Anastomosis of both posterior and anterior flaps or only anterior flaps in external dacryocystorhinostomy

Primary acquired nasolacrimal duct obstruction - epidemiology, clinical signs and surgical treatment

AIM

The aim of this study was to discuss the epidemiological aspects, clinical picture and the mode of surgical treatment in patients with primary acquired nasolacrimal duct obstruction (PANDO).

Fusiform Anastomosis Technique with a Single Longitudinal Incision in the Lacrimal Sac in External Dacryocystorhinostomy

BACKGROUND

In the present study, we aimed to evaluate the surgical outcomes of the fusiform anastomosis technique in external dacryocystorhinostomy (ex-DCR) that we designed in the form of a physiological tube, which sufficiently covered the bone ostium with the mucosa.

MATERIAL AND METHODS

This was a retrospective observational study that included 145 eyes of 131 patients who underwent ex-DCR due to nasolacrimal duct obstruction. The patients were divided into two groups. Group 1 included 73 eyes of 65 patients who underwent fusiform anastomosis, and group 2 included 72 eyes of 66 patients who underwent conventional anterior and posterior flap anastomosis. The open nasolacrimal passage with lacrimal irrigation and the absence of reflux were accepted as anatomical success, and the absence of epiphora symptoms was accepted as functional success. The groups were compared in terms of anatomical success, functional success, and granulation tissue formation.

RESULTS

Anatomical success was observed in 73 eyes (100%) in group 1 and 66 eyes (91.6%) in group 2 (p = 0.01). Functional success was observed in 72 of 73 eyes (98.6%) in group 1 and 65 of 72 eyes (90.2%) in group 2 (p = 0.02). Nasal endoscopic examination performed in 32 eyes in group 1 and 28 eyes in group 2 revealed that granulation tissue was observed in 7 of 28 eyes (25%) in group 2, while there were no eyes with granulation tissue in group 1 (p = 0.01).

CONCLUSION

The fusiform anastomosis technique in ex-DCR provided excellent anatomical success and extremely good functional success.

Positional relationship between medial canthal tendon and common canalicular orifice: A cadaveric study

PURPOSE

To examine the positional relationship between the medial canthal tendon (MCT) and the common canalicular orifice (CCO) in cadavers.

METHODS

This experimental anatomical study was conducted using 75 orbits from 48 embalmed Japanese cadavers fixed in 10% buffered formalin (24 orbits from 17 males and 51 orbits from 31 females; 38 right and 37 left; mean age at time of death, 84.1±9.2 years). The vertical width of the MCT on the level of the medial orbital rim and the angle between the MCT and axial plane were measured. In addition, the vertical distance from the CCO to the lower edge of the MCT was measured. Positive values of the distance were indicated when the CCO was located below the lower edge of the MCT.

RESULTS

The vertical distance from the CCO to the lower edge of the MCT was -1.43±1.31mm. Only 13 orbits (17.3%) showed the CCO located on the same level (2 orbits, 2.7%) or below the lower edge of the MCT (11 orbits, 14.7%), while the CCO was located above the lower edge of the MCT in 62 orbits (82.7%). In multiple regression analyses, both the MCT width and angle between the MCT and axial plane were not correlated with the distance (P>0.050).

CONCLUSIONS

As the CCO was mostly found to be located above the inferior margin of the MCT, the creation of the bony window up to the MCT's inferior margin is not sufficient in external dacryocystorhinostomy to completely expose the CCO.

Transconjunctival dacryocystorhinostomy: An aesthetic approach

PURPOSE

To report the anatomical and cosmetic outcome of transconjunctival dacryocystorhinostomy (TDCR) in an Asian Indian population.

METHODS

TDCR was initially performed in cadaver eyes followed by patients with primary acquired nasolacrimal duct obstruction (NLDO). This was a prospective noncomparative case series of all consecutive TDCRs performed between April 2013 and June 2015. Outcome measures were anatomical patency, epiphora, presence of diplopia, aesthetic outcome, and health status.

RESULTS

A total of 17 (18 eyes) patients with a mean age 43.9 ± 11.8 years (range, 32-75) were included in the study. Eight were males, and one patient underwent TDCR in both eyes. TDCR was successfully performed in 15/18 (82%) eyes under local anesthesia. Procedure converted to transcutaneous external DCR in two and dacryocystectomy in one patient each. Mean duration of surgery was 52.6 (range, 29-110) min. Anatomical patency and relief from epiphora was achieved in all (15/15) eyes after TDCR at a median follow-up of 15.5 months. At final follow-up, objective assessment of the cosmetic outcome graded the surgical scar at the lateral canthus as invisible in all except one and conjunctival fornix as visible only after eyelid eversion in all patients. Disturbance of the medial fat pad was not seen in any patient. A questionnaire-based health status evaluation showed marked improvement in anxiety/depression before and after TDCR with an overall well-being score of 88 on a scale of 0-100 (worst-best) after TDCR.

CONCLUSIONS

TDCR offers a promising aesthetic approach in patients with primary acquired NLDO and gives excellent functional and cosmetic outcome.

External Dacryocystorhinostomy With or Without Double Mucosal Flap Anastomosis: Comparison of Surgical Outcomes

The aim of this study was to compare surgical outcomes of external dacryocystorhinostomy with or without double mucosal flap anastomosis. A retrospective chart review was performed for 205 sides of 178 patients diagnosed with nasolacrimal duct obstruction. Double-flap anastomosis was performed on 57 sides (double-flap group) and complete flap excision on 148 sides (no-flap group). Criteria for surgical success were defined as no or minimal intermittent epiphora and no reflux on lacrimal irrigation 12 months postoperatively. Consequently, surgery was successful for 53 sides (93.0%) in the double-flap group and 138 sides (93.2%) in the no-flap group. There was no statistically significant difference in success rate between the groups (P = 0.947, the Fisher exact probability test). This study demonstrated that external dacryocystorhinostomy without flap anastomosis had a surgical outcome similar to that of double-flap anastomosis.

Modified External Dacryocystorhinostomy in Primary Acquired Nasolacrimal Duct Obstruction

BACKGROUND

Epiphora secondary to acquired nasolacrimal duct obstruction is a common ophthalmic problem in adults requiring surgical management. External dacryocystorhinostomy (DCR) is a reliable but difficult surgical technique for the treatment of nasolacrimal duct obstruction.

PURPOSE

To evaluate the success rate and complications of modified external DCR in patients with primary acquired nasolacrimal duct obstruction.

MATERIALS AND METHODS

This hospital based prospective interventional study included 56 patients with primary acquired nasolacrimal duct obstruction. Diagnosis of nasolacrimal duct obstruction was made through irrigation of the nasolacrimal drainage system. All patients were operated by modified technique of external DCR with anastomosis of the anterior lacrimal and nasal mucosal flaps only, whereas posterior mucosal flaps were excised. Patients were followed up for a period of 6 months. During the follow up, success rate and complications if any were recorded. Success was defined objectively by a patent lacrimal passage on irrigation and subjectively by the absence of watering or discharge.

RESULTS

The mean age of the study population was 39.23 ± 10.66 years, and 78.6% of patients were females (male to female ratio 1:3.7). The average operation time was 36.48 ± 4.72 minutes. Objective and subjective success rates were 92.9% and 89.3%, respectively after a follow up period of 6 months. Intraoperatively, haemorrhage occurred in 3 patients (5.3%) and laceration of the nasal mucosa in 4 patients (7.1%). Postoperative complications included significant lid swelling and periorbital ecchymosis in 3 patients (5.3%), epistaxis in 2 patients (3.6%) and hypertrophic scar in 2 patients (3.6%).

CONCLUSION

These results suggest that modified external DCR with anterior flaps anastomosis only is a simple, safe, less time consuming surgical technique that is easy to perform, and the outcome is comparable to conventional DCR.

Comparison of Modifications in Flap Anastomosis Patterns and Skin Incision Types for External Dacryocystorhinostomy: Anterior-Only Flap Anastomosis with W Skin Incision versus Anterior and Posterior Flap Anastomosis with Linear Skin Incision

Purpose. To compare the outcomes of external dacryocystorhinostomy (E-DCR) by using two different flap anastomosis patterns and skin incision types. Methods. This study included 79 patients (88 eyes) with lacrimal drainage system disorders who underwent E-DCR surgery. Fifty eyes of 44 patients (group A) underwent E-DCR by suturing anterior and posterior flaps (H-flap) of the lacrimal sac with curvilinear skin incision whereas in 38 eyes of 35 patients (group B) DCR was performed by suturing only anterior flaps (U-flap) with W skin incision. Results. The success rate was evaluated according to lacrimal patency and scar assessment scores. Patency was achieved in 78 patients (88.6%). In terms of groups, patency was 44 eyes (88.0%) in group A and 34 eyes (89.5%) in group B. There was no statistically significant difference in the success rates of lacrimal patency between the two groups. Further, there was no statistically significant difference concerning cutaneous scar scores. Conclusion. Our study suggests that anastomoses of only anterior flaps or both anterior and posterior flaps have similar success rates; suturing only anterior flaps is easier to perform and shortens the operative time. In addition, W skin incision is a reasonable alternative to curvilinear incision for reducing scar formation.

The Dacryocystorhinostomy Ostium Granulomas: Classification, Indications for Treatment, Management Modalities and Outcomes

AIM

Ostium granulomas following dacryocystorhinostomy (DCR) have not been studied in detail previously. This study aims to classify the DCR-related granulomas based on their ostial locations and to assess the outcomes of their management.

METHODS

A retrospective consecutive case series of 47 ostial granulomas evaluated over a period of 2 years were included in this study. All patients underwent detailed endoscopic examination to assess the granuloma locations and their response to initial topical steroids treatment. Persistent granulomas either underwent further management with excision or intralesional steroids based on their location. Patients were followed up for a minimum of 6 months. The primary outcome measure was resolution of granuloma.

RESULTS

The mean age at presentation was 45 years with a female preponderance (68%). 70% (33/47) of granulomas were following external DCR and 30% (14/47) occurred in the setting of endonasal DCR. The most common location was an edge granuloma in 46.8% (22/47) followed by a combined granuloma in 21.2% (10/47). 91.4% (43/47) underwent initial treatment with topical nasal steroids. The remaining 4 (8.5%) underwent primary excision. Among those treated with topical steroids (n = 43), 9.3% (4/43) underwent further treatment with intralesional triamcinolone. Overall, 4.2% (2/47) recurred in 6 weeks following resolution and were treated with excision.

CONCLUSION

We recommend routine endoscopic evaluation of all the DCR ostia. Detection of granulomas in early stages and appropriate management as per guidelines proposed may aid in better outcomes.

Dacryocystorhinostomy ostium: parameters to evaluate and DCR ostium scoring

AIM

This study aims to provide a systematic protocol for the evaluation of a dacryocystorhinostomy (DCR) ostium and to propose a scoring system to standardize the assessment.

METHODS

Retrospective evaluation of 125 consecutive lacrimal ostia post-DCR was performed. Medical records were screened, and photographs and videos were assessed to note the details of various ostial parameters. The major time points in evaluation were 4 weeks, 6 weeks, 3 months, and 6 months post-DCR. The ostia were defined and parameters like shape, size, location, and evolution of ostium were noted. Evaluation parameters were defined for internal common opening (ICO), ostium stents, and ostium granulomas. Ostium cicatrix and synechiae were graded based on their significance. Surgical success rates were computed and ostium characteristics in failed cases were studied.

RESULTS

A total of 125 ostia were evaluated on the aforementioned ostium parameters. Because five ostia showed a complete cicatricial closure with no recognizable features, the remaining 120 ostia were studied. The ostium location was anterior to the axilla of middle turbinate in 85.8% (103/120) of the cases. Moreover, 76.6% (92/120) of the ostia were circular to oval in shape, with a shallow base. The ostium size was >8×5 mm in 78.3% (94/120) of the cases. The ICO was found to be located in the central or paracentral basal area in 75.8% (91/120). The anatomical and functional success rates achieved were 96% and 93.6%, respectively. All the five cases with anatomical failures showed a complete cicatrization and the ICO movements were poor in all the three cases of functional failure.

CONCLUSION

The article attempts to standardize the postoperative evaluation of a DCR ostium and provides a systematic protocol and scoring system for possible use by surgeons and researchers alike.

External dacryocystorhinostomy and transnasal canthopexy: new details of combined surgery

PURPOSE

To describe the authors' modified combined surgical technique for external dacryocystorhinostomy and transnasal canthopexy.

METHODS

A retrospective medical record review was performed including patients with late posttraumatic telecanthus and nasolacrimal duct obstruction treated by their combined dacryocystorhinostomy-transnasal canthopexy technique. In this technique, the bony window is extended superiorly and posteriorly further than in standard dacryocystorhinostomy, to allow pulling the canthus though the window, but at the same time not disturbing the suture of the dacryocystorhinostomy anastomosis. The lacrimal sac opening is performed under the canthal tendon, and only an anterior anastomosis is performed. Silicone intubation was performed only in cases with evidence of canalicular disease, marked sac inflammation or atrophic sac. The wires are fixed to the contralateral orbit, passed through the 2 middle holes of a 4-hole straight 1,7 mm microplate. The microplate is placed on the contralateral side to avoid in-fracture of the contralateral orbital bones from the pressure exerted by the transnasal wires.

RESULTS

Combined external dacryocystorhinostomy-transnasal canthopexy surgery was performed on 13 eyelids of 11 consecutive patients for correction of medial telecanthus and nasolacrimal duct obstruction. Proper canthal position and lacrimal pathway patency were achieved in all cases after a mean follow up of 14.6 months.

CONCLUSIONS

Combined dacryocystorhinostomy-transnasal canthopexy surgery with superior and posterior enlargement of the bony window avoided crossing of the wires and flaps and achieved a high success rate in the reconstruction of the lacrimal drainage pathway. This technique proved to be effective in the treatment of posttraumatic telecanthus with nasolacrimal duct obstruction.

Meta-analysis of the effect of posterior mucosal flap anastomosis in primary external dacryocystorhinostomy

PURPOSE

We aimed to compare the outcomes of primary external dacryocystorhinostomy and silicone tube with anterior and posterior mucosal flap anastomosis, versus dacryocystorhinostomy and silicone intubation with anterior mucosal flap anastomosis.

METHODS

We utilized the electronic databases PubMed, EMBASE, Ovid, Cochrane Central Register of Controlled Trials, and MEDLINE® to find articles related to external dacryocystorhinostomy. For inclusion in this meta-analysis, we isolated prospective and retrospective comparative studies of adult patients with acquired nasolacrimal duct obstruction, or chronic dacryocystitis, who had undergone primary external dacryocystorhinostomy and silicone intubation with anterior and posterior flap anastomosis; versus primary dacryocystorhinostomy and silicone intubation with anterior flap anastomosis. The minimum follow-up period for each study was 4 months.

RESULTS

We identified and analyzed seven studies. Overall, dacryocystorhinostomy with anterior and posterior flap anastomosis was performed on 368 eyes, while primary external dacryocystorhinostomy with anterior flap anastomosis was performed on 397 eyes. There was no significant difference in the success rates of both techniques (risk ratio: 0.987; 95% confidence interval 0.946-1.030).

CONCLUSION

For patients with acquired nasolacrimal duct obstruction or chronic dacryocystitis, there was no significant difference in the resolution of epiphora, and patency of the lacrimal system, between those who underwent external dacryocystorhinostomy with anterior and posterior mucosal flap anastomosis, and those who had dacryocystorhinostomy with anterior flap anastomosis.

External dacryocystorhinostomy: Tips and tricks

Dacryocystorhinostomy or DCR is one of the most common oculoplastics surgery performed. It is a bypass procedure that creates an anastomosis between the lacrimal sac and the nasal mucosa via a bony ostium. It may be performed through an external skin incision or intranasally with or without endoscopic visualization. This article will discuss the indications, goals, and simple techniques for a successful outcome of an external DCR.