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

Cost-effectiveness analysis of endoscopic dacryocystorhinostomy using Markov modelling

OBJECTIVE

To determine the cost-effectiveness of endoscopic dacryocystorhinostomy (DCR).

METHODS

We constructed a Markov model in which patients with nasolacrimal duct obstruction received endoscopic DCR or no surgery. Incremental cost-effectiveness ratios, 1-way sensitivity analyses, and probabilistic sensitivity analyses were used to evaluate for model sensitivity to multiple model inputs.

RESULTS

Endoscopic DCR was found to be cost-effective with an incremental cost-effectiveness ratio of US$2162 per quality-adjusted life-year. The model was most sensitive to the health utility deduction from epiphora. Probabilistic sensitivity analysis found endoscopic DCR to be cost-effective over no surgery 93.7% of the time.

CONCLUSIONS

Endoscopic DCR is a cost-effective treatment for patients with epiphora. The model is very sensitive to the negative effect epiphora has on quality of life. With the advancement of health care technology and surgical techniques, the success rates of endoscopic DCR continue to improve and to be an even more efficacious and economical treatment for nasolacrimal duct obstruction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Medical Malpractice Trends in Dacryocystorhinostomy and Orbital Decompression

Background and Objective

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

Methods

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

Results

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

Conclusion

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

The importance of clinical presentation on long-term outcomes of external dacryocystorhinostomies: Our experience on 245 cases

PURPOSE

External dacryocystorhinostomy (EXT-DCR) is a surgical approach commonly used to treat post-canalicular acquired lacrimal obstruction whose success rate has been described, equally with endoscopic DCR, to be superior to other available treatments.

METHODS

At San Raffaele Hospital, Milan (Italy), from January 2008 to December 2020, 245 EXT-DCRs were performed. All patients underwent routine pre-operative work-up including Jones tests and probing and irrigation of the lacrimal pathway; when necessary, a multidisciplinary approach with nasal endoscopy was performed. The surgical approach was followed by positioning of a bicanalicular stent which was left in place for 6 months. Success was defined as resolution of clinical signs/symptoms and free lacrimal flow on functional test.

RESULTS

Of the cases enrolled, 26.9% were treated for recurrent epiphora (group 1), and 73.1% for epiphora associated with chronic dacryocystitis (group 2). After a median follow-up of 71 months, group 1 had success at T0 (1 month) and T1 (long-term) of 81.8% and 60.6%, respectively, compared to 93.8% and 77.7% in group 2. Statistical analysis showed a significant association with surgery both at T0 (p = 0.018) and T1 (p = 0.012) with group 2 showing better outcomes. Additionally, the cosmetic outcome of the external scar was defined as invisible in 91.8% of cases and slightly visible in 8.2%.

CONCLUSIONS

External dacryocystorhinostomy provides long-term reliable results particularly in case of chronic dacryocystitis. Moreover, the optimal esthetic outcome of the external scar should be no longer considered the only guiding principle of treatment modality, particularly in the elderly.

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.