Scarring in external dacryocystorhinostomy: fact or fiction?

Medial lacrimal sac excision versus conventional H-shaped lacrimal sac opening in external dacryocystorhinostomy: a comparative cohort study

PURPOSE

The external dacryocystorhinostomy (Ex-DCR) is a reliable but surgically challenging procedure to overcome a nasolacrimal duct obstruction (NLDO). The aim of this study is to describe the outcomes of a modified technique of lacrimal sac opening and to compare it with the conventional Ex-DCR.

METHODS

This comparative cohort study included adult patients undergoing Ex-DCR for primary acquired NLDO by or under supervision of one surgeon. Group 1 (conventional Ex-DCR including H-shaped incision, anastomosis of the anterior mucosal flap to nasal mucosal flap and resection of the posterior sac flap) was compared with Group 2 (modified Ex-DCR including excision of the medial lacrimal sac and anastomosis of remaining anterior sac flap to nasal mucosal flap). Outcome measures included the success rate (defined as complete symptom relief or patent irrigation after three months), reoperation rate, redo-free survival within five years, and occurrence of postoperative bleeding and postoperative infection.

RESULTS

138 patients were included. The success rates were 94.7% (54/57 cases) for Group 1 and 96.3% (78/81) for Group 2 (p-value = 0.658). The redo-rate was 5.3% (3/75) in Group 1 and 2.5% (2/81) in Group 2 (p = 0.331). Two-year redo-free survival probability estimates were 89.8% for Group 1 and 96.3% for Group 2, respectively. No complications occurred in Group 2, whereas in Group 1, one patient (1.8%) suffered from postoperative bleeding and one (1.8%) from postoperative infection.

CONCLUSIONS

This study showed that our modified Ex-DCR technique is equally efficacious compared with the conventional Ex-DCR technique in adult patients with NLDO.

Surgical success of 'W' shaped incision versus Tear Trough incision in External Dacryocystorhinostomy

PURPOSE

To compare surgical success (cosmetic, anatomical & functional) of 'W' shaped incision versus tear-trough incision in external dacryocystorhinostomy (eDCR).

METHODS

In a prospective study (November 2018 - March 2020), 61 eyes of chronic dacryocystitis underwent eDCR randomized into group T (30 eyes) & group W (31 eyes). The functional and objective cosmetic assessment was done at 3 months using Munk's and Devoto's scores respectively. The subjective cosmetic evaluation was done using a questionnaire. Grades 0-1 were considered the cosmetic and functional success after assessing the respective scores. The patent lacrimal passage was defined as anatomical success.

RESULTS

Mean age was 40.1 ± 14.9 years with female preponderance. Intraoperative skin flap button-holing & reversible darkening of their apices were specific complications of Group W. In the early postoperative period, lid edema & epiphora were significantly more in group T (p < 0.05). The functional success rate in group T and W was 93.3% and 93.5%, respectively (p = 0.53). There was a 100% anatomical success rate in group T whereas 96.8% in group W (p = 0.51). The subjective cosmetic success rate was 83.3% in group T and 80.6% in group W (p = 0.78) while objective cosmetic success rate was 63.3% and 67.7% in group T and group W, respectively (p = 0.72).

CONCLUSION

Surgical success in terms of cosmetic, anatomical & functional outcomes of W-shaped incision were comparable to the conventional Tear trough incision.

Dacriocistorrinostomía externa, conjuntivo-dacriocistorrinostomía y cirugía de la vía lagrimal en el meato inferior

Introducción y objetivo: Realizar una revisión sobre la dacriocistorrinostomía externa (DCR-ext), sondaje de la vía lagrimal y conjuntivodacriocistorrinostomía(CDCR) empleadas ante la obstrucción de la vía lagrimal. Material y métodos : Revisión bibliográfica sobre técnicas quirúrgicas mencionadas. Discusión: La obstrucción de la vía lagrimal puede dividirse según su localización en proximales y distales. Ante obstrucciones distales, la DCR ext es la técnica gold standard con porcentajes de éxito superiores al 95%, y la CDCR en caso de obstrucciones proximales.El sondaje de la vía lagrimal es la primera indicación quirúrgica en obstrucción congénita.

Cutaneous scar visibility after external dacryocystorhinostomy: A comparison of curvilinear and W shaped incision

Purpose

The major drawback of an external dacryocystorhinostomy (ExDCR) is visible skin scar leading to poor patient satisfaction. In this study we have analyzed the skin scarring objectively after Curvilinear incision (CLI) and W shaped incision (WSI).

Methods

This is prospective trial done at Department of Ophthalmology at tertiary level hospital. All the patients with primary acquired nasolacrimal duct obstruction were included in the study. Patients were assigned to group A(CLI) or Group B (WSI). Cosmetic outcome was assessed by scar visibility at 1st, 3rd and 6th month postoperatively by two ophthalmologists separately, who were unaware of incision type.

Results

We studied 64 patients with median age 59.0 years (IQR [Interquartile range]: 50.0–66.8 years). Scar visibility was significantly (p = 0.001) more in WSI group at all follow-ups. None of the patients of CLI group showed visible scar at six months whereas ten patients (31.3%) of WSI group still had minimal scar (p < 0.001). Older patients had significantly less scar than younger patients. The time taken to perform ExDCR was significantly more with WSI (41.0 min, IQR: 40.0–44.0 min) than for CLI (33.0 min., IQR: 31.3–35.0 min); p < 0.05. Overall complication rates were similar in both the groups (p > 0.05) but extension of skin incision was more common in WSI group.

Conclusions

We found that CLI is more aesthetic, simpler, requiring less operative time and less incision related complications when compared with WSI.

Transcanalicular laser dacryocystorhinostomy for acquired nasolacrimal duct obstruction: an audit of 104 patients

PURPOSE

External dacryocystorhinostomy (DCR) is considered as the gold standard in the treatment of acquired nasolacrimal duct obstruction. However, many advances have been made towards the development of modern minimally invasive therapies. These new techniques were proven less harmful to the patients' skin and medial palpebral structures with their palpebral-canalicular pump mechanism. Options include endonasal and transcanalicular procedures. Here, we report on our 2-year experience with the surgical technique, results and complications of transcanalicular laser-assisted DCR.

METHODS

This is a retrospective study. A total of 104 patients with acquired nasolacrimal duct obstruction underwent transcanalicular laser-assisted DCR combined with bicanalicular silicon intubation. We then analyzed intra-/post-operative complications and subjective and objective success rates. The institutional ethics committee ruled that approval was not necessary. The trial was registered with the German Clinical Trials Register (DRKS00012879).

RESULTS

Transcanalicular laser-assisted DCR in combination with bicanalicular silicon intubation could be performed surgically successfully in 101 patients (97%). In three cases (3%) using the superior canalicular approach, positioning of the laser instrument at the anteroinferior rim of the middle turbinate failed. Complications included thermal injury to the canaliculus (one), canalicular infection (two) and silicon tube prolapse (ten). Functional success (resolution of preoperative symptoms) was achieved in 80 cases (77%), functional failure occured in 24 cases with all patients reporting persisting epiphora, 15 reporting failure to irrigate the nasolacrimal duct and 15 requiring secondary external DCR.

CONCLUSIONS

Laser-assisted DCR shows promising results with few complications. It seems well suited as a second-step procedure after failed recanalization and before external DCR.

[Minimally invasive bypass surgery for nasolacrimal duct obstruction : Transcanalicular laser-assisted dacryocystorhinostomy]

BACKGROUND

In recent years, the minimally invasive surgical procedure of transcanalicular laser-assisted dacryocystorhinostomy (TKL-DCR) has gained importance in the treatment of primary acquired nasolacrimal duct obstructions (PANDO).

OBJECTIVES

Surgical indications, functional success rates, potential advantages, and complications of TKL-DCR are presented and compared with the standard procedures external (EXT-DCR) and endonasal DCR (EN-DCR).

METHODS

The study comprises a PubMed literature review and our own clinical results.

RESULTS

Using TKL-DCR either as the primary surgical treatment for PANDO, or as a secondary procedure following failure (reobstruction of the surgical ostium) of previous EXT-DCR resulted in good functional success rates (60-90%). The duration of surgery (10-15 min) and the period of recovery are significantly shorter than in EXT-DCR. Visible cutaneous scars and significant postoperative nose bleeding are not among the complications of TKL-DCR, due to the lack of a skin incision and the coagulative ability of the diode laser. The smaller sized surgical ostium has been considered the main disadvantage of TKL-DCR, since it might be prone to earlier reobstruction. On the other hand, TKL-DCR spares the anatomical structures that form the physiological tear pump, which should favor tear drainage. In very few cases, thermal damage to the canaliculus has been observed as a complication.

CONCLUSIONS

Given the satisfying functional results, TKL-DCR is a valid alternative to the "gold standard" procedure EXT-DCR, especially in patients who particularly request speedy recovery and who do not want to take the risk of visible skin scaring. Future studies will have to investigate whether the smaller surgical ostia of TKL-DCR remain patent and whether functional success rates decrease during a longer follow-up period of >2 years.

The cosmetic outcome of external dacryocystorhinostomy scar and factors affecting it

Purpose:

To study the cosmetic outcome of external dacryocystorhinostomy (Ex-DCR) and to detect the factors affecting it.

Patients and Methods:

Prospective randomized interventional study included forty patients who were treated by 40 Ex-DCRs. In twenty patients, medial canthal vertical incision was used and in the other twenty cases, subciliary incision was used. The skin was closed using vicryl 6-0 or prolene 6-0 interrupted sutures, and each one was randomly used in twenty patients (10 patients of each incision type). Cosmetic outcome was evaluated 6 months postoperative by the patients and by an oculoplastic surgeon on a four grades scale. Cosmetic results and its correlation to patients’ age, sex, skin complexion, type of incision, and type of skin sutures were studied.

Results:

The mean scar grading was 0.98 ± 1.0 and 1.3 ± 1.0 in patients’ and examiner's assessment. About 27.5% described their scars as cosmetically significant. The cosmetic outcome was significantly affected by the type of incision with only 5% significant scars in subciliary incision group. Prolene 6-0 suture was associated with better cosmetic results with 15% significant scars. 50% of dark-skinned patients showed cosmetically significant scars. Although no correlation was found between patients’ age and cosmetic outcome, pediatric patients showed higher tendency to scar visibility with mean scar grade 1.2 ± 1.0 and 1.5 ± 0.9 in patients’ and examiner's assessment.

Conclusion:

Dark skinned and pediatric patients are more prone to visible Ex-DCR scar. The use of subciliary approach and prolene 6-0 skin sutures is associated with more favorable cosmetic outcome.

Cosmetic evaluation of surgical scars after external dacryocystorhinostomy

AIM

To evaluate the surgical scars of external dacryocystorhinostomy (DCR) cosmetically.

METHODS

Totally 50 consecutive cases of primary acquired nasolacrimal duct obstruction (PANDO) were included in the study. Surgical scars were assessed by the patients and two independent observers at 2, 6 and 12wk postoperatively on the basis of visibility of the scars and still photographs respectively and were graded from 0-3. Kappa test was utilised to check the agreement of scar grading between the two observers. Wilcoxan signed ranks test was used to analyse the improvement of scar grading.

RESULTS

Thirty-four (68%) patients graded their incision site as very visible (grade 3) at 2wk. At 6 and 12wk, incision site was observed as grade 3 by 7 (14%) and 1 (2%) patients respectively. Photographic evaluation of patients by 2 observers showed an average score of 2.75, 1.94 and 0.94 at 2, 6 and 12wk respectively. Change in scar grading from grade 3 to grade 0 in consecutive follow-up (2, 6 and 12wk) was found to be highly significant both for the patient as well for the observers (P<0.0001).

CONCLUSION

The external DCR is a highly effective and safe procedure and in view of low percentage of cases who complained of marked scarring in the present study, thus scarring should not be the main ground for deciding the approach to DCR surgery, even in young cosmetically conscious patients.

Techniques to minimize skin incision scar for external dacryocystorhinostomy

Although there has been a narrowing in the gap in successful functional outcomes between external and endonasal DCR, external DCR is still being frequently performed when cost, availability of additional surgical instruments and visual systems, surgeon's experience and preference are concerned. Nonetheless, skin incisions at the lateral nasal sidewall of the lower eyelid inevitably leave cutaneous scars. The purpose of this review is to evaluate the outcomes of current modified surgical practices that prevent a conspicuous scar in external DCR.

Aesthetic assessment in periciliary "v-incision" versus conventional external dacryocystorhinostomy in Asians

PURPOSE

To determine the functional and aesthetic outcomes of periciliary "v-incision" external dacryocystorhinostomy (DCR) and to compare with conventional approach.

METHOD

Charts review of consecutive cases of "v-incision" (VDCR) or conventional DCR performed in a single institute, between January 2007 and March 2014. All procedures were performed or supervised by a single surgeon. Two periciliary incisions were made near the skin-mucosal junction at the upper and lower eyelid margins medial to the punctum joining at the medial canthal angle to form a "v" shape. Subcutaneous dissection was carried out inferomedially to reach the anterior lacrimal crest. DCR was then performed in the usual manner. Functional success was defined as no persistent or recurrent epiphora and patency on irrigation of the lacrimal drainage system at least 6 months post-surgery. A cross-sectional aesthetic survey was conducted by asking the patients to rate their scar appearance satisfaction on a visual analogue scale (VAS). External photographs were graded by two independent, masked physicians using VAS as well as the Stony Brook scar evaluation scale (SBSES).

RESULTS

Sixty-one patients with median age of 64 years met the inclusion criteria, with median follow-up duration of 28 months. Thirty-eight eyes underwent VDCR, and 23 had conventional DCR. The functional success rate for VDCR was 83.3, 95 % confidence intervals (95%CI) [lower 0.68, upper 0.92] and for conventional DCR was 73.9 %, 95%CI [lower 0.54, upper 0.87]; without statistically significant difference (p = 0.38). VDCR patients rated higher aesthetic outcome on VAS (mean scores 95.5 ± 16.8 vs 82.9 ± 25.1, p = 0.03). On the SBSES, both observers gave higher aesthetic scores to the VDCR group (observer #1 4.6 ± 1.1 and #2 4.7 ± 1.2, p < 0.01) than conventional DCR (observer #1 3.1 ± 2.8 and #2 2.8 ± 2.1, p < 0.01). More patients reported that they could wear spectacles within 1 week post-VDCR (44.7 vs 4.3 %, p < 0.01).

CONCLUSION

"V-incision" external DCR has a similar functional success rate to that of the conventional approach and has superior aesthetic outcomes as reported by surgeons and patients. However, a higher proportion of trainees under supervision performed conventional DCR, and it is uncertain whether the outcomes were also influenced by the level of surgeon's expertise.

Comparison of the effect of W-shaped and linear skin incisions on scar visibility in bilateral external dacryocystorhinostomy

BACKGROUND

The aim of this study was to compare the effect of W-shaped skin (WS) and linear skin (LS) incisions on cutaneous scar tissue formation in patients who have undergone bilateral external dacryocystorhinostomy.

METHODS

Sixteen patients (14 females and two males) with acquired bilateral nasolacrimal duct obstruction were included in this prospective, interventional comparative study. LS incision was applied to one side and WS skin incision to the other side. The skin incisions were assessed 6 months after each procedure by the patients themselves and by two ophthalmologists who were unaware of the skin incision shape and side. Scar tissue that was not recognized under the same light conditions and in the same room from a 100 cm distance was recorded as grade 1. Minimally visible scar tissue was assessed as grade 2, moderately visible scar tissue as grade 3, and easily visible scar tissue as grade 4.

RESULTS

The mean scar assessment scores recorded by the first ophthalmologist were 2.50±0.82 for the LS group and 1.25±0.45 for the WS group (P<0.001). The second ophthalmologist's assessment scores were 2.25±0.86 for the LS group and 1.25±0.45 for the WS group (P<0.001). The mean patient self-assessment score for the incision scars was 2.44±1.03 for the LS group and 1.56±0.73 for the WS group (P<0.001).

CONCLUSION

Compared with LS incision, WS incision resulted in less cutaneous scar tissue formation in patients who have undergone bilateral external dacryocystorhinostomy.

[Study of the cutaneous scar after external dacryocystorhinostomy]

AIM

To objectively analyze the cutaneous scar after external dacryocystorhinostomy and to compare the cosmetic result of a nasal incision and an inferior eyelid incision.

PATIENTS AND METHODS

All patients consecutively operated between January 2007 and December 2009 were notified of an examination. The cutaneous scar was photographed and de visu analyzed by the two authors who gave marks : 20, no visible scar ; 10, visible scar but cosmetically considered not detrimental ; 0, visible scar and considered unesthetic.

RESULTS

Eighteen of the 60 patients notified came for examination. One hundred percent of ten patients operated via an inferior eyelid incision were graded 20 versus 25% of eight patients operated via a nasal incision. Of these patients, 62.5% were graded 10. Only one patient was marked 0 (nasal incision).

DISCUSSION

The inferior eyelid incision seemed to give much better cosmetic results than the nasal incision.

External dacryocystorhinostomy: assessing factors that influence outcome

PURPOSE

To present the experience of external dacryocystorhinostomy (DCR) at a tertiary referral center and investigate factors that may affect clinical outcomes.

METHODS

The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to patient demographics, preoperative assessment, operative details, surgical technique, postoperative management, and clinical outcomes. This information was then analyzed, with emphasis on factors that influence surgical outcomes and success.

RESULTS

A total of 338 cases were reviewed. The mean age at time of surgery was 64.82 years and the majority of patients were female (65%). Epiphora was the major preoperative symptom. Assisted local anesthesia and day stay surgery were the most common surgical settings. There was a statistically significant difference in theatre time between consultant and trainee surgeons (P < 0.00001). The mean final follow-up time was 11 months. Overall, 77.3% of patients had full resolution of symptoms and 20.8% had partial resolution. Only five patients (1.9%) had no resolution of symptoms. There was no significant difference in outcomes between consultants and trainees. Patients with anatomical nasolacrimal obstruction had significantly better outcomes compared with functional obstruction (P = 0.04). The postoperative fluorescein dye disappearance test was a good predictor of clinical success (P = 0.005). Silicone intubation for greater than 6 months was associated with better outcomes (P = 0.002).

CONCLUSIONS

The results at our tertiary center are comparable to results stated in the literature. In our series, only the amount of nasolacrimal obstruction and duration of postoperative intubation influenced surgical success.

UK survey of the present role of ear, nose and throat surgeons in lacrimal surgery

INTRODUCTION

The objective of this study was to evaluate the current involvement of ear, nose and throat (ENT) surgeons in lacrimal surgery.

SUBJECTS AND METHODS

A postal survey was distributed to 796 practicing UK consultant otorhinolaryngologists listed at the drfoster website.

RESULTS

Overall, 531 questionnaires were returned, giving a response rate of 66.7%. Of these, 108 (20.6%) respondents indicated they were involved in lacrimal surgery. The majority of otolaryngologists seem to work in collaboration with ophthalmologists. In our survey, 98% (106) perform endoscopic dacryocystorhinostomy (DCR). Most respondents believed lacrimal intubation and dilation to have limited success, endoscopic DCR to have moderate success and external DCR to have high success.

CONCLUSIONS

Lacrimal surgery is carried out in a spirit of collaboration with ophthalmologists rather than competition. Endoscopic DCR is the favoured surgical procedure of otolaryngologists. The perceived success rate for endoscopic DCR reported in this survey coincides with that reported in the literature.

Tips on How to Avoid the DCR Scar

A permanent facial scar following external approach (transcutaneous) dacryocystorhinostomy is fortunately rare. Meticulous surgical technique is the key factor in avoiding a visible scar. Simple measures to avoid a scar include use of local anaesthesia, location of the incision, maintaining a bloodless surgical field, using a skin flap technique and simple orbicularis and skin wound closure. Although endonasal endoscopic dacryocystorhinostomy is gaining clinical acceptance and popularity, the external dacryocystorhinostomy is regarded as the gold standard in terms of surgical success, with a high patient satisfaction.

The practice of dacryocystorhinostomy (DCR) surgery by ophthalmologists in the United Kingdom (UK)

PURPOSE

To study the practice of dacryocystorhinostomy (DCR) surgery by ophthalmologists in the United Kingdom (UK) looking at the evaluation techniques used, surgical variations, and follow-up management of DCR cases.

METHODS

A mail-shot questionnaire was designed and distributed to every UK consultant ophthalmologist on the specialist register held by the Royal College of Ophthalmologists. The questionnaire consisted of eight questions and an image of a typical DCR candidate so respondents could illustrate details of their surgical incision. The data received was entered into a database and analyzed with the SPSS statistical package. The variation in incisions was divided into various sub-types and quantified accordingly. The chi-square test and analysis of variance (ANOVA) were used to calculate significance, which was set at p < 0.05.

RESULTS

A response rate of over 75% was achieved amongst the 800 questionnaires dispatched, almost one-third of which perform DCR surgery. Of these, almost 50% were non-lacrimal specialists. The majority never use the endonasal approach, with 59% never performing preoperative nasal endoscopy. Most respondents use a standard incision 10-15 mm long with routine silicone intubation. Lacrimal specialists tended to remove tubes earlier (week 4 to 8) and suture posterior flaps more often than non-specialists. Significant differences in practice were found between lacrimal and non-lacrimal specialists in most parameters, in addition to differences between members and non-members of the National Oculoplastic Surgery Society.

CONCLUSIONS

A minimum of 200 DCR surgeons are practicing in the UK where almost 50% are non-lacrimal specialists. Marked variations exist in the perioperative DCR practice.

Evaluation and management of congenital nasolacrimal duct obstruction

Congenital nasolacrimal obstruction is a common disorder in infants that results in persistent tearing and may lead to infections, such as dacryocystitis, orbital cellulitis, and bacterial conjunctivitis. The true incidence of this disorder in healthy newborns remains controversial. The most frequently quoted number of 6% comes from a study of 200 consecutive live births in the 1940s in which nasolacrimal patency was assessed by the presence or absence of discharge on compression of the lacrimal sac. Estimates from other studies, which often use different criteria for diagnosis, vary considerably from 1.2% to 30%. The incidence of the disorder is higher in children who have craniofacial disorders and Down's syndrome. This article reviews the causes and treatment of congenital nasolacrimal obstruction.