Results of intraoperative mitomycin C application in dacryocystorhinostomy

Mitomycin C augmented canalicular silicone intubation versus external dacryocystorhinostomy in primary acquired nasolacrimal duct obstruction: a retrospective study

PURPOSE

Given the improvement in the instruments and techniques, novel surgical interventions emerged to avoid osteotomy from the gold standard dacryocystorhinostomy (DCR) for treating primary acquired nasolacrimal duct obstruction (NLDO). This study compares external dacryocystorhinostomy versus canalicular silicone intubation using Mitomycin C (MMC) in primary acquired nasolacrimal duct obstruction (NLDO).

METHODS

60 cases were diagnosed with primary acquired NLDO enrolled in a retrospective study at the Department of Ophthalmology, Menoufia University Hospital, Egypt, from June 2021 to July 2023. Data were collected from patient files, the study was conducted, statistics were conducted and the research was written during the period from May 2024 to August 2024. Patients were randomly allocated into two groups: thirty cases underwent external DCR (Group Ex-DCR), and twenty-six underwent silicone intubation with MMC (Group SIMMC). This study was registered in the clinical trials with Gov ID: NCT037808.

RESULTS

At six months, external DCR and SI with MMC had success rates of 90% and 80.7%, respectively, with no statistically significant difference between both groups.

CONCLUSION

Silicon intubation with MMC is comparable to external DCR in terms of safety and efficacy, with the advantage of being a less invasive procedure, more accessible with a shorter learning curve, and shorter operative time in primary acquired NLDO.

A major review on punctal stenosis: Part II: Updated therapeutic interventions, complications, and outcomes

We continue our review of on punctal stenosis by providing a detailed discussion of management modalities, their complications, and outcomes. There is a significant change in the understanding of punctal and peripunctal anatomy, puncto-canalicular junction, and the lacrimal pump mechanisms. While the snip punctoplasty procedures are still practiced, there is an increasing trend toward nonincisional procedures. The nonincisional procedures in select cases appear to be equally effective as the incisional ones. Although simple to use, punctal plugs never became the mainstay of treatment because of design issues and the inability to address the coexisting canalicular stenosis. Placing stents only in the lower punctum in cases of upper and lower punctal stenosis should be discouraged, and management needs to address punctal stenosis and not which punctum is involved. Several types of stents are used in the management of punctal stenosis, mostly based on surgeon's preference. The benefits of adjuvant mitomycin C are uncertain. In view of literature on how stent biofilms can themselves cause chronic inflammation, placing them for prolonged periods should be reviewed and debated. Enhanced understanding of the molecular pathogenesis of punctal stenosis and addressing the current controversies in management would help standardize the therapeutic interventions available in the lacrimal armamentarium.

Use of Mitomycin C in Dacryocystorhinostomy: A Report by the American Academy of Ophthalmology

PURPOSE

To review the literature on the adjuvant use of mitomycin C (MMC) during dacryocystorhinostomy (DCR) in adults with primary nasolacrimal duct obstructions (NLDOs) to determine the efficacy in improving functional and anatomic outcomes with an acceptable level of risk.

METHODS

A literature search conducted in November 2020 and updated in November 2022 yielded 137 articles. Twenty-four articles met the inclusion criteria and were rated for level of evidence by the panel methodologist. Inclusion criteria required controlled studies on the effect of MMC on outcomes of external, endoscopic endonasal, or diode laser-assisted transcanalicular DCR in adults with primary acquired nasolacrimal obstruction with 6 months minimum follow-up and at least 10 participants.

RESULTS

Six of the 24 articles were rated level I evidence, 15 level II , and 3 level III. In primary external DCR, MMC significantly improved functional outcomes in 3 of 9 series. In primary endoscopic endonasal DCR, MMC significantly improved functional outcomes in 1 of 9 series. In revision endoscopic endonasal DCR, MMC significantly improved functional success in 1 of 3 series. The use of MMC did not improve outcomes statistically in any diode laser-assisted transcanalicular DCR studies. Concentrations of MMC ranged from 0.05 to 1 mg/ml, with 0.2 mg/ml used most frequently in 12 series, with duration of application ranging from 2 to 30 minutes. Ostium size was significantly larger in MMC groups than in control groups at 6 months after surgery in 4 of 5 reporting studies. However, these larger ostia did not confer higher functional success rates. Reporting of adverse events related to MMC were rare, with delayed cutaneous wound healing reported in 1 of 750 patients.

CONCLUSIONS

Intraoperative use of MMC in external and endoscopic endonasal DCR has been shown to improve functional and anatomic outcomes compared with controls in some series, but there is no agreement on the recommended concentration or application time for MMC in DCR. The data support that MMC use can result in a larger ostium size, decreased granulation tissue formation, and a decreased number of postoperative nasal debridements compared with controls, but this does not translate into improved functional success.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Re-establishing Lacrimal drainage by Canaliculorhinostomy, after dacryocystectomy - A viable option in symptomatic patients

Purpose

To evaluate the outcome and efficacy of a modified technique of canaliculo-dacryocystorhinostomy (canaliculoDCR) in the complete absence of lacrimal sac, as a means to re-establish lacrimal drainage in post dacryocystectomy(DCT) patients.

Methods

A retrospective, non-randomised interventional study including 15 proven and established post DCT patients with intact canaliculi of at least 7- 8mm. The patients presented with bothersome tearing to the Oculoplasty clinic from January 2017 to January 2018. Patients were operated by a single surgeon (ST). Procedure involved creating a bony ostium of optimum size, internal membranectomy and the nasal mucosal flap anchored appropriately to create a passage in line with the common canaliculus(CC). Adjunctively bicanalicular intubation and mitomycin- C (MMC) were used.

Results

Of the 15 patients who were operated,10 females and 5 males, 14 (93.33%) had functionally and anatomically patent lacrimal passage after the modified canaliculoDCR, 1 (6.66%) was symptomatically better with partial regurgitation of clear fluid. 3(20%) had tube prolapse after first month post operatively, which although significant, was not related to the technique. They were repositioned as an office procedure and retained thereafter till removal, no other tube related or MMC related sequelae was seen. No intra operative complication was encountered.

Conclusion

With a success rate of 93.33% and a resultant patent lacrimal tear drainage passage and trivial complication such as tube prolapse, we can conclude, this technique of modified canaliculoDCR in post DCT patients is a safe and effective procedure with promising results, thereby avoiding cumbersome methods and maintenance of Jones tube while at the same time providing symptomatic relief to the patients.

Efficacy of probing adjunctive with low-dose mitomycin-C irrigation for the treatment of epiphora in adults with nasolacrimal duct stenosis

PURPOSE:

The purpose of the study was to investigate the efficacy of adjunctive low-dose mitomycin-C (MMC) during successful lacrimal duct probing in adults with nasolacrimal ducts (NLDs) stenosis.

MATERIALS AND METHODS:

This is a prospective case–control study on patients with NLD stenosis who were randomized into two groups. All patients underwent probing without or with an application of MMC. Former group received 0.2 mg/ml MMC irrigation for 5 min. The main outcome measures were objective evaluation of patency with irrigation, as well as patients' subjective assessment of improvement.

RESULTS:

There were 73 eyes in 58 consecutive patients; patient mean age ranged from 19 to 78 years (mean 44 years). Female included larger group of patients (63%) and mean duration of the symptoms was 26.1 months (range, 2–120 months). After mean follow-up of 11 months (range, 9–14 months), 23 (60%) of the 38 eyes in the MMC groups and 8 (22%) of the 35 eyes in control group had complete response and remained symptom free. This difference was statistically significant (P = 0.005). According to the patient's satisfaction, epiphora was partially improved in 6 (17%) eyes of control group and 4 (10%) eyes in MMC group. Application of MMC has a better outcome in patients with severe stenosis (P = 0.007); patients who had symptoms more than 12 months (P = 0.02) and patients with constant epiphora were compared with intermittent symptoms (P = 0.001). No complications were detected during patients follow-up.

CONCLUSION:

This study suggests acceptable long-term results for probing adjunctive with MMC irrigation for adults with NLD stenosis that can be recommended as a simple and effective procedure for these patients.

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

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

Intra-Operative Mitomycin-C as Adjuvant Therapy in External and Endonasal Dacryocystorhinostomy: Systematic Review and Meta-Analysis

PURPOSE

To evaluate the effect of mitomycin-C (MMC) on the success of external (Ex-DCR) or endoscopic dacryocystorhinostomy (En-DCR).

METHOD

A systematic review of randomized clinical trials of Ex- or En-DCR with and without the use of MMC to treat primary acquired nasolacrimal duct obstruction (NLDO) was done. Two authors independently searched six databases from 1990 to 2019, using the terms "dacryocystorhinostomy" and "mitomycin-C." Statistical and meta-analyses were performed using RevMan 5.3 software.

RESULTS

Twenty-seven studies involving 2158 surgeries were included in this systematic review. The Ex-DCR group comprised 14 studies [odds ratio (OR): 2.74; 95% confidence intervals (CI) 1.54-4.87; I² = 30%], while the En-DCR group 13 studies (OR: 1.69; 95% CI 1.21-2.37; I² = 0%). The use of MMC slightly increased the success rate of Ex- or En-DCR (OR: 2.1; 95% CI 1.52-2.9; I² = 14%).

CONCLUSION

The intraoperative use of MMC is safe and slightly improves the success rate of Ex- or En-DCR. However, the evidence was very weak.

Antimetabolites as an adjunct to dacryocystorhinostomy for nasolacrimal duct obstruction

BACKGROUND

Nasolacrimal duct obstruction (NLDO) is a condition that results in the overflow of tears (epiphora) or infection of the nasolacrimal sac (dacryocystitis). The etiology of acquired NLDO is multifactorial and is not fully understood. Dacryocystorhinostomy (DCR) is the surgical correction of NLDO, which aims to establish a new drainage pathway between the lacrimal sac and the nose. The success of DCR is variable; the most common cause of failure is fibrosis and stenosis of the surgical ostium. Antimetabolites such as mitomycin-C (MMC) and 5-fluorouracil (5-FU) have been shown to be safe and effective in reducing fibrosis and improving clinical outcomes in other ophthalmic surgery settings (e.g. glaucoma and cornea surgery). Application of antimetabolites at the time of DCR has been studied, but the utility of these treatments remains uncertain.

OBJECTIVES

Primary objective: To determine if adjuvant treatment with antimetabolites improves functional success in the setting of DCR compared to DCR alone. Secondary objectives: To determine if anatomic success of DCR is increased with the use of antimetabolites, and if the surgical ostium is larger in participants treated with antimetabolites.

SEARCH METHODS

We searched the Cochrane Register for Controlled Trials (CENTRAL) (which contains the Cochrane Eye and Vision Trials Register) (2019, Issue 9), Ovid MEDLINE, Embase.com, PubMed, LILACS (Latin American and Caribbean Health Sciences Literature database), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic searches. We last searched the electronic databases on 6 September 2019.

SELECTION CRITERIA

We only included randomized controlled trials. Eligible studies were those that compared the administration of antimetabolites of any dose and concentration versus placebo or another active treatment in participants with NLDO undergoing primary DCR and reoperation. We only included studies that had enrolled adults 18 years or older. We also included studies that used silicone intubation as part of the DCR procedure.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened the search results, assessed risk of bias, and extracted data from the included studies using an electronic data collection form.

MAIN RESULTS

We included 31 studies in the review, of which 23 (1309 participants) provided data relating to our primary and secondary outcomes. Many of the 23 studies evaluated functional success, while others also assessed our secondary outcomes of anatomic success or ostium size, or both. Study characteristics Participant characteristics varied across studies, with the age of participants ranging from 30 to 70 years. Participants were predominantly women. These demographics correspond to those most frequently affected by nasolacrimal duct obstruction. Almost all of the studies utilized MMC as the antimetabolite, with only one using 5-FU. We assessed most trials as at unclear risk of bias for most domains. Conflicts of interest were not frequently reported, although the antimetabolites used are generic medications, and studies were not likely to be conducted for financial interest. Findings Twenty studies provided data on the primary outcome of functional success, of which 7 (356 participants) provided data at 6 months and 14 (909 participants) provided data beyond 6 months. At six months, the results showed no evidence of effect of antimetabolite on functional success (risk ratio (RR) 1.12, 95% confidence interval (CI) 0.98 to 1.29; low-certainty evidence). Beyond six months, the results favored the antimetabolite group (RR 1.15, 95% CI 1.07 to 1.25; moderate-certainty evidence). Fourteen studies reported data on the secondary outcome of anatomic success, of which 4 (306 participants) reported data at 6 months and 12 (831 participants) provided data beyond 6 months. Results at six months showed no evidence of effect of antimetabolite on anatomic success (RR 1.02, 95% CI 0.95 to 1.11; low-certainty evidence). Beyond six months, participants in the antimetabolite group were more likely to achieve anatomic success than those receiving DCR alone (RR 1.09, 95% CI 1.04 to 1.15; moderate-certainty evidence). At six months and beyond six months follow-up, two studies reported mean change in ostium size. We did not conduct meta-analysis for the various follow-up periods due to clinical, methodological, and statistical heterogeneity. However, point estimates from these studies at six months consistently favored participants in the antimetabolite group (low-certainty evidence). Beyond six months, while point estimates from one study favored participants in the antimetabolite group, estimates from another study showed no evidence of a difference between the two groups. The certainty of evidence at both time points was low. Adverse events Adverse events were rare. One study reported that one participant in the MMC group experienced delayed wound healing. Other studies reported no significant adverse events related to the application of antimetabolites.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that application of antimetabolites at the time of DCR increases functional and anatomic success of DCR when patients are followed for more than six months after surgery, but no evidence of a difference at six months, low-certainty of evidence. There is low-certainty evidence that combining antimetabolite with DCR increases the size of the lacrimal ostium at six months. However, beyond six months, the evidence remain uncertain. Adverse effects of the application of antimetabolites were minimal.

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.

The Role of Mitomycin C in Preventing Synechia and Stenosis after Endoscopic Sinus Surgery

Background

Synechia and stenosis formation after endoscopic sinus surgery (ESS) represents a potential source of surgical failure. Mitomycin C (MMC) has been used successfully in other fields to decrease postoperative scar formation. We hypothesize that the topical application of MMC reduces the incidence of stenosis and synechia formation after ESS.

Methods

This study is a randomized, controlled, single-blinded study based in a tertiary care teaching hospital. After routine ESS, a pledget soaked in MMC (0.5%) was randomly placed into the middle meatus of one nasal cavity for 5 minutes and a pledget soaked in saline was placed in the contralateral side in each patient. A blinded observer followed the patients for any evidence of stenosis or synechia formation. The medical records of enrolled patients were reviewed for demographics, diagnosis, prior surgery, type of sinus surgery, complications, incidence of stenosis/synechia, and need for further procedures.

Results

Twenty-nine patients were included in the final analysis. The mean follow-up period was 15 months (range, 3–32 months). There were no complications in this series. Eight patients experienced 10 episodes of synechia formation and one patient experienced 1 episode of synechia formation and 1 episode of stenosis of the maxillary sinus ostium. Seven of the 12 episodes of synechia/stenosis occurred on the side of the MMC application and the remaining 5 episodes occurred on the side opposite to the MMC application. This difference was not statistically significant.

Conclusion

The topical application of MMC did not decrease the incidence of stenosis and synechia formation after ESS. (American Journal of Rhinology 18, 311–314, 2004)

Mitomycin-C in dacryocystorhinostomy: From experimentation to implementation and the road ahead: A review

Dacryocystorhinostomy (DCR) is the procedure of choice in patients with epiphora due to primary acquired nasolacrimal duct obstruction. The evolution of surgical tools, fiber-optic endoscopes, effective anesthesia techniques, and the adjunct use of antimetabolites intraoperatively; namely mitomycin-C (MMC) have significantly contributed to the advancement of DCR surgery. MMC is a systemic chemotherapeutic agent derived from Streptomyces caespitosus that inhibits the synthesis of DNA, cellular RNA, and protein by inhibiting the synthesis of collagen by fibroblasts. Even the cellular changes in the human nasal mucosal fibroblasts induced by MMC at an ultrastructural level have been documented. There, however, seems to be a lack of consensus regarding MMC: The dosage, the route of delivery/application, the time of exposure and subsequently what role each of these variables plays in the final outcome of the surgery. In this review, an attempt is made to objectively examine all the evidence regarding the role of MMC in DCR. MMC appears to improve the success rate of DCR.

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.

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.

[Therapeutic methods of scar prevention at the site of endonasal dacryocystorhinostomy]

Success rate of endonasal dacryocystorhinostomy (DCR) varies from 82% to 91%. The bulk of unsatisfactory results is due to excessive scarring at the site of the created opening (dacryostoma, DS). Mitomycin C is the most extensively studied drug of those affecting regeneration processes, however, the data on its efficacy at DS site is contradictory. Despite ongoing search for new agents able to interfere in the physiological process of scarring, the number of relevant studies is yet insufficient. Thus, development of methods of scarring prevention after endonasal DCR takes the highest priority in dacryology.

Treatment of Refractory Gastrointestinal Strictures With Mitomycin C: A Systematic Review

BACKGROUND AND AIMS

Refractory benign gastrointestinal (GI) strictures represent a difficult management problem given the limited therapeutic interventions available. We performed a systematic review of all published cases using mitomycin C in the treatment of GI strictures.

METHODS

Searches of MEDLINE and Embase databases were performed to identify studies reporting application of mitomycin C for GI strictures. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction were performed independently by 2 authors.

RESULTS

Of 549 citations, 24 studies with 145 patients (74% pediatric and 26% adult) met inclusion criteria. Esophageal strictures were the most common (79%) site of refractory strictures treated with mitomycin C, with caustic injury the most common underlying etiology. The concentration (range, 0.1 to 2 mg/mL; median, 0.4 mg/mL), number of applications (range, 1 to 12; median, 1), duration of applications (range, 1 to 5; median, 2 min), and technique of application (cotton pledget, spray, injection, special catheters) varied among studies. Ninety-one patients (73%; children: 80%, adults: 59%) had a complete response; 26 (21%) had a partial response. Only 1 (0.7%) adverse event was reported: cutaneous sclerosis attributed to microperforation and mitomycin C extravastion after injection. Mean follow-up was 23 (4 to 60) months.

CONCLUSIONS

Local mitomycin C application seems to be a safe and effective therapy for benign refractory GI strictures of varying etiology in both pediatric and adult populations. Although the results of this systematic review are highly encouraging, it should be considered investigational. Additional randomized trials and larger prospective studies are needed to confirm these results and to better define the optimal dose, concentration, duration and technique of mitomycin C application.

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.

Clinical outcomes of dacryocystorhinostomy with or without intraoperative use of mitomycin C: a systematic review and meta-analysis

PURPOSE

To examine the possible benefit of intraoperative use of mitomycin C (MMC) application in dacryocystorhinostomy (DCR) and to assess its potential risk.

METHODS

Systematic review and meta-analysis of randomized-controlled trials (RCTs). A comprehensive literature search was performed according to a protocol set in advance. The participants included 811 patients of which 820 eyes were sampled for 14 RCTs. Only pertinent RCTs were identified and included in this meta-analysis. The primary efficacy measure was "patency of irrigation" at follow-up end point. The subjective outcome of "symptom relief" was also extracted as a secondary efficacy measure. For each study, relative risk was extracted. Heterogeneity, publication bias, subgroup, and meta-regression analyses were performed.

RESULTS

RevMan version 5.0 software was used for statistical analysis. In the primary efficacy measure, the use of MMC can significantly increase the rate of "patency of irrigation" [risk ratio (RR), 1.10; 95% confidence interval (CI), 1.04-1.17; P=0.0006]; the outcome of "symptom relief" was also affected by the use of MMC (RR, 1.15; 95% CI, 1.05-1.26; P=0.003). Sensitivity analysis suggested that the result was comparatively reliable.

CONCLUSION

Intraoperative use of MMC can bring about a positive effect to the outcomes of "patency of irrigation" and "symptom relief," which increases the success rate of DCR surgery.

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.

Use of adjunctive mitomycin C in external dacryocystorhinostomy surgery compared with surgery alone in patients with nasolacrimal duct obstruction: A prospective, double-masked, randomized, controlled trial

BACKGROUND

The most common cause for the failure of external dacryocystorhinostomy (DCR) surgery is the formation of granulation tissue at the osteotomy site or common canaliculus.

OBJECTIVES

The aims of this study were to assess the efficacy of intraoperative adjunctive mitomycin C (MMC) treatment in external DCR surgery and to compare this procedure with the standard DCR procedure alone in the long term (1 year).

METHODS

In this prospective, double-masked, randomized, controlled trial, patients with primary acquired nasolacrimal duct obstruction were randomized (using a random number table) into 2 groups based on surgical procedure. In the MMC group, intraoperative adjunctive MMC 0.2 mg/mL was applied to the osteotomy site for 30 minutes. The control group underwent standard DCR procedure only. The results of the DCR surgeries were assessed using objective findings (eg, cessation of excessive tearing via nasolacrimal duct irrigation and the improvement in height of tear meniscus) and subjective symptoms (asking patients to describe the degree of tearing improvement). Both the patients and the researchers who were assessing the study outcomes were masked to treatment group.

RESULTS

One hundred eyes of 100 Turkish patients were assessed and equally randomized to the MMC (27 women, 23 men; mean [SD] age, 47.0 [7.6] years) and control (26 women, 24 men; mean age, 46.6 [8.8] years) groups. The follow-up period was not significantly different between the MMC and the control groups (13.1 [1.1] vs 13.2 [1.4] months). Significantly more eyes in the MMC group than the control group remained symptom-free throughout the 1-year follow-up period (45/50 [90%] vs 33/50 [66%]; P=0.005). Significantly more patients in the control group than the MMC group had an improvement in symptoms at the 1-year follow-up (8/50 [16%] vs 2/50 [4%] eyes; P=0.005). Based on the patency of the drainage system, the success rate was significantly greater in the MMC group than the control group (48/50 [96%] vs 42/50 [84%]; P=0.005). Based on nasolacrimal duct irrigation, significantly fewer patients in the MMC group than the control group had an enclosed naso-lacrimal duct (2/50 [4%] vs 8/50 [16%]). No adverse effects (eg, abnormal nasal bleeding, mucosal necrosis, infection) or any other surgical adverse events were observed.

CONCLUSIONS

In the management of these patients with primary acquired nasolacrimal duct obstruction, adjunctive intraoperative MMC application with standard DCR surgery had a significantly higher success rate than did standard DCR surgery alone. Further large, double-masked, randomized studies are needed to confirm these findings.

Endoscopic dacryocystorhinostomy with flap suturing

Multiple reports have demonstrated the efficacy of endoscopic dacryocystorhinostomy (DCR). However the results of the same have varied from centre to centre. Many still regard external DCR as the gold standard. To describe an endoscopic DCR technique which anatomically simulates an external DCR and assess its results. Prospective, nonrandomized and noncomparative interventional case series. Clinical charts of patients with nasolacrimal duct obstruction based on symptomatic, clinical and radiological basis were included in the study. All surgeries were done endonasally using standard operative technique. The modification in the standard technique included creating a wide exposure of the lacrimal sac, incising the sac and the suturing the medial wall of the lacrimal sac with the lateral nasal wall. The same was achieved by using either vascular clips or 5.0 vicryl sutures. Twenty (11 females and 9 males) were included in the study. The average age of the patients was 56.86 years old (range 27-85 years old). The main presenting symptom was epiphora and 1 patient with mucocele. Successful outcome was measured in terms of relief of sympto anatomical patency assessed by sac syringing and nasal endoscopy showing a wide patent lumen. A primary success rate of 95% and ultimate rate of 100% was achieved in the cases with a nasolacrimal duct (NLD) block while an overall success rate of 82.6% was noted when the cases with NLD block and common canalicular block were considered together. Endoscopic DCR can now easily replace external DCR as a standard. It is not only minimally invasive, but has minimal complications and using this technique, we have been able to achieve very high success rates.

Meta-analysis of the adjunctive use of mitomycin C in primary and revision, external and endonasal dacryocystorhinostomy

PURPOSE

To determine whether application of the anti-proliferation agent, mitomycin C (MMC), to the osteotomy site during dacryocystorhinostomy (DCR) surgery increases surgical success rates.

METHOD

We conducted a comprehensive meta-analysis of randomised controlled clinical studies relating to the adjunctive use of MMC in primary and revision, as well as external (EX-DCR) and endonasal DCR (EN-DCR).

RESULTS

15 studies met our inclusion criteria with a total of 850 DCR procedures. The mean concentration of MMC used was 0.3 mg/ml (range 0.02-0.75 mg/ml) and mean duration of application 18 min (range 2-30 min). MMC significantly reduced the failure rate of primary EX-DCR (risk ratio, RR, 0.51; 95% confidence interval, CI, 0.31-0.86) and revision EN-DCR (RR 0.43; 95% CI 0.21-0.89). The adjunctive use of MMC in primary EN-DCR, however, did not confer a significant reduction in failure rate compared with control (RR 0.94; 95% CI 0.44-2.04). We found a deficiency of evidence regarding the potential benefit of MMC in revision EX-DCR. Only two cases of adverse effects relating to the use of MMC were reported among the studies, both of which related to delayed wound healing.

CONCLUSIONS

Application of MMC to the osteotomy site is a safe and effective way of increasing surgical success rate in primary EX-DCR and revision EN-DCR, but does not provide any significant benefit in primary EN-DCR. Further studies are required to evaluate the potential effect of MMC in revision EX-DCR.

Comparative study of dacryocystorhinostomy with and without intraoperative application of Mitomycin C

Aims and objectives

To compare the outcome of dacryocystorhinostomy surgery with and without the intraoperative use of Mitomycin C.

Methods

Our study is a prospective comparative case study in which 50 patients of primary acquired nasolacrimal duct obstruction were divided on the basis of random sampling into the conventional dacryocystorhinostomy group and the Mitomycin C group in which Mitomycin C 0.2 mg/ml was used intraoperatively. Patients were followed on 1st postoperative day, 1st, 3rd, 6th weeks, 3rd and 6th months. Patient symptoms and satisfaction were noted. Patency of lacrimal passage was assessed by lacrimal syringing and tear meniscus height was recorded on each follow-up.

Results

At the end of 6 months of follow-up, 96% of patients were asymptomatic in the Mitomycin C group whereas 80% patients in the conventional group were asymptomatic. On lacrimal syringing 24 (96%) eyes had patent passage in the Mitomycin C group where as only 1 (4%) patient had complete block with regurgitation of mucopurulent fluid. In the conventional group 20 (80%) eyes had patent passage, 4 (16%) eyes had complete block with regurgitation of mucopurulent fluid and 1 (4%) eye had partially patent passage on lacrimal syringing. Out of 25 eyes, 24 had normal tear meniscus height, and 1 had high tear meniscus height in the Mitomycin C group in comparison to the conventional group in which out of 25 eyes 20 eyes had normal, 1 had moderate and 4 eyes had high tear meniscus height. Intraoperative and postoperative complications in both the groups were identical.

Conclusion

Although the difference between the two groups was not statistically significant, a distinctly higher success was achieved in patients undergoing dacryocystorhinostomy with intra operative Mitomycin C as compared to conventional dacryocystorhinostomy.

Transcanalicular endoscope combined laser-assisted dacryocystorhinostomy

Aims:

In this study, we have tried to assess the success rate and difficulties that we came across while performing the transcanalicular endoscope combined laser-assisted dacryocystorhinostomy (T-ECLAD).

Materials and Methods:

A prospective study of 60 patients suffering from nasolacrimal duct obstruction confirmed by preoperative syringing was carried out at the Regional Institute of Ophthalmology. T-ECLAD is a new minimally invasive dacryocystorhinostomy procedure, which is performed by diode laser (980 nm diode laser with power of 10 watts) through lacrimal canaliculi with the help of a cannula and fiber optic cable. The interior of the nasal cavity was visualized with the help of the nasal endoscope on a monitor. Success of procedure was assessed by patency of the lacrimal drainage system on irrigation.

Results:

We performed 56 successive T-ECLAD. The average procedure time was 10 min, and on an average 235 Joules of laser energy was needed. We observed a patent nasolacrimal duct on irrigation in 39 out of 56 treated eyes. 1 patient had partial, 5 patients had blocked irrigation, and 10 patients did not return for follow up. This yields a success rate of 69.6% (if we exclude patients who did not return for follow up) with an average follow-up period of 6 months.

Conclusions:

The 980-nm T-ECLAD is a new contribution to the field of lacrimal surgery. It is a minimally invasive and quick procedure.

Long-Term Success of Modified External Dacryocystorhinostomy for the Treatment of Distal Common Canalicular Block

PURPOSE

Epiphora caused by common canalicular obstruction is difficult to manage. Distal common canalicular block caused by membranous obstruction near its junction with the lacrimal sac can be managed by modified dacryocystorhinostomy (DCR) consisting of internal membranectomy. We report our experience with this technique during long-term follow-up.

DESIGN

A prospective interventional case series was performed at a tertiary care center including 15 patients with a diagnosis of distal common canalicular obstruction.

METHODS

External DCR was performed, and after lacrimal sac opening, membranous obstruction at the distal end of the common canaliculus was identified and managed successfully in all cases. Mitomycin C was applied, and silicone intubation was done for 2 months. The main outcome measures were anatomical success (patent syringing) and functional success (complete relief of epiphora) at a minimum follow-up period of 1 year.

RESULTS

Fourteen (93%) cases were completely relieved of epiphora with patent lacrimal syringing at a mean follow-up of 15.4 months (P = 0.0001, McNemar test). The postoperative complications occurred in 4 cases and included nasal bleeding, lateral displacement of silicone tube at medial canthus, complete extrusion of silicone tube (at 4 weeks), and noticeable incisional scar.

CONCLUSIONS

Distal common canalicular obstruction can be successfully managed with DCR with internal membranectomy and silicone intubation with mitomycin C. It avoids excision of common canaliculus as compared with canaliculo-DCR. The procedure is safe and effective with minor complications.

Use of mitomycin C in endo-DCR

OBJECTIVE

To evaluate the role of topical Mitomycin C in Endoscopic Dacryocystorhinostomy (DCR), for the prevention of stomal stenosis.

PATIENTS

Thirty patients undergoing endoscopic DCR for chronic dacryocystitis were studied prospectively. The follow up period was 12 months.

TECHNIQUE

PATIENTS were divided into two groups randomly. All of them underwent endoscopic DCR. One group was subjected to topical Mitomycin C application after surgery while the control group was not.

MAIN OUTCOME MEASURES

Postoperative relief of epiphora and endoscopic documentation of the patency of the stoma were the main outcome measures.

RESULTS

80% cases of the Mitomycin C group and 86.67% cases of the non Mitomycin C group had long-term successful results. This result is not statistically significant (p> 0.2).

CONCLUSION

Intraoperative Mitomycin C application does not alter the long-term results in endoscopic DCR. A properly and adequately performed surgery is more vital for successful result.

Effect of mitomycin C on success rate in dacryocystorhinostomy with silicone tube intubation and improper flaps

PURPOSE

To assess the effect of mitomycin C on surgical success rate of dacryocystorhinostomy and silicone intubation in patients with improper flaps.

METHODS

The study was a randomized clinical trial. The patients with indication for dacryocystorhinostomy surgery with silicone intubation (inappropriate lacrimal sac or nasal mucosal flaps during surgery and/or history of dacryocystitis in the past 3 months) were randomly assigned to application of mitomycin C (0.02%) on surgical flaps (group A) or a control group without mitomycin C application (group B). Main outcome measures were subjective symptomatic improvement and result of irrigation test at last follow-up visit.

RESULTS

The study enrolled 88 patients (88 eyes); there were 42 patients in group A and 46 patients in group B. There was an average follow-up of 10 months (range 6-15 months) following surgery. Significant improvement (no tearing with patent lacrimal system in irrigation) was observed in 31 patients (73.8%) in group A and 32 patients (69.6%) in group B. There was no statistically significant difference in no improvement (no change in tearing state and obstruction in irrigation test), relative improvement (decreased tearing and passage of fluid with force in irrigation test), and significant improvement rate between the 2 groups of study (p>0.05).

CONCLUSIONS

Application of mitomycin C on surgical flaps during dacryocystorhinostomy surgery with silicone intubation in patients with improper flaps has no proven beneficial effect on success rate of surgery.

Mitomycin C–Enhanced Revision Endoscopic Dacryocystorhinostomy

Objectives

(1) To conduct an adequately powered randomized controlled trial investigating the safety and efficacy of mitomycin C–enhanced revision endoscopic dacryocystorhinostomy (DCR) and (2) to analyze causes of failure after primary endoscopic DCR.

Study Design

A randomized controlled study.

Setting

General hospital.

Subjects and Methods

Seventy-six revision endoscopic DCRs were randomized into 2 groups: endoscopic DCR with mitomycin (group I), where 0.5 mg/mL mitomycin C was applied for 10 minutes, and endoscopic DCR without mitomycin (group II). Follow-up settings were done to document the patient’s subjective improvement, to judge ostium patency on irrigation, and to record any complications.

Results

Causes of failure in the original 92 patients included canalicular obstruction (14%), small misplaced bony window (43%), very small nasolacrimal stoma due to development of synechia (23%), and complete closure of nasolacrimal stoma with tough fibrous tissue (63%). There was no significant difference between the 2 groups in subjective and objective success rates and adverse events. Group I demonstrated a significantly longer operative time and a significantly lower number of debridement sessions (mean of 1.2 vs 1.9).

Conclusions

Recurrent nasolacrimal duct obstruction after primary endoscopic DCR is mainly due to reclosure of the nasolacrimal stoma with synechia and fashioning of the small misplaced bony window. Mitomycin C does not increase the success rate of revision endoscopic DCR. It is a safe procedure and may be of value only in patients inaccessible to strict follow-up because it induces a better healing profile in terms of mucosal recovery, wound healing, and less need for debridement sessions.

[Corrective techniques of lacrimal obstruction in the vertical system]

PURPOSE

To describe current surgical techniques of dacryocystorhinostomy (DCR) and to compare their effectiveness by analysing the advantages and disadvantages between external, endonasal and transcanalicular surgery.

PATIENTS AND METHODS

A total of 91 DCRs were analysed using a retrospective, cross-sectional and multicentre study in 75 patients who had symptoms of nasolacrimal duct obstruction. Of these, 28 were operated using external DCR, 31 endonasal technic, and 32 transcanalicular DCR with diode laser. Outcomes were evaluated subjectively using patient symptoms for the grade of epiphora and the results from the syringing before and after surgery.

RESULTS

External DCR was performed in 28 cases, with 19 cases asymptomatic (67.85%), and 20 patients had a patent tract (71.42%). Endonasal DCR was performed in 31 cases, of which 19 cases were asymptomatic (61.29%), and 21 showed patency of the nasolacrimal duct (67.74%). A transcanalicular technique was performed in 32 cases, with absence of epiphora in 24 patients (75%), and the syringing was successful in 24 of them (75%).

CONCLUSIONS

Any of these 3 surgery techniques would be an adequate treatment for lacrimal obstruction, due to the significant development of endonasal and transcanalicular techniques in recent decades. With improvement, we could use either endonasal or transcanalicular techniques with diode laser with the same lever of effectiveness as the classic external approach, with the advantages of minimally invasive surgery.

Conventional dacryocystorhinostomy in a failed Trans-canalicular laser-assisted dacryocystorhinostomy

We report the success rate and problems associated with conventional dacryocystorhinostomy (DCR) in failed cases of Trans-canalicular, laser-assisted DCR (TCLADCR). Out of 50 patients operated by the TCLADCR technique during the period 2005 – 2006, 33 patients had failure, which was confirmed on syringing of the nasolacrimal passage. Before considering them for conventional DCR, a thorough ear, nose, throat (ENT) examination was done by an ENT surgeon, to rule out a nasal pathology. All the patients were operated by the conventional standard DCR method at a medical college. While performing the surgery, the problems that came across were identified and noted. The success rate was found to be 91% in this study in a follow-up period of one year, with no major intra-operative problems. Conventional DCR is still a gold standard and should be considered as a procedure of choice in failed cases of TCLDCR.

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.

Combined posterior flap and anterior suspended flap dacryocystorhinostomy: A modification of external dacryocystorhinostomy

BACKGROUND

External dacryocystorhinostomy (DCR) remains a reliable surgical technique for the treatment of obstruction of lacrimal drainage system beyond the common canalicular opening.

AIM

To describe a simple modified double flap external DCR technique.

MATERIALS AND METHODS

Ninety six consecutive cases of chronic dacryocystitis with or without mucocele were selected irrespective of age and sex. In a modification to routine external DCR, a modified technique was followed, where both anterior and posterior flaps of lacrimal sac and nasal mucosa are created and sutured. Two double armed sutures were used to join the edges of anterior flaps, and elevate them anteriorly to avoid adhesion or apposition with underlying sutured posterior flaps, and to approximate the deep plane of the wound.

RESULTS

At the end of average follow-up period of 13 months, we observed 98.9% objective and 96.8% subjective success rates. The average operation time was 45 minutes. No significant intraoperative or postoperative complications were noticed.

CONCLUSION

We believe that combined posterior flap and anterior suspended flap DCR technique is simple to perform and has the advantage of both double flap DCR and anterior suspension of anterior flaps. The results of the study showed the efficacy of this simple modification.

The effects of repetitious topical use of mitomycin C on antrostomy patency in maxillary antrostomy created rabbit model

The aim of our study was to investigate the effect of the topical use of mitomycin C (MMC) intraoperatively in single dose and intra-postoperatively in two doses on the narrowing of antrostomy in maxillary rabbit sinus antrostomies created experimentally. And also to determine the local and systemic side effects of topical MMC. With this objective, 0.6 mg/ml MMC was used to the first group at single dose and to the second group intraoperatively and on third day postoperatively in two doses topically for 5 min. After 8 weeks, although the mean area of antrostomy was larger than that in the control side in the first group, which received single dose MMC, the difference was not statistically significant (p = 0.287). The second group received two doses, and the antrostomy areas were found to be significantly larger than the controls (p = 0.05). Overall, the sides that received MMC were significantly larger (p = 0.029). From the point of histopathological examination of the tissue, it was seen that two-dose MMC increased the edema indicating inflammation and antrostomy resolved with normal respiratory tract epithelium. It was shown by measuring the blood values that nephrotoxic and myelosupressant effect of MMC occurring in systemic use did not occur with single or double dose topical use. Our results demonstrate that even if the number of cases was low, two doses of topical MMC usage prevent the narrowing of antrostomy while single dose MMC does not. And two-dose topical MMC usage does not have local and systemic side effects.

Efficacy of endonasal dacryocystorhinostomy, using 'cold steel' instruments without stenting, in treatment of distal nasolacrimal duct obstruction

OBJECTIVE

To assess the efficacy of an endonasal dacryocystorhinostomy technique using conventional instruments, without the use of any adjunctive techniques.

STUDY DESIGN

Prospective, non-randomised, cohort study.

METHODS

Patients diagnosed with nasolacrimal duct obstruction between January 2006 and December 2008 were included in the study. Seventy-eight endonasal dacryocystorhinostomies (primary or revision) were performed with conventional 'cold steel' instruments. The technique involved complete exposure and marsupialisation of the lacrimal sac. No adjunctive procedures were used. Success was defined as complete resolution of epiphora and a patent lacrimal system, evaluated by lacrimal irrigation and endoscopy, one year post-operatively.

RESULTS

Seventy-four of the 78 cases were symptom-free after a minimum follow up of 12 months, giving an overall success rate of 94.9 per cent. The success rates for primary and revision cases were 95.5 and 90.9 per cent, respectively.

CONCLUSION

Meticulous surgical technique can ensure high success rates with the use of conventional cold steel instruments, without the use of adjunctive procedures, making endonasal dacryocystorhinostomy a cost-effective, reliable procedure.

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.

The use of adjunctive topical mitomycin in endoscopic congenital choanal atresia repair

OBJECTIVE

To evaluate the efficacy of topical mitomycin in providing the patency of the neochoanae in children undergoing transnasal endoscopic congenital choanal atresia (CA) repair.

METHODS

A retrospective analysis of surgical results in CA patients who were treated in Selcuk University, Meram Medical Faculty, Department of Otolaryngology between November 2002 and November 2009 was performed. All patients underwent transnasal endoscopic approach using nasal telescopes and traditional sinus instrumentation together with a microdebrider. Mitomycin was used according to the senior surgeon's preference, and certainly not in a randomized fashion. After completion of surgery, mitomycin 0.4 mg/ml was applied to the neochoanae for 3 min. Postoperative stenting was performed in all patients.

RESULTS

CA was unilateral in 8 subjects (mean age 71.8+/-41.7 months; range 18 months-144 months) and bilateral in 12 subjects (mean age 4.6+/-1.3 days; range 3-7 days). Among the subjects, 75% was female in both groups. Fourteen subjects under endoscopic repair without mitomycin, whereas mitomycin was used in 6 patients (4 bilateral, 2 unilateral). Stents were left at least 3 weeks postoperatively (mean 31+/-10 days; range 21-45 days). The patients were followed-up at least 6 months (range 6-72 months). No symptomatic restenosis requiring further dilatations was seen in patients treated with preoperative mitomycin, whereas restenosis was detected in 6 subjects (42.9%) treated without mitomycin postoperatively within 6 months period (Fisher's Exact Test 2-sided, p=0.12). These subjects underwent revision endoscopic repair with mitomycin and had no need for further dilatations with acceptable control of symptoms during a follow-up period ranging between 14 and 78 months.

CONCLUSION

Mitomycin improves the surgical treatment outcome of CA and reduces the rate of restenosis significantly without any complications. However, further prospective randomized studies are needed to fully investigate the benefits of mitomycin therapy in CA surgery.

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.

Factors affecting the success of external dacryocystorhinostomy

PURPOSE

To assess the success rate of external dacryocystorhinostomy (Ext-DCR) and factors affecting it in a university hospital.

MATERIALS AND METHODS

In a retrospective interventional non-comparative case series, records of 276 Ext-DCRs in 274 patients in a 9-year period were reviewed. 'Complete success' was defined as patent system on irrigation (objective) and absence of symptoms (subjective). Patent system on irrigation with minimal postoperative symptoms was considered as partial success. The chi-square and Fisher's exact tests with 95% confidence interval (CI) were used to analyze the data (SPSS release version 9.0, Chicago).

RESULTS

The age range was 3-84 years (mean: 41.5, SD: 17.7). The majority of the patients (66.7%) were female. The most common presumed etiology was primary acquired nasolacrimal duct obstruction (PANLDO) (227/276, 82.2%). A silicone tube was inserted in 111 patients (40.2%). Follow-up was from 6 to 89 months (mean: 11.5, SD: 10.4). Overall complete success rate was 89.1% (246/276). It was 92% (209/227) in PANLDO, 72.7% (16/22) in congenital NLDO (P: 0.01, 95% CI: 0.024-0.030), 71.4% (10/14) in traumatic NLDO (P: 0.001, 95% CI: 0.012-0.017), 90% (9/10) in previous failed DCR (P: 0.6, 95% CI: 1), and two out of three patients with previous nasal/sinus surgery. Gender, type of presenting symptoms, duration of preoperative symptoms, silicone tube insertion in PANLDO, and associated canalicular stenosis did not have a significant effect on the success.

CONCLUSION

Ext-DCR is an effective and highly successful procedure for the treatment of NLDO regardless of the etiology.