Comparison of Nonlaser Endoscopic Endonasal Revision Surgery and Diode Laser Transcanalicular Revision Surgery for Failed Dacryocystorhinostomy

Retrospective study of success rate and associated factors of two laser dacryocystorhinostomy techniques, in a third-level hospital

BACKGROUND AND OBJECTIVE

To compare the success rate of two laser dacryocystorhinostomy (L-DCR) techniques.

MATERIALS AND METHODS

A retrospective study of patients who underwent surgery for acquired nasolacrimal duct obstruction (NLDO) between 2000 and 2021, carried out in a third level hospital, using L-DCR and modifications of this technique. Intraoperative findings, complications, and anatomical and functional success rate of the 2 techniques were analyzed. The follow-up time was 1 year.

RESULTS

We included 92 lacrimal ducts with NLDO. 66 (71.7%) were women. 78 (84.8%) underwent unilateral surgery. The mean age was 62.77 ± 13.08 years. 61 (66.3%) underwent intraoperative laser dacryocystorhinostomy with MMTC (L-DCR + MMTC) and 31 (33.6%) L-DCR associated with endoscopic ostium enlargement (L-DCRend-amp). The one-year anatomical/functional success rate of the L-DCRend-amp + MMTC was 71%/64,5%. L-DCR + MMTC obtained a lower success rate, 65.6/60,7% (p = 0.391). There were no differences throughout the follow-up between the anatomical or functional success rates of the 2 techniques, nor between the different visits (p > 0,05). Intraoperative findings rate was 3.63% in L-DCR + MMTC, and 32.26% in L-DCRend-amp + MMTC. Postoperative complication rate was 3.27% in L-DCR + MMTC, and 3.23% in L-DCRend-amp + MMTC.

CONCLUSIONS

The L-DCRend-amp + MMTC gets a higher success rate than the L-DCR + MMTC. We must consider the surgical time-cost of the L-DCRend-amp + MMTC, as well as the learning curve of endoscopy techniques, and the skill of the surgeon, without a clear benefit in the success rate.

Primary transcanalicular diode laser-assisted dacryocystorhinostomy: long-term success rates and risk factors for recurrence

OBJECTIVE

The aim of the study was to investigate the long-term success rates of transcanalicular endolaser dacryocystorhinostomy (TC-DCR) surgery along with the factors that possibly affect surgical success.

METHODS

Patients (n = 300) who underwent unilateral TC-DCR operations in the department of ophthalmology of our university hospital between January 2011 and June 2021 were included in the study. The subjects were divided into 2 groups, with group 1 showing no recurrence (n = 205) and group 2 showing recurrence (n = 95).

RESULTS

The mean follow-up period for the 300 patients was 26.7 ± 7.0 months (range, 11-33 months). The overall success rate was 205 of 300 (∼68%). Although, based on the univariate risk analysis, age, operative time, total laser power, tube removal time, septum deviation, fistulisation, and intraoperative hemorrhage were found to be risk factors, in multivariate risk analysis, only total laser power, septum deviation, and intraoperative bleeding were determined to be the main risk factors.

CONCLUSION

The success rate of TC-DCR was lower than that of traditional external DCR, but because TC-DCR is a minimally invasive aesthetic surgery with a short operative time, it may become a preferred option by more ophthalmologists, especially for young patients without intranasal pathology and coagulation disorders and elderly patients at risk for general anaesthesia. It should be taken into account that the chances of success are relatively lower among patients with total laser power applied during surgery, intraoperative hemorrhage, fistulization, and septum deviation. In TC-DCR, bleeding control, short operative time, and low laser power are important to achieve a high success rate. Also, 1 year after TC-DCR, even the presence of anatomic drainage may lower the functional success of patients, so follow-up should be continued.

Endocanalicular Laser Dacryocystorhinostomy and its modifications: A systematic review of techniques and success rates

OBJECTIVE

the main objective of this work is to review the articles that refer to transcanalicular diode laser dacryocystorhinostomy (TCL-DCR) in acquired nasolacrimal duct obstruction (NLDO), as well as its modifications.

MATERIAL AND METHODS

A systematic review of publications related to TCL-DCR of the lacrimal duct from 2000 to March 2021 was carried out in the MEDLINE, EMBASE and COCHRANE LIBRARY databases. The search terms in Spanish and English were: «Endocanalicular laser», dacryocystorhinostomy or «primary DCR-L» or «laser» and «tear ducts».

RESULTS

After subjecting the articles to the inclusion and exclusion criteria, we got 49 articles: 21 retrospective and 28 prospective studies. The bibliometric result obtained guaranteed, for this review, a level C recommendation according to the Scottish Intercollegiate Guidelines Network scale.

CONCLUSIONS

Currently, the classic TCL-DCR has lower success rates than its modifications, so we suggest using the latter. We prefer TCL-DCR with IS-MMC or TCDL associated with endoscopy techniques, without being able to opt for any option, since their success rates are very similar. We leave the choice to the discretion of the surgeon, depending on the management skills of endonasal techniques. More studies, with longer follow-up, and better defined criteria are necessary to clarify which is the best TCL-DCR technique.

Comparison of Piezosurgery and Hammer-Chisel in Endoscopic Dacryocystorhinostomy

BACKGROUND

In this study, we compared the advantages and disadvantages of piezosurgery and hammer-chisel used in endoscopic dacryocystorhinostomy (EDCR).

MATERIAL AND METHODS

Between January 2012 and January 2016, 10 women and 8 men in whom piezosurgery was used (group 1) and 11 women and 7 men in whom hammer-chisel was used (group 2) during EDCR operations were compared retrospectively. Recurrence, operation time, postoperative bleeding, and operative cost were evaluated in patients who were followed for an average of 11.8 months. In addition, visual analogue scale (VAS) was used to assess pain at 6 hours postoperatively.

RESULTS

No recurrence was observed in group 1, but recurrence was observed in 2 patients in group 2 (P = 0.685). There was no postoperative bleeding in both groups. The mean duration of operation was 30.6 ± 8.2 minutes in group 1 and 46.8 ± 9.5 minutes in group 2 (P = 0.038). The VAS score in group 1 was 2.7 ± 1.4 and the VAS score in group 2 was 5.8 ± 2.2 (P = 0.01). Piezosurgery costs an additional $325 for each patient while the use of the hammer-chisel does not incur additional costs.

CONCLUSION

Piezosurgery causes shorter operation time, less recurrence, and less pain when compared with hammer-chisel.

Revision eDCR using a superior pedicled mucosal flap

BACKGROUND

Endoscopic dacryocystorhinostomies (eDCRs) show patency rates between 81% and 94%. However, dacryocystorhinostomy (DCR) failure and the need for revision remain a significant challenge. One of the principal challenges in revision eDCR is the need to surgically identify the correct osteotomy site and maintain long-term patency in the setting of previously instrumented and potentially scarred tissue. At the same time, the surgeon must assume that the blood supply to the commonly described anterior and posteriorly pedicled flaps has been compromised.

OBJECTIVE

The objective of the study is to describe a novel flap technique for revision eDCR.

METHODS

The superior based mucosal flap is a novel technique that provides a vascularized mucosa preserving technique in revision eDCR despite previous instrumentation of the lacrimal system. This technique provides wide exposure of the revision osteotomy site while simultaneously allowing a viable mucosal flap to be replaced at the conclusion of the procedure, thereby minimizing bone exposure and cicatricial restenosis.

RESULTS

The authors have utilized this technique in 13 procedures with 100% positive identification of the lacrimal sac, a 0% complication rate, and a 100% success rate after a mean follow-up of 26.93 ± 10.33 months (range 6-35 months).

CONCLUSION

The eDCR using the superior pedicled mucosal flap provides excellent exposure of the maxillary bone and the lacrimal sac. This method preserves vascularity of the flap using a superiorly based pedicle which is typically inviolate during both open and endoscopic primary DCR. The mucosal flap can then be replaced, thereby minimizing bone exposure and optimizing patency.

Transcanalicular Diode Laser-Assisted Revision Surgery for Failed Dacryocystorhinostomy With or Without Distal or Common Canalicular Obstruction

PURPOSE

To report the outcomes of transcanalicular diode laser-assisted revision surgery for failed dacryocystorhinostomy with/without distal or common canalicular obstruction.

METHODS

The medical records and recorded videos of consecutive transcanalicular diode laser-assisted revision surgeries performed for failed dacryocystorhinostomy between May 2011 and May 2015 were reviewed. Cases of unavailability of video and cases lost to follow up after surgery were excluded from the study. With respect to the level of obstruction, lacrimal drainage systems were divided into Group 1 (obstruction at the level of the ostium) and Group 2 (obstruction at the level of the distal or common canaliculus). Data associated with anatomical and functional success were analyzed.

RESULTS

Revision dacryocystorhinostomy surgeries were performed on 68 patients during the study period. Transcanalicular diode laser-assisted revision surgeries were performed on 48 eyes of 39 patients. Mean follow-up period after revision surgery was 13.3 ± 12.6 months. Overall, anatomical success rate was 83.3% (40/48) and functional success rate was 68.8% (33/48). Anatomical success rates and functional success rates in the 2 groups showed no significant difference (80.0% [24/30] vs. 86.7% [13/15], p = 0.699; 70.0% [21/30] vs. 66.7% [10/15], p = 1.000, respectively).

CONCLUSIONS

Transcanalicular diode laser-assisted revision surgery may be an alternative technique for failed dacryocystorhinostomy. Distal or common canalicular obstruction did not affect the outcomes of revision surgeries.

Revision External Dacryocystorhinostomy Results After a Failed Dacryocystorhinostomy Surgery

Objective

To report revision external dacryocystorhinostomy (rE-DCR) results following failed dacryocystorhinostomy (DCR) surgery.

Methods

A retrospective review of patients who underwent rE-DCR between June 2006 and June 2015 at Yıldırım Beyazıt University Ankara Ataturk Training and Research Hospital Department of Ophthalmology. Data were collected on the primary surgery technique and patient demographics.

Results

Forty-one rE-DCRs were performed on 40 patients after various failed DCR techniques. Two patients had failed DCR twice, and 38 patients had failed DCR once. Six of these previous failed DCRs were multidiode laser DCR, two of them were endoscopic DCR, and 33 were external dacryocystorhinostomy (E-DCR). In all rE-DCR procedures, silicone tube intubation was performed, and the tube was removed at least 6 months after surgery. We used mitomycin C on 16 patients (40%). At the last examination, six patients still had epiphora (15%), and their nasolacrimal passage was obstructed. Thirty-four patients had no complaints, and their passages were open (85%).

Conclusion

The rE-DCR procedure has high success rates for failed DCR surgeries, whichever procedure was performed.