The safety and efficacy of mitomycin C in endonasal endoscopic laser-assisted dacryocystorhinostomy

Molecular mechanisms regulating wound repair: Evidence for paracrine signaling from corneal epithelial cells to fibroblasts and immune cells following transient epithelial cell treatment with Mitomycin C

In this paper, we use RNAseq to identify senescence and phagocytosis as key factors to understanding how mitomyin C (MMC) stimulates regenerative wound repair. We use conditioned media (CM) from untreated (CMC) and MMC treated (CMM) human and mouse corneal epithelial cells to show that corneal epithelial cells indirectly exposed to MMC secrete elevated levels of immunomodulatory proteins including IL-1α and TGFβ1 compared to cells exposed to CMC. These factors increase epithelial and macrophage phagocytosis and promote ECM turnover. IL-1α supplementation can increase phagocytosis in control epithelial cells and attenuate TGFβ1 induced αSMA expression by corneal fibroblasts. Yet, we show that epithelial cell CM contains factors besides IL-1α that regulate phagocytosis and αSMA expression by fibroblasts. Exposure to CMM also impacts the activation of bone marrow derived dendritic cells and their ability to present antigen. These in vitro studies show how a brief exposure to MMC induces corneal epithelial cells to release proteins and other factors that function in a paracrine way to enhance debris removal and enlist resident epithelial and immune cells as well as stromal fibroblasts to support regenerative and not fibrotic wound healing.

Evaluation of Topical Mitomycin-C Eye Drops After Reconstructive Surgery for Anophthalmic Contracted Socket

Purpose

To report the outcomes of using topical mitomycin-C (MMC) after reconstructive surgery for contracted socket and to compare the results with those of the conventional postoperative treatment.

Patients and Methods

The medical records of patients who underwent reconstructive surgery for contracted anophthalmic socket were retrospectively reviewed. Based on the postoperative treatment protocol, two groups of patients were identified; group I (15 patients) who received topical MMC drops (0.02%) 4 times daily for 6 weeks and group II (15 patients) who received the conventional treatment (topical antibiotic-steroid combination). Preoperative data were extracted for age, gender, cause and timing of anophthalmia, history of previous surgeries, preoperative forniceal depth and socket volume (SV). The main postoperative outcome measures were superior fornix depth (SFD), inferior fornix depth (IFD) and SV at the end of 6th postoperative month. Prosthesis fitting and complications were also considered for analysis.

Results

The mean preoperative IFD was 1.67±0.04 mm in group I and 1.58±0.37 mm in group II, by the end of the 6th postoperative month it increased to 6.1 ±0.27 mm and 5.12 ±0.25mm, respectively. The mean preoperative SFD in group I was 8.3±0.9 mm and 8.9±1.1 mm in group II, by the end of the 6th postoperative month SFD became 13.4±1.2 mm and 10.2±1.4 mm in groups I and II, respectively. The mean SV measured six months postoperatively was 1.9±0.2 mL and 1.3±0.09 mL in groups I and II, respectively. These differences in the postoperative SFD, IFD and SV between both groups were statistically significant. More cases reported successful fitting in group I than in group II but this difference was not statistically significant.

Conclusion

Postoperative use of topical MMC is associated with higher forniceal depth and greater SV when compared to the conventional treatment in socket reconstructive surgeries with amniotic membrane graft (AMG).

Effect of allergic rhinitis on the outcomes of diode laser dacryocystorhinostomy

PURPOSE

Studies on patients with nasolacrimal duct obstruction have suggested the presence of comorbid allergic rhinitis. This study aimed to investigate the role of allergic rhinitis in the long-term surgical failure of diode laser dacryocystorhinostomy.

MATERIALS AND METHODS

A total of 153 patients undergoing diode laser dacryocystorhinostomy between 2013 and 2017 were included in the study. In the consultation and follow-up, a skin prick test, endoscopic nasal examination, and nasal symptom scoring were performed.

RESULTS

A total of 137 patients participated in the follow-up. The nasolacrimal obstruction complaints were completely resolved in 112 patients (81.8%). Of these, eight (7.1%) had positive skin prick tests. The preoperative complaints continued postoperatively in 25 (18.2%) patients. Nasal endoscopy revealed synechiae in one of these patients, whereas no anatomic deformities were observed in the other 24 patients. Of the 25 patients, 21 (84%) had positive skin prick tests. Those patients had signs of allergic rhinitis on endoscopic examination and high nasal symptom scores. There were significant differences in skin prick test results and nasal symptom scores between the two groups (p < 0.05).

CONCLUSION

Allergic rhinitis may affect the success of dacryocystorhinostomy in patients with nasolacrimal duct obstruction. To increase the chances of surgical success, besides choosing the appropriate surgical procedure, it may be useful to treat allergic rhinitis pre- and postoperatively.

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.

Study of Endonasal Endoscopic Dacryo-cystorhinostomy with Special Reference to Mitomycin-C

The aim of this study was to evaluate long-term results in patients with nasolacrimal duct obstruction treated with intranasal endoscopic dacryo-cystorhinostomy (DCR) with intraoperative topical application of mitomycin-C. The procedure was carried out in 34 subjects (41eyes). Patients with post-saccal stenosis were divided into two groups, 21 patients were treated with intranasal endoscopic dacryo-cystorhinostomy with intraoperative application of Mitomycin-C (MMC) and the other 20 cases underwent procedure only without Mitomycin-C. Effectiveness of drug at rhinostomy site was assessed in relation to granulation formation, adhesions and ostium size. Outcomes were assessed on the basis of relief of subjective symptoms, patency of rhinostomy site confirmed via syringing and final ostium size at end of 6 months, 1 and 2 year. Success rate was 100% at 3 and 6 months follow-up in both the groups. At the end of 1 year, one failure was noted in control group which had to undergo revision endoscopic DCR with overall success rate decreasing to 97%. This was maintained at the end of second year. Results revealed that adjunctive use of Mitomycin-C was effective at 3 months when granulation tissue formation was significantly lesser in MMC group compared to no MMC group. Topical application of Mitomycin-C has been found to be beneficial in preventing adhesions and also resulted in larger neo-ostium. We concluded that results with intraoperative topical application of Mitomycin-C in endoscopic dacryo-cystorhinostomy are encouraging. It can favourably affect wound healing and result in larger rhinostomy size/ostium. Mitomycin-C is safe and effective adjunct in endoscopic dacryo-cystorhinostomy procedure. Level of evidence Individual prospective cohort study, level 1b.

Evaluation of Role of Mitomycin C in the Cases of Nasolacrimal Duct Blockage Undergoing Endoscopic Dacryocystorhinostomy

Dacryocystorhinostomy is a common surgical procedure done for the treatment of obstruction of the lacrimal sac or nasolacrimal duct. Adjunctive use of a wound healing inhibitor like Mitomycin C is considered to minimize the risk of complications and increase the success rate of endoscopic endonasal DCR. The current study is aimed to compare the results of endoscopic DCR without silicon stents with or without Mitomycin C and to see for any complications resulting from the surgery. This was a prospective study carried out in the department of Otorhinolaryngology at Safdarjung Hospital, New Delhi from February 2015 to September 2017. Out of the 30 patients who were included in the study, 15 underwent endoscopic DCR without the application of Mitomycin C (Group I) and the remaining 15 with application of Mitomycin C without using stents (Group II). The main criteria for success were the resolution of epiphora and patency on lacrimal irrigation. Success rate in Group I was 86.67% as compared to Group II where the success rate was 93.33%. There were two failures in Group I (13.33%) whereas one failure in Group II (6.66%). More complications were noted in Group I (granulations 13.33%, synechiae 13.33%, persistent epiphora 13.33%) than in Group II (granulations 13.33%, synechiae 6.67%, persistent epiphora 6.67%). To conclude, we have found topical Mitomycin C as a safe and effective means of preventing adhesions and ostium closures in patients undergoing endoscopic DCR.

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.

Efficacy of adjunctive mitomycin C in transcanalicular diode laser dacryocystorhinostomy

The objective of the study was to compare the success rate of transcanalicular laser dacryocystorhinostomy (TCL-DCR) with or without the use of adjunctive mitomycin C (MMC) in cases with primary nasolacrimal duct obstruction (NLDO). This retrospective study was comprised of 68 patients with uncomplicated primary NLDO. There were two groups in the study: the Group 1 (n = 35) patients underwent TCL-DCR surgery with MMC and the Group 2 (n = 33) patients underwent TCL-DCR surgery without MMC. All patients had bicanalicular silicone tube intubation. The main outcome measures were patent osteotomy as visualized endoscopically and patent nasolacrimal irrigation. The follow-up period was 12 months. All patients had unilateral TCL-DCR with silicone tube intubation. Six months following surgery, the silicone tubes were removed. At the final evaluation, success rates were 80 % in Group 1 and 78.8 % in Group 2. There was no statistically significant difference between the two groups (p = 0.52). No complications related to MMC usage were recorded during the study period. Intraoperative use of MMC has no beneficial effect on the success rate in TCL-DCR.

Efficacy of adjunctive mitomycin C in transcanalicular diode laser dacryocystorhinostomy in different age groups

PURPOSE

To evaluate the efficacy of adjunctive mitomycin C (MMC) in transcanalicular multidiode laser dacryocystorhinostomy (TCL-DCR) in different age groups.

METHODS

Ninety-six eyes of 96 patients who underwent TCL-DCR for the treatment of nasolacrimal duct obstruction were included in this retrospective, comparative study. Patients were divided into 4 groups based on age and intraoperative use of MMC: group 1, TCL-DCR without MMC in the 20- to 44-year age group; group 2, TCL-DCR with MMC in the 20- to 44-year age group; group 3, TCL-DCR without MMC in the 45- to 76-year age group; group 4, TCL-DCR with MMC in the 45- to 76-year age group. The postoperative evaluation consisted of calculating and comparing the success rates between groups.

RESULTS

Success rates at the final visit were 50% for group 1, 66.66% for group 2, 79.16% for group 3, and 84.61% for group 4. The differences between group 1 and group 4, and group 1 and group 3, were significant (p = 0.01 and p = 0.038, respectively). Logistic regression showed that age group had significant effect on success rate (p = 0.013). However, use of MMC had no significant effect on success rate (p = 0.23).

CONCLUSIONS

The success rates of the TCL-DCR with MMC application were found to be higher than those of TCL-DCR without MMC in different age groups. However, the differences did not reach statistical significance. In addition, our study demonstrated that age may be a significant factor influencing the surgical outcome of TCL-DCR.

Safety and efficacy of adjunctive intranasal mitomycin C and triamcinolone in endonasal endoscopic dacryocystorhinostomy

One of the common causes of failure in dacryocystorhinostomy for nasolacrimal duct obstruction (NLDO) is mucosal scarring and fibrosis around the ostium. Steroid and mitomycin C (MMC) can potentially reduce scarring by their action on the inflammatory and proliferative phase of wound healing, respectively. The purpose of this study is to evaluate the safety and efficacy of combined usage of adjunctive MMC and intranasal triamcinolone (TA) in endonasal endoscopic dacryocystorhinostomy (EE-DCR). This is a retrospective interventional case series. All patients underwent mechanical EE-DCR in two regional hospitals in Hong Kong from January 2005 to December 2006 were included. All received intraoperative MMC application for 5 min and gelfoam soaked with TA onto the ostium. Main outcome measures include the anatomical and functional success rate at follow-up at least 6 months after operation. Other outcomes include complications occurred during and after operation. A total of 73 EE-DCR were performed in 69 patients. Three patients had simultaneous bilateral DCR; one had sequential DCRs for both sides. At the last follow-up, anatomical success was achieved in 68 cases (93 %) and both anatomical with functional success in 67 cases (92 %). No major complication was observed. Minor complications included asymptomatic mucosal adhesion between the nasal septum and lateral nasal wall in one patient and moderate secondary hemorrhage in another. EE-DCR with adjunctive MMC and TA is a safe and successful procedure for the treatment of NLDO.

Mitomycin C in dacryocystorhinostomy: the search for the right concentration and duration--a fundamental study on human nasal mucosa fibroblasts

PURPOSE

To establish primary cultures of human nasal mucosal fibroblasts (HNMFs) and to test the effect of varying concentrations of mitomycin C (MMC) and treatment durations on cellular proliferation and viability of the fibroblasts.

DESIGN

Laboratory investigation.

METHODS

Nasal mucosa harvested from patients undergoing a dacryocystorhinostomy was used to establish primary cultures by explant culture method. Cells were expanded and frozen at every passage, and passage 3 cells were used for further experiments. The cells were then treated with different concentrations of mitomycin C (0.1-0.5 mg/ml) for different time periods (3, 5, and 10 minutes). Cell viability was checked by MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay. Cellular proliferation index was determined with bromodeoxyuridine immunostaining. Apoptotic index was measured using annexin A5 affinity assay, propidium iodide staining, and 4',6-diamidino-2-phenylindole counterstaining. The actin cytoskeletons of fibroblasts were studied using phalloidin staining.

RESULTS

The doubling time of cultured HNMFs is approximately 24 hours. Similarly, 0.4 mg/ml beyond 5 minutes and 0.5 mg/ml concentration at all time points were lethal and caused extensive cell death when compared with controls. A concentration of 0.2 mg/ml for 3 minutes of exposure prevented cell proliferation of HNMF cells by inducing cell cycle arrest, without causing extensive apoptosis.

CONCLUSIONS

The minimum effective concentration appears to be 0.2 mg/ml for 3 minutes. This in vitro study could be the starting point for further clinical and histopathologic studies to validate its clinical usefulness.

Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction

PURPOSE

To study the effect of bicanalicular silicone intubation on endonasal endoscopic mechanical dacryocystorhinostomy (EEM-DCR) for primary acquired nasolacrimal duct obstruction (PANDO).

DESIGN

Randomized clinical trial.

PARTICIPANTS

A total of 120 consecutive adults (103 females) with a presenting age of 64 ± 13.7 years (range, 39-92 years) underwent EEM-DCR for PANDO from November 2005 to May 2009 in a lacrimal referral center.

METHODS

The EEM-DCR was performed by 2 lacrimal surgeons using standard techniques. Patients were randomly assigned to receive or not receive bicanalicular silicone intubation for 8 weeks. No antimetabolite was used. All patients received a course of oral antibiotics during nonabsorbable nasal packing for flaps tamponade, which was removed at the first postoperative visit. Patients were assessed at 1, 3, 6, 12, 26, and 52 weeks after the operation.

MAIN OUTCOME MEASURES

Surgical success was defined by symptomatic relief of epiphora, reestablishment of nasolacrimal drainage confirmed by irrigation by 1 masked observer, and positive functional endoscopic dye test by the operative surgeon at 12 months postoperatively. Intraoperative and postoperative complications were recorded.

RESULTS

A total of 118 of the 120 randomized cases completed 12 months of follow-up. Two patients died of unrelated medical illnesses during follow-up. At 12 months postoperatively, there was no statistical difference in the success rate between patients with (96.3%) and without (95.3%) intubation (P=0.79). The odds ratio of failure without silicone intubation was 1.28 (95% confidence interval, 0.21-7.95). There was no difference in the incidence (P=0.97) or the time to develop (P=0.12) granulation tissue between the 2 groups. No significant difference was found between successful and failed cases in terms of age (P=0.21), sex (P=0.37), laterality (P=0.46), mode of anesthesia (P=0.14), surgeon (P=0.26), use of stent (P=0.79), or presence of granulation tissue postoperatively (P=0.39).

CONCLUSIONS

The current study design provided 90% statistical power to detect more than 21% difference in surgical outcome, and no such difference was found whether intubation was used or not used in EEM-DCR for PANDO at the 12-month follow-up.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Success rate and complications of endonasal dacryocystorhinostomy with unciformectomy

BACKGROUND

Endonasal dacryocystorhinostomy (DCR) has been widely used to treat nasolacrimal duct obstruction. Here, we evaluated the anatomical advantages of the uncinate process as a landmark and to study the effect of unciformectomy on success rate and complications of endonasal DCR .

METHODS

In total, 288 eyes of 265 adult patients who underwent endonasal DCR between January 2003 and February 2010 were reviewed retrospectively. The eyes were classified into two groups, according to whether unciformectomy was performed or not. All surgical procedures and surgical indications were the same except unciformectomy and endonasal DCR was performed by one surgeon. Unciformectomy was performed by resecting the anterior part of uncinate process.

RESULTS

One hundred and eighty-six eyes of 168 patients received endonasal DCR with unciformectomy, and 102 eyes of 97 patients received endonasal DCR alone. The average success rate of endonasal DCR with unciformectomy was 97.8 % and that of endonasal DCR alone was 90.2 %, with statistically significant difference (Student's t-test, p-value < 0.05). There were 14 eyes with post-operative nasolacrimal obstruction, caused by granuloma in five eyes, intranasal synechia in two eyes, membranous obstruction in six eyes, and canalicular stenosis in one eye. There were no serious complications such as orbital fat prolapse, cerebrospinal fluid leak, or delayed hemorrhage.

CONCLUSIONS

Anterior resection of the uncinate process gives improved access to the lacrimal bone by exposing the medial aspect of the lacrimal fossa and forming the precise location of the osteotomy on the lacrimal bone during endonasal DCR. Thus, the uncinate process can be used as an anatomical landmark for endonasal DCR. The unciformian endonasal DCR improves operation success rate by allowing access to the large space of the nasal cavity and reducing the synechiae of the nasal cavity.

Results of nonendoscopic endonasal dacryocystorhinostomy

BACKGROUND

Surgical scarring on the face and disrupted anatomy in the medial canthal area following external dacryocystorhinostomy (DCR) can be avoided by an endonasal approach. This study examined the outcome of direct visualization endonasal DCR, performed by young surgeons and residents.

METHODS

A retrospective case series of 75 consecutive endonasal DCRs performed under direct visualization from July 2002 to July 2004 were reviewed. Surgery was performed by surgeons and residents who had received no special training in the procedure. Full success was defined as no symptoms of tearing after surgery and anatomical patency with fluorescein flow on nasal endoscopy or patency to lacrimal syringing. Partial success was defined as a tearing decrease compared with prior to surgery and with anatomical patency, and failure was defined as no significant improvement in persistent tearing. The average follow-up duration was 26.83 ± 16.26 (range 6-55) months.

RESULTS

Seventy-five DCRs were performed on 63 patients (four male, 59 female) of mean age 49.44 ± 16.63 (range 21-85) years. The surgery was successful in 54/75 eyes (72%), 37/54 eyes (68.5%), and 30/42 eyes (71.4%) at 6, 12, and 24 months, respectively. Partial success was achieved in 13/75 (17.3%), 9/54 (16.7%), and 9/42 (21.4%), and the failure rates were 10.7%, 14.8%, and 7.1% at 6, 12, and 24 months, respectively. The overall functional success with this technique was 74.7% and the overall anatomical patency was 92.0%. There were no serious complications arising from the surgery; three minor complications were documented, ie, an incorrectly placed silicone tube in the lower canaliculus, tube prolapse, and postoperative bleeding which needed nasal packing and eventually a developed retention cyst in the nasal cavity.

CONCLUSION

Endonasal DCR under direct visualization is a simple technique with minimal complications and a low learning curve, without the necessity for expensive instruments.

Surgical results of endoscopic dacryocystorhinostomy and lacrimal trephination in distal or common canalicular obstruction

Objectives

To evaluate the surgical outcomes of endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone stenting in patients with distal or common canalicular obstructions.

Methods

The medical records of 29 patients (31 eyes) from January 2001 to December 2009 who underwent endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone tube insertion for the treatment of distal or common canalicular obstructions were retrospectively reviewed. The level of obstruction was confirmed by intraoperative probing. The outcome of the surgery was categorized as a complete success, partial success, or failure according to the functional and anatomic patency.

Results

The average age of the patients was 52 years. The duration of silicone intubation ranged from 4 to 11 months with an average of 5.7±1.6 months. The follow-up period after stent removal ranged from 4 to 15 months with an average of 8.2±3.3 months. Complete success was achieved in 25 out of 31 eyes (80.6%), partial success in 4 out of 31 eyes (12.9%), and failure in 2 out of 31 eyes (6.5%).

Conclusion

Endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone stent intubation may be safe and considered as an initial treatment of patients with distal or common canalicular obstructions.

Significance of adjunctive mitomycin C in endoscopic dacryocystorhinostomy

PURPOSE

The purpose of this study is to observe the effect of intraoperative topical application of mitomycin C (MMC) on the results of endoscopic dacryocystorhinostomy.

DESIGN

This is a prospective, randomized, controlled, single-blind study.

SETTINGS

Hospitalized treatment was done in a tertiary medical college hospital and research center that deals with a predominantly rural population.

PATIENTS

Patients with primary acquired postsaccal obstruction causing chronic dacryocystitis were considered.

METHODS

A total of 38 patients were randomized into either a mitomycin group or a control group. Both of these groups were subjected to an identical surgical procedure, except that 0.2 mg/dL of MMC was used in the mitomycin group, whereas normal saline was used in the control group. The follow-up period was at least 6 months. An asymptomatic patient with a visible stoma at nasendoscopy and free flow of saline into the nose with lacrimal syringing after 6 months after surgery was used as criteria for defining a successful result.

RESULTS

The success rate was 82.3% when MMC was used and 85.7% among the controls (P > .05). Granulations, adhesions, and obliterative sclerosis occurred in a similar number of patients of both groups. However, granulations and adhesions did not have a bearing on the success rate in either group.

CONCLUSION

Mitomycin C did not appear to influence the occurrence of granulations, synechiae, or obliterative sclerosis, nor did it alter the success rate significantly.

Prospective randomized comparison of mitomycin C application in endoscopic and external dacryocystorhinostomy

The aim of the study is to compare the subjective (relief of symptoms) and objective (endoscopic visualization of ostium patency at the time of syringing) outcomes at the end of two procedures-Endonasal DCR versus External DCR with Mitomycin C and to assess the role of Mitomycin C in maintaining patency of nasolacrimal drainage system. Prospective randomized comparative study was performed. Thirty-five patients were enrolled in each endoscopic and external dacryocystorhinostomy groups with Mitomycin C (MMC) application. The 37 eyes underwent endonasal DCR (28 unilateral primary eyes + 1 bilateral primary eyes + 5 unilateral revision eyes + 1 bilateral revision eye) while 35 eyes underwent external DCR (34 unilateral primary eyes + 1 unilateral revision eye). Mitomycin C 0.2 mg/ml was applied intra-operatively for 5 min to the ostium site at the end of endonasal or external DCR procedure. Objective assessment by syringing at the end of 1 year in the endonasal group showed 35 eyes (94%) were patent, 1 (3%) was partially blocked and 1(3%) was completely blocked; while in external group all 35 eyes (100%) were patent. Endoscopic visualization of the ostium at the time of syringing showed only one eye (3%) in the endonasal group was blocked while all the other eyes in both groups were patent. Both groups had a mean follow-up of 6-36 months. No complications were associated with use of Mitomycin C. In conclusion, intra-operative use of Mitomycin C in both endoscopic DCR and external DCR is safe and effective in increasing the success rate.

Mitomycin C in Revision Endoscopic Dacryocystorhinostomy: A Prospective Randomized Study

Background

Endoscopic dacryocystorhinostomy (EN-DCR) is an effective and safe procedure when treating saccal and postsaccal nasolacrimal duct obstruction. However, sometimes scarring of the rhinostomy site caused by fibrosis may occur, particularly in revision operations. The application of intraoperative mitomycin C (MMC), an antiproliferative agent, has been introduced as one possible technique to improve the outcome. We conducted a prospective, randomized study to evaluate if the use of MMC improves the success in endonasal revision DCR procedure.

Methods

Thirty revision EN-DCR procedures were performed during 2004–2010. The patients were randomized into two study groups, according to whether the intraoperative MMC was used or not. The technique of EN-DCR procedure in both groups was the same, but in the MMC group, at the end of the procedure a piece of tampon soaked in MMC (0.4 mg/mL) was placed into the rhinostoma for 5 minutes. No silicone stents were inserted. The surgical outcome at the 6-month follow-up visit was considered successful if the lacrimal sac irrigation succeeded and if the patients’ symptoms were relieved.

Results

The success rate after revision EN-DCR with MMC was 93% and without MMC was 60%. The overall success rate was 77%. The difference between the two groups was not statistically significant (p = 0.08). The relief of the symptoms between groups in both the Nasolacrimal Duct Obstruction Symptom Score and ocular symptoms was statistically significant (p = 0.007 and p = 0.02, respectively).

Conclusion

The results of our study indicate that the application of intraoperative mitomycin C may improve the outcome in revision EN-DCR.

Endoscopic dacryocystorhinostomy not using canalicular silicone intubation tube with and without mitomycin C: a comparative study

Purpose

To determine the outcome and safety of endoscopic dacryocystorhinostomy (EN-DCR) with the use of adjunctive mitomycin C (MMC) in nasolacrimal duct obstruction in adults.

Methods

In this retrospective, comparative case series, 54 consecutive adult patients underwent EN-DCR. We performed endonasal dacryocystorhinostomy with adjunctive MMC in 28 patients and endonasal dacryocystorhinostomy without MMC in 26 patients. All patients underwent a standardized procedure, with an endonasal approach to the lacrimal sac, surgical removal of nasal mucosa, lacrimal bone, and a fragment of the frontal process of the maxilla. The medial wall of the lacrimal sac was removed completely. In the study group (28 patients), a neurosurgical cottonoid soaked in MMC at 0.5 mg/mL was placed at the osteotomy site for 5 minutes (not using canalicular silicone intubation tube). In the other group (26 patients), standard endonasal dacryocystorhinostomy technique was used without MMC (not using canalicular silicone intubation tube). Main outcome measures were resolution of epiphora, absence of discharge, and patency of the ostium confirmed by irrigation at 6 months.

Results

The EN-DCR procedure with adjunctive MMC was successful in 24 (85.71%) cases. The mean follow-up was 14.3 months (8–24 months). No significant complications were encountered. In the control group, the EN-DCR was successful in 19 patients (73.07%). The mean follow-up was 13.2 months (6-24 months).

Conclusions

Endoscopic dacryocystorhinostomy with MMC is a safe and successful procedure for the treatment of nasolacrimal duct obstruction in adults.

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.

Transconjunctival dacryocystorhinostomy: scarless surgery without endoscope and laser assistance

PURPOSE

To evaluate the efficacy of a novel external dacryocystorhinostomy technique with transconjunctival approach to avoid facial scarring without the use of endoscope and/or laser.

METHODS

In this prospective interventional case series, 25 eyes of 22 patients with epiphora due to primary nasolacrimal duct obstruction were included. Lower eyelid conjunctival inferomedial vestibular incision was used to access the lacrimal sac and nasal mucosa. Bone apertures were created with burr and rongeurs, and saccal and nasal flaps were anastomosed. Bicanalicular silicone intubation was done. Conjunctival wound edges were apposed and left unsutured. Intraoperative difficulties and complications are noted. Patients were followed up postoperatively for an average period of 11 months. Criteria for success were relief of epiphora and patency to irrigation.

RESULTS

In 12 (48%) eyes, the surgeries were completed without complications with the formation of both the anterior and posterior flaps. Epiphora resolved in 18 of 19 eyes (94.7%) in which transconjunctival dacryocystorhinostomy could be completed. In 7 eyes (28%), only anterior flaps could be sutured. The authors needed to convert to external dacryocystorhinostomy in 6 patients (34%) during whose surgeries the nasal mucosa could not be exposed adequately via the transconjunctival route. Epiphora and failure to irrigation started in one eye (5.3%) at the postoperative fourth month and required reoperation. No complications occurred, except granuloma formation at the conjunctival incision site in 2 eyes (10.6%) and a 1-mm-long lower eyelid margin laceration in one eye (5.3%). Epiphora resolved in the remaining 6 eyes that underwent external DCR.

CONCLUSION

Transconjunctival dacryocystorhinostomy, which is performed without endoscope and/or laser assistance, has a high success rate comparable to external DCR and does not leave a visible facial scar.

Endonasal dacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa

PURPOSE

In the last 15 years, endonasal dacryocystorhinostomy (End-DCR) has become an alternative to external dacryocystorhinostomy. In most series reported, it appears that End-DCR had a higher failure rate than Ext-DCR. Uncontrolled epithelialization of the surgical site as compared with the fashioning of mucosal flaps may explain the somewhat lower success rate. The purpose of our study is to validate a modification of a new technique described by Tsirbas and Wormald in which the nasal mucosa is preserved and brought in contact with the lacrimal mucosa during End-DCR, leaving an epithelialized surgical site at the end of the operation.

METHODS

A retrospective study was performed from November 2001 to January 2003. Patients with epiphora and or chronic or recurrent dacryocystitis were evaluated. Patients with symptomatic nasolacrimal duct obstruction (NLDO) and who met the criteria for End-DCR were selected. NLDO was diagnosed based on symptoms, along with a blocked irrigation or an abnormal bone substract dacryocystogram. The surgical procedure involved a manual osteotomy of the frontal process of the maxilla and removal of the lacrimal bone with the creation of posteriorly hinged lacrimal sac and nasal mucosal flaps.

RESULTS

Forty-five patients underwent End-DCR with preservation of the lacrimal and nasal mucosa. Five patients had bilateral surgery. A total of 50 surgeries were performed. Twenty-four surgeries were performed on the right side and 26 on the left. Patients were evaluated at 1 week, 1 month, and 3 months after surgery. Evaluation included asking about subjective symptoms of epiphora, lacrimal irrigation on the 3 visits, and endoscopic evaluation of the surgical site at 3 months. Surgery was considered successful when patients did have relief of their epiphora and had a patent system with irrigation. Forty-nine patients (98%) were asymptomatic at 1 month and at 3 months with both a patent system tested with irrigation and a patent ostium evaluated with the endoscope. One patient who had undergone bilateral surgery had blockage of the fistula on the left side at 3 months. The patient underwent endoscopic revision surgery and was patent 1 year afterward. A phone survey was performed from January to May 2008. Thirty-four patients (75%) were reached. Two patients were still tearing and were brought for reassessment. One had an open lacrimal system and one was blocked.

CONCLUSIONS

This study validates the concept of preserving the lacrimal and nasal mucosa through an endoscopic approach to treat NLDO. Early and controlled lining of the fistula with mucosal flaps appears to prevent closure of the ostium and leads to a high success rate comparable with that of external dacryocystorhinostomy. This can be accomplished successfully with a manual osteotomy thus avoiding the use of power drills and burrs.

Endonasal laser-assisted microscopic dacryocystorhinostomy: surgical technique and follow-up results

PURPOSE

Endonasal dacryocystorhinostomy is known as an increasingly attractive and effective approach for the surgical treatment of nasal duct obstruction with minimal complications and best cosmetic consequences. In a relatively large-scale case-series study over a 5-year period, we describe the surgical technique and 12-month follow-up results of microscopic laser dacryocystorhinostomy with particular regard to the effect of various pre-/postoperational factors (ie, patients' sex, age, symptoms chronicity, previous interventions, duration of silicone intubation) on the surgical outcome.

MATERIALS AND METHODS

A total of 162 cases in 151 patients with chronic epiphora, mucocele, or recurrent episodes of dacryocystitis were included in the study. Endonasal laser dacryocystorhinostomy was performed using a surgical microscope with transcanalicular lacrimal sac illumination. The laser types used were potassium-titanyl-phosphate and neodymium:yttrium-aluminum-garnet for ablation of nasal mucosa and application to bone, respectively. Patients were evaluated 6 months and 1 year later. Data were analyzed by chi(2) tests.

RESULTS

There were no major complications during or after the operations. Complete cure occurred in 89.5% (after 6 months) and 74.2% (after 1 year) of the cases. Anatomical patency was shown by lacrimal system irrigation with fluorescein in 81.5% of the cases after the 12-month follow-up. It was found that patients younger than 55 years, with symptoms lasting less than 1 year, and without history of nasal problems, had significantly higher surgical success rates (P < .05). Moreover, rates of failure were significantly lower in cases whose canaliculi were intubated for 5 to 6 months (P < .05).

CONCLUSIONS

Endonasal microscopic laser dacryocystorhinostomy is a safe and minimally invasive procedure with reasonable results. It has many advantages over external or other conventional approaches. Successful results could be further enhanced by more wisely selecting the patients and by silicone extubation after 6 months.

A Systematic Review of Outcomes after Dacryocystorhinostomy in Adults

Background

This study was designed to systematically review the clinical outcomes of dacryocystorhinostomy (DCR) surgery. Data sources included PubMed for English language literature from January 1966 to December 2008 combined with a manual review of citations within article bibliographies.

Methods

Citations acquired from the targeted search were filtered independently by two researchers. Relevant articles were reviewed to obtain information including interventions and outcome measures. The surgical techniques were categorized into external DCR (EX-DCR), endonasal laser-assisted DCR (LA-DCR), and nonlaser endoscopic endonasal DCR techniques (EN-DCR). Articles were then assigned level-of-evidence grades as defined by the Oxford Center for Evidence-Based Medicine.

Results

A total of 73 studies that fulfilled the inclusion criteria were analyzed. Of these, 68 were graded as level 4, 11 were graded as level 3b, and 1 was graded at level 2b evidence. A total of 4800 patients were pooled, from which 4921 DCRs were performed. All studies reported success during the follow-up period, although the outcome measures used were not consistent in the studies. Success varied between 65 and 100% after EX-DCR compared with EN-DCR, which varied from 84 to 94%. The success rate of LA-DCR varied widely between 47 and 100%. There was low evidence base to support the use of silicone stent to improve surgical success. Most studies did not show significantly improved outcomes with an antimetabolite. The overall intra- and postoperative complication rates were 1.0 and 6%, respectively.

Conclusions

DCR is an effective and safe method for the treatment of nasolacrimal obstruction. Meta-analysis of outcomes was not feasible because of the heterogenous patient groups and outcome measures used. Nonetheless, the literature provides considerable levels 3 and 4 evidence to support DCR surgery in adults. Outcomes after EN-DCR and EX-DCR were comparable. The failure rate for LA-DCR was higher.

CLINICAL RESEARCH, Endoscopic Radiofrequency-Assisted Dacryocystorhinostomy with Double Stent: A Personal Experience

AIM

To report the success rate of endoscopic radiofrequency-assisted dacryocystorhinostomy with double stent and the use of a Griffiths collar button.

METHOD

A prospective, single surgeon, uncontrolled, interventional case series study was designed to include 112 patients with nasolacrimal duct obstruction. Endoscopic radiofrequency-assisted dacryocystorhinostomy (ERA-DCR) with insertion of a Griffiths collar button was done on 102 patients with unilateral nasolacrimal duct obstruction and 10 patients with bilateral nasolacrimal duct obstruction. The operation was defined as a success if: a) preoperative epiphora was resolved; b) nasolacrimal patency was achieved as confirmed by lacrimal irrigation as well as by endoscopic observation of fluorescein dye flowing through the surgical ostium on lacrimal irrigation.

RESULTS

A total of 122 ERA-DCR procedures was done, of which 117 procedures involved cases of primary acquired nasolacrimal duct obstruction (PANDO) and five procedures involved cases of previously failed endonasal DCR. Two failures were observed in this study out of the 117 procedures done on PANDO cases. The success rate is computed at 98% (115/117). The postoperative follow-up period was 28.08 +/- 14.7 months.

CONCLUSION

Endoscopic radiofrequency-assisted dacryocystorhinostomy with double stent and the use of a Griffiths collar button shows a success rate of 98% in the long-term patency of the intranasal ostium.

Endoscopic-assisted reconstructive surgery of the lacrimal duct

Reconstructive surgery of the nasolacrimal duct, or dacryocystorhinostomy, can be performed via an external or endonasal approach. For almost a century external dacryocystorhinostomy was the gold standard for correction of lacrimal duct obstruction. The endonasal approach became a safe surgical procedure using endoscopes and has the same anatomic and functional success rate as the external approach. It can be performed in adults and in children with close collaboration between a rhinologist and an ophthalmologist. An overview is given of the literature and of the authors' experience in this field.

Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is a well-established alternative to external approaches in the treatment of nasolacrimal canal obstruction. From July 2004 to December 2008, 92 endoscopic DCRs were performed on 88 patients at the Department of Otorhinolaryngology, San Raffaele Hospital, Milan. All patients were affected by chronic dacryocystitis with epiphora. Preoperative work-up included Jones tests, lacrimal pathways irrigation, nasal endoscopy, and imaging evaluation by computed tomography. The technique involved anastomosis of nasal mucosal, lacrimal sac flaps and a large bony ostium. A silicone tube was inserted in all patients that remained for a period of 3 months. The first endoscopic intervention was successful in 91.30% of patients. After a second revision endoscopic DCR, the overall success rate raised to 95.65%. Anastomosis of nasal mucosal between lacrimal sac flaps plays a key role in endoscopic DCR with a high success rate both in primary nasolacrimal obstructions and in revision cases.

Long-term results in endoscopic dacryocystorhinostomy: Is intubation really required?

Objective: The long-term (median follow-up eight years) results of endoscopic dacryocystorhinostomy approach and silicone intubation were evaluated by various aspects.

Study Design: Case series with planned data collection of 38 procedures for postsaccal stenosis were analyzed.

Subjects and Methods: Silicone intubation was not used in 19 of the randomly selected procedures. Anatomical and functional surgical success was evaluated subjectively and objectively.

Results: The patients' complaints improved in 84.2 percent of eyes in the intubation group, and in 94.7 percent of the group without intubation, with a mean follow-up of 112 and 96 months after surgery, respectively. Postoperative endoscopic examinations revealed that the rhinostomy opening was visible in 17 sides with intubation (89.5%) and 18 sides without intubation (94.7%).

Conclusions: Considering the similar surgical success rates, and disadvantageous factors such as granulation formation, patient discomfort, and cost related to intubation, we recommend endoscopic dacryocystorhinostomy without intubation as the treatment of choice in cases of chronic epiphora due to postsaccal stenosis of the lacrimal drainage system.

Revision endoscopic dacryocystorhinostomy with betamethasone injection under assisted local anaesthetic

PURPOSE

To determine the success rate of revision endoscopic dacryocystorhinostomy (DCR) with an injection of intraoperative betamethasone under local anaesthetic.

METHODS

In a prospective, nonrandomized consecutive case series, 16 adult patients (19 eyes) with failed primary endoscopic DCR underwent revision surgery under assisted local anaesthetic. During revision endoscopic DCR, 1mg of betamethasone was injected into the lacrimal sac and scar tissue surrounding the surgical osteum. The surgical success rate was then determined based on anatomical patency and resolution of patient symptoms.

RESULTS

There were 16 patients (12 female, 4 male) and 3 had bilateral surgery. Patient ages ranged from 43 to 92 (mean 67). Follow up ranged from 1 to 15 months (mean 9). Anatomical patency was achieved in 16 cases (84%) and patient symptoms had improved in 17 cases (89%). Of the two cases that continued to have symptoms 1 achieved anatomical patency and the other had not.

CONCLUSIONS

Revision endoscopic DCR, under assisted local anaesthetic, had a high success rate (89%) when an injection of betamethasone was administered intraoperatively.

Nonlaser endoscopic endonasal dacryocystorhinostomy with adjunctive mitomycin C in children

PURPOSE

To determine the outcome and safety of pediatric endonasal dacryocystorhinostomy with the use of adjunctive mitomycin C.

METHODS

A prospective, nonrandomized and noncomparative interventional case series study was performed in 71 consecutive procedures. Sixty patients 16 years of age and younger underwent nonlaser endonasal dacryocystorhinostomy with the use of adjunctive mitomycin C. Eleven patients had a simultaneous bilateral procedure performed. All patients underwent a standardized procedure, with an endonasal approach to the lacrimal sac and surgical removal of nasal mucosa, lacrimal bone, and a fragment of the frontal process of the maxilla. The medial wall of the lacrimal sac was completely removed and a neurosurgical cottonoid soaked in mitomycin C at 0.5 mg/ml placed at the osteotomy site for 5 minutes. All patients underwent bicanalicular or monocanalicular silicone intubation.

RESULTS

The main outcome measures were the resolution of epiphora, lacrimal discharge, and patency of the ostium confirmed either by endoscopic visualization and/or irrigation at 6 months or a normal dye disappearance test. Thirteen patients' (18%) final evaluation was via telephone survey. The mean follow-up was 12.3 months. Nonlaser endonasal dacryocystorhinostomy with adjunctive mitomycin C was successful in 67 cases (94.4%). African descent was strongly associated with a higher rate of obstruction (p < 0.001). Infection at the time of surgery (p = 0.051) and less than 3 months intubation (p = 0.059) were also borderline significant. Previous trauma, gender, age, and side operated had no influence on the final outcome. No significant complications were encountered.

CONCLUSIONS

Nonlaser endonasal dacryocystorhinostomy with mitomycin C is a safe and successful procedure for the treatment of congenital nasolacrimal duct obstruction in children. It has the advantage of leaving no scar and of preserving the medial canthal structures. It can be successfully performed as a simultaneous bilateral procedure.

[Endoscopic dacryocystorhinostomy in patients with postsaccal stenosis of lacrimal duct]

Dynamic development of the endoscopic treatment of the lacrimal duct obstruction has been observed for the last 20 years. Various causes of the tear outflow disorders, different levels of lacrlmal duct blockage may require different surgical approach and sometimes additional modern equipment. THE AIM of the study was to present the results of treatment of possibly uniform group of patients with lacrimal duct obstruction in whom the same method of endoscopic surgery was applied.

MATERIAL AND METHOD

16 patients with postsuccal level of obstruction were qualified for the study. All of them were treated endoscopically with mucosal flap formation. Patients in whom synechiae in the upper part of the sac or at the orifice of common canalicullus were found during the procedure were excluded from the study, as well as the patients with Wagener's granulomatosis and posttraumatic form of lacrimal obstruction.

RESULTS

Release of epiphora and proper patency of lacrimal system corroborated by irrigation test was achieved in 14 (87,5%) patients of the studied group. In 2 (12,5%) patients recurrence of symptoms was observed. In both cases too small osteotomy and lack of surgical technique precision were the cause of failure. No major complications in the studied group were observed.

CONCLUSIONS

Endoscopic dcryocystorhinostomy Is low traumatic and effective procedure of surgical treatment of lacrimal duct obstruction. The success is determined by high precision of surgical technique.

Efficacy of mitomycin C irrigation after removal of an occluded nasolacrimal stent

PURPOSE

Mitomycin C (MMC) acts as a potent fibroblastic inhibitor, and topical application of MMC is effective in preventing scar formation. The purpose of this study was to evaluate the safety and efficacy of MMC irrigation after removal of an occluded nasolacrimal stent from the lacrimal system.

MATERIALS AND METHODS

A total of 57 lacrimal systems after removal of an occluded stent were assigned to one of two groups: 23 lacrimal systems were irrigated with MMC after stent removal (MMC group), and 34 lacrimal systems were not irrigated with MMC after stent removal (non-MMC group). In the MMC group, the lacrimal systems were irrigated with 0.2 mg/mL MMC through the inferior lacrimal punctum for 3 minutes in three different sessions: immediately, 1 week, and 1 month after stent removal. The mean and cumulative patency rates after stent removal were calculated using the Kaplan-Meier method and were compared between the two groups using the log-rank test.

RESULTS

Stent removal and MMC irrigation were technically successful in all lacrimal systems. There were no side effects or complications associated with MMC use. The mean patency rate after stent removal was higher in the MMC group than that of the non-MMC group: 10.5 months (95% CI: 7.04, 13.91) versus 4.5 months (95% CI: 2.40, 6.63), respectively. There was a statistically significant difference in the cumulative patency rates after stent removal between the two groups (P = .005, log-rank test).

CONCLUSIONS

Mitomycin C irrigation is safe and effective in increasing patency rate of lacrimal systems after removal of an occluded nasolacrimal stent.

Efficacy of mitomycin-C irrigation after balloon dacryocystoplasty

PURPOSE

To evaluate the safety and efficacy of mitomycin-C irrigation after balloon dacryocystoplasty in the treatment of epiphora caused by obstruction of the lacrimal system.

MATERIALS AND METHODS

Thirty-five lacrimal systems in 33 patients with obstruction of the lacrimal system were assigned to one of two groups: 17 lacrimal systems were irrigated with mitomycin-C after balloon dacryocystoplasty (mytomycin-C group), and 18 were not irrigated with mitomycin-C after balloon dacryocystoplasty (non-mitomycin-C group). In the mitomycin-C group, the lacrimal systems were irrigated with 0.2 mg/mL mitomycin-C via the inferior lacrimal punctum in three different sessions: immediately, 1 week, and 1 month after balloon dacryocystoplasty. The cumulative patency rates after balloon dacryocystoplasty were calculated by using the Kaplan-Meier method and were compared between the two groups with use of the log-rank test.

RESULTS

Balloon dacryocystoplasty and subsequent mitomycin-C irrigation were technically successful in all lacrimal systems. There were no side effects or complications associated with mitomycin-C use. The cumulative patency rate in the mitomycin-C group was significantly higher than that in the non-mitomycin-C group after balloon dacryocystoplasty (P = .0150, log-rank test).

CONCLUSIONS

Mitomycin-C irrigation is safe and effective in increasing the patency rate of the lacrimal system after balloon dacryocystoplasty.

Use of the Diode Laser With Intraoperative Mitomycin C in Endocanalicular Laser Dacryocystorhinostomy

PURPOSE

To determine the safety and efficacy of the diode laser with intraoperative mitomycin C in endocanalicular laser dacryocystorhinostomy (ECL-DCR).

METHODS

In a prospective case series of 40 ECL-DCRs using the diode laser, mitomycin C was placed intraoperatively in all cases. The main outcome measure was resolution or improvement of epiphora and no major laser damage intranasally. Patients were followed for at least 18 months.

RESULTS

Forty consecutive ECL-DCRs on 30 patients (23 females, 7 males, mean age 62 years) were performed from April 2000 to December 2001. The success rate at 12 months postoperatively was 87.5%. All failures were due to a constricted nasal osteotomy. No significant intraoperative or postoperative complications were recorded.

CONCLUSIONS

Diode laser ECL-DCR with mitomycin C appears to be a safe and effective treatment modality for primary acquired nasolacrimal duct obstruction.

Acquired nasolacrimal duct obstruction

Acquired nasolacrimal duct obstruction is a common problem. Although tearing is the usual complaint, the clinical presentation can range from a patient having no symptoms to one with a life-threatening infection. Despite many studies providing useful clues, the exact pathophysiology of the obstructive process is incompletely understood. The clinician must be able to accurately make the diagnosis, which is often a clinical one, because many treatments with excellent success are available.

Effect of mitomycin C on the size of antrostomy after endoscopic sinus surgery

OBJECTIVES

Mitomycin C (MMC) is an antibiotic-antineoplastic agent that decreases fibroblast proliferation and scar formation. We aimed to evaluate the effect of MMC on the size of antrostomy and the mucociliary clearance rate.

METHODS

We selected 20 patients with chronic sinusitis on both sides. After middle meatal antrostomy, we selected one side, and a piece of Merocel soaked with 1.5 mL of MMC (0.4 mg/mL) was applied for 5 minutes. On the other side, normal saline solution was applied for a control. The size of the antrostomy was measured serially after surgery with a ruler. Mucociliary clearance was assessed by the saccharin test.

RESULTS

The effect of MMC in maintaining the size of the antrostomy was only significant during the first month. The relative size (the ratio of the remaining antrostomy area compared to the area in the immediate postoperative period) in the first month was significantly greater on the MMC-treated side than on the control side. The results of the saccharin test were not different between the two sides.

CONCLUSIONS

Topical MMC application may have a short-term effect in maintaining the patency of the antrostomy site. However, it does not seem to improve the relative size over an extended period of time.