Rachel K. Sobel, Vinay K. Aakalu, Edward J. Wladis, Jurij R. Bilyk, Michael T. Yen, Louise A. Mawn
To assess the efficacy of endonasal dacryocystorhinostomy (DCR) compared with external DCR.
A literature search was conducted in the PubMed database in March 2016 and updated in October 2017 and February 2019. The search strategy was designed to update the first Ophthalmic Technology Assessment on endonasal DCR from 2001 by identifying new peer-reviewed human studies reported since 2000 in the English language that compare results of endonasal DCR with those of external DCR. The searches yielded 169 articles. Of these, 13 met the inclusion criteria and were assigned a level of evidence rating.
Six of the 13 studies included in this assessment were rated level II and 7 were rated level III. Three of the 13 studies drew conclusions based on statistically significant results, but all of these were level III evidence. Two of these significant studies demonstrated lesser efficacy of endonasal laser DCR (63%–64%) compared with external DCR (94%; P = 0.0002, 0.024). The third study reported that nonlaser endonasal DCR was superior to external DCR (84% vs. 70%; P = 0.03). The remainder of the studies did not find statistically significant differences in success rates between the 2 techniques.
Limited data suggest that laser endonasal DCR may be less effective than external DCR. Existing data are inadequate to draw conclusions about whether endonasal DCR is superior to, equivalent to, or inferior to the gold standard external DCR.
The American Academy of Ophthalmology prepares Ophthalmic Technology Assessments to evaluate new and existing procedures, drugs, and diagnostic and screening tests. The goal of an Ophthalmic Technology Assessment is to review the available research systematically for clinical efficacy, effectiveness, and safety. After review by members of the Ophthalmic Technology Assessment Committee, other Academy committees, relevant subspecialty societies, and legal counsel, assessments are submitted to the Academy’s Board of Trustees for consideration as official Academy statements. The purpose of this assessment by the Ophthalmic Technology Assessment Committee Oculoplastics and Orbit Panel is to compare the efficacy of endonasal dacryocystorhinostomy (DCR) with external DCR.
Cheong, Timothy Z.; Davies, Rodger P.
An 81-year-old man with unilateral nasolacrimal duct obstruction underwent routine endonasal dacryocystorhinostomy and 2 days postoperatively developed a severe headache and rigors. Subsequent CT and MRI imaging demonstrated a defect in the floor of the right anterior cranial fossa, which possibly was damaged during the operation, and meningoencephalitis of the adjacent frontal lobe gyrus. Following intravenous antibiotic treatment, the patient made a full recovery with no ongoing sequelae, and his epiphora completely resolved. To the authors’ knowledge, this is the first report of meningoencephalitis following endonasal dacryocystorhinostomy. This complication should be considered in any patient with a febrile septic presentation or headache following endonasal dacryocystorhinostomy.
Jinhwan Park, Joonsik Lee & Sehyun Baek
To correlate the pathologic features and heat shock protein 47 (HSP47) expression in the nasal mucosa and lacrimal sac with the surgical outcomes of endoscopic endonasal dacryocystorhinostomy (EDCR).
Specimens of the nasal mucosa and lacrimal sac over the rhinostomy site were collected during the operation. Haematoxylin–eosin and immunohistochemical staining were performed to determine the pathologic features (inflammation, fibrosis, squamous metaplasia) and the expression of HSP47 in the epithelium and sub-epithelial glands of the nasal mucosa and lacrimal sac. The success or failure of EDCR was determined 6 months after surgery.
A total of 30 patients (30 eyes) were included in this study. Inflammation and squamous metaplasia of the nasal mucosa were not associated with the surgical outcome of EDCR (p = 0.485 and 0.069, respectively), but there was an association with fibrosis of the nasal mucosa (p = 0.003). In addition, HSP47 in the nasal mucosa was associated with the surgical outcomes (p = 0.005). Inflammation of the lacrimal sac was not associated with the surgical outcome of EDCR (p = 0.509), but fibrosis and squamous metaplasia of the lacrimal sac were (p = 0.005 and 0.008, respectively). Additionally, HSP47 in the lacrimal sac was associated with surgical outcomes (p < 0.001).
Fibrosis and squamous metaplasia of the nasal mucosa and lacrimal sac lowered the success rate of EDCR. HSP47 also lowered the surgical success rate. Fibrosis was correlated with the expression of HSP47.
PURPOSE: The purpose of this study is to compare the success rates of endoscopic endonasal dacryocystorhinostomy (EN-DCR) and external DCR (EX-DCR) for the treatment of primary acquired nasolacrimal duct obstruction (PANLDO). DESIGN: This was a retrospective, comparative, nonrandomized clinical study. METHODS: Reviewed medical records of PANLDO underwent DCR at Far-Eastern Memorial Hospital from May 2011 to June 2017. Data regarding the lacrimal passage system, comorbidities, surgical outcomes, and postoperative complications were analyzed. Anatomical success was defined as patency confirmed by intranasal endoscopic inspection of the ostium and successful lacrimal irrigation; functional success was defined as complete resolution of epiphora and positive fluorescein dye disappearance test, which were assessed at postoperative 6th months. RESULTS: One hundred and seventy patients (37 males, 133 females, mean age 57 years) underwent 178 DCR surgeries for PANLDO. The overall anatomical success rate was 94.4% (93.5% in EN-DCR vs. 95.8% in EX-DCR, P = 0.511) and functional success rate was 90.4% (90.7% in EN-DCR and 90.1% in EX-DCR, P = 0.909). Surgical outcomes were comparable between two groups. Complication rate was low in both groups, including 11 cases of early canalicular stent dislodge (7 in EN-DCR, 4 in EX-DCR), one case of postoperative nasal bleeding in EN-DCR, and two skin wound dehiscence and three cutaneous keloid formation in EX-DCR. None of these cases were concluded into surgical failure at the final visit. The time to symptoms relief was statistical significantly shorter in EN-DCR group (1.7 vs. 3.7 weeks in EX-DCR, P < 0.001). CONCLUSIONS: Success rate of DCR for PANLDO in our study was high, and complication rate was low for both endoscopic and external approaches. There was no statistically significant difference between them. EN-DCR provided higher satisfaction due to quicker recovery and lack of external incision. Endoscopic DCR should be considered as the primary treatment of choice for PANLDO.
Upender Wali, Buthaina Sabt, Yahya Al Badaai, Abdullah Al-Mujaini
Dacryocystorhinostomy (DCR) means creation of anastomosis for direct communication between the lacrimal sac and the nasal cavity through a bony ostium. There are different surgical techniques available for DCR. These include external DCR, endomechanical laser DCR, endonasal laser DCR, and transcanalicular laser-assisted DCR. Diode laser-assisted DCR offers many and specific advantages over conventional DCR.
We present our experience with 23 patients who underwent transcanalicular laser-assisted DCR without stent at a single institution for a variety of indications….
WengOnn Chan, Geoff Wilcsek, Raf Ghabrial, Robert Alan Goldberg, Peter Dolman, Dinesh Selva & Raman Malhotra
We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006–2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.
E.L. Atkova, Fedorov, A.O. Root, S.D. Iartsev, N.N. Krakhovetsky, V.D. Yartsev
To study the antifibrotic effectiveness of mitomycin-C in the tissues of the ostium site after it application for endonasal endoscopic dacryocystorhinostomy.
Material and methods
The study included 45 patients (48 cases) with primary obstruction of the nasolacrimal duct. All patients underwent endoscopic endonasal dacryocystorhinostomy (EEDCR). At the final stage of the operation, a swab with MMC was placed in the region of the formed ostium at a concentration of 0.2 mg/ml for 3 min. An ostium was not intubated. After that, biopsies of the mucous of the nasal cavity and lacrimal sac were performed to study the morphological changes that occur in the tissues overtime, as well as to calculate the concentration of the drug in the tissues.
According to the chemical analysis, the concentration of MMC immediately after application was 0.626 ± 0.176 μg/g; after 30 min the concentration of the drug was reduced to 0.23 ± 0.06 μg/g; a day after the operation the drug was not found in the tissue samples. Morphological study established that the repair processes occurring in the mucosa of the nasal cavity and the lacrimal sac after EEDCR are similar to the reparative processes without the use of MMC. The effectiveness of surgical treatment: “positive results” – 77.1% of cases, “relapses” – 22.9% of cases.
Few studies have focused on the intranasal localization of the lacrimal sac during endoscopic dacryocystorhinostomy: landmarks in order to find the medial wall of the lacrimal sac have been described, but there is a lack of description of methods for the verification of the complete marsupialization of the lacrimal sac during surgery. In this report, we propose an easy and effective method for certain intraoperative identification of lacrimal sac.
A method in order to verify the effective marsupialization of the lacrimal sac is applied and described: to ensure that the opening of the sac in the nasal cavity is complete, the surgeon should identify the Rosenmuller valve, which is the end of the common canaliculus in the lacrimal sac. Continuous irrigation with saline solution through the inferior canaliculus can be useful to obtain a clean surgical area and to permit easy intraoperative identification of the valve.
Between 2007 and 2015, 193 endoscopic dacryocystorhinostomies were performed in our institutions. Postoperative surgical success at last follow-up (minimum 12 months) was 93.8% (181 out of 193 of cases). No major complications were observed.
Correct and complete exposure of the lacrimal sac during surgery is crucial for a good outcome: when the opening of the common canaliculus is identified, the surgeon is assured that the sac has been correctly and completely marsupialized inside the nasal cavity.