define anatomical success as demonstrated patency of the nasolacrimal drainage system at 10 weeks postoperatively while subjective success is defined as complete resolution or significant improvement of symptoms as reported by patients at the same time point.ResultsIn our study, we were able to demonstrate that out of 288 END-DCRs, an average anatomical success rate of 89.6% and an average subjective success rate of 81.3% were achievable.ConclusionsWe conclude that the success rates using our endonasal approach remain similar to those obtained using the external approach, as reported within the literature, and may be considered as a primary treatment option for acquired NLDO.

External Versus Endoscopic Endonasal Dacryocystorhinostomy

DCR is the treatment of choice for NLDO. External DCR has remained the standard approach since the 1890s. With advances in technique and technology, and more otolaryngologists and ophthalmologists performing endoscopic DCR, more studies have been conducted, some with equivalent success rates between the 2 approaches. Endoscopic endonasal DCR offers the advantages of avoiding a skin incision with similar success rates with experienced surgeons. However, the technique necessitates more surgical equipment, and has a steep learning curve. Both approaches have low complication rates and serious complications are very rare. The decision for the type of approach to use depends on the surgeon’s experience, the patient’s preference or concerns, and the resources available within a particular health system.

Comparison of impact of four surgical methods on surgical outcomes in endoscopic dacryocystorhinostomy

PURPOSE

To evaluate differences in the surgical outcomes of endoscopic dacryocystorhinostomy (DCR) according to four different surgical methods.

MATERIAL AND METHODS

This retrospective study included 222 patients who underwent endoscopic DCR from 2011 to 2013. All patients were assigned to one of four groups according to instruments for incision of nasal mucosa and the formation of mucosal flap: group 1, a sickle knife with mucosal flap; group 2, a sickle knife without mucosal flap; group 3, electrocautery with mucosal flap; and group 4, electrocautery without mucosal flap. The follow up period was at least 6 months.

RESULTS

There were 33 eyes in group 1, 44 eyes in group 2, 49 eyes in group 3, and 97 eyes in group 4. There were no significant differences in success rate between groups (P = 0.878). Wound healing time was significantly different between groups (P < 0.001). In post hoc analysis, wound healing time was significantly shorter in group 1 and group 2 than in group 3 and group 4. The vertical ostium size and postsurgical complication were not significantly different between groups.

CONCLUSIONS

The use of cold instruments such as sickle knife may be more helpful and effective for shortening wound healing time rather than making mucosal flaps in endoscopic DCR.

Endoscopic dacryocystorhinostomy with silicone, polypropylene, and T-tube stents; randomized controlled trial of efficacy and safety

OBJECTIVE

To compare the efficacy and safety of endoscopic dacryocystorhinostomy (En-DCR) with different stent materials for lacrimal sac intubation in primary nasolacrimal ductal obstructions.

STUDY DESIGN

Randomized controlled study with three parallel groups. Level of evidence is 1b.

METHODS

A total of 91 patients (five bilateral) with primary nasolacrimal duct obstruction (NLDO) at a tertiary referral center scheduled for En-DCR were to allocated into three stent groups with a sealed envelope and were randomized into three treatments: silicone, Prolene (polypropylene), and otologic T-tube. Ophthalmology and otolaryngology clinics evaluated the patients preoperatively and postoperatively with endoscopes, lacrimal system syringing, and dacryocystography. The success of the stents was evaluated 12 months after surgery with symptom relief and ostial patency. Complications were also noted.

RESULTS

The overall success rate of the En-DCR in the stent groups was 78.1% (75/96); specifically, 87.5% (28/32) with silicone, 84.4% (27/32) with Prolene, and 62.5% (20/32) with T-tube. The efficacy of the procedures with the T-tube was significantly lower than that of the Prolene and silicone (p = .031, χ(2) test). There were no significant differences between the silicone and Prolene (p = .718, χ(2) test). Prolene was found to be related with orbital complications. Spontaneous loss is a particular complication of otologic T-tube and highly portends to failure.

CONCLUSIONS

The results of our study suggest that efficacy, defined as anatomic and functional success, is equally high for silicone and Prolene stents and lower for otologic T-tube in En-DCR.

Endoscopic vs external dacryocystorhinostomy-comparison from the patients' aspect

AIM

To compare the success and complication rates, duration of surgeries and clinical comfort after endoscopic dacryocystorhinostomy (END-DCR) or external dacryocystorhinostomy (EXT-DCR).

METHODS

Fifty patients who underwent EXT- or END-DCR between January 2010-2012 were involved in the study. A questionnaire was applied to patients preoperatively, and postoperatively. Subjective success was defined by absence of epiphora, objective success by a normal nasolacrimal lavage and a positive functional endoscopic dye test (FEDT). Postoperative pain and cosmetic result of surgery were interpreted by the patients, who were also asked whether they would offer this surgery to a friend or would prefer this surgery once more if necessary.

RESULTS

Twenty-five patients underwent END-DCR and 25 underwent EXT-DCR. Mean duration of surgeries were 35min both for EXT-DCR (30-50) and END-DCR (35-50) (P=0.778). Intraoperative bleeding were documented in 48% of EXT-DCR and 4% of END-DCR cases (P<0.001). In total 96% of EXT-DCR and 100% of END-DCR patients had subjective success. Objective success was 100% in each group. There was no significant difference between the epiphora scorings and FDDT results in postoperative visits among the groups. END-DCR group reported less pain in first week and month (P<0.05, P<0.05). More patients in END-DCR group were happy with the cosmetic result in first week and month (P<0.001, P<0.001). More patients in END-DCR group offered this surgery to a friend (P<0.001). All patients in END-DCR group preferred this surgery once more if necessary, only 48% in EXT-DCR preferred the same method (P<0.001).

CONCLUSION

Although both END- and EXT-DCRs provide satisfactory outcomes with similar objective and subjective success rates, we demonstrated that the endonasal approach caused significantly less pain in early postoperative period than the external approach. Clinical comfort defined by the patients was quite higher in END-DCR group, in which patients mainly were pleased to encounter a sutureless surgical area.

[Comparison of 3T dacryo-MRI by instillation with dacryo-CT scan for evaluation of epiphora]

OBJECTIVES

Epiphora is frequently related to stenosis of the lacrimal drainage pathways. In the evaluation of stenosis, dacryo-CT scan remains the gold standard, despite the need for radiation and catheterization of the lacrimal passages. Evaluation by high field 3T MRI compared to the gold standard in the morphological study of the lacrimal passages and quantification of the stenosis is attractive considering the lack of radiation and non-invasive nature of the technique.

METHODS

Twenty-four patients were included, including 9 with bilateral epiphora, representing 33 pathological drainage systems out of 48. Twenty-three drainage systems underwent subsequent surgery (18 patients, 5 patients bilaterally).

RESULTS

The average diameter on CT scan images of the superior canaliculus was 0.70 mm (± 0.46), of the inferior canaliculus 0.69 (±0.42), the common canaliculus 0.68 (± 0.58), the lacrimal sac 4.32 (± 2.10), and the nasolacrimal duct 1.15 mm (±1.42). 3T dacryo-MRI overestimated the diameters by 0.35 to 1mm (up to 20 % of the lacrimal sac size), and the concordance between dacryo-CT scan and 3T dacryo-MRI was of average value (kappa 0.5, P<0.05) concerning the diagnosis of stenosis. Furthermore, dacryo-CT scan demonstrated higher sensitivity (72.7 %) than 3T dacryo-MRI (42.4 %).

CONCLUSIONS

The two techniques are not equivalent in the diagnosis of stenosis. An optimization of protocols and an evaluation on a larger cohort remain necessary before dacryo-CT scan can be replaced by dacryo-MRI in routine practice.

Outcomes of endonasal dacryocystorhinostomy without mucosal flap preservation

PURPOSE

Dacryocystorhinostomy (DCR) is the standard procedure for the treatment of acquired nasolacrimal duct obstruction (NLDO) that can be performed through an external or endonasal approach. Both techniques create a fistula from the lacrimal sac into the nasal cavity via a bony osteotomy. Historically, external DCR has been considered the gold standard; however, recent reports suggest endonasal DCR is an effective alternative. There are numerous variations of endonasal DCR described in the literature that report variable success rates. The purpose of this study is to describe the approach and success rate with endonasal DCR in which nasal mucosa, bone, and lacrimal sac mucosa are sequentially removed.

METHODS

The authors retrospectively reviewed cases of endonasal DCR from 2004 to 2011 from 2 institutions (the University of California, San Diego, California, and the Fante Eye and Face Center in Denver, Colorado, U.S.A.). Patients with a history of epiphora and NLDO confirmed with punctal irrigation were included. Exclusion criteria were the presence of canalicular obstruction, history of orbital trauma, and prior DCR surgery. Success was defined as subjective relief of epiphora and confirmation of ostium patency with irrigation.

RESULTS

A total of 324 patients (74 men, 250 women; mean age 59.3) encompassing 407 endonasal DCR cases were included in the study. The total case success rate was 92.2% with an average follow-up time of 91.5 days. Revision surgery was performed in 7 of the failed cases and resulted in success in 6 of these cases.

CONCLUSIONS

Endonasal DCR is a simple and effective approach to surgically treat NLDO and offers success rates comparable with external DCR.

Anatomic study of the lacrimal fossa and lacrimal pathway for bypass surgery with autogenous tissue grafting

Purpose:

To study the microsurgical anatomy of the lacrimal drainage system and to provide anatomical evidence for transnasal endoscopic lacrimal drainage system bypass surgery by autogenous tissue grafting.

Materials and Methods:

A total of 20 Chinese adult cadaveric heads in 10% formaldehyde, comprising 40 lacrimal ducts were used. The middle third section of the specimens were examined for the following features: the thickness of the lacrimal fossa at the anterior lacrimal crest, vertical middle line, and posterior lacrimal crest; the cross section of the upper opening, middle part, and lower opening of the nasolacrimal canal; the horizontal, 30° oblique, and 45° oblique distances from the lacrimal caruncle to the nasal cavity; the distance from the lacrimal caruncle to the upper opening of the nasolacrimal duct; and the included angle between the lacrimal caruncle–nasolacrimal duct upper opening junction and Aeby's plane.

Results:

The middle third of the anterior lacrimal crest was significantly thicker than the vertical middle line and the posterior lacrimal crest (P > 0.05). The horizontal distance, 30° oblique distance, and 45° oblique distance from the lacrimal caruncle to the nasal cavity exhibited no significant differences (P > 0.05). The included angle between the lacrimal caruncle and the lateral wall middle point of the superior opening line of the nasolacrimal duct and Aeby's plane was average (49.9° ± 1.8°).

Conclusion:

The creation of the bony tunnel should start from the middle or posterior middle part of the lacrimal fossa, extending toward the anterior inferior region with an optimal downward oblique angle of 45°.

Endonasal dacryocystorhinostomy with mucosal flaps: our experience

The endoscopic dacryocystorhinostomy (DCR) has distinct advantage over external DCR. There is no ugly scar on the face, less intraoperative bleeding, it is a daycare procedure and patient is discharged on the same day evening. Endoscopic DCR is considered to be a superior alternative technique to the conventional external DCR. Patients diagnosed with nasolacrimal duct obstruction between Jan 2009 and Jan 2011 were included in the study. One hundred and twenty endo DCR were performed with conventional 'cold steel' instruments. The technique involved complete exposure and marsupialization of the lacrimal sac. The surgical technique involved the creation of nasal mucosal and large posterior lacrimal flaps at the medial lacrimal sac wall and the two flaps were placed in close apposition. Success was defined as complete resolution of epiphora and a patent lacrimal system, evaluated by lacrimal irrigation and endoscopy, 1 year postoperatively.

New mucosal flap modification for endonasal endoscopic dacryocystorhinostomy in Asians

AIM

To describe a simple modification of fashioning the mucosal flap for endonasal endoscopic dacryocystorhinostomy (EES-DCR) in Asians and investigate its efficacy.

METHODS

A total of 120 patients with unilateral primary chronic dacryocystitis (PCD) were randomized into two groups: the new shaped nasal mucosal flap group (group A) and the removed nasal mucosal flap group (group B). All patients underwent standard EES-DCR. Patients in group A were performed a new shaped nasal mucosal flap covering the bared bone around the opened sac and those in group B was removed the nasal mucosal flap uncovering the bared bone. Patients were followed up for one year. The occurrence of granulation tissue, the proliferation of scar tissue and success rate of EES-DCR was compared.

RESULTS

In the present study, complete postoperative data were acquired from 54 patients in group A and from 57 patients in group B. During process of review, the occurrence of granulation tissue was at the ostium margins account for 15% (8/54) in group A and 39% (22/57) in group B (P<0.05). At the one-year review, scar tissue was present in 5 patients in group A compared with 18 in group B (P<0.05). The success rate of EES-DCR was 98% (53/54) in group A and 84% (48/57) in group B (P<0.05).

CONCLUSION

The simple modification of fashioning nasal mucosal flap can effectively cover the bared bone around the opened sac and reduce formation of granulation tissue, lessen the risk of scar tissue formation and closure of ostium, thus improve the success rate of EES-DCR in Asians.

A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction

PURPOSE

To compare success rates of external dacryocystorhinostomy (DCR) and endoscopic endonasal DCR for acquired nasolacrimal duct obstruction (NLDO).

DESIGN

Historical cohort study.

PARTICIPANTS

100 patients who underwent external DCR and 105 patients who underwent endoscopic endonasal DCR.

METHODS

A retrospective review of medical records of patients with acquired NLDO who underwent DCR from 2004-2010 was performed. Data regarding the lacrimal drainage system, eye examination, surgical outcomes, patient symptom control, and postoperative care were analyzed.

MAIN OUTCOME MEASURES

Surgical success was defined by patient's resolution of symptoms with patency on irrigation. Surgical failure was defined as no symptomatic reduction in epiphora and/or an inability to irrigate the lacrimal system postoperatively.

RESULTS

A total of 205 patients underwent surgeries for acquired NLDO. The average age was 69 years, and 62.4% of subjects were female. Pooled results showed that both surgical approaches had similar success rates (endoscopic endonasal DCR 82.4% versus external DCR 81.6%; P = 0.895). Complication rates were low in both types of surgery. This included three patients with postoperative hemorrhage (two who had endonasal DCR surgery and one having external DCR surgery). This resolved with conservative treatment. Postoperative problems with lacrimal patency (including canalicular obstruction) occurred to 6.8% of endoscopic patients and 9% of those with the external DCR surgery. Of the 14 patients who had their silicone tubes fall out before the 2-month assessment, 10 were classified as failures (71%), in contrast to only a failure rate of 13.9% of those whose tubes were present for the recommended time. This difference was statistically significant (P < 0.01).

CONCLUSION

The success rate of DCR for acquired NLDO in our group of patients was high overall with a low complication rate between the two types of surgery. There was no statistically significant difference between endoscopic and external DCR. Endoscopic surgery may have a benefit of preserving the lacrimal pump system and leaving no surgical scar. Patient preference and availability of each service should direct management. Hence endoscopic endonasal DCR surgery should be considered for primary treatment of nasolacrimal duct obstruction.

Effects of Merogel coverage on wound healing and ostial patency in endonasal endoscopic dacryocystorhinostomy for primary chronic dacryocystitis

PURPOSE

To investigate the effects of Merogel coverage on ostial patency in endonasal endoscopic dacryocystorhinostomy (EES-DCR) for primary chronic dacryocystitis (PCD).

METHODS

In all, 260 patients with unilateral PCD were randomized into two groups: the Merogel group and the control group. All patients underwent EES-DCR. The Merogel group received Merogel covering the wound 1-2 mm around the ostium and the control group received no treatment. Patients were followed up for 9 months. The mucosal epithelialization of the wound, the proliferation of fibrosis tissue, and the success rate of ostial patency were compared.

RESULTS

Our study included 112 patients in the Merogel group and 115 patients in the control group. At the 2-week review, intact mucosal epithelium lined the ostia in 96 Merogel patients compared with 80 control patients (ITT analysis: χ(2)=4.502, P=0.034). At the 9-month review, scars were present in 18 patients in the Merogel group compared with 39 patients in the control group (ITT analysis: χ(2)=9.909, P=0.002, ITT analysis). No differences were observed in the granulation formation between the two groups. The success rate of ostial patency reached 94.6% (106/112) in the Merogel group compared with 80% (92/115) in the control group (ITT analysis: χ(2)=4.151, P=0.042).

CONCLUSION

Merogel coverage may enhance the success rate of EES-DCR for PCD by promoting mucosal epithelial healing and preventing excessive scarring.