Zhiheng Lin, Carl Philpott, Katherine Sisson & Bridget Hemmant
A gentleman with recurrent epiphora after two failed endonasal dacryocystorhinostomies was found to have a squamous cell carcinoma of the lacrimal sac at his third operation via an external approach. CT showed contralateral nodal involvement; however, biopsy of the node found it to be histologically distinct from the lacrimal sac lesion. A PET-CT revealed a second primary lesion located at the contralateral palatine tonsil. We discuss the histological features of squamous cell carcinomas and the impact on prognosis. This case highlights the importance of nasoendoscopy prior to lacrimal surgery. There should be a low threshold for lacrimal sac biopsy, and any anatomical or histological inconsistency should prompt further investigation.
Farzad Pakdel, Mohammad Soleimani, Abolfazl Kasaei, Kambiz Ameli, Niloofar Pirmarzdashti, Ali Sadeghi Tari, Mehrbod Ghasempour & Ali Banafsheafshan
We aimed to show the outcome of very early endoscopic dacryocystorhinostomy (VE-EDCR) in a routine pool of patients with acute dacryocystitis (AD) and abscess formation compared with the standard late external dacryocystorhinostomy L-ExDCR.
This was a prospective nonrandomized comparative study conducted from June 2013 to March 2016. Patients with AD and abscess formation were referred to our oculo-facial clinic in a university-based hospital. All patients received systemic antibiotics and were assigned to either of treatment groups. Patients in group 1 underwent late external transcutaneous DCR (L-ExDCR) and group 2 underwent EDCR within 3 days after first visit, named VE-EDCR. Primary outcome measure was success of surgery.
Forty-one eyes of 41 patients with acute suppurative AD, were included from June 2013 to March 2016. Twenty-two patients underwent VE-EDCR and 19 underwent L-ExDCR. Mean age of patients was 43.41 (SD = 19.84, range 14–98) years. Mean follow-up was 14 (SD = 2.4) months. Anatomic, functional, and overall success in L-ExDCR and VE-EDCR groups were (89.5 and 86.4%, p = 0.99) (89.5% and 86.4%, p = 0.99) (89.5% and 81.8%, p = 0.66) respectively. Mean duration of cellulitis in VE-EDCR and L-ExDCR were 8.00 (SD = 4.63) and 16.11 (SD = 11.58) days, respectively (p = 0.027). No remarkable adverse event was found.
Success of very early endonasal endoscopic DCR is comparable with the traditional late external DCR. Duration of cellulitis is shorter in VE-EDCR. This therapeutic approach can be considered in patients with acute suppurative dacryocystitis.
David S. Curragh, Craig James & Dinesh Selva
Purpose: To report a case of a lacrimal sac tumour identified at the time of endoscopic dacryocystorhinostomy and describe a swinging inferior turbinate approach to the nasolacrimal duct (NLD) to facilitate an en-bloc excision of the lacrimal drainage apparatus.
Methods: An 88-year-old male presented with a 6-month history of epiphora and mucocele. Endonasal DCR was performed for nasolacrimal duct obstruction (NLDO). Intraoperatively, a biopsy was performed of abnormal appearing lacrimal sac mucosa, following opening of the lacrimal sac. Subsequent definitive management was performed via a combined external and endoscopic approach using a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without removal of the bony medial wall of the maxillary sinus.
Results: The excised lacrimal drainage showed insitu and invasive squamous cell carcinoma of the canaliculi and lacrimal sac with focal divergent neuroendocrine and sebaceous differentiation. There was no local tumour recurrence or metastatic spread at 3 months of follow-up.
Conclusions: We describe a swinging inferior turbinate approach to the NLD to facilitate an en-bloc excision of the lacrimal drainage apparatus, without entering the maxillary sinus. We believe this modified technique is a useful option to consider in the management of tumours of the lacrimal drainage apparatus.
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….