Dacryocystorhinostomy in south west England

Experience of the First Three Years of Independent Practice Following Surgical Training: Time Taken and Long-Term Outcomes of Powered Endoscopic Dacryocystorhinostomy

PURPOSE

To describe the changes in the time taken and the long-term outcomes of powered endoscopic dacryocystorhinostomy (PEnDCR) performed by a freshly trained surgeon in the first three years following the surgical training.

METHODS

A retrospective interventional analysis was performed on all patients who underwent a primary or a revision PEnDCR from October 2016 to February 2020. Data obtained include demographics, presentation, previous interventions, pre-operative endoscopy findings, intra-operative findings, post-operative complications, and outcomes. Intra-operative features like the Boezaart surgical field scale, adjunctive endonasal procedures, and time taken for the procedure were noted. A minimum follow-up of 12 months was considered for final analysis. Statistical analysis was performed using software R (v 4.1.2).

RESULTS

A total of 159 eyes of 155 patients underwent PEnDCR, of which 141 eyes were primary surgeries. The mean age was 64.28 years, with M:F ratio being 1:2.5. The number of cases performed per year steadily increased after the first year, and so was the case with adjunctive endonasal procedures. The mean procedure time showed an average reduction by 10.80 and 12.81 minutes for surgeries with and without adjunctive endonasal procedures (p < .001). The majority (77.3%, 123/159) of the intra-operative fields were classified as Grade 3 on the Boezaart scale. The practice of post-operative mitomycin C use significantly and steadily reduced over the three years (p < .001). Bleeding and granuloma formation were the common undesirable post-operative findings and showed a significant (p < .001) decline beyond the first year. The anatomical and functional success were (96.18%, 91.72%), (95.71%, 92.14%), and (96.16%, 91.94%), respectively, at 12, 24 and 36 months follow up.

CONCLUSION

Several intra-operative and post-operative parameters of PEnDCR patients showed improvement beyond the first year of independent practice. The success rates were well-maintained in the long term.

Outcomes of endoscopic dacryocystorhinostomy: Experience of a fellowship trainee at a tertiary care center

Aim:

The study aims to report a single trainee's experience of learning and performing endoscopic endonasal dacryocystorhinostomy (En-DCR).

Settings and Design:

This study was a retrospective, interventional case series.

Subjects and Methods:

Fifty-four eyes of fifty patients presenting at a tertiary eye care center over 1 year were included in the study. All cases underwent endoscopic DCR with mitomycin-C and silicone intubation. The parameters studied included demographics, clinical features, intraoperative details, and postoperative ostium evaluation. Stent removal and nasal endoscopy were performed at 6 weeks and a further ostium evaluation at 3 and 6 months following surgery. Anatomical success rate was defined as patent irrigation, and functional success rate was defined as positive functional endoscopic dye test and absence of epiphora.

Results:

Fifty-four eyes of fifty patients were operated, and three cases were lost to follow-up after surgery. The mean age at presentation was 34 (4–75) years. Clinical diagnosis included primary acquired nasolacrimal duct (NLD) obstruction in 72% (39/54), acute dacryocystitis in 15% (8/54), failed DCR in 7% (4/54), and persistent congenital NLD obstruction in 5% (3/54). The first five cases needed intervention by the mentor for superior osteotomy. Common variations in anatomical landmarks were posterior location of sac, large ethmoidal bulla, high internal common opening, and thick maxillary bone. Surgical time taken in the last 27 eyes was significantly lesser compared to the surgical duration taken in the initial 27 cases (P < 0.05). Anatomical and functional success rate was 94% (48/51) at 6 months follow-up period.

Conclusions:

Endoscopic En-DCR has a good success rate when performed by oculoplastic surgery trainees. Nasal anatomical variations, instrument handling, and adaptation to monocular view of endoscope are few of the challenges for beginners. Structured skill transfer can help trainees to learn and perform En-DCR with acceptable success rates.

The outcomes of endoscopic dacryocystorhinostomy in children: A systematic review

OBJECTIVES

To systematically review and discuss the published results about the application of endoscopic dacryocystorhinostomy in treating children with nasolacrimal duct obstruction.

METHODS

In October 2014 an appropriate string was run on PubMed to retrieve all relevant articles. A cross-check was performed by two of the authors on abstracts and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the procedures' rate of success and failure was performed.

RESULTS

Fourteen studies were identified comprising a total of 346 subjects affected by nasolacrimal duct obstruction (unilateral or bilateral). Overall there were 393 surgical procedures, all performed with an exclusive endoscopic approach. The average length of follow-up was reported in twelve studies resulting 15.2 months and ranging from 3 to 27.1 months. On the basis of our statistical analysis the mean (95% CI) rate of failure was 0.14 (0.09-0.21). The mean (95% CI) rate of success resulted 0.87 (0.80-0.91).

CONCLUSIONS

Although in young patients the nasal anatomy is more complex and narrow than in adults our review showed as the endoscopic dacryocystorhinostomy allows similar results in terms of success compared to the external approach.

Endoscopic endonasal dacryocystorhinostomy combined with canaliculus repair for the management of dacryocystitis with canalicular obstruction

Purpose. The aim of this study is to propose a simple and efficient combination surgery for the management of dacryocystitis with canalicular obstruction. Methods. A retrospective noncomparative case series of dacryocystitis with canalicular obstruction has been studied. Twelve patients with dacryocystitis and canalicular obstruction underwent a conventional endoscopic endonasal dacryocystorhinostomy (EE-DCR) combined with a modified canalicular repair. Postoperative observations included slit lamp, fluorescein dye disappearance test, lacrimal syringing, lacrimal endoscopy, and nasal endoscopy. Results. After 6-18 months of postoperative follow-up, the symptoms of epiphora and mucopurulent discharge disappeared completely in 10 patients, and occasional or intermittent epiphora remained in 2 patients. All of the twelve patients showed an opened intranasal ostium and normal fluorescein dye disappearance test. Patent bicanalicular irrigation was achieved in 9 patients. One patient had a partial and the other two had a complete reobstruction by lacrimal irrigation to their repaired lower canaliculus; however, all of them had a patent lacrimal irrigation to upper canaliculus. The functional success rate for the combination surgery is 83% (10/12), and anatomical success rate is 75% (9/12). Conclusion. EE-DCR combined with modified canalicular repair is a simple and efficient method for the management of dacryocystitis with canalicular obstruction.

Outcomes in Primary Powered Endoscopic Dacryocystorhinostomy: Comparison between Experienced versus Less Experienced Surgeons

Background

This study compares the anatomic and functional outcomes of primary powered endoscopic dacryocystorhinostomy (DCR) in surgeons of differing levels of experience.

Methods

A retrospective interventional study was performed of all consecutive powered endoscopic DCRs performed at a tertiary institution over a period of 10 years from 2002 to 2012. All patients completed a minimum of 3 months follow-up after stent removal. Patient records were reviewed for demographic data, clinical and surgical profiles, adjunctive procedures, complications, and success rates at last follow-up. The level of surgeon's experience performing the DCR was also documented. Anatomic success was defined as patent ostium on irrigation and functional success as free flow of dye into ostium on functional endoscopic dye test and resolution of epiphora.

Results

Among the 160 DCRs performed by the consultant, all except four underwent intubation; 54.4% (68/125) of these patients required adjunctive procedures. There were no major complications in this group and at a long-term mean follow-up of 14.2 months, the anatomic and functional success rates were 98.1 and 95.6%, respectively. Among the 100 DCRs performed by the fellows, all underwent intubation and 40.8% (29/71) of the patients required adjunctive procedures. The complications include three cases of ostium granulomas and two patients each with postoperative bleeding, stent prolapse, and turbinoseptal synechiae. At the mean follow-up of 10.9 months, the final anatomic success was achieved in 95% of the cases and functional success in 89% of the cases.

Conclusion

Powered endoscopic dacryocystorhinostomy is an effective procedure and offers excellent results in the hands of experienced surgeons. A good transfer of knowledge and skills along with supervision when required ensures a good surgical success rate, even when the training fellows operate.

The surgical outcome of endoscopic dacryocystorhinostomy according to the obstruction levels of lacrimal drainage system

OBJECTIVES

Many factors influence the outcome of endoscopic dacryocystorhinostomy (DCR). One of the most important prognostic factors is the level of obstruction in the lacrimal drainage system. The main objective of this report is to evaluate both the frequency of obstruction by anatomical region of the lacrimal drainage system on dacryocystography (DCG) and the surgical outcome of endoscopic DCR according to the obstruction level.

METHODS

A retrospective series of 48 patients (60 eyes) who had undergone endoscopic DCR from January 2005 to November 2007 were enrolled. Preoperative evaluation consisted of a standard examination which included lacrimal irrigation, probing, DCG and osteomeatal unit (OMU) computed tomography. Patients were classified into four groups according to the obstruction level on DCG. Surgical outcome was evaluated postoperatively by subjective improvement of epiphora and patent rhinostomy opening on nasal endoscopic exam.

RESULTS

Of 60 eyes, the levels of obstruction were the common canaliculus in 14 eyes (23.3%), the lacrimal sac in 13 eyes (21.7%), the duct-sac junction in 13 eyes (21.7%) and the nasolacrimal duct (NLD) in 20 eyes (33.3%). The ductsac junction obstruction was treated most successfully (100%), followed by NLD obstruction (90%), common canaliculus obstruction (78.6%) and saccal obstruction (69.2%).

CONCLUSION

In patients with lacrimal drainage system obstruction, preoperative evaluation of obstruction level using DCG may be helpful for predicting the surgical outcome of endoscopic DCR. The saccal obstruction may have a worse prognosis than the other obstruction levels.

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.

Silicone Tubing is not Necessary after Primary Endoscopic Dacryocystorhinostomy: A Prospective Randomized Study

Background

Endoscopic dacryocystorhinostomy (EN-DCR) is an effective procedure when treating saccal and postsaccal obstructions of the nasolacrimal pathway. The benefit of silicone tubing after DCR is still controversial. We conducted a prospective, randomized study to evaluate the necessity of bicanalicular silicone tubes after primary EN-DCR.

Methods

Forty-six consecutive primary EN-DCR procedures were performed in 42 patients during 2004-2007. The patients were randomized into two study groups according to whether silicone tubing was used or not.

Results

The overall success rate after primary EN-DCR was 89%: with silicone tubes it was 78%, and without silicone tubes it was 100%. The difference between these two groups was statistically significant (p < 0.049). The follow-up period was 6 months and included three follow-up visits: 1 week, 2 months, and 6 months postoperatively. If inserted, the silicone tubes were removed at the 2-month visit.

Conclusion

The results of our prospective, randomized study showed that the use of silicone tubes after primary EN-DCR is not necessary.

Trephination and Silicone Stent Intubation for the Treatment of Canalicular Obstruction: Effect of the Level of Obstruction

PURPOSE

To investigate the efficacy of canalicular trephination and silicone stent intubation procedure for relief of epiphora according to the level of obstruction within the canaliculus.

METHODS

The medical records of 32 patients (41 eyes) who underwent canalicular trephination followed by silicone stent intubation of the nasolacrimal system for the treatment of canalicular obstruction were retrospectively reviewed. Canalicular obstruction was diagnosed on preoperative irrigation and probing. Level of obstruction was confirmed by intraoperative probing. Proximal obstruction was classified as those within 4 mm of the punctum, distal obstruction as those 5 mm or greater from the punctum, and common canalicular obstruction as those 10 mm or greater from the punctum. Silicone stents were kept in for a minimum of 5 months, and outcome was based on symptomatic relief of epiphora at the end of follow-up (minimum of 6 months). Partial relief of epiphora was defined as improved symptoms and at least a fair clearance on fluorescein dye disappearance testing.

RESULTS

On average, 49% of eyes had complete relief of epiphora, 38% had partial relief, and 13% had no relief. Eighty percent of eyes with distal lower canalicular obstructions had complete relief of epiphora and 20% had partial relief of epiphora. Eyes with distal bicanalicular obstructions had 66% complete and 33% partial relief. Patients with common canalicular obstructions had 59% complete, 29% partial, and 12% no relief. Proximal bicanalicular obstructions were the least successful, with 55% partial relief and 45% no relief.

CONCLUSIONS

Success of canalicular trephination and silicone stent intubation for treatment of canalicular obstruction is based on the site of obstruction. Distal monocanalicular obstructions have the highest degree of symptomatic epiphora relief, followed by distal bicanalicular, common, and proximal obstructions.

Epidemiology of chronic dacryocystitis and success rate of external dacryocystorhinostomy in Nepal

PURPOSE

To study the epidemiology of chronic dacryocystitis and the success rate of external dacryocystorhinostomy (DCR) in Nepal.

PATIENTS AND METHODS

This is a retrospective descriptive and interventional case series. A total of 662 records of patients with chronic dacryocystitis due to nasolacrimal duct obstruction, who were treated by means of external DCR without bicanalicular silastic tube intubation, were studied.

STATISTICS

Mean for age with standard deviation and confidence intervals were calculated. The significance of the difference in means was calculated using the unpaired t-test.

RESULTS

Of 662 patients, 67.6% were female. The mean age of the patients was 27.4 +/- 13.7 years (SE = 0.53, 95% CI = 26.34-28.46). Chronic dacryocystitis due to nasolacrimal duct obstruction was found in 86 patients (13.0%) from the high hills (mean age = 35.3 +/- 11.4 years, 95% CI = 32.85-37.75), but most patients (576, 87.0%) were from the subtropical lowlands with a monsoon climate (mean age = 26.9 +/- 13.3 years, 95% CI = 25.8-28.0; p = < 0.01). An overall success rate of 88.6% (89.8% for high-hill patients and 87.4% for those from the lowlands) was obtained after DCR.

CONCLUSION

Chronic dacryocystitis is more common in the subtropical plains of Nepal with a monsoon climate than in the high hills. It is predominantly found in pre-menopausal females. External DCR without bicanalicular silastic tube intubation is an effective method for treating chronic dacryocystitis due to NLDO in these patients.

Minimal-invasive Therapie der Epiphora durch Ballonkatheterdilatation und Stentimplantation

PURPOSE

To examine the clinical outcome of the ballon dilatation in stenosis and obstruction of the nasolacrimal duct.

MATERIAL AND METHODS

63 patients (69 nasolacrimal duct systems) with epiphora and proven obstruction of the nasolacrimal duct were treated with ballon dilatation, respectively Stentimplantation. In 55 cases there was a pre- or postsaccal stenosis, in 14 cases an occlusion of the nasolacrimal duct system. The diagnosis was established by dacryocystography.

RESULTS

Technical success was obtained in 61 cases (n=50/55 stenosis; n=11/14 occlusions). Over a mean follow-up of 6 months patency of the nasolacrimal duct system was achieved in 83,6% (46/55) in stenosis. In occlusion the clinical outcome was 42,9% (6/14).

CONCLUSION

Balloon dacryocystoplasty and Stentimplantation are minimal-invasive alternatives, performed in local anesthesia that recover the normal anatomy of the nasolacrimal duct system. They are a good alternative in the treatment of epiphora caused by nasolacrimal duct obstructions.

Analysis of the results of surgical endoscopic dacryocystorhinostomy: effect of the level of obstruction

AIM

One of the main factors in determining success rate of lacrimal surgery is the level of obstruction in the lacrimal drainage system. There are only few reports which quantify this, and none on endoscopic dacryocystorhinostomy (DCR).

METHODS

A case series of patients who had endoscopic DCR for anatomical obstruction of the lacrimal drainage system was performed. All patients who had lacrimal blockage referred to a district general hospital, irrespective of the level of blockage, had endoscopic DCR as the initial treatment by the authors. A total of 191 endoscopic DCRs were performed between 1994 and 1999. No other forms of lacrimal surgery were performed during this period. The level of the obstruction was assessed by the ophthalmologist before the operation and confirmed at surgery. All cases were followed up for a minimum of 6 months, and 96 cases were also reviewed 12 months after surgery. The outcome of the endoscopic DCR operation for each eye was categorised into complete cure, partial cure, or no improvement according to the degree of symptomatic relief following the operation.

RESULTS

Complete relief from epiphora was achieved in 89% of cases overall at 6 months. The success rate in cases with lacrimal sac/duct obstruction (93%) or common canalicular blockage (88%) was comparable. In canalicular obstruction, however, the complete cure rate was lower at 54%. The benefit of the operation was maintained at 12 months.

CONCLUSION

This study demonstrates that the success rate of surgical (non-laser) endoscopic DCR is comparable to that reported for external DCR. Moreover, the technique is appropriate for initial treatment of patients with common canalicular or even canalicular obstruction.

Endoscopic dacryocystorhinostomy in children

BACKGROUND

Persistent nasolacrimal duct obstruction (NLDO) often requires treatment by probing, intubation, or balloon dacryoplasty. Refractory cases have been managed by external dacryocystorhinostomy (DCR), which leaves a scar; however, this procedure is generally avoided in young children. Endoscopic DCR has been successfully performed in adults and described in children. We report the success of this procedure in a series of pediatric patients.

METHODS

A retrospective review of all endoscopic lacrimal procedures performed in a 3-year period was undertaken. Seventeen children (22 ducts) with persistent NLDO after at least one failed probing, with or without silicone tube placement, underwent endoscopic DCR. Follow-up ranged from 6 to 36 months, and success was defined as resolution of tearing and discharge by follow-up clinical evaluation and by parental history.

RESULTS

All but 2 patients (88%) with NLDO showed complete resolution of tearing and discharge. These 2 patients had recurrent symptoms after the Crawford tubes were removed and required revision endoscopic DCR. No complications from this procedure were noted.

CONCLUSIONS

Endoscopic DCR is a safe and effective means of treating persistent NLDO in infants and young children when simple probing, intubation, or balloon procedures have failed. The team ophthalmology-otolaryngology endoscopic approach provides a highly successful alternative for patients with a persistent distal obstruction that might otherwise require an external procedure.