Local anaesthetic endonasal endoscopic laser dacryocystorhinostomy: analysis of patients' acceptability and various factors affecting the success of this procedure

Surgical outcomes of endoscopic dacryocystorhinostomy: analysis of age effect

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

Endoscopic anatomy of the lacrimal sac for dacryocystorhinostomy. A cadaveric study

Objectives:

To assist the endoscopic localization of the lacrimal sac (LS) relative to nearby landmarks.

Methods:

This is a descriptive prospective anatomical study. Sixteen lateral nasal walls were dissected endoscopically to identify and localize the LS between October and November 2015. Multiple measurements were obtained from the NS to the anterior and posterior walls of the LS, as well as to the middle turbinate axilla (MTA) and from the MTA to the LS borders.

Results:

The average distance from the NS to the anterior border of the LS was 42.0 mm and the posterior border was 48.5 mm. The average widths of the LS were 7.55 mm superiorly, and 6.6 mm inferiorly representing a mathematical proof that the LS is a trapezoid shape. The mean distance from the NS to the MTA was 47.3 mm. Nine of the 16 lacrimal sacs (56.3%) were found to be partially overlapped by the MTA. The LS was only totally overlapped and lying posterior to the MTA in one side (6.3%), while in 6 sides (37.5%) the LS lay anterior to the MTA.

Conclusion:

Endoscopic surgeons should be aware of the location of the LS relative to nearby landmarks, particularly the MTA. Representing a mathematical proof that the LS is wider at it upper part than lower part best presented as a trapezoid shape. We have provided additional measurements that may prove useful in cases of difficult exposure.

Outcomes of endoscopic endonasal dacryocystorhinostomy for intractable lacrimal dacryostenosis and associated factors

AIM

To examine the effects of patient age, canalicular obstruction, mode of anesthesia, and duration of nasolacrimal intubation on the outcomes of endoscopic endonasal dacryocystorhinostomy (DCR).

METHODS

Totally 56 eyes of 46 patients with prolonged epiphora underwent minimally invasive endoscopic endonasal DCR. A successful surgical outcome was defined as a significant improvement in symptoms, adequate water passage from the puncta to the nasal cavity, and patency of the DCR ostium. All outcomes were assessed at least 6mo after extubation. Fisher's exact test was used to discuss the factors, and then the logistic regression analysis was made by SAS 9.4 software.

RESULTS

The overall success rate was 75.0%, and complete resolution was observed in 27 eyes. The success rate was higher for patients with ≥6mo intubation than for those with <6mo intubation. However, there were no significant differences in outcomes between groups stratified by age (<65 or ≥65y), presence or absence of canalicular obstruction, mode of anesthesia (local or general), and use or nonuse of a radiowave unit. One patient developed subcutaneous emphysema around the eye and nose and one developed subcutaneous hemorrhage after surgery.

CONCLUSION

Endoscopic endonasal DCR can be considered safe and minimally invasive with reasonable success rates, particularly when the duration of nasolacrimal intubation is ≥6mo.

Patient satisfaction following endoscopic endonasal dacryocystorhinostomy: a quality of life study

PURPOSE

To assess the subjective success and quality of life of adult patients post endoscopic endonasal dacryocystorhinostomy (EE-DCR) for acquired nasolacrimal duct obstruction.

DESIGN

Retrospective, questionnaire study performed at least 6 months post EE-DCR.

PARTICIPANTS

Hundred and ten of the 282 consecutive patients who underwent EE-DCR.

METHODS

A standardised questionnaire (Glasgow Benefit Inventory, GBI) was used to analyse the quality of life. The questionnaire examines four parameters, providing total, subscale, social, and physical scores.

MAIN OUTCOME MEASURES

We aimed to assess patient experience following EE-DCR surgery. Total GBI scores range from -100 to +100, the former reflecting maximal negative benefit and corresponding to subjective worsening of tearing and impact on quality of life. Any positive score reflects a satisfactory surgical outcome and +100 represents maximal positive benefit. A score of zero is no perceived benefit.

RESULTS

The average age was 62 years, 63% were female. In three of the parameters measured, there was a subjective improvement post surgery: subscale score 22.16 (95% CI: 15.23-29.09), total score 15.04 (95% CI: 9.74-20.35), and social support score 4.67 (95% CI: 0.93-8.42). Physical health scored -4.47 (95% CI: -10.25 to 1.32). Secondary analyses demonstrate no statistical significance with respect to outcome whether a trainee or consultant performed the procedure. Younger patients (under split median of 63.5) had a better total score 19.04 (95% CI: 11.35-27.74) than those older than 63.5 years (11.04, 95% CI: 3.61-18.47).

DISCUSSION

This study shows that EE-DCR gave patients improvement in quality of life, proven by a validated questionnaire. The mean total score of 15.04 found in our study compares with the 18.7 recorded by Feretis et al in 2009. Results were irrespective of the grade of surgeon, similar to the findings of Fayers et al for functional successes.

CONCLUSION

This study supports the use of EE-DCR for the improvement of quality of life in adult patients.

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.

Transcanalicular diode laser-assisted dacryocystorhinostomy

Objective:

We present a prospective, non-comparative case series study of 126 consecutive diode laser-assisted transcanalicular dacryocystorhinostomy (TCL-DCR) procedures on 122 patients. We analyzed success rate, procedure time and amount of laser energy needed for a 5 mm osteotomy.

Materials and Methods:

One hundred and twenty-two patients with nasolacrimal duct obstruction were included in the study. The procedure was performed under general anesthesia, and the nasal mucosa was anesthetized. An endoscope was used for examination of the lacrimal pathways. The site of osteotomy was determined with transillumination of the lateral nasal wall. We achieved osteotomy by applying laser energy via an optic fiber. We used a 980 nm diode laser with power of 10 Watts. We inserted a bicanalicular silicone stent as the last step. Success of procedure was absence of epiphora (subjective), or patency of the lacrimal drainage system on irrigation (objective).

Results:

We performed 126 successive endoscopic laser (EL-DCR) with bicanalicular intubation in 122 patients. The average procedure time was 12 min, and on average 245 Joules of laser energy was needed. The silicone stents were removed three to eight months after surgery. We observed absence of epiphora and a patent nasolacrimal duct on irrigation in 105 out of 126 treated eyes. Eighteen patients had epiphora despite a patent nasolacrimal duct on irrigation. This yields a success rate of 83.3%, with an average follow-up period of 12 months.

Conclusions:

The 980 nm EL-DCR with bicanalicular intubation is a new contribution to the field of lacrimal surgery. It is a minimally invasive quick procedure yielding a high success rate.

Long-term results of endonasal dacryocystorhinostomy

The aim of this study is to review the long-term results of endonasal endoscopic dacryocystorhinostomy (DCR) according to our experience as well as to evaluate potential prognostic factors for long-term outcomes. The files of 165 patients who underwent endonasal DCR at a tertiary referral centre between 1991 and 2001 were retrospectively assessed. Furthermore, these cases were clinically evaluated at least 5 years after surgery and completed a subjective result evaluation questionnaire. A cure was reported by a total of 112 (67.9%) subjects and significant improvement without need for further treatment was noted in 23 cases (13.9%). Thirty (18.2%) cases were considered as failures. The overall successful outcome according to the subjective symptom evaluation was 81.8%. Poor correlation between clinical findings and subjective report of symptoms was found. None of the prognostic factors that were assessed affected outcomes significantly. In conclusion, long-term success rates for endonasal DCR seem to be comparable to previously published short-term results.

Symptom assessment in patients with functional and primary acquired nasolacrimal duct obstruction before and after successful dacryocystorhinostomy surgery: a prospective study

AIM

To evaluate symptoms in patients with functional (FNLDO) and primary acquired (PANDO) nasolacrimal duct obstruction, evaluated prospectively before and after successful dacryocystorhinostomy (DCR) surgery.

DESIGN

A questionnaire delivered by interview, pre- and postintervention.

METHODS

Consecutive patients with either FNLDO or PANDO were derived from a tertiary referral clinic and private practice of two surgeons (GW and ICF). The preoperative cohort consisted of 33 FNLDO patients and 28 PANDO patients. Of these, only 31 patients elected to proceed to DCR surgery. There were 12 FLNDO patients and 19 PANDO patients in the postoperative cohorts, all with definitive surgical success. Successful DCR surgery was indicated by positive endoscopic Jones 1 testing. Symptoms in relation to the patient's vision, reading, driving, mood, work and embarrassment were assessed. The severity of these symptoms was also graded.

RESULTS

Vision and reading in particular were affected in both preoperative cohorts, and patients suffered significantly from embarrassment. Of the postoperative cohorts, the FNLDO cohort had a reduced percentage of patients suffering each symptom type, whereas the PANDO group had a reduction in percentage of patients reporting each symptom in some but not all areas. However, the overall severity was reduced in both groups, and embarrassment was significantly reduced in both groups.

CONCLUSION

In both FNLDO and PANDO populations, symptoms bother patients significantly, and successful DCR surgery has a positive effect on the patient's physical and psychological well-being.

Clinical outcome of endonasal KTP laser assisted dacryocystorhinostomy

BACKGROUND

To evaluate the clinical outcome of primary endonasal laser assisted dacryocystorhinostomy (ENL-DCR) using the potassium-titanyl-phosphate laser.

METHODS

We retrospectively reviewed all primary ENL-DCRs performed within a period of twelve months by the same combined Ophthalmology and Otorhinolaringology team in Freeman Hospital, Newcastle upon Tyne, UK. The main outcome measure for success was resolution or significant improvement of epiphora. Details of surgery, intraoperative and postoperative complications, as well as pathology associated with failure were also studied. Patients were followed up for at least 12 months.

RESULTS

A total of 41 consecutive ENL-DCRs on 29 patients (22 females, 7 males, mean age 75 years) were analysed. All patients had bicanalicular silicone intubation for at least 4 months. The success rate at 12 months postoperatively was 78.1%. Pathology associated with failure included: intranasal pathology (12.2%), mucocele (7.3%), and systemic sarcoidosis (2.4%). No significant intra-operative complications were recorded.

CONCLUSION

The ENL-DCR with potassium-titanyl-phosphate laser can be considered as a safe and efficient primary procedure for the treatment of nasolacrimal duct obstruction.