External dacryocystorhinostomy: A critical overview of the current evidence

PURPOSE

External dacryocystorhinostomy (ext-DCR) is still considered the gold standard in the treatment of distal lacrimal duct obstruction. Despite an overall high success rate, some patients do relapse after surgery and the ideal perioperative management has not been identified yet. The purpose of this study is to critically discuss the published evidence in the last five years on the medical and surgical management of external dacryocystorhinostomy. Furthermore, the drawbacks of the available literature and the perspectives in this field will be also highlighted.

METHODS

Systematic review of the literature in the last 5 years by using PubMed and Google Scholar.

RESULTS

A total of 64 articles were included. Many technical modifications and surgical refinements have been proposed but a formal comparison among the various techniques is hampered by methodological heterogeneity. The use of local anesthesia, and the perioperative adjunctive techniques to reduce the risk of restenosis are also gaining popularity but the level of evidence remains weak.

CONCLUSION

Ext-DCR offers satisfactory clinical outcomes even though there are many gray areas that need to be addressed in future high-quality studies.

A critical update on endoscopic dacryocystorhinostomy

Objectives

Endoscopic dacryocystorhinostomy (endo-DCR) is becoming a workhorse in the management of distal lacrimal duct obstruction. It yields success rates comparable to external DCR, with the advantage of no external scars. However, it requires multidisciplinary expertise and many uncertainties in terms of proper indications, technique, and perioperative management still exist.

Methods

Systematic review of the literature in the last 5 years using PubMed and Google Scholar.

Results

A total of 66 articles were included. Many technical modifications and surgical refinements have been proposed, but a formal comparison of the various techniques is hampered by methodological heterogeneity. The use of local anaesthesia and perioperative adjunctive techniques to reduce the risk of restenosis are also gaining popularity even if the level of evidence remains weak.

Conclusions

Endo-DCR offers satisfactory clinical outcomes even though there are many grey areas that need to be addressed in future high-quality studies.

Factors Influencing Endoscopic Dacryocystorhinostomy Outcomes: A Comprehensive Clinical and Histopathological Analysis and Review of the Literature

Purpose

The main challenge in maintaining long-term success of endoscopic dacryocystorhinostomy is preventing fibrosis and scarring at the anastomosis site. Despite numerous studies on surgical techniques, research on histological factors linked to postoperative scarring is limited. This study evaluated long-term (range, 12-18 months) outcomes and systematically examined clinical and histopathological factors that may contribute to restenosis.

Patients and Methods

This retrospective study included 47 patients who underwent a unilateral surgery intervention for primary acquired lacrimal duct obstruction. The following clinical and histopathological variables were considered to assess the risk factors for the development of restenosis: sex, age, duration of disease, clinical manifestation of disease, clinical features of the lacrimal sac perceived intraoperatively, fibrosis, and mononuclear cell infiltrates.

Results

Statistical analysis showed that only patient sex (Pearson's chi-squared test, p = 0.007) and severity of intraoperative adhesions in the lacrimal sac (Pearson's chi-square test, p = 0.029) were significantly linked to restenosis. However, the skewed male-to-female ratio, few surgical failures make the conclusion that sex is a risk factor speculative. Thus, only adhesion intensity can be considered a risk factor. Additionally, fibrosis assessed using trichrome staining and T-cell lymphocytic infiltration showed potential negative prognostic value in a larger cohort.

Conclusion

Our findings indicate that patients with significant lacrimal sac adhesions, identified during endoscopic dacryocystorhinostomy, are particularly prone to postoperative restenosis. Although histological and immunohistochemical studies did not reveal a correlation between the analyzed data and restenosis, a larger patient cohort might show that fibrosis and T-cell lymphocytic infiltration could potentially have a negative prognostic value. The poorer treatment outcomes in women, seen in our study as well as in other investigations, may be due to anatomical and physiological traits of the female lacrimal drainage system that predispose them to stenosis. This hypothesis requires further study in a larger cohort.

Prospective, randomised clinical trial on the necessity of using a silicone intubarium in the context of endonasal-endoscopic dacryocystorhinostomy (EN-DCR) in patients with postsaccal lacrimal duct stenosis

BACKGROUND

This prospective clinical study evaluates the effect of a silicone stent tube (SST) on the success rate of endonasal-endoscopic dacryocystorhinostomy (EN-DCR) to treat primary acquired nasolacrimal duct obstruction.

METHODS

Patients were randomly assigned to receive EN-DCR with or without SST intubation over a period of 3 months. The surgery was performed using standardized techniques. Patients were assessed at three different timepoints: one day, 12 weeks and 24 weeks after the surgery. The results were compared in order to evaluate statistical differences. Surgical success was determined by means of positive irrigation procedures, as well as by the improvement of symptoms and a high level of patient satisfaction.

RESULTS

A total of 56 randomized cases completed 24 weeks of follow up. 1 Patient dropped out due to malignant genesis of the nasolacrimal duct obstruction. After 24 weeks of follow up no statistically significant differences in levels of epiphora (p > .10) or patency (p > .16) were revealed. Comparisons regarding changes in time did not show levels of significance (p > .28).

CONCLUSIONS

This study could not confirm a statistically significant benefit or disadvantage for SST Insertion in EN-DCR.

Morphological features of regenerative processes after dacryocystorinostomy with the use of mitomycin C

PURPOSE

To study the morphological features of regenerative processes in dynamics after dacryocystorinostomy (DCR) with the use of Mitomycin C (MMC).

METHODS

The study includes 31 cases. All patients underwent endonasal endoscopic DCR. Group 1 included 16 cases who received MMC injections. Group 2 included 15 cases who were treated with MMC on collagen sponge into the area of formed anastomosis. Biopsies for histological examination were taken on the 2nd, 5th, 7th, 14th, 21st, 28th and 60th days after the surgery. The samples were subjected to histological examination.

RESULTS

Activated fibroblasts were detected in patients of group 2 on the 5th day after the surgery which became the main cellular elements by the 14th day, and incomplete fibroblast mitoses were observed in group 1 by the 14th day. On the 28th day after the surgery, the transformation of the extracellular matrix into loose connective tissue was determined in patients of group 2, while single cellular elements represented by fibroblasts were preserved in biopsies obtained from patients of group 1. By the 60th day after the surgery, the restoration of a full-fledged epithelial lining was observed in all specimens.

CONCLUSION

With the injection of MMC, inhibition of collagenogenesis by depression of extracellular collagen matrix formation, production of abortive mitoses in cells and inhibition of maturation and transformation of fibroblasts occur. The regeneration process takes place after MMC injection under a relative decrease in fibroblast impact.

Endoscopic and external dacryocystorhinostomy: A therapeutic proposal for distal acquired lacrimal obstructions

Endoscopic (END-DCR) and external dacryocystorhinostomies (EXT-DCR) are nowadays considered the gold standard techniques for non-oncologic distal acquired lacrimal disorders (DALO). However, no unanimous consensus has been achieved on which of these surgeries is the most suitable to the individual patient. Herein, we review the available literature of the last 30 years with the aim of defining a simple and reproduceable treatment algorithm to treat DALO. A search of PubMed, EMBASE, Scopus and Cochrane databases was last performed in December 2021 to examine evidence regarding the role of END-DCR and EXT-DCR in primary and revision surgeries. If considered primary surgeries, END-DCR should be preferred in case of intranasal comorbidities, given the possibility to directly visualize and treat potential intranasal pathologies. Conversely, EXT-DCR should be chosen in case of need/preference for local anesthesia, given the major historical experience and wider surgical field that helps to resolve intra-operatory complications (e.g., bleeding) in an uncollaborative patient. In the absence of the abovementioned conditions, the decision of one or other approach should be discussed with the patient. In recurrent cases, END-DCR should be considered the treatment of choice given the major likelihood to visualize the causes of primary failure and directly resolve it. In conclusion, END-DCR should be considered the treatment of choice in revision cases or in primary ones associated with intranasal pathologies, whereas EXT-DCR should be chosen if local anesthesia is needed. In the absence of these scenarios, it is still open to debate which of these two approaches should be used.

Does Bicanalicular Intubation Improve the Outcome of Endoscopic Dacryocystorhinostomy?

The aim of this study was to compare the success of endoscopic dacryocystorinostomy with and without bicanalicular intubation in the treatment of distal nasolacrimal duct obstruction. Methods: In a prospective, randomized, comparative study, endoscopic dacryocystorinostomy without bicanalicular silicone intubation (Group I) and endoscopic dacryocystorinostomy with intubation (Group II) were performed in patients with distal nasolacrimal duct obstructions. The tubes were removed 3 months after surgery in Group II, and the patients were followed up for 6 months after surgery. Therapeutic success was defined as the fluorescein dye disappearance test grade 0–1 corresponding with a complete resolution of symptoms. Results: Thirty patients, aged 23–86 years, were included in the study. The success rate was 13/15 (86.67%) in Group I and in 14/15 (93.33%) in Group II. The difference between the two groups was not statistically significant (p = 0.483). Most common complications were granulations that occurred in 1/15 (6.67%) patient in Group I and in 2/15 (13.33%) patients in Group II. Adhesions in rhinostomy with epiphora and persistent secretion were observed in 1/15 (6.67%) patient in Group II. Conclusions: Bicanalicular intubation does not significantly increase the success rate of EDCR in distal nasolacrimal obstruction in adults.

Evaluation of the efficacy of postoperative triamcinolone in endoscopic dacryocystorhinostomy using lacrimal symptom questionnaire

PURPOSE

To evaluate the effect of postoperative nasal triamcinolone spray use in primary endoscopic dacryocystorhinostomy using The Lacrimal Symptom Questionnaire.

METHODS

This study included a series of 50 consecutive retrospective cases with primary endoscopic dacryocystorhinostomy and with silicone stent implantation who were followed up for 6 months postoperatively. Patients using nasal triamcinolone spray for 3 months postoperatively were included in the triamcinolone group. Patients not using triamcinolone were included in the control group. Lacrimal stents were removed 3 months postoperatively. The Lacrimal Symptom Questionnaire (Lac-Q) was performed in the preoperative and postoperative 6th month. Anatomical success, functional success, and changes in lacrimal symptom and social impact scores were compared between the two groups 6 months after surgery.

RESULTS

Results of 48 endoscopic dacryocystorhinostomies performed on 48 patients (23 triamcinolone group, 25 control group) meeting the inclusion criteria were analyzed. The anatomical success rate (95.7% vs. 84.0%, p = 0.350) and the functional success rate (91.3% vs. 76.0%, p = 0.249) were higher in the triamcinolone group, but this difference was not statistically significant. No complications were observed in the triamcinolone group, whereas complications developed in two patients in the control group (p = 0.490). The mean change in total lac-Q score was 11.0 in the triamcinolone group and 9.0 in the control group (p = 0.011). The mean change in social impact score was 4.0 in the triamcinolone group and 3.0 in the control group (p = 0.005). Mean change in lacrimal symptom score was 6.0 in the triamcinolone group and 6.0 in the control group (p = 0.368) CONCLUSIONS: Our study indicated that postoperative use of triamcinolone spray increases the success rate of endoscopic dacryocystorhinostomy and also revealed that triamcinolone may also lead to greater improvement in quality of life scores than the control group using a validated questionnaire.

The importance of clinical presentation on long-term outcomes of external dacryocystorhinostomies: Our experience on 245 cases

PURPOSE

External dacryocystorhinostomy (EXT-DCR) is a surgical approach commonly used to treat post-canalicular acquired lacrimal obstruction whose success rate has been described, equally with endoscopic DCR, to be superior to other available treatments.

METHODS

At San Raffaele Hospital, Milan (Italy), from January 2008 to December 2020, 245 EXT-DCRs were performed. All patients underwent routine pre-operative work-up including Jones tests and probing and irrigation of the lacrimal pathway; when necessary, a multidisciplinary approach with nasal endoscopy was performed. The surgical approach was followed by positioning of a bicanalicular stent which was left in place for 6 months. Success was defined as resolution of clinical signs/symptoms and free lacrimal flow on functional test.

RESULTS

Of the cases enrolled, 26.9% were treated for recurrent epiphora (group 1), and 73.1% for epiphora associated with chronic dacryocystitis (group 2). After a median follow-up of 71 months, group 1 had success at T0 (1 month) and T1 (long-term) of 81.8% and 60.6%, respectively, compared to 93.8% and 77.7% in group 2. Statistical analysis showed a significant association with surgery both at T0 (p = 0.018) and T1 (p = 0.012) with group 2 showing better outcomes. Additionally, the cosmetic outcome of the external scar was defined as invisible in 91.8% of cases and slightly visible in 8.2%.

CONCLUSIONS

External dacryocystorhinostomy provides long-term reliable results particularly in case of chronic dacryocystitis. Moreover, the optimal esthetic outcome of the external scar should be no longer considered the only guiding principle of treatment modality, particularly in the elderly.

Multidisciplinary approach to lacrimal system diseases

Pathologies of the lacrimal drainage system range from benign to malignant lesions. However, independently of the etiological origin, the most common presenting symptom is represented by epiphora due to the dysfunction of the lacrimal system. Different diagnostic tools are now available, but for the most the first diagnostic approach is characterized by an ophthalmological visit, associated with nasal endoscopy, usually performed by an otolaryngologist. Frequently the diagnostic work-up is completed with a radiological exam (e.g. maxilla-facial CT or dacryocystography), whose role is still to be determined. Once a diagnosis has been made, different treatments are available in relation to the type of the disease, and commonly need close cooperation between an ENT and ophthalmic surgeon given the close anatomical structures involved. Taking into account all these aspects, the aim of this review is to highlight how a multidisciplinary approach to lacrimal pathologies is mandatory from diagnosis to treatment in order to offer the best clinical approach.

Role of anaesthesia in endoscopic and external dacryocystorhinostomy: A meta-analysis of 3282 cases

Distal acquired lacrimal obstruction is a common adulthood pathology whose primary treatment is represented by EXT-DCR and END-DCR. When considering their influencing factors, the role of the type of anaesthesia applied during these surgeries has a major role. The aim of this study is to systematically analyse the influence of general and local/regional anaesthesia on the final success rates of EXT-DCR and END-DCR. Primary EXT-DCR and END-DCR articles published later than 2000 with at least 50 single clinician procedures were selected. Exclusion criteria included acute dacryocystitis, tumours, studies focussing on revision surgeries, surgeries with adjunctive procedures, not clearly demarcated surgeons, mixed cohort study of acquired and congenital disorders. This systematic review was conducted in accordance with MOOSE guidelines; where feasible, a meta-analysis of the collected results was conducted. As a result, 11,445 articles were selected of which 2741 were examined after screening, and 16 included after full text review (0.6% of the initial papers). Among all papers included, the number of EXT-DCR was not enough to provide a solid analysis of the effect of anaesthesia; conversely, a significant difference of success rate was noted between local anaesthesia + sedation (85.1%, IC 77.8%-90.4%), and general anaesthesia (90.8%, IC 88.8%-92.4%) in END-DCR (p = 0.048). In conclusion, END-DCR performed with general anaesthesia should be considered as the solution of choice; however, local anaesthesia, eventually associated with a sedation, can be used as an alternative in selected cases. No meaningful conclusions could be drawn for EXT-DCR, due to the lack of data.

Long-term results of a balloon-assisted endoscopic approach in failed dacryocystorhinostomies

Purpose

Endoscopic endonasal balloon-assisted dacryoplasty is a minimally invasive surgical approach that can be applied after failure of dacryocystorhinostomy with recurrence of distal acquired lacrimal obstruction.

Methods

At the Department of Otolaryngology, San Raffaele Hospital, Milan (Italy), from December 2016 to October 2020, 14 patients underwent trans-nasal balloon-assisted dacryoplasty after a failed dacryocystorhinostomy (both external and endoscopic endonasal). The routinary pre-operative work-up included multidisciplinary study of the lacrimal disease, which consisted in primary ophthalmological and otorhinolaryngological visits associated with nasal endoscopy, in which a radiological exam was added if needed. The surgical approach includes pneumatic enlargement of the stenotic rhinostomy, created during the primary dacryocystorhinostomy, using a high-pressure trans-nasal balloon catheter. Anatomical success was considered when the ostium was patent upon irrigation, while functional success was considered as resolution of epiphora or free lacrimal flow on functional test.

Results

Among 14 patients included and after a mean follow-up of 19.5 months (range 13–51 months), anatomic success was achieved in 100% of patients and functional success was achieved in the 85.7% (12/14). Operative time ranged from 9 to 28 min (mean 18 min) and no complications were reported.

Conclusion

Trans-nasal balloon-assisted dacryoplasty is a mini-invasive surgical approach to treat failed dacryocystorhinostomies with reliable and stable outcomes in the long term. The absence of post-surgical complications, high success rate and short operative time are the main features of this innovative procedure.