A consideration of the time taken to do dacryo-cystorhinostomy (DCR) surgery

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.

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.

Success and complications of endoscopic laser dacryocystorhinostomy vs. external dacryocystorhinostomy: A systematic review and meta-analysis

A systematic review and meta-analysis were conducted to evaluate the success and complications of endoscopic laser dacryocystorhinostomy (ELDCR) vs. external dacryocystorhinostomy (ExDCR) in primarily acquired nasal duct obstruction. The search of PubMed, Embase, and Cochrane Central Register of Controlled Trials databases revealed 109 studies on ELDCR and ExDCR. Eleven studies were found to be suitable for review. The primary objective was to compare the success rate between ELDCR and ExDCR. The secondary objectives were to analyze the surgical time, overall complications, bleeding, infection, intranasal synechia, and granulation tissue. Pooled analysis of all studies revealed that ELDCR had a significantly lesser success rate compared to ExDCR (80.3% vs. 91.6%; odds ratio [OR] 0.41; 95% confidence interval [CI] [0.27, 0.62]; P < 00001; I2 = 13%). However, there were no difference in the overall complication rate (12.0% vs. 13.0%; OR 1.04; 95% CI [0.17, 6.33]; P = 0.97, I2 = 80%) and intranasal synechiae (9.5% vs. 4.3%; OR 2.22 [1.04, 4.72]; P = 0.04; I2 = 10%). The ExDCR group had significantly increased risks of bleeding (1.9% vs. 13.0%; OR 0.20; 95% CI [0.09, 0.47]; P = 0.0002; I2 = 0%) and infection (0.3% vs. 4.6%; OR 0.09; 95%CI [0.02, 0.51]; P = 0.006; I2 = 0%). Nevertheless, ELDCR needed a shorter surgical time compared to ExDCR (mean difference [MD] -28.35, 95% CI [-35.45, -21.26], P < 0.00001, I2 = 78%). Although ELDCR is associated with lesser bleeding, lesser infection, and shorter surgical duration, the success rate of ExDCR is higher.

Outcomes of 8 × 8 mm osteotomy in powered external dacryocystorhinostomy

Purpose

To study the endoscopic ostium characteristics and outcome of 8 × 8 mm osteotomy in external dacryocystorhinostomy (DCR) using the microdrill system.

Methods

This prospective interventional pilot study was performed on 40 eyes of 40 patients with primary acquired nasolacrimal duct obstruction (NLDO) from June 2021 to September 2021 in patients undergoing external DCR. An 8 × 8 mm osteotomy was performed using round, cutting burr attached to a microdrill system. Success was defined as patent ostium on lacrimal syringing (anatomical) and a Munk score <3 (functional) at 12 months. Postoperative endoscopic ostium evaluation was done using a modified DCR ostium (DOS) scoring system at 12 months.

Results

The mean age of the study participants was 42.41 ± 11.77 years and the male-to-female ratio was 1:4. The mean duration of surgery was 34.15 ± 1.66 minutes and that for osteotomy creation was 2.5 ± 0.69 minutes. The mean intraoperative blood loss was 83.37 ± 11.89 ml. Anatomical and functional success rates were 95% and 85%, respectively. The mean modified DOS score was "excellent" in 34 patients (85%), "good" in 1 patient (2.5%), "fair" in 4 patients (10%), and "poor" in 1 patient (2.5%). Complications included nasal mucosal injury in 10% (4/40) of patients, complete cicatricial closure of ostium in 2.5% (1/40), incomplete cicatricial closure in 10% (4/40), nasal synechiae in 5% (2/40), and canalicular stenosis in 2.5% (1/40).

Conclusion

An 8 × 8 mm-sized osteotomy created by powered drill and covered by lacrimal sac-nasal mucosal flap anastomosis in external DCR is an effective technique that has minimal complications and shorter surgical time.

Revision dacryocystorhinostomy: systematic review and meta-analysis

PURPOSE

The goal of this study is to determine if a certain revision DCR approach (external, endoscopic endonasal, laser transcanalicular) is superior to others. Additionally, this investigation evaluates the effect of the primary surgery on success of revision.

METHODS

This investigation is a systematic review and meta-analysis. All studies specifying type of primary DCR and revision DCR were included. Proportion of successes of each revision for every primary surgery was obtained from the included studies. Meta-analyses were performed to determine cumulative proportions of successes across studies.

OUTCOME MEASURES

Significant differences in the proportions yielded by meta-analysis of successes among different surgical approaches.

RESULTS

The type of primary surgery did not significantly influence overall revision success if the same procedure was used for the revision. Overall successes per each revision type were not significantly different. When performing subgroup analyses per each primary surgery, all methods of revisions were similar in efficacy with one exception: when the primary surgery was done using the laser transcanalicular approach, external revision outperformed repetition of the primary method.

CONCLUSIONS

Regarding success of re-operation, surgeons can use the method they are most comfortable with to perform DCR revisions. However, primary transcanalicular laser DCRs should be revised, if necessary, using the external approach.

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.

Dry eye after Lester Jones tube insertion for epiphora

Purpose: To report the occurrence of dry eye after Lester Jones tube (LJT) insertion. Methods: Retrospective case series from a single unit. The dacrocystorhinostomy (DCR) was carried out using both endoscopic and external approachs; however, insertion of LJT used the same method as either a primary or secondary procedure. Dry eye as an outcome measure was only confirmed after three separate visits using the presence of both patient symptoms and dry eye signs with none preceding tube insertion. Results: Fifty-four patients underwent consecutive LJT insertion over a 5-year period. Mean age was 52.6 (range 25-73 years). The majority were female 39 (72%). Revision surgery was required in 15 (27%) with 3 or more occurring in 6 (11%). In total, 9 patients developed dry eyes (17%). Mean age was 60 (range 47-73) years, 5 females and 4 males. Four of the dry eye individuals had undergone primary LJT insertion and the remaining five received their first LJT 6-24 (mean 15) months post-DCR. Two dry eye patients had previously undergone LASIK and radiotherapy. Conclusion: A risk of dry eye following LJT placement is higher than the literature suggests. This should be considered and counseled, especially in those who have underlying pre-disposing factors. Ease of removal may be a desirable attribute in such cases.

Simultaneous Bilateral Endonasal Endoscopic Dacryocystorhinostomy: A Low Cost, Fast, and Successful Method

The etiology of primary nasolacrimal duct obstruction is largely unknown, and this disease may occur bilaterally in a small percentage of patients. In this retrospective study, the authors aimed to discuss the cost, operation time, complications, and success rate of simultaneous bilateral endonasal endoscopic surgery. Twenty-eight patients (16 female, 12 male) were enrolled in this study, with a mean age of 55 years old (range: 43-76). The success rate was 91% (51/56), and the mean operation time was 44 minutes. Only minor and transient complications were observed in 2 of the patients. Overall, the authors believe that a bilateral endoscopic dacryocystorhinostomy would be useful in a single session, based on its advantages of low morbidity, low cost, and high success.

Prevention of re-obstruction in watery eye treatment: three-flap technique in external dacryocystorhinostomy

PURPOSE

To examine the surgical outcome of three-flap external dacryocystorhinostomy (3-flap ex-DCR) based on the most common site of granulation occurrence in no-flap endonasal DCR (no-flap en-DCR).

METHODS

This was a retrospective observational study. We first examined the location of granulation occurrence in the osteotomy site using nasal endoscopy after no-flap en-DCR on 53 sides of 37 patients (5 male, 32 female) with nasolacrimal duct obstruction. Based on the results of this surgery, we performed 3-flap ex-DCR on 70 sides of 61 patients (18 male, 43 female) with nasolacrimal duct obstruction. Anatomical success was defined as no reflux under lacrimal irrigation and a patent osteotomy site under nasal endoscopic examination at postoperative 12 months. Functional success was defined as no symptoms of watery eyes over the same period.

RESULTS

In the no-flap en-DCR patients, the granulation was formed in 42 sides (79.2 %): 18 sides (34.0 %) on the superior portion, 9 sides (17.0 %) on the inferior portion, 35 sides (66.0 %) on the anterior portion, and only 1 side (1.9 %) on the posterior portion, which was very small. Based on these results, we performed the 3-flap ex-DCR with the anterior, superior, and inferior flaps. Anatomical success with this technique was achieved in all sides (100 %), and functional success was obtained in 66 of 70 sides (94.3 %).

CONCLUSIONS

The 3-flap ex-DCR did not cause recurrent nasolacrimal duct obstruction, rendering it a very useful technique in terms of quality of life and medical economics.

External Versus Endoscopic Endonasal Dacryocystorhinostomy

DCR is the treatment of choice for NLDO. External DCR has remained the standard approach since the 1890s. With advances in technique and technology, and more otolaryngologists and ophthalmologists performing endoscopic DCR, more studies have been conducted, some with equivalent success rates between the 2 approaches. Endoscopic endonasal DCR offers the advantages of avoiding a skin incision with similar success rates with experienced surgeons. However, the technique necessitates more surgical equipment, and has a steep learning curve. Both approaches have low complication rates and serious complications are very rare. The decision for the type of approach to use depends on the surgeon’s experience, the patient’s preference or concerns, and the resources available within a particular health system.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons

PURPOSE

To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees.

METHODS

Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips.

RESULTS

Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 ± 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 ± 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 ± 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% in the previous 2 years. In cases that failed, video-analysis highlighted inadequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling, bone removal and posture.

CONCLUSION

Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

Time taken for superior osteotomy in primary powered endoscopic dacryocystorhinostomy: is there a difference between an ultrasonic aspirator and a mechanical burr?

BACKGROUND

The purpose of this study is to report the time taken for superior osteotomy and complications during this step in primary powered endoscopic dacryocystorhinostomy (PEnDCR) using the piezoelectric system and mechanical burr.

METHODS

This prospective interventional comparative series was performed on all consecutive patients who underwent a primary PEnDCR over a 4-month period. The surgery was performed as per standard protocols and all patients were operated on by a single surgeon (M.J.A.). Parameters documented were demographic data, type of powered instrument used, time taken for superior osteotomy, exposure of the agger nasi, exposure of entire sac, and complications such as excess bleeding, soft tissue injury, or mucosal burns. Statistical analyses were performed using the linear mixed-effect model and 2-sample t tests.

RESULTS

A total of 55 PEnDCRs were studied, 29 in the mechanical burr group and 26 in the piezoelectric or ultrasonic group. The mean time for superior osteotomy in the mechanical burr group was 3.71 minutes (range, 1.75 to 6.58 minutes); in the ultrasonic group it was 4.12 minutes (range, 1.33 to 6.25 minutes). There was no significant difference (p = 0.17) between the 2 groups. Subcategory analyses of time taken by age (p = 0.057) and sex (p = 0.56) did not show any difference between the groups. Two patients in the mechanical burr group had an insignificant superficial sac injury and 1 patient in the ultrasonic group suffered epithelial burns away from the site of osteotomy, which resolved spontaneously without any sequelae. There was no excess bleeding in any of the groups.

CONCLUSION

The time taken by mechanical burr and piezoelectric system are comparable for superior osteotomy in PEnDCR. If anatomical boundaries are respected, their use appears to be safe without major complications.

Learning curve for use of the sonopet ultrasonic aspirator in endoscopic dacryocystorhinostomy

PURPOSE

The Sonopet Ultrasonic Aspirator is a surgical tool that uses low-frequency ultrasonic vibrations to fragment tissue while simultaneously irrigating and aspirating the surgical field. This technology is becoming more widely used in orbital, lacrimal, neurological, and skull base surgery, but few studies have examined the learning curve associated with adoption of this technology. We present our surgical learning curve, pearls, and pitfalls using the newest generation Sonopet Ultrasonic Aspirator Universal handpiece in endoscopic dacryocystorhinostomy (eDCR) surgery.

METHODS

Retrospective chart review of consecutive eDCR surgeries performed by a single surgeon adopting the Sonopet Universal handpiece. Data collected include demographic information, indications for surgery, surgical time, intraoperative findings, anatomic and functional results, and complications.

RESULTS

Twenty-six eDCR surgeries in 20 patients were performed from October 2011 - May 2013. Most patients were female (85.7%) with mean age 53.6 years (range 4-84) and mean follow up of 378 days (range 7-761). For routine unilateral and bilateral surgeries, surgery time decreased by 36.4% and 33.9% before reaching a plateau of 67.2 and 80.7 minutes per case, respectively. Mean surgery time for non-sequential unilateral complex cases was 85.1 minutes, which did not vary significantly over the learning curve. We achieved 100% anatomic success and 84.6% functional success.

CONCLUSIONS

The Sonopet Ultrasonic Aspirator Universal handpiece can be used safely and effectively for eDCR surgery. A significant learning curve exists for adoption of this technology. Appropriate handpiece tip selection and machine setting adjustments are crucial for successful adoption of this technology and avoidance of complications.

Analysis of 104 cases of endonasal dacryocystorhinostomy in a tertiary care hospital: a prospective study

To evaluate the results of endoscopic endonasal dacryocystorhinostomy performed in a tertiary care hospital. Prospective, nonrandomized, interventional clinical study. A prospective interventional study was performed on 104 patients presenting with epiphora between January 2006 and January 2010. All patients were operated by one surgeon. Out of 104 cases, 08 cases were of revision endonasal dacryocystorhinostomy (DCR). Bicanalicular silicon intubation was performed in all cases of revision endonasal DCR. Twelve patients had concomitant sinonasal disease for which septoplasty or FESS was done. The patency of nasolacrimal duct was assessed by doing syringing of lacrimal passage weekly for 1 month, monthly for 3 month, then at 6 month and 1 year. Out of 104 patients 10 patients lost follow up after surgery. Ninety four patients were followed for 1 year. On syringing, rhinostomy site was found patent in 80 patients (85.10 %), therefore they were fully satisfied. In 6 cases (6.38 %) minimal block was seen with clear fluid regurgitation, were to some extent symptomatically relieved and were found to be satisfied, whereas in 08 cases (8.51 %) syringing showed complete block. They required further management. Success rate of our study is comparable to other studies on endonasal DCR as well as external DCR, with advantages of less intra-operative bleeding, shorter operative time, better cosmesis, preservation of lacrimal pump mechanism. Other nasal pathology can be treated at the same time. Our results are clinically as well as statistically highly significant (P value < 0.0001).

Transcanalicular endoscope combined laser-assisted dacryocystorhinostomy

Aims:

In this study, we have tried to assess the success rate and difficulties that we came across while performing the transcanalicular endoscope combined laser-assisted dacryocystorhinostomy (T-ECLAD).

Materials and Methods:

A prospective study of 60 patients suffering from nasolacrimal duct obstruction confirmed by preoperative syringing was carried out at the Regional Institute of Ophthalmology. T-ECLAD is a new minimally invasive dacryocystorhinostomy procedure, which is performed by diode laser (980 nm diode laser with power of 10 watts) through lacrimal canaliculi with the help of a cannula and fiber optic cable. The interior of the nasal cavity was visualized with the help of the nasal endoscope on a monitor. Success of procedure was assessed by patency of the lacrimal drainage system on irrigation.

Results:

We performed 56 successive T-ECLAD. The average procedure time was 10 min, and on an average 235 Joules of laser energy was needed. We observed a patent nasolacrimal duct on irrigation in 39 out of 56 treated eyes. 1 patient had partial, 5 patients had blocked irrigation, and 10 patients did not return for follow up. This yields a success rate of 69.6% (if we exclude patients who did not return for follow up) with an average follow-up period of 6 months.

Conclusions:

The 980-nm T-ECLAD is a new contribution to the field of lacrimal surgery. It is a minimally invasive and quick procedure.

The ultrasonic bone aspirator in transnasal endoscopic dacryocystorhinostomy

PURPOSE

To evaluate the outcomes of endoscopic dacryocystorhinostomy (eDCR) with and without the use of ultrasonic bone aspirator (UBA; Sonopet).

METHODS

A retrospective, institutional review board approved chart review of all eDCRs over 49 months. Data included demographics, indication/etiologic factors of nasolacrimal duct obstruction, comorbidities, intraoperative findings, epiphora symptoms pre- and postoperatively, and complications. Patients were grouped in eDCR with or without UBA.

RESULTS

One hundred and twenty-three primary eDCRs in 99 patients were included, 59 with UBA and 64 without UBA. Most patients were Caucasians (80.8%) and women (72.0%), with a mean age of 55.9 years (range, 9-89). There were no significant differences in the demographics of the 2 subgroups. Complete resolution of symptoms was obtained in 81.3% of procedures without UBA and in 79.7% with UBA. Most patients (72.7%) were deemed idiopathic preoperatively. Lacrimal sac biopsy demonstrated significant pathologic factors in 9 (7.3%) cases, with 7 (5.7%) of these resulting in a new diagnosis for the patient. There were no cases of cerebrospinal fluid leakage, visual loss, diplopia, infection, or uncontrolled epistaxis in either group.

CONCLUSIONS

Early results of eDCR with UBA appear to show reasonable efficacy. The overall success and failure rates of eDCR with and without UBA are similar. Neither group had any complications in this study, although any conclusion on the overall safety of the procedure is limited by the power of this study.

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

PURPOSE

To evaluate the outcomes of external dacryocystorhinostomy (DCR) by using two different patterns of flap anastomosis; one only with anterior flap anastomosis and the other with both anterior and posterior flap anastomosis.

METHODS

One hundred and sixty-four patients were enrolled in the study. Patients were then randomly divided into two groups as follows: those who underwent DCR with both anterior and posterior flap anastomosis (Group 1) and those who underwent DCR with only anterior flap anastomosis (Group 2). Surgical success was defined as patient satisfaction, disappearance of epiphora and lacrimal patency up to 12 months after surgery.

RESULTS

After 12 months, the DCR with both anterior and posterior flap anastomosis had a success rate of 89.8% (71/79), while the DCR with only anterior flap anastomosis had a success rate of 89.4% (76/85). There was no statistically significant difference between the two groups (p < 0.05).

CONCLUSION

Anastomosis of posterior flaps does not seem to affect success rate of external DCR. Creating only the anterior anastomosis is technically simpler and does not seem to negatively influence the outcome of DCR surgery.

Cadaveric anatomical comparison of the lateral nasal wall after external and endonasal dacryocystorhinostomy

PURPOSE

Much literature has accumulated espousing the relative merits of endonasal and external dacryocystorhinostomy (DCR). However, there is comparatively little information on the relative anatomic differences between these 2 approaches. The purpose of this study is to investigate the anatomic relationships of the lateral nasal wall for endonasal and external DCR.

METHODS

Ten cadaver half heads were used in this study. Half were subject to endonasal and half to external DCR procedures. The lateral nasal wall was then dissected and measurements were taken of ostium and anastomosis size and position relative to other landmarks on the lateral nasal wall. Relationships were compared between the 2 procedures.

RESULTS

The dimensions and area of the ostium and the anastomosis were similar between the 2 procedures. The lower portion of the ostium was located more inferiorly in endonasal DCR. Additionally, the ostium was more likely to be found lateral to the axilla of the middle turbinate in endonasal DCR, when compared with anterior for external. External DCR was also more likely to involve opening the anterior ethmoid air cells than endonasal approach.

CONCLUSION

Endonasal and external DCR osteomies appear to be of similar size, with the endonasal opening being located slightly lower and more posterior on the lateral nasal wall.

Assessment of patient satisfaction following external versus transcanalicular dacryocystorhinostomy with a diode laser and evaluation if change in quality of life after simultaneous bilateral surgery in patients with bilateral nasolacrimal duct obstruction

AIM

To compare patient satisfaction and experience after external dacryocystorhinostomy (EX-DCR) versus transcanalicular DCR (TC-DCR) with a diode laser and to evaluate the change in quality of life following simultaneous bilateral DCR.

METHODS

Prospective evaluation of 38 eyes of 19 patients with bilateral nasolacrimal duct obstruction (NLDO) who underwent TC-DCR for the right eye (Group 1) and EX-DCR for the left eye (Group 2) simultaneously. The subjective outcomes (tearing, irritation, pain, discharge, swelling, and change in visual acuity) of the patients in the two groups at 1 week, 1 month, and 3 months were compared using a questionnaire. The patients answered the questions in the Glascow Benefit Inventory (GBI) to evaluate the change in quality of life after simultaneous bilateral DCR at 1 month and 3 months. The symptom scores were compared between Group 1 and Group 2 using a Mann-Whitney test. The Wilcoxon test was used for the comparison of intragroup differences.

RESULTS

The overall symptom scores significantly improved in both groups. The overall symptom score and six ocular symptom scores did not show a significant difference between the two groups at 1 week, 1 month, and 3 months. Quality of life of the patients significantly improved after simultaneous bilateral surgery according to GBI scoring at 1 month and 3 months.

CONCLUSION

The subjective outcomes significantly improved in similar ways after successful TC-DCR and EX-DCR during the early postoperative period. Our study shows that simultaneous bilateral DCR confers a significant quality of life improvement.

Endonasal endoscopic dacryocystorhinostomy: how to achieve optimal results with simple punch technique

Endonasal endoscopic dacryocystorhinostomy (EEDCR) has been popularized as a minimally invasive technique. Although preliminary reports revealed less success in comparison with external approaches, recent endonasal endoscopic surgeries on various types of DCR have preserved advantages of this technique while diminishing the failures. We described our experience on EEDCR, including the main advantages and disadvantages of it. Hundred consecutive cases of lachrymal problems underwent EEDCR utilizing simple punch removal of bone, instead of powered instrumentation or lasers. The medial aspect of the sac was removed in all of patients, while preserving normal mucosa around the sac. Hundred cases of EEDCR were performed on 81 patients, with 19 bilateral procedures. Nine procedures were performed under local anesthesia. Based on a mean 14 months follow-up, 95 cases were free of symptoms, revealing 95% success rate. The punch technique diminishes the expenses of powered or laser instrumentation with comparable results. It seems that preserving normal tissues and creating a patent rhinostomy with least surgical trauma and less subsequent scar, plays the most important role in achieving desirable results.

External vs. endonasal dacryocystorhinostomy: six of one, a half dozen of the other?

PURPOSE OF REVIEW

The purpose of this review is to describe the results from published clinical studies evaluating the efficacy of two types of dacryocystorhinostomy, namely external and endonasal.

RECENT FINDINGS

Many studies report high success rates with either procedure in alleviating the consequences of nasolacrimal duct obstruction. However, only a few studies have compared the two approaches in a prospective, randomized fashion.

SUMMARY

Both types of procedure achieve excellent outcomes, and there is no definitive evidence from published, large-scale studies that one approach is superior to the other.

Epiphora: an evidence based approach to the 12 minute consultation

BACKGROUND

Epiphora is the presence of a watering eye which may be due to reflex tearing or defective drainage of tears. Whilst most cases present to the ophthalmologist the otolaryngologist has a key role to play in both assessment and management of these patients.

METHODS

This review was based on a literature search last performed on 21st October 2009. MEDLINE and Cochrane databases were searched using the subject headings 'epiphora' or 'functional epiphora' in combination with diagnosis, investigation, management, treatment, intervention and surgery. Results were limited to English language articles. The personal biographies of the senior authors were also used.

CONCLUSION

An accurate assessment of the site and degree of obstruction is important to ensure the correct management is undertaken. Medical treatment with nasal steroid spray may be effective but the majority of obstructed cases will require surgical intervention in the form of dacryocystorhinostomy (DCR). There is increasing evidence that powered endoscopic DCR has outcomes comparable with the 'gold standard' procedure of external DCR.

Transcanalicular diode laser-assisted dacryocystorhinostomy

Objective:

We present a prospective, non-comparative case series study of 126 consecutive diode laser-assisted transcanalicular dacryocystorhinostomy (TCL-DCR) procedures on 122 patients. We analyzed success rate, procedure time and amount of laser energy needed for a 5 mm osteotomy.

Materials and Methods:

One hundred and twenty-two patients with nasolacrimal duct obstruction were included in the study. The procedure was performed under general anesthesia, and the nasal mucosa was anesthetized. An endoscope was used for examination of the lacrimal pathways. The site of osteotomy was determined with transillumination of the lateral nasal wall. We achieved osteotomy by applying laser energy via an optic fiber. We used a 980 nm diode laser with power of 10 Watts. We inserted a bicanalicular silicone stent as the last step. Success of procedure was absence of epiphora (subjective), or patency of the lacrimal drainage system on irrigation (objective).

Results:

We performed 126 successive endoscopic laser (EL-DCR) with bicanalicular intubation in 122 patients. The average procedure time was 12 min, and on average 245 Joules of laser energy was needed. The silicone stents were removed three to eight months after surgery. We observed absence of epiphora and a patent nasolacrimal duct on irrigation in 105 out of 126 treated eyes. Eighteen patients had epiphora despite a patent nasolacrimal duct on irrigation. This yields a success rate of 83.3%, with an average follow-up period of 12 months.

Conclusions:

The 980 nm EL-DCR with bicanalicular intubation is a new contribution to the field of lacrimal surgery. It is a minimally invasive quick procedure yielding a high success rate.

Endonasal laser-assisted microscopic dacryocystorhinostomy: surgical technique and follow-up results

PURPOSE

Endonasal dacryocystorhinostomy is known as an increasingly attractive and effective approach for the surgical treatment of nasal duct obstruction with minimal complications and best cosmetic consequences. In a relatively large-scale case-series study over a 5-year period, we describe the surgical technique and 12-month follow-up results of microscopic laser dacryocystorhinostomy with particular regard to the effect of various pre-/postoperational factors (ie, patients' sex, age, symptoms chronicity, previous interventions, duration of silicone intubation) on the surgical outcome.

MATERIALS AND METHODS

A total of 162 cases in 151 patients with chronic epiphora, mucocele, or recurrent episodes of dacryocystitis were included in the study. Endonasal laser dacryocystorhinostomy was performed using a surgical microscope with transcanalicular lacrimal sac illumination. The laser types used were potassium-titanyl-phosphate and neodymium:yttrium-aluminum-garnet for ablation of nasal mucosa and application to bone, respectively. Patients were evaluated 6 months and 1 year later. Data were analyzed by chi(2) tests.

RESULTS

There were no major complications during or after the operations. Complete cure occurred in 89.5% (after 6 months) and 74.2% (after 1 year) of the cases. Anatomical patency was shown by lacrimal system irrigation with fluorescein in 81.5% of the cases after the 12-month follow-up. It was found that patients younger than 55 years, with symptoms lasting less than 1 year, and without history of nasal problems, had significantly higher surgical success rates (P < .05). Moreover, rates of failure were significantly lower in cases whose canaliculi were intubated for 5 to 6 months (P < .05).

CONCLUSIONS

Endonasal microscopic laser dacryocystorhinostomy is a safe and minimally invasive procedure with reasonable results. It has many advantages over external or other conventional approaches. Successful results could be further enhanced by more wisely selecting the patients and by silicone extubation after 6 months.

A Systematic Review of Outcomes after Dacryocystorhinostomy in Adults

Background

This study was designed to systematically review the clinical outcomes of dacryocystorhinostomy (DCR) surgery. Data sources included PubMed for English language literature from January 1966 to December 2008 combined with a manual review of citations within article bibliographies.

Methods

Citations acquired from the targeted search were filtered independently by two researchers. Relevant articles were reviewed to obtain information including interventions and outcome measures. The surgical techniques were categorized into external DCR (EX-DCR), endonasal laser-assisted DCR (LA-DCR), and nonlaser endoscopic endonasal DCR techniques (EN-DCR). Articles were then assigned level-of-evidence grades as defined by the Oxford Center for Evidence-Based Medicine.

Results

A total of 73 studies that fulfilled the inclusion criteria were analyzed. Of these, 68 were graded as level 4, 11 were graded as level 3b, and 1 was graded at level 2b evidence. A total of 4800 patients were pooled, from which 4921 DCRs were performed. All studies reported success during the follow-up period, although the outcome measures used were not consistent in the studies. Success varied between 65 and 100% after EX-DCR compared with EN-DCR, which varied from 84 to 94%. The success rate of LA-DCR varied widely between 47 and 100%. There was low evidence base to support the use of silicone stent to improve surgical success. Most studies did not show significantly improved outcomes with an antimetabolite. The overall intra- and postoperative complication rates were 1.0 and 6%, respectively.

Conclusions

DCR is an effective and safe method for the treatment of nasolacrimal obstruction. Meta-analysis of outcomes was not feasible because of the heterogenous patient groups and outcome measures used. Nonetheless, the literature provides considerable levels 3 and 4 evidence to support DCR surgery in adults. Outcomes after EN-DCR and EX-DCR were comparable. The failure rate for LA-DCR was higher.

Tips on How to Avoid the DCR Scar

A permanent facial scar following external approach (transcutaneous) dacryocystorhinostomy is fortunately rare. Meticulous surgical technique is the key factor in avoiding a visible scar. Simple measures to avoid a scar include use of local anaesthesia, location of the incision, maintaining a bloodless surgical field, using a skin flap technique and simple orbicularis and skin wound closure. Although endonasal endoscopic dacryocystorhinostomy is gaining clinical acceptance and popularity, the external dacryocystorhinostomy is regarded as the gold standard in terms of surgical success, with a high patient satisfaction.

An unusual variation in the anatomy of the uncinate process in external dacryocystorhinostomy

Variations in the bony components of the nose are often encountered. One such variation was found in a 49-year-old male who had undergone conventional external dacryocystorhinostomy for adult onset nasolacrimal duct blockage. Intraoperatively, a thick bar of bone was seen beneath and parallel to the lacrimal sac fossa after a complete osteotomy had been made. Another osteotomy had to be fashioned in this bone to reach the nasal cavity. Postoperative 3D computed tomographic scan revealed the bone to be an anatomical variation of the uncinate process of the ethmoidal bone which was rather anteriorly placed, much thicker than usual, and attached to the nasal roof.

The uncinate process is thin, curved and its anterior edge may frequently overlap some part of the lacrimal fossa. However, to our knowledge, the presence of such a large and thick uncinate process necessitating an additional large osteotomy has not been reported.

Endoscopic harvesting of autogenous fascia lata

PURPOSE

To describe a technique of endoscopic harvesting of autogenous fascia lata.

METHODS

A retrospective, noncomparative clinical study to evaluate the technique of videoendoscope assistance in harvesting autogenous fascia lata was conducted during a 1-year period in 2002. A small incision approximately 2 cm long is made over the lateral aspect of the thigh, either as a low or high approach. A sheathed 4-mm rigid 0- or 30-degree endoscope is used to visualize the length of the fascia lata along both its superficial aspect and its undersurface. Standard endoscopic brow lifting instruments are then used to dissect a length of fascia under direct visualization.

RESULTS

Three patients underwent harvesting of autogenous fascia lata under endoscopic visualization (2 high-thigh and 1 low-thigh technique). Adequate lengths of fascia lata, approximately 12 cm long, were harvested and no complications occurred. The endoscope was particularly useful in identifying the anatomical structures adjacent to the fascia. The technique was easy to use, but took twice as long as traditional harvesting techniques.

CONCLUSIONS

Videoendoscopy allows complete visualization of anatomical structures during harvesting of autogenous fascia lata. It highlights the anatomy for teaching and provides an alternative approach to conventional harvesting methods.

Morphological and morphometric evaluation of lacrimal groove

The nasolacrimal canal is placed at the anterior part of the inferior lateral wall of the orbit and opens to the inferior nasal meatus. The canal can be obstructed by acquired diseases such as dacryocystitis and posttraumatic epiphora due to nasoorbitoethmoidal fractures. Furthermore in nasolacrimal canal obstructions, dacryocystorhinostomy with balloon dilatation is used frequently. In evaluation of the nasolacrimal canal's acquired diseases, obstruction etiologies and during the reopening of the canal with balloon dilatation, knowing the lacrimal groove's morphology and morphometry play an important role. The aim of the present study was to evaluate not only the morphological features and types but also the morphometric measurements of lacrimal groove. A total of 60 (30 right, 30 left) adult human dry bone maxillae (both male and female samples) from the collection of the Department of Anatomy of Dokuz Eylül University Medical School were used. Digital compass with 0.01 mm sensitivity was used for measurements. Average length of lacrimal groove was 9.62 +/- 2.10 mm. Average width of lacrimal groove was 5.88 +/- 1.53 mm at upper one-third, 8.04 +/- 2.05 mm at middle one-third, and 5.94 +/- 1.28 mm at lower one-third. In 87.7% of cases a crista was observed at the end of the lacrimal groove. Among them, 34.0% were directed to inferior, 54.0% were directed to posterior and 12.0% were horizontal. The present results on the width, length, shape and direction of the lacrimal groove could mediate the etiology of nasolacrimal canal obstructions and could be helpful in surgical approaches and clinical treatment.

Endoscopic 'cold steel' versus laser dacryocystorhinostomy: completing the audit cycle

INTRODUCTION

Dacryocystorhinostomy via an endonasal route has been adopted in our department. This audit study describes and compares our results for external, laser endonasal and 'cold steel' endonasal techniques. Success was defined as a subjective report of eye watering being 'better' or 'cured'. Data were obtained from a retrospective review of the medical records of all patients undergoing primary dacryocystorhinostomy in our department. 'Gold standard': External dacryocystorhinostomy performed by a consultant ophthalmologist was taken as our gold standard. In our study, the success rate for external dacryocystorhinostomy was 94 per cent. First cycle - laser-assisted endonasal dacryocystorhinostomy: Our initial results for endonasal laser-assisted dacryocystorhinostomy produced a success rate of 64 per cent, which was significantly worse than that for external dacryocystorhinostomy. These results have been previously published.

CHANGE IN PRACTICE

Evidence suggested that cold steel endonasal dacryocystorhinostomy was more effective, and we adopted this as our technique of choice. Second cycle - cold steel endonasal dacryocystorhinostomy: Over a four-year period, 57 cases completed a full nine months' follow up. 93 per cent were completed as day cases and 39 per cent were performed under local anaesthetic. The success rate was 79 per cent (45/57). There was no difference in success rates when this procedure was compared with external dacryocystorhinostomy (p = 0.55). The type of anaesthetic used (i.e. local vs general) made no difference to the success rate (p = 0.93).

CHANGE IN PRACTICE

Cold steel endonasal dacryocystorhinostomy was as effective as the gold standard, i.e. external dacryocystorhinostomy. Laser-assisted dacryocystorhinostomy was significantly less successful than external dacryocystorhinostomy. Due to the benefits of decreased operating time, lower morbidity and success under local anaesthetic, we recommend cold steel endonasal dacryocystorhinostomy as our procedure of choice for the treatment of epiphora.

Cost-efficiency of endoscopic and external dacryocystorhinostomy

Background:

In most centres in the United Kingdom, endoscopic dacryocystorhinostomy is currently undertaken as a joint operation between ophthalmologists and otolaryngologists. The addition of an extra surgeon, the use of endoscopic equipment and the relatively lower success rate of this procedure made us compare endoscopic dacryocystorhinostomy and external dacryocystorhinostomy with regards to costs and income for our hospital.

Methods:

All 38 primary endoscopic dacryocystorhinostomy cases performed in our centre in 2001–2003 were retrospectively compared with the 49 external dacryocystorhinostomy cases performed in 1993–2000. Cost–income calculations were made based on: rate of local anaesthesia, success rate, rate of day case admission, hospital reference cost for dacryocystorhinostomy, and the income per case extracted from national tariffs (based on the Health Resources Group). Also, the average number of cases per session was used to calculate the income gained per session for each method.

Results:

The following rates between the endoscopic and the external dacryocystorhinostomy were found: local anaesthesia, 29 vs 6 per cent, respectively; day-case operation, 95 vs 12 per cent, respectively; and success rate, 87 vs 94 per cent, respectively. The average number of endoscopic dacryocystorhinostomy cases conducted in a single theatre session was twice that of external dacryocystorhinostomy cases. Endoscopic dacryocystorhinostomy generated approximately twice the income of external dacryocystorhinostomy (£6585 vs £3292, respectively).

Conclusion:

Endoscopic dacryocystorhinostomy is more cost-effective than external dacryocystorhinostomy, despite having a lower success rate and greater usage of resources, as the endoscopic procedure generates more income. This is mainly due to the higher number of cases per session and the higher rates of local anaesthesia and day case operations possible.

Lacrimal drainage obstruction and dacryocystorhinostomy in children

PURPOSE

To determine the outcome of dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction (NLDO) in children.

METHODS

A review of medical records of 104 cases (82 patients) of paediatric DCR who underwent DCR at the Sydney Eye Hospital from 1995 to 2004. The main outcome measures included post-operative symptomatic relief of presenting symptoms, complications, subjective visibility of any scar, and general satisfaction. Statistical methods included chi(2) tests, and Student's t-tests for the comparison of variables among groups.

RESULTS

Ninety-four external, 10 endoscopic primary procedures, and five revision procedures were included. Fifty-six of the cases were primary NLDO, and 48 were secondary NLDO. The mean follow-up was 1.44 years. Average age at surgery was 6.6+/-4.2 years (mean+/-SD). Ninety-one eyes needed DCR for the involvement of the lower lacrimal outflow system, and 13 eyes were NLDO associated with congenital punctual/canalicular dysgenesis.Most of the complications of external DCR were related to Jones tube placement. Five cases (4.8%) needed DCR revision. There was a significantly higher incidence of revision surgery in the non-stented group (P<0.01), and the Jones tube group (P<0.001) as compared with the silicone intubation stent group.

CONCLUSIONS

External DCRs have acceptable long-term clinical and cosmetic results, and low post-operative complication rate. Cases with punctal stenosis or those requiring Jones tube insertion are associated with a higher complication rate. Silicone intubation is associated with a lower need for operative revision.

Simultaneous bilateral external dacryocystorhinostomy

PURPOSE

To assess the outcome and complications of simultaneous bilateral external dacryocystorhinostomy (DCR) surgery.

METHODS

The records of all patients who underwent bilateral external DCR in a single session between November 1999 and October 2005 were reviewed.

RESULTS

The study cohort comprised 59 patients (50 females, nine males; age range: 6-72 years; mean age: 49 years). Nasolacrimal duct obstruction was acquired primarily in 54 patients, congenitally in three and secondary to sinonasal surgery in two. Thirteen eyes of eight patients had a history of unsuccessful lacrimal surgery. The operation was performed under local anaesthesia plus sedation in 54 patients (92%). Total intraoperative haemorrhage varied from 3 mL to 200 mL (median: 17 mL; mean: 37 mL). Excessive intraoperative haemorrhage (= 100 mL) occurred in five patients (9%). Total duration of surgery varied between 70 and 140 min, with an average of 89 min. Postoperatively, early bleeding requiring intranasal tamponade developed in one patient (2%) and bilateral wound infection in one patient (2%). Surgical success rate was 95%. Mean follow-up time was 8.8 months (range: 3-38 months).

CONCLUSION

This study supports that the simultaneous bilateral external DCR surgery may not adversely affect surgical success and complication rates.

Nasolacrimal stents for the treatment of epiphora: technical problems and long-term results

PURPOSE

To evaluate the long-term effectiveness of nasolacrimal stents for the treatment of obstructive epiphora, and the complications related to the procedure.

METHODS

This study is a non-randomized prospective clinical trial. Eighty-five patients underwent fluoroscopally-guided placement of polyurethane stent in 86 lacrimal systems for the treatment of severe idiopathic obstructive epiphora. The sites of obstruction were: sac-duct junction (n = 65), sac (n = 10), and nasolacrimal duct (n = 11). The procedure was performed in an outpatient basis under local anesthesia. Patients were followed for a mean of 24 months (1-84) with clinical examinations and/or dacryocystography. Clinical success was defined as symptoms resolution or improvement, and the patency of the lacrimal system to irrigation.

RESULTS

Stent placement was technically successful in 76 (88.4%) eyes. Technical failures (11.6%) were caused by inability to pass the guide-wire through the lacrimal system. Immediate complications occurred in 19 (22%) eyes, were mild and included: self-limited epistaxis (7), mild palpebral hematoma (7), moderate pain (3), lacrimal puncta bleeding (1), palpebral emphysema (1), and false passage (1). Of the 76 inserted stents, 33 (43.4%) became occluded, and 43 (56.6%) remained patent after a mean of 24 months. Mean duration of stent patency was 38 months. Clinical success was achieved in 40 (52.6%) of the successfully implanted stents.

CONCLUSIONS

The procedure is well tolerated and can be performed on an outpatient basis. Patency decreases with follow-up, and, in the long-term, the success rate is inferior to that achieved by external dacryocystorhynostomy. However, it many be considered as a valid alternative to surgery in selected patients.

Evaluation of the cosmetic significance of external dacryocystorhinostomy scars

PURPOSE

To evaluate the significance of the surgical scar of external dacryocystorhinostomy (DCR) as assessed by the patients.

DESIGN

Cross-sectional questionnaire-based study.

METHODS

Two hundred ninety-seven external DCRs were performed in 263 patients at the private practices of consultants who were attached to the Sydney Eye Hospital. Structured questionnaires were sent to patients, and the responses were evaluated. Patients were asked to assess the visibility of the scar and the significance of the scar to them on a scale of 1 (least) to 5 (greatest).

RESULTS

The average age of patients was 67.9 +/- 16 years, (72% female, 28% male). Ninety-six percent of the patients were caucasians of Australian/West European descent. Sixty-one of 296 scars (20.6%) were felt to be visible by patients; 31 scars (10.5%) were rated >1 on a scale of 1 to 5 and 12 scars (4%) were rated >2. The average age of patients was highest for those patients with invisible scars, and the lowest average age was for those with scars that were rated >1. A significantly higher proportion of female patients complained of marked scarring (>1 on a scale of 1 to 5). A significantly higher proportion of patients who complained of discomfort during suture removal also complained of marked scarring.

CONCLUSION

In view of the low percentage of patients who complained of marked scarring, scarring should not be the main ground for deciding the approach to DCR surgery, particularly in older patients. These results are valid for the population that was studied and may be different for different racial backgrounds.

External versus endoscopic dacryocystorhinostomy for acquired nasolacrimal duct obstruction in a tertiary referral center

PURPOSE

To compare success rates of external dacryocystorhinostomy (DCR) and endoscopic endonasal DCR for acquired nasolacrimal duct obstruction (NLDO).

DESIGN

Retrospective, comparative, nonrandomized clinical study.

PARTICIPANTS

One hundred forty-three patients (176 surgeries) operated for acquired NLDO.

METHODS

A review of electronic medical records of patients with acquired NLDO who underwent DCR at the Jules Stein Eye Institute from 1999 to 2004 was performed. Data regarding the lacrimal drainage system, comprehensive eye examination, surgical outcome, and postoperative nasal endoscopy were analyzed.

MAIN OUTCOME MEASURES

Surgery failure was defined as (1) no marked improvement in tearing or any episode of postoperative dacryocystitis, (2) inability to irrigate the lacrimal system postoperatively, and (3) postoperative nasal endoscopy with scarring in the intranasal osteotomy or no visualization of fluorescein dye. Postoperative nasal endoscopy was performed in all failed cases and in >50% of all patients.

RESULTS

One hundred forty-three patients (48 male and 95 female; mean age, 63 years) underwent 176 DCR surgeries for acquired NLDO. Success was achieved in 135 cases (76.7%), and failure in 41 (23.3%). Of the 41 failed cases, anatomical obstruction at the fistula site was found in 20 (49% of failed cases), whereas functional failure with no evidence of obstruction was found in 21 (51%). Surgery revision was performed in 22 cases (12.5%), but it was successful in only 9 (5.1%); patients who failed the first revision were likely to fail additional revisions (P = 0.02). History of facial trauma was associated with surgery failure. In our patients, endoscopic DCR (86 cases) had a significantly higher success rate than external DCR (90 cases), 84% versus 70% (P = 0.03). Complications included 1 patient with nose bleeding on the first postoperative day that resolved with nasal packing and 2 patients with sump syndrome that resolved after endoscopic revision.

CONCLUSIONS

The success rate of DCR for acquired NLDO in our group of patients was 77%, lower than reported in previous studies, with endoscopic surgery showing better results. Success rates of revision surgery were relatively low (<50%), and patients who fail the first revision are not likely to benefit from additional revisions.