A simple and evolutional approach proven to recanalise the nasolacrimal duct obstruction

Long-term outcomes of laser dacryoplasty combined with intubation using a new silicon tube in patients with lacrimal duct obstruction

AIM

To determine the 15-year outcomes of laser dacryoplasty (LDP) in patients with lacrimal duct obstruction; and to evaluate LDP combined with intubation using a new silicone tube to treat complicated cases.

METHODS

Patients with lacrimal duct obstruction and treated with LDP between April 2000 and April 2005 were investigated retrospectively. Totally 116 eyes with completed 15-year follow-up records were included in this study. For complicated cases (52 eyes of 52 patients), both LDP and intubation using a self-made silicon tube were performed. For patients with uncomplicated obstruction (64 eyes of 61 patients), only LDP was performed. Outcomes were assessed based on results of lacrimal irrigation and degree of symptoms during follow-up.

RESULTS

At the follow-up time of 15y, 81 eyes achieved full success (69.8%); 21 eyes got improved (18.1%); and 14 eyes were considered failure (12.1%). The success rate was 71.2% (37/52 eyes) for complicated cases; and 68.8% (44/64 eyes) for uncomplicated cases. No statistically significant difference between two groups was observed (P=0.961). No postoperative complication was observed.

CONCLUSION

LDP is a well-tolerated, simple, and effective procedure with satisfactory long-term outcomes in selected patients, which make it a good alternative to conventional dacryocystorhinostomy. In addition, intubation with the self-made mono-canalicular silicone tube facilitates the management of complicated cases with few complications.

Optimizing clinical outcomes for endoscopic lacrimal duct recanalization in patients with complete PANDO

PURPOSE

The study aims to describe modifications and refinements in the technique and technology of Transcanalicular Endoscopic Lacrimal Duct Recanalization (TELDR) based on anatomical foundations to optimize its clinical outcomes in patients with complete Primary Acquired Nasolacrimal Duct Obstruction (PANDO).

METHODS

The medical records of 115 patients who underwent TELDR procedures from January 2018 to July 2020 were reviewed retrospectively. Of the 115 patients, only those 35 patients with complete PANDO characterized by longstanding epiphora of 3-5 years duration, dense, diffuse fibrous tissue obstruction involving the sac, sac duct junction and the entire length of the nasolacrimal duct were included in the study. Parameters for success were analyzed based on patency on irrigation, functional endoscopic dye test, and improvement of epiphora.

RESULTS

Forty-five cases from 35 patients with complete PANDO were included in the study. The mean length of time from the date of operation to silicone stent removal was 8.1 weeks, while the mean length of follow-up starting from the removal of silicone stent to last follow-up was 61.0 weeks. There were 95.6% anatomic patency on canalicular irrigation with saline and 95.6% functional patency based on functional endoscopic dye test. There was significant improvement of epiphora (p value of < 0.0001) post-operatively.

CONCLUSION

The results of modified TELDR improved clinical outcomes and could be a definitive treatment in patients with complete PANDO with longstanding, dense, diffuse, fibrous tissue obstruction. Patients who experience reobstruction, may undergo a repeat of the recanalization approach.

Improvement in Dacryoendoscopic Visibility after Image Processing Using Comb-Removal and Image-Sharpening Algorithms

Recently, a minimally invasive treatment for lacrimal passage diseases was developed using dacryoendoscopy. Good visibility of the lacrimal passage is important for examination and treatment. This study aimed to investigate whether image processing can improve the dacryoendoscopic visibility using comb-removal and image-sharpening algorithms. We processed 20 dacryoendoscopic images (original images) using comb-removal and image-sharpening algorithms. Overall, 40 images (20 original and 20 post-processing) were randomly presented to the evaluators, who scored each image on a 10-point scale. The scores of the original and post-processing images were compared statistically. Additionally, in vitro experiments were performed using a test chart to examine whether image processing could improve the dacryoendoscopic visibility in a turbid fluid. The visual score (estimate ± standard error) of the images significantly improved from 3.52 ± 0.26 (original images) to 5.77 ± 0.28 (post-processing images; p < 0.001, linear mixed-effects model). The in vitro experiments revealed that the contrast and resolution of images in the turbid fluid improved after image processing. Image processing with our comb-removal and image-sharpening algorithms improved dacryoendoscopic visibility. The techniques used in this study are applicable for real-time processing and can be easily introduced in clinical practice.

3D morphological classification of the nasolacrimal duct: Anatomical study for planning treatment of tear drainage obstruction

BACKGROUND

The purpose of this study is to analyze and classify morphological features of the nasolacrimal duct (NLD) through 3D reconstruction to help understand the causes and treatment of NLD obstruction.

METHODS

In this study, we included 63 males and 55 females who underwent autopsy without NLD obstruction with ages ranging from 20 to 78 years. The NLD was defined from the lacrimal fossa to the opening of the BNLD to the inferior meatus, and all continuous CT images showing the NLD were selected. Segmentation was performed semi-automatically, and the reconstruction and measurement of NLD was performed using the Mimics program.

RESULTS

Overall NLD length, bony nasolacrimal duct (BNLD) length, anteroposterior and transverse diameters at the entrance to the BNLD, anteroposterior and transverse smallest diameters of the BNLD, BNLD volume, and lacrimal sac BNLD angle were significantly higher in males than females (p < .05). BNLD direction in the coronal plane was slightly more likely to be inward. The most common type in both sexes was cylinder type (42.0%), males were more likely to have lower-thicker types (34.1%), and females more likely to have upper-thicker types (22.7%).

CONCLUSION

There were sex differences in NLD measurements, and females had significantly smaller NLDs. These results may partially explain the increased prevalence of primary acquired NLD obstruction in females. The BNLD tends toward the midline, and inclines posteriorly.

Posture-Dependent 24-Hour Intraocular Pressure Fluctuation Patterns in an Intraocular Hypertension Monkey Model

Purpose

We investigate 24-hour intraocular pressure (IOP) fluctuation patterns and the influence of body position on IOP in a chronic ocular hypertension (COHT) monkey model.

Methods

We recorded 24-hour IOPs (nine time points) in the different body positions in 10 eyes with normal and eight with high IOP (with random selection of one eye of each monkey) using a Tonopen. The IOPs at various time points and in different body positions were compared.

Results

The average 24-hour IOPs in the immediate-supine, 10-minute supine, 10-minute seated, and immediate-seated positions in the COHT models were 28.64 ± 9.82, 25.42 ± 7.62, 23.49 ± 7.67, and 20.53 ± 7.80 mmHg, respectively. The diurnal-to-nocturnal IOP changes were 8.51 ± 2.93, 5.81 ± 3.67, 5.48 ± 2.97, and 3.59 ± 2.74 mmHg, respectively. The sudden shift between the supine and seated positions bring greater IOP variations (8.11 ± 2.85 mmHg) in the COHT monkeys, and the IOP fluctuations reached 14 to 38 mmHg when considering body position and the measurement time points.

Conclusions

The measurement time and body position influenced IOP. More elevated IOP occurred in the immediate-supine position and during the transient shift between the seated and supine positions. Maintaining a fixed position for sufficient time before measurement is important.

Translational Relevance

Glaucoma patients should focus on the importance of IOP measurements in the clinic occurring after an adequate amount of time in a fixed body position.

[Microendoscopic minimally invasive techniques in lacrimal surgery]

BACKGROUND

Lacrimation of the eye is a relatively common problem, the cause of which must be clarified by differential diagnostics. The most important symptom of a dysfunction of lacrimal drainage is epiphora.

METHODS

Due to the enhancement and miniaturization of endoscopes, which were originally used in gastroduodenoscopy in the 1990s, it is possible to check the anatomical structure and visualize pathological changes of the lacrimal drainage system, which is only approximately 1 mm in diameter. As shown by the results, mechanical stenoses are often caused by recurrent chronic inflammation. A complete stenosis usually occurs only slowly due to dysregulation of the lacrimal unit.

CONCLUSION

In contrast to the assumptions that were valid before the implementation of microendoscopy, complete stenoses are often only punctate and do not stretch over long distances. Shortly after the introduction of microendoscopic diagnostics minimally invasive therapy techniques, such as laser dacryoplasty (LDP) and microdrill dacryoplasty (MDP) were established. These procedures have enabled for the first time preservation of the entire physiology of the lacrimal drainage pump system despite surgical intervention after recanalization.

Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction

BACKGROUND

A dacryocystorhinostomy (DCR) procedure aims to restore drainage of tears by bypassing a blockage in the nasolacrimal duct, through the creation of a bony ostium that allows communication between the lacrimal sac and the nasal cavity. It can be performed using endonasal or external approaches. The comparative success rates of these two approaches have not yet been established and this review aims to evaluate the relevant up-to-date research.

OBJECTIVES

The primary aim of this review is to compare the success rates of endonasal DCR with that of external DCR. The secondary aim is to compare the complication rates between the two procedures.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2016, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to 22 August 2016), Embase (January 1980 to 22 August 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to 22 August 2016), Web of Science Conference Proceedings Citation Index- Science (CPCI-S) (January 1990 to 22 August 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 22 August 2016. We requested or examined relevant conference proceedings for appropriate trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing endonasal and external DCRs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility and extracted data on reported outcomes. We attempted to contact investigators to clarify the methodological quality of the studies. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included two trials in this review. One trial from Finland compared laser-assisted endonasal DCR with external DCR, and one trial from India compared mechanical endonasal DCR (using punch forceps) with external DCR. The trials were poorly reported and it was difficult to judge the extent to which bias had been avoided.Anatomic success was defined as the demonstration of a patent lacrimal passage on syringing, or endoscopic visualisation of fluorescein dye at the nasal opening of the anastomoses after a period of at least six months following surgery. Subjective success was defined as the resolution of symptoms of watering following surgery after a period of at least six months. Both included trials used anatomic patency demonstrated by irrigation as a measure of anatomic success. Different effects were seen in these two trials (I² = 76%). People receiving laser-assisted endonasal DCR were less likely to have a successful operation compared with external DCR (63% versus 91%; risk ratio (RR) 0.69, 95% confidence intervals (CI) 0.52 to 0.92; 64 participants). There was little or no difference in success comparing mechanical endonasal DCR and external DCR (90% in both groups; RR 1.00, CI 0.81 to 1.23; 40 participants). We judged this evidence on success to be very low-certainty, downgrading for risk of bias, imprecision and inconsistency. The trial from Finland also assessed subjective improvement in symptoms following surgery. Resolution of symptoms of watering in outdoor conditions was reported by 84% of the participants in the external DCR group and 59% of those in the laser-assisted endonasal DCR group (RR 0.70, CI 0.51 to 0.97; 64 participants, low-certainty evidence).There were no cases of intraoperative bleeding in any participant in the trial that compared laser-assisted endonasal DCR to external DCR. This was in contrast to the trial comparing mechanical endonasal DCR to external DCR in which 45% of participants in both groups experienced intraoperative bleeding (RR 1.00, 95% CI 0.50 to 1.98; 40 participants). We judged this evidence on intraoperative bleeding to be very low-certainty, downgrading for risk of bias, imprecision and inconsistency.There were only two cases of postoperative bleeding, both in the external DCR group (RR 0.33, 95% CI 0.04 to 3.10; participants = 104; studies = 2). There were only two cases of wound infection/gaping, again both in the external DCR group (RR 0.20, CI 0.01 to 3.92; participants = 40; studies = 1). We judged this evidence on complications to be very low-certainty, downgrading one level for risk of bias and two levels for imprecision due to the very low number of cases.

AUTHORS' CONCLUSIONS

There is uncertainty as to the relative effects of endonasal and external DCR. Differences in effect seen in the two trials included in this review may be due to variations in the endonasal technique, but may also be due to other differences between the trials. Future larger RCTs are required to further assess the success and complication rates of endonasal and external DCR. Different techniques of endonasal DCR should also be assessed, as the choice of endonasal technique can influence the outcome. Strict outcome criteria should be adopted to assess functional and anatomical outcomes with a minimal follow-up of six months.

Nasolacrimal recanalization as an alternative to external dacryocystorhinostomy for treating failed nasolacrimal duct intubation

To compare the surgical duration and clinical outcomes of nasolacrimal recanalization versus external dacryocystorhinostomy (DCR) in the treatment of failed nasolacrimal duct intubation.This is a retrospective, comparative, and interventional study. We evaluated the outcomes of 66 consecutive patients undergoing either nasolacrimal recanalization (n = 32) or DCR (n = 34) in a tertiary lacrimal disease referral center. Length of surgical duration, clinical outcomes, and rate of recurrence at 18 months postoperatively were compared.The mean surgical duration was 18.5 minutes (range, 15-25 minutes) for nasolacrimal recanalization and 48.2 minutes (range, 45-61 minutes) for DCR, respectively (P < 0.001). The rate of success was 84.4% in the recanalization group and 85.3% in the DCR group, respectively (P = 0.91). The time to recurrence was 2.6 ± 1.1 months in the recanalization group and 5.6 ± 2.1 months in the DCR group (P < 0.001). Five failed cases in each group received a secondary DCR surgery with the same resolution rate (40%). The absence of ocular discharge at baseline was a significant predictor for a successful outcome in the recanalization group (P = 0.04) but not in the DCR group (P = 0.63).Nasolacrimal recanalization is an effective, safe, and time-saving alternative to DCR for the treatment of failed nasolacrimal duct intubation. Clinicians should be cautious in patients with discharge.

[Modern, minimally invasive surgery of the lacrimal duct system]

Dacryorrhea is a relatively common but often difficult problem from a differential diagnostic aspect. The most important symptom of dysfunction of lacrimal drainage is called epiphora. Due to the enhancements and miniaturization of endoscopes originally used in gastroduodenal surgery, since the 1990s it is possible to check the anatomical structure and the pathological changes of the lacrimal drainage system, which is only 1 mm in diameter. Mechanical stenosis is often caused by recurrent chronic inflammation. Complete stenosis is usually only dot-like and seldom occurs over a long distance. Shortly after the development of tools for microendoscopic diagnosis, therapeutic techniques were established, such as laser dacryoplasty (LDP) for which a laser is used and microdrill dacryoplasty (MDP) for which a drill is used. These procedures allow for the first time the whole physiology of the lacrimal drainage system to be preserved despite surgical intervention.

[Modern, minimally invasive surgery of the lacrimal duct system]

Epiphora (tearing) is the main symptom of a dysfunction of the lacrimal drainage. Tearing is a common problem and the cause can not easily be identified. Since development and miniaturisation of gastroduodenal endoscopes in the 1990s, it is possible to check the anatomical structure and the pathological changes of the lacrimal drainage system, which has a diameter of 1 mm. Mechanical stenosis is often caused by recurring chronic inflammation. Complete stenosis is usually only punctual and seldom over a long distance. Shortly after the development of microendoscopic diagnostic tools, therapeutic techniques using a laser for the dacryoplasty (LDP) or a microdrill for the dacryoplasty (MDP) were established. For the first time, these treatments enable preservation of the whole physiology of the lacrimal drainage system in spite of surgical intervention.

A novel technique to recanalize the nasolacrimal duct with endodiathermy bipolar probe

Aims:

To evaluate a new approach for recanalization (RC) of nasolacrimal duct obstruction in the treatment of the symptomatic nasolacrimal duct obstruction (NLDO).

Materials and Methods:

A prospective, interventional, comparative study in 302 eyes of 209 patients of symptomatic nontraumatic NLDO. Eyes with previous failed surgery were excluded. One hundred and fifty-one eyes underwent RC with 20 G endodiathermy bipolar probe connected to a 7 W diathermy followed by bicanalicular intubation under direct visualization. One hundred and fifty-one eyes underwent standard external dacryocystorhinostomy (DCR). Follow-up was for 24 months and evaluation was done on basis of change in symptoms and lacrimal syringing. Data was analyzed by Chi-square test and unpaired t-test. P value < 0.05 was considered statistically significant.

Results:

Success defined as an asymptomatic patient or freely patent syringing was 92.7% (140 eyes) in RC group and 83.44% (126 eyes) in DCR group. Success was significantly more (P ≤ 0.01) in RC than DCR group. Surgical time was significantly less in RC than DCR (P ≤ 0.001). In RC group, RC could not be performed in three eyes and had to be later taken up for DCR. Intubation after RC was not achieved in four eyes; however these eyes had a patent pathway till 24 months. Twenty-two eyes had a premature extrusion of the tube; but the success rate in these (20 eyes) was comparable to the others within the group (P > 0.05). Two eyes in RC and one in DCR group had complications.

Conclusions:

RC with 20 G endodiathermy bipolar probe is a quick, simple, and effective alternative to standard external DCR.

Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction

BACKGROUND

Dacryocystorhinostomy (DCR) procedures can be performed using external or endonasal approaches. The comparative success rates of these procedures are unknown.

OBJECTIVES

To compare the success rates of external and endonasal approaches to DCR.

SEARCH STRATEGY

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 11), MEDLINE (January 1950 to December 2010), EMBASE (January 1980 to December 2010), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (December 2010), ClinicalTrials.gov (www.clinicaltrials.gov) (December 2010) and Web of Science Conference Proceedings Citation Index- Science (CPCI-S) (January 1990 to December 2010). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 7 December 2010. We requested or examined relevant conference proceedings for appropriate trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing external and endonasal dacryocystorhinostomies.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and assessment of quality with a predefined form. We contacted investigators to clarify the methodological quality of the studies.

MAIN RESULTS

We identified one trial that fulfilled the inclusion criteria. This trial compared 64 DCR procedures (32 external and 32 endonasal procedures). Endonasal DCR was four times more likely to fail compared to external DCR. This was statistically significant (95% confidence interval (CI) 1.25 to 12.84).

AUTHORS' CONCLUSIONS

The only trial included in the review provides evidence that endonasal DCR has statistically higher risk of failure compared to external DCR. However, this conclusion is limited by paucity of RCTs, small number of participants and lack of clarity of the methodological process. Well conducted RCTs with sufficient power are required to answer the research question.

Modern lacrimal duct surgery from the ophthalmological perspective

BACKGROUND

From the 1990's onward, it has been possible to assess changes in the lacrimal duct by direct, minimally invasive diagnostic inspection with the aid of miniaturized endoscopes originally used in gastroduodenal surgery. It has been shown in this way that mechanical lacrimal duct stenosis often develops gradually as the result of recurrent chronic inflammation. Absolute stenoses are often located at a single point rather than extending over a longer segment of the duct.

METHODS

Advances in lacrimal duct surgery are presented through a selective review of the relevant literature.

RESULTS

Roughly 70% to 80% of all mechanical stenoses of the lacrimal duct can be reopened during endoscopic surgery with the use of a laser or a miniaturized drill.

CONCLUSION

With the methods described here, it is now possible for the first time to perform surgery that obviates the need for a bypass procedure and maintains or restores the normal physiological function of the lacrimal system.