A clinical trial of endoscopic vs external dacryocystorhinostomy for partial nasolacrimal duct obstruction

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.

Functional epiphora: an under-reported entity

PURPOSE

To determine the etiology of epiphora in a tertiary Australian lacrimal clinic and highlight the high proportion of 'functional' cases.

METHODS

Single-center retrospective review: Records of adult patients presenting to a tertiary lacrimal clinic from January 2011 to February 2021 with epiphora were reviewed. Patients underwent testing with syringing/probing and lacrimal imaging to reach a diagnosis of functional epiphora. Functional epiphora was diagnosed based on the exclusion of alternate causes of epiphora on clinical examination, patent lacrimal syringing, normal dacryocystography, and delay on dacryoscintigraphy.

RESULTS

Five hundred and seventy-six symptomatic eyes of 372 adult patients (mean 66.2 ± 15.5 years, 63.4% females) with epiphora were evaluated for causes. Post-sac obstruction (stenosis/complete obstruction) and functional epiphora (non-anatomical delay) were the most common causes of presentations to the lacrimal clinic (26% each). Functional epiphora with post-sac delay was substantially more common than functional epiphora with pre-sac delay (89% vs. 11% of functional epiphora cases). In 16% of the cases, no cause for the epiphora was found while more than one cause (multifactorial) was present 11% of the time.

CONCLUSION

Functional epiphora was found to be as common as a nasolacrimal anatomical obstruction when lacrimal imaging is utilized.

DCR for nasolacrimal duct stenosis may be less effective than for complete obstruction

OBJECTIVES

To ascertain the success of endo-DCR in nasolacrimal duct stenosis (NLDS) versus nasolacrimal duct obstruction (NLDO).

METHODS

Consecutive adult patients with epiphora attending a tertiary lacrimal clinic from February 2012 to February 2021 were reviewed. NLDS was diagnosed by patent lacrimal syringing and combined dacryocystography (NLD stenosis) and dacryoscintigraphy (post-sac delay) findings in all eyes. Cases with evidence of canalicular stenosis or other identifiable causes of epiphora were excluded. The epiphora resolution and improvement rates following endo-DCR were compared between NLDS and complete NLDO cases.

RESULTS

DCRs in 24 NLDS (23 patients, 69.6% females, mean age 61.0 ± 17.07) and 58 NLDO (56 patients, 69.6% females, mean age 61.9 ± 17.4) were included. Resolution of epiphora was achieved in 10 (41.7% [95% CI 0.24-0.61]) of the NLDS cases compared to 40 (69.0% [95% CI 0.56-0.79]) in NLDO (p = 0.021). Improvement of epiphora (i.e., either improvement or resolution) was noted in 17 (70.8% [95% CI 0.51-0.85]) of NLDS and 53 (91.4% [95% CI 0.81-0.96]) of NLDO cases (p = 0.034). Three patients (12.5%) with NLDS had subsequent lacrimal procedures (one DCR revision, two Jones tube) at a median of 14 (range 11-21) months. 71.4% of the NLDS patients responded to a phone questionnaire at a median of 93 months postoperatively. Of these, 46.7% reported resolution or significant improvement, and 33.3% reported slight improvement. 64.3% said they would recommend DCR to others suffering from epiphora.

CONCLUSION

Endo-DCR may benefit approximately 70% of patients with NLDS. The success of endo-DCR in complete NLDO may be higher.

Functional Versus Anatomical Nasolacrimal Obstruction: Are There Differences in Epiphora Severity, Symptoms, or Effects on Quality of Life?

PURPOSE

To elucidate whether the specific cause of nasolacrimal duct drainage impairment impacts the severity, symptoms, and implications on visual tasks and quality of life (QOL) in epiphora.

METHODS

A retrospective review of consecutive adult patients with epiphora attending a tertiary lacrimal clinic from June 2011 to March 2021 was conducted. Cases with evidence of canalicular stenosis, a mucocele, or other identifiable causes of epiphora were excluded. A structured interview assessed the epiphora severity (Munk), symptomatology, precipitating factors, and effects on visual tasks and QOL. Following lacrimal syringing, all eyes were investigated with dacryocystography and dacryoscintigraphy. The domains of the interview were compared between nasolacrimal duct obstruction (NLDO), stenosis (NLDS), and nonanatomical functional delay (FNLDO).

RESULTS

One hundred twenty-two symptomatic eyes (63 patients; mean age 63.3 ± 17.2 years; 59% females) were included. There was no difference in Munk score between the groups (NLDO = 3.71 ± 0.18, NLDS = 3.79 ± 2.0, FNLDO = 3.85 ± 0.15; p = 0.82). In all 3 groups, most cases had a Munk >2 (86.8%, 75.9%, and 89.1%, respectively; p = 0.25). Discharge was more common in NLDO (65.7%) compared with NLDS (30.0%) and FNLDO (36.4%, p = 0.006). Worsening in the cold/wind was more frequent in FNLDO (77.1%) compared with NLDO (48.5%, p = 0.029). Effects on visual tasks and QOL were not significantly different.

CONCLUSIONS

FNLDO patients experience a high severity of epiphora, comparable to patients with NLDS and those with complete NLDO. The distinction between FNLDO and NLDS had little consequence on reported symptoms, precipitating factors, visual tasks, and QOL. Discharge may be more specific to NLDO, whereas precipitating cold or wind is more specific to FNLDO.

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.

Endoscopic dacryocystorhinostomy with short-term, pushed-type bicanalicular intubation vs. pulled-type monocanalicular intubation for primary acquired nasolacrimal duct obstruction

Dacryocystorhinostomy (DCR) has been a primary treatment for adults with nasolacrimal duct obstruction, while the optimal approach and technique remain controversial. With the advancement of endoscopic DCR and the silicone stents, an update of the surgical outcomes and preferable approaches is required. This study aims at comparing the surgical outcomes of endoscopic DCR using pushed bicanalicular intubation (BCI) to pulled monocanalicular intubation (MCI) in adults with primary acquired nasolacrimal duct obstruction (PANDO). Forty five eyes of 45 patients were enrolled, including 22 eyes of 22 patients treated with endoscopic DCR with pulled MCI and 23 eyes of 23 patients with pushed BCI from January 2014 to June 2021. The success rates at stent removal, 1 month and 3 months after removal were 95, 91, and 82%, respectively, in the MCI group, and 100, 87, and 87% in the BCI group. The BCI group had better success rates but failed to reach a significant difference (p = 0.49, p = 0.67, p = 0.24, respectively). After analyzing with binary logistic regression, the implant material was demonstrated as the predictive of surgical success (p = 0.045). There was no significant difference in success rates between patients with dacryocystitis and those without dacryocystitis. We conclude that endoscopic DCR with pushed BCI is easily manipulated and has a promising surgical outcome over pulled MCI. Stent indwelling duration as well as history of dacryocystitis have less influence on the success rates.

Outcomes of intubation and endoscopic DCR in functional nasolacrimal duct obstruction

BACKGROUND

To ascertain the success of lacrimal intubation and DCR in alleviating epiphora due to functional nasolacrimal duct obstruction (FNLDO).

METHODS

Consecutive adult patients with epiphora attending a tertiary lacrimal clinic from May 2010 to February 2021 were reviewed to identify cases with FNLDO. FNLDO was defined as epiphora with the exclusion of alternate causes of watering on clinical examination, patent lacrimal syringing, normal DCG, and post-sac delay on DSG. Epiphora resolution and improvement rates in FNLDO were compared between lacrimal intubation and endo-DCR.

RESULTS

23 endo-DCRs (20 patients, 65% females, mean age 68.9±12.2) and 41 intubations (29 patients, 61.2% females, mean age 65.0±14.1) performed in FNLDO were included. Resolution of epiphora was achieved in 15 of the DCR procedures (median follow-up 9 months) compared to 14 of intubations (median follow-up 10 months). Significant epiphora improvement (i.e., either improvement or resolution) was noted in 21 DCRs and 24 intubations. Seven patients undergoing intubation as the primary procedure had endo-DCR performed following the intubation. Among respondents to a phone questionnaire, 53.8% who had endo-DCR (median 69 months) and 50% that had intubation (median 28 months) reported significant improvement in epiphora.

CONCLUSIONS

Improvement in epiphora due to FNLDO was approximately 59% in intubations, while the success of endo-DCR was higher (91%). The long-term results of these interventions warrant further investigation.

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.

Pulled versus Pushed Monocanalicular Silicone Intubation in Adults with Lacrimal Drainage System Stenosis: A Comparative Case Series

Purpose

To compare the success rate and complications of pulled versus pushed monocanalicular intubation in adults with incomplete lacrimal drainage system obstruction (lacrimal drainage system stenosis).

Methods

Patients with lacrimal drainage system stenosis (Munk grade ≥3), including both nasolacrimal duct (NLD) stenosis and common canalicular stenosis, were recruited in this prospective comparative case series. Patients underwent probing and either Monoka (51 eyes) or Masterka (48 eyes) intubation under general or local anesthesia. Tubes were removed 4–14 weeks after the procedure. Six months after tube removal, Munk grades 0 and 1 were defined as a complete success, Munk grade 2 was defined as a partial success, and Munk grade ≥3 was defined as failure. All complications were recorded.

Results

Ninety-nine eyes from 89 patients with lacrimal drainage system stenosis who underwent either Monoka (51 eyes) or Masterka (48 eyes) intubation were included. The mean (SD) age of the patients was 55.4 (12) years in the Monoka group and 53.5 (12.9) in the Masterka group. Groups were matched on demographics. Masterka intubation could not be performed in one eye. Complete and partial successes were observed in 52.9% (27/51) and 17.6% (9/51) of eyes in the Monoka group and 42.6% (20/47) and 12.8% (6/47) of eyes in the Masterka group, respectively (p=0.29). There was a trend toward a higher total success rate in patients with NLD stenosis treated with Monoka 66.7% (26/39) than Masterka 45.5% (15/33) intubation (p=0.07). This trend also existed in patients with common canalicular stenosis (83.3% (10/12) vs. 76.6% (11/14), p=0.75). Age, sex, bilateral involvement, and duration of intubation did not have a significant impact on the success rate. Early tube loss, slit puncta, and temporary superficial punctate keratopathy were observed complications.

Conclusion

Intubation with the pulled monocanalicular silicone tube was associated with a slightly but not significantly higher success rate in adults with lacrimal drainage system stenosis. Patients with NLD stenosis may achieve better results with pulled silicone tubes.

Incidence of Dacryocystorhinostomy (DCR) in France: A Nationwide Study over the 2010-2019 Period

BACKGROUND

To assess the annual incidence, surgical technique preferred (i.e. external versus endonasal) and the characteristics of patients undergoing a Dacryocystorhinostomy (DCR) in France over a 10-year-period.

METHODS

A national observational cohort study was conducted in France between January 2010 and December 2019. Data were collected from the national PMSI (Programme de Médicalisation des Sytèmes d'Information) database provided by the CNAM (Caisse Nationale de l'Assurance Maladie). All patients undergoing a DCR were included.

RESULTS

Twenty-one thousand one hundred ninety-nine patients, with a mean age of 70.4 years, were included. A female predominance (78%) was noted. The mean annual number of DCRs was 2481 (2366-2633), corresponding to a mean incidence of 3.8 per 100,000 person-years. This number remained stable over the study period (p = .966). Of the 24,808 DCRs, external DCRs were more prevalent compared to endonasal procedures (70.8% vs. 29.2%, p = .0001). Six hundred and fifteen (2.5%) associated acts were performed intraoperatively, mainly during endonasal DCR (96.3%). A total of 10,857 (43.8%) silicone stents were placed intraoperatively. Bicanalicular silicone stenting was preferred over the monocanalicular stenting. All the regions performed more likely external DCR except the Île-de-France area where endonasal DCR was performed in 75.6% of procedures. DCRs were mainly performed by an ophthalmologist (80%).

CONCLUSION

The mean annual incidence of external and endonasal DCRs remained stable over the study period. Endonasal DCR was more likely performed by the otorhinolaryngologists, emphasizing the need to develop personalized endonasal training in the ophthalmology residency program.

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.

Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

[Treatment choice in dacryostenosis based on single-photon emission computed tomography and X-ray computed tomography findings]

AIM

To develop surgical indications in dacryostenosis within the vertical portion of lacrimal pathways that would consider findings of single-photon emission computed tomography (SPECT) combined with X-ray computed tomography (CT).

MATERIAL AND METHODS

A total of 96 patients with isolated vertical-portion dacryostenosis (127 cases) were enrolled. The examination included collecting Munk's scores for epiphora, optical coherence tomography of the lower tear meniscus, lacrimal scintigraphy, and SPECT/CT. Group 1 (40 cases) was composed of patients with lacrimal obstruction on CT, group 2 (87 cases) - of those whose lacrimal pathways proved passable. There were also 3 patients (4 cases) from group 1, whose lacrimal pathways, despite being blocked on CT, were still passable on SPECT. Surgeries performed in group 1 were endoscopic endonasal dacryocystorhinostomy (DCR) (36 cases) and pathways recanalization with bicanalicular intubation and balloon dacryoplasty (DCP) (4 cases). In group 2, all patients (87 cases) underwent recanalization with bicanalicular intubation (supplemented with balloon DCP in 32 cases). Surgical results were evaluated 8-12 months after the treatment. In group 2, particular attention was paid to the concordance in locations of dacryostenosis provided by CT and SPECT scans.

RESULTS

Favorable outcomes of endoscopic endonasal DCR were obtained in as many as 32 cases from group 1 (88.9%), while in 4 cases (12.1%) the condition relapsed. Of those patients whose stenosis was not complete on SPECT, 3 cases (75.0%) improved, 1 (25.0%) - relapsed. In group 2, favorable outcomes were obtained in 65 cases (74.7%), relapses were 22 (25.3%). A high concordance in stenosis locations by CT and SPECT was noted in 60 cases of those who improved (92.3%) and 3 cases of those who relapsed (13.6%).

CONCLUSION

The value of information provided by SPECT/CT has proved high in patients with nasolacrimal duct stenosis or obstruction. A combined scan allows to establish causal relationships between anatomical changes and functional failure of lacrimal pathways and to make an optimal treatment choice.

Histopathologic effects of a low molecular weight heparin on bone healing in rats: a promising adjuvant in dacryocystorhinostomy

AIM

To investigate the effect of short-term prophylactic dose of a low molecular weight heparin (LMWH) drug on the bone healing process in an animal model simulating the osteotomy obtained in dacryocystorhinostomy.

METHODS

Forty male Wistar albino rats were divided into 2 groups. Subcutaneous injections of enoxaparin 1 mg/kg (enoxaparin-treated group) and saline solution (control group) were performed once daily for 4d, beginning on the first preoperative day. The osteotomy was created at the femoral diaphysis in all animals by using a Kirschner wire. Each group was further divided into 2 subgroups depending on the timing of the second operation, 14 or 21d following initial osteotomy. Patent osteotomy area on the second and the third weeks in each group were calculated by using a computer software on digital micrographs.

RESULTS

The patent osteotomy areas at the second and the third weeks were significantly larger in the enoxaparin-treated group than those of the control group (P<0.001 for each time-period). In the control group, the patent osteotomy area at the third week of healing was significantly smaller than that of the second week (P=0.003), whereas there was no significant difference between these two measurements in the enoxaparin-treated group (P=0.185).

CONCLUSION

Short-term administration of enoxaparin resultes in a significant alteration in bone healing at 14 and 21d after injury. LMWHs can be regarded as promising alternative adjuvants in dacryocystorhinostomy after being evaluated with further clinical and animal studies.

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.

Practice patterns in endoscopic dacryocystorhinostomy: survey of the American Rhinologic Society

BACKGROUND

The introduction of advanced endoscopic techniques has facilitated significant growth in endoscopic dacryocystorhinostomy (EnDCR). The purpose of this study is to evaluate clinical practice patterns of otolaryngologists performing EnDCR.

METHODS

A 25-item survey was electronically disseminated to the American Rhinologic Society (ARS) membership from November 17, 2014 to December 14, 2014. The target group encompassed 1157 ARS members.

RESULTS

A total of 85 (7.3%) physicians completed the survey. EnDCR was performed by 87% of respondents. The annual average number of EnDCR cases ranged from 1 to 10 in 65% of respondents, 11 to 25 in 15%, 26 to 50 in 6%, and >50 in 1%. A total of 48% of respondents had some to a lot of DCR exposure during training, and 60% had completed a rhinology fellowship. Respondents frequently perform preoperative nasal endoscopy and computed tomography (CT) imaging, but very infrequently perform ophthalmologic workup. Lacrimal stents were used often or always in 80%, with 38% keeping stents in place for 6 to 8 weeks. The mucosal flap preservation technique was used often or always in 40%. Topical antimetabolites were used often or always in only 1%. Ophthalmology was present in most cases to perform lacrimal intubation. Postoperative antibiotics, topical ophthalmic steroids, and oral steroids were prescribed often or always in 62%, 47%, and 23%, respectively. Postoperative endoscopic debridement was performed often or always in 69%. A total of 81% of respondents followed DCR patients for >2 months, with 17% following these patients for >1 year.

CONCLUSION

There is widespread integration of EnDCR procedures into rhinologic clinical practice among respondents. EnDCR practice patterns demonstrate moderate variation. In conjunction with evidence-based medicine, these trends can highlight areas of controversy and help advance patient care.

Results of Endoscopic Endonasal Dacryocystorhinostomy; Necessity of Teamwork and Patient Selection

Our aim was to evaluate the clinical results of endoscopic endonasal surgical dacryocystorhinostomy (EES-DCR) as team work by an ophthalmologist and an ear-nose-throat (ENT) surgeon and the appropriate selection of the patients. All candidates for DCR underwent computed tomography (CT) scan of the paranasal sinuses (PNS). Patients who did not want a scar on the medial canthus skin or who had intranasal problems received EES-DCR, which was performed as team work by an ophthalmologist and an ENT surgeon. Surgical success was the resolution of epiphora (i.e., functional success) and free passage of the fluid on irrigation (i.e., anatomical success) by six months after surgery. One hundred twenty-eight patients underwent EES-DCR. Six months after the operation, six patients had surgical failure (three cases of anatomical failure and three cases of functional failure); the success rate was therefore 95.3%. The most common intranasal problems that led to EES-DCR were septal deviation, sinusitis, close proximity of the agger nasi to the lacrimal bone, and concha bullosa; moreover, 15.5% of patients selected EES-DCR for cosmetic reasons. In conclusion, Cooperation between ophthalmologists and ENT surgeons in the preoperative assessment of patients with epiphora before EES-DCR increases its success rate, and it can replace external DCR in some patients.

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.

Evaluation of dacryocystorhinostomy using optical coherence tomography and rebamipide ophthalmic suspension

Purpose

To evaluate the surgical outcome of dacryocystorhinostomy (DCR) by measuring the tear meniscus, using optical coherence tomography and rebamipide ophthalmic suspension.

Methods

Patients with nasolacrimal obstruction and chronic dacryocystitis who were scheduled for an endonasal DCR underwent tear meniscus examinations before and 2 months after surgery. Vertical scans of the inferior menisci were performed before and at 1, 3, 5, 7, and 10 minutes after the instillation of rebamipide ophthalmic suspension. The tear menisci areas were measured with imaging software. Ten young adults without epiphora formed the control group.

Results

Anatomical success was achieved on 22 sides of 21 patients. The patients’ postoperative tear menisci were significantly smaller than the preoperative menisci at all points during the test, and the response to volume loading in the postoperative patients was corrected to nearly that of the young, healthy adults. Nevertheless, the postoperative meniscus area tended to be larger than that of the young adults at all points.

Conclusion

The reduced tear meniscus area after DCR reflected the success of the surgical procedure. However, incomplete recovery of the meniscus after the test might suggest a residual disorder of the lacrimal drainage system after DCR.

Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy

BACKGROUND

Dacryocystorhinostomy (DCR) is commonly performed for epiphora, dacryocystitis and during tumor surgery. External (EXT-DCR) and endoscopic DCR (END-DCR) are both practiced. END-DCR was initially performed with laser (EL-DCR) but has shifted to careful bone removal with mechanical drills (EM-DCR). High level evidence from comparative cohorts was sought to compare outcomes.

METHOD

Medline (1966 - January 28th, 2013) and Embase (1980 - January 28(th), 2013) were searched for comparative studies (RCT/cohorts) of END-DCR to EXT-DCR for acquired nasolacrimal duct (NLD) obstruction. Primary outcome was DCR success, defined as resolution of symptoms and/or patent NLD on irrigation or dacroscintography. Secondary outcomes were scarring, infection and post-operative bleeding. Meta-analysis was performed with the Mantel-Haenszel Method and presented as Risk Ratios (RR) with Confidence Intervals (CI).

RESULTS

The search identified 3582 studies and 355 were reviewed after screening. Full text review yielded 19 studies (4 RCTs and 15 cohorts). Overall, EXT-DCR had slightly better success rates than END-DCR (RR 0.96, CI 0.93-1.00). However, EM-DCR outcomes were comparable to EXT-DCR (RR 1.02, CI 0.98-1.06), whereas EL-DCR had poorer outcomes (RR 0.85, CI 0.79-0.91) when compared separately. The RR for scarring, bleeding and infection with END-DCR versus EXT-DCR was 0.07 (CI 0.02-0.22), 0.72 (CI 0.46-1.13) and 0.24 (CI 0.11- 0.54), respectively. The rates of reported revision surgery were similar.

CONCLUSION

DCR is a procedure with high success rates. Endoscopic procedures differ greatly by technique with EM-DCR offering comparable results to EXT-DCR, without the risk of cosmetically unacceptable scars.

Changes in cytokines in tears after endoscopic endonasal dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction

PURPOSE

We attempted to compare the cytokine composition of tears between primary acquired nasolacrimal duct (NLD) obstruction and normal controls. We investigated the changes in cytokines in tears after endoscopic endonasal dacryocystorhinostomy (DCR).

PATIENTS AND METHODS

Eighteen patients underwent endonasal DCR, with seven patients undergoing bilateral DCR, resulting in twenty-five DCRs in total. Eleven contralateral un-operated eyes were used as normal controls. Silicone stents were removed 3 months after surgery. Tear samples were collected from all eyes before surgery, and at 1 month, 2 months, 3 months, and 4 months after surgery. The level of interleukin (IL)-1β, IL-2, IL-6, IL-10, transforming growth factor (TGF)-β2, fibroblast growth factor (FGF)-2, and vascular endothelial growth factor (VEGF) in the tears was measured.

RESULTS

The concentrations of IL-2, IL-6, IL-10, VEGF, and FGF-2 were significantly higher in eyes with NLD obstruction than controls before surgery (P=0.006, 0.018, 0.002, 0.048, and 0.039, respectively). Most inflammatory cytokines (IL-1β, IL-2, IL-6, VEGF, and FGF-2) were higher in the tears of the DCR group compared with the controls during the postoperative follow-up, but then rapidly decreased to the level of the controls after removal of the silicone stent. The recurred eyes showed a higher level of TGF-β2 and FGF-2 in tears compared with the eyes that showed good surgical results (P<0.005 and <0.005, respectively).

CONCLUSION

The tear levels of inflammatory cytokines were higher in eyes with NLD obstruction than controls. The changes in cytokine level during the postoperative period showed the importance of cytokine analysis in understanding wound healing after DCR.

External vs. endonasal dacryocystorhinostomy: has the current view changed?

In past years, external dacryocystorhinostomy has been considered the gold standard in terms of functional outcome for treatment for nasolacrimal duct obstruction. In comparison, interest in the use of the recently developed endonasal dacyocystorhinostomy procedure has been rekindled because of advances in instrumentation. For the past 10 years, differences in the outcomes between the two techniques have been reduced; thus, currently, the choice of the type of surgery is associated with the experience of the surgeon, resources available in the healthcare system and patient preferences.

Assessment and management of proximal and incomplete symptomatic obstruction of the lacrimal drainage system

Epiphora is a common complaint of patients who present to an Ophthalmology Clinic. In many cases, epiphora is due to an obstruction in the lacrimal drainage system. However, a subgroup of symptomatic patients with epiphora has a patent lacrimal drainage system. Such cases are usually termed ‘functional obstruction’ and / or ‘stenosis of the lacrimal drainage system’. Various etiologies and diagnostic and therapeutic approaches have been described in literature, which implies the lack of a standardized approach. This article will review the evolving diagnostic and therapeutic approaches in literature, and in the end, propose a paradigm in approaching this group of patients.