Silicone Tubing after Endoscopic Dacryocystorhinostomy: Is it Necessary?

Is Nasal Packing Necessary After Endoscopic Dacryocystorhinostomy Without Stent and Mucosal Flaps Preservation?

OBJECTIVE

This study aimed to evaluate the effect of nasal packing on the surgical success and postoperative complications of endoscopic dacryocystorhinostomy (EnDCR) without using stents and mucosal flaps.

METHODS

The retrospective study comprised of 75 eyes of 65 consecutive patients undergoing EnDCR with the biting and removing technique. The patients were assigned to 2 groups depending on whether the biodegradable synthetic polyurethane foam was used or not (the packing group, 34 eyes; the nonpacking group, 41 eyes). At least 6 months after the EnDCR, the postoperative outcomes including anatomical and functional successes, and the postoperative complications such as synechia, granuloma, and bleeding were compared between the packing and nonpacking groups.

RESULTS

Synechia was lower in the packing group (23.5% versus 24.4%) but it was not statistically significant (P = 0.93). There were also no significant differences in the granuloma and bleeding complications between the 2 groups (respectively, P = 0.72, P = 0.08). The success rates of anatomical and functional reached 88% in the packing group compared with 82.9%, and 75.6% in the nonpacking group (respectively, P = 0.74, P = 0.76).

CONCLUSIONS

The present study findings suggest that both groups have no superiorities over each other in the surgical outcomes after the EnDCR. However, further randomized studies are recommended before the generalization can be made.

A New Way of Managing Canalicular Injury Associated With Late Eyelid Burns

PURPOSE

This study aimed to introduce a new way to rebuild the canalicular system of patients with occluded punctums after long-time burns.

METHODS

Cases with eyelid burns associated canalicular injury presented at Eye Hospital of Wenzhou Medical University from June 1st, 2015 to September 30th 2017 were referred to department of Orbital & Oculoplastic Surgery. Cases with occluded both superior and inferior punctuns were recommended to surgery. Twenty-seven cases were enrolled in our study. Patients were followed up at 1, 2, and 4 weeks and 3, 4, 6, and 12 months postoperatively. Success of the surgery was defined as being free of epiphora and purulence postoperatively, a normal functional endoscopic dye test, free-flowing irrigation through the lacrimal system, and the presence of upper and lower punctum ostium.

RESULTS

With a follow-up of 12 months postoperative, there were 22 cases that showed surgical success outcome according to the set criteria. The success rate of our surgery is 81.48%.

CONCLUSION

The surgical procedure used in our study is an effective and easy way to treat patiens with occluded punctum after long-time burns. The utility of silicone intubation is necessary and delayed tubing removal maybe meaningful in these kinds of patients.

[Intraoperative prevention of dacryocystitis relapse]

The article reviews the literature devoted to modern intraoperative methods of preventing cicatricial process at the site of dacryostoma after endonasal endoscopic dacryocystorhinostomy. Despite the constant improvement of the surgery technique, complications in the postoperative period still occur. They include the formation of granulation tissue at the sites of dacryostoma, synechiae in the nasal cavity, or narrowing of the dacryostoma, which ultimately leads to a relapse of the disease. The main prevention methods are construction of flaps from the medial wall of the lacrimal sac, from mucosa of the nasal cavity, and intubation of the dacryostoma with the lacrimal implant. They are used separately and in various combinations.

Endoscopic-Powered Dacryocystorhinostomy Without Stenting: Long-term Outcomes of 120 Procedures

Background The necessity of silicone stenting in endoscopic dacryocystorhinostomy (DCR) procedures is a controversial subject in the literature. Objective The purpose of the present study is to assess the long-term anatomical and functional outcomes of endoscopic-powered DCR (EP-DCR) without stenting or mucosal flaps. Methods One hundred twenty EP-DCR procedures were performed in 107 patients. Anatomical success was defined as a patent ostium on irrigation and functional success as free flow of dye from the ostium and resolution of epiphora. Results The mean follow-up was 46.5 months (range: 24-87). Of the 120 procedures, 13 were bilateral and 94 were unilateral. Anatomical and functional success rates of 92.5% were obtained. Conclusion EP-DCR without stenting is a safe and economic technique that provides satisfactory long-term results and could be considered as the treatment of choice for patients with postsaccal nasolacrimal duct obstruction.

Species-specific characteristics of the biofilm generated in silicone tube: an in vitro study

Background

To investigate characteristics of biofilm which is usually found in silicone tube for nasolacrimal duct surgery and can be the root of chronic bacterial infections eventually resulted in surgical failure.

Methods

To form a biofilm, sterile silicone tube was placed in culture media of Staphylococcus aureus, Corynebacterium matruchotii, Pseudomonas aeruginosa, or Streptococcus pneumonia. Biofilms formed on these silicone tubes were fixed with 95% ethanol and stained with 0.1% crystal violet. After staining, the optical densities of biofilms were measured using spectrophotometer on a weekly basis for 12 weeks.

Results

Staphylococcus aureus group and Pseudomonas aeruginosa group formed significantly more amounts of biofilms compared to the control group. The maximum optical densities of the two groups were found on week 3–4 followed by a tendency of decrease afterwards. However, the amounts of biofilms formed in other groups of silicone tubes were not statistically significant from that of the control group.

Conclusions

Bacterial species that could form biofilm on silicone tube included Staphylococcus aureus (week 3) and Pseudomonas aeruginosa (Week 4). It is important to first consider that the cause of infection around 1 month after silicone tube intubation can be Staphylococcus aureus and Pseudomonas aeruginosa.

Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction

BACKGROUND

A dacryocystorhinostomy (DCR) procedure aims to restore drainage of tears by bypassing a blockage in the nasolacrimal duct, through the creation of a bony ostium that allows communication between the lacrimal sac and the nasal cavity. It can be performed using endonasal or external approaches. The comparative success rates of these two approaches have not yet been established and this review aims to evaluate the relevant up-to-date research.

OBJECTIVES

The primary aim of this review is to compare the success rates of endonasal DCR with that of external DCR. The secondary aim is to compare the complication rates between the two procedures.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2016, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to 22 August 2016), Embase (January 1980 to 22 August 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to 22 August 2016), Web of Science Conference Proceedings Citation Index- Science (CPCI-S) (January 1990 to 22 August 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 22 August 2016. We requested or examined relevant conference proceedings for appropriate trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing endonasal and external DCRs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for eligibility and extracted data on reported outcomes. We attempted to contact investigators to clarify the methodological quality of the studies. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included two trials in this review. One trial from Finland compared laser-assisted endonasal DCR with external DCR, and one trial from India compared mechanical endonasal DCR (using punch forceps) with external DCR. The trials were poorly reported and it was difficult to judge the extent to which bias had been avoided.Anatomic success was defined as the demonstration of a patent lacrimal passage on syringing, or endoscopic visualisation of fluorescein dye at the nasal opening of the anastomoses after a period of at least six months following surgery. Subjective success was defined as the resolution of symptoms of watering following surgery after a period of at least six months. Both included trials used anatomic patency demonstrated by irrigation as a measure of anatomic success. Different effects were seen in these two trials (I² = 76%). People receiving laser-assisted endonasal DCR were less likely to have a successful operation compared with external DCR (63% versus 91%; risk ratio (RR) 0.69, 95% confidence intervals (CI) 0.52 to 0.92; 64 participants). There was little or no difference in success comparing mechanical endonasal DCR and external DCR (90% in both groups; RR 1.00, CI 0.81 to 1.23; 40 participants). We judged this evidence on success to be very low-certainty, downgrading for risk of bias, imprecision and inconsistency. The trial from Finland also assessed subjective improvement in symptoms following surgery. Resolution of symptoms of watering in outdoor conditions was reported by 84% of the participants in the external DCR group and 59% of those in the laser-assisted endonasal DCR group (RR 0.70, CI 0.51 to 0.97; 64 participants, low-certainty evidence).There were no cases of intraoperative bleeding in any participant in the trial that compared laser-assisted endonasal DCR to external DCR. This was in contrast to the trial comparing mechanical endonasal DCR to external DCR in which 45% of participants in both groups experienced intraoperative bleeding (RR 1.00, 95% CI 0.50 to 1.98; 40 participants). We judged this evidence on intraoperative bleeding to be very low-certainty, downgrading for risk of bias, imprecision and inconsistency.There were only two cases of postoperative bleeding, both in the external DCR group (RR 0.33, 95% CI 0.04 to 3.10; participants = 104; studies = 2). There were only two cases of wound infection/gaping, again both in the external DCR group (RR 0.20, CI 0.01 to 3.92; participants = 40; studies = 1). We judged this evidence on complications to be very low-certainty, downgrading one level for risk of bias and two levels for imprecision due to the very low number of cases.

AUTHORS' CONCLUSIONS

There is uncertainty as to the relative effects of endonasal and external DCR. Differences in effect seen in the two trials included in this review may be due to variations in the endonasal technique, but may also be due to other differences between the trials. Future larger RCTs are required to further assess the success and complication rates of endonasal and external DCR. Different techniques of endonasal DCR should also be assessed, as the choice of endonasal technique can influence the outcome. Strict outcome criteria should be adopted to assess functional and anatomical outcomes with a minimal follow-up of six months.

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.

Primary Endonasal DCR Without Stent: Our Experience and Case Series Analysis

Endonasal dacryocystorhinostomy is widely accepted and effective treatment option for nasolacrimal duct obstruction. It can be done with or without the use of stents. This study was carried out to evaluate the results of endonasal DCR surgery and to access efficacy of this procedure without stenting. This is a prospective clinical study conducted in Departments of ENT and Ophthalmology, L.N. Medical College and J.K. Hospital, Bhopal from October 2008 to April 2012. A total of 90 patients with epiphora as evidenced by nasolacrimal duct blockage on syringing were included in the study. These patients underwent endoscopic DCR without stenting. The cases were followed up to 18 months postoperative. Surgical success was defined as anatomical patency and symptomatic relief at the end of the follow up period. Failure was defined as no symptomatic relief, and/or acute dacryocystitis, and/or non patent lacrimal drainage system. Surgical success was observed in 80 of 90 (88.89 %) patients. Incidence of complication was low as only 6 patients had minor complication of bleeding, synechie and granulation tissue formation. It was concluded that high success rates could be achieved in case of nasolacrimal duct obstruction by endoscopic DCR. Thus, we can minimize complications, discomfort, the cost of stenting and follow up visits after endonasal DCR surgery.

Upregulation of inflammatory genes in the nasal mucosa of patients undergoing endonasal dacryocystorhinostomy

Background

Epiphora is a common complaint of nasolacrimal duct obstruction (NLDO) in adults. The precise pathogenesis of NLDO is still unknown, but inflammatory processes are believed to be predisposing factors. Endoscopic dacryocystorhinostomy (EN-DCR) is an effective surgical technique for treating symptomatic NLDO. The purpose of the procedure is to relieve the patient’s symptoms by creating an opening, ie, a rhinostoma, between the lacrimal sac and the nasal cavity. Although the success rates after EN-DCR are high, the procedure sometimes fails due to onset of a fibrotic process at the rhinostomy site. The aim of this prospective comparative study was to investigate inflammation-related gene expression in the nasal mucosa at the rhinostomy site.

Methods

Ten participants were consecutively recruited from eligible adult patients who underwent primary powered EN-DCR (five patients) or septoplasty (five controls). Nasal mucosa specimens were taken from the rhinostomy site at the beginning of surgery for analysis of gene expression. Specimens were taken from the same site on the lateral nasal wall for controls. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed for the inflammatory genes interleukin (IL)-6, IL-1β, and CCL2, and because of a clear trend of increased inflammation in the EN-DCR samples, a wider PCR array was performed to compare inflammation-related gene expression in EN-DCR subjects and corresponding controls.

Results

Our qRT-PCR results revealed a clear trend of increased transcription of IL-6, IL-1β, and CCL2 (P=0.03). The same trend was also evident in the PCR array, which additionally revealed notable differences between EN-DCR subjects and controls with regard to expression of several other inflammation-related mediators. At 6-month follow-up, the success rate after primary EN-DCR was 60%, ie, in three of five patients.

Conclusion

The present study demonstrates that there is an intense inflammation gene expression response in the nasal mucosa of patients undergoing EN-DCR.

Primary endoscopic dacryocystorhinostomy with or without silicone tubing: a prospective randomized study

BACKGROUND

Endoscopic dacryocystorhinostomy (DCR) is an effective surgical procedure to treat saccal and postsaccal stenosis or nasolacrimal duct obstruction. The use of silicone tube after endoscopic DCR is still controversial. A prospective randomized study was conducted to compare the success rate between the use of silicone stent and no use of silicone stent in endoscopic DCR.

METHODS

A prospective randomized study was conducted at Aseer Central Hospital and Abha Private Hospital, Abha, Kingdom of Saudi Arabia, on all patients undergoing endoscopic DCR between July 1, 2006 and 30 June 30, 2010. Patients were allocated randomly for endoscopic DCR with or without stent. The data collection included age, sex, diagnosis, method, and duration of surgery. Patients were followed up postoperatively at 1 week, 1 month, and then every 3 months for 1 year.

RESULTS

During the period of the study a total of 173 cases of postsaccal stenosis underwent endoscopic DCR (67 male and 106 female subjects). The mean age was 51.8 years (range, 18-72 years). A stent was used in 92 patients (53.2%) and not used in 81 patients (46.8%). With silicone tubing the success rate was 96%, and without silicone tubing it was 91%, an overall success rate of 94%. The odds ratio of failure without a silicone tube was 3.25 but confidence interval was from 0.84 to 12.60 and the difference between these two groups was statistically not significant (p = 0.117).

CONCLUSION

In this study, there was no statistically significant advantage of using endoscopic DCR with stent over the endoscopic DCR without stent.

Surgical results of endoscopic dacryocystorhinostomy and lacrimal trephination in distal or common canalicular obstruction

Objectives

To evaluate the surgical outcomes of endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone stenting in patients with distal or common canalicular obstructions.

Methods

The medical records of 29 patients (31 eyes) from January 2001 to December 2009 who underwent endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone tube insertion for the treatment of distal or common canalicular obstructions were retrospectively reviewed. The level of obstruction was confirmed by intraoperative probing. The outcome of the surgery was categorized as a complete success, partial success, or failure according to the functional and anatomic patency.

Results

The average age of the patients was 52 years. The duration of silicone intubation ranged from 4 to 11 months with an average of 5.7±1.6 months. The follow-up period after stent removal ranged from 4 to 15 months with an average of 8.2±3.3 months. Complete success was achieved in 25 out of 31 eyes (80.6%), partial success in 4 out of 31 eyes (12.9%), and failure in 2 out of 31 eyes (6.5%).

Conclusion

Endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone stent intubation may be safe and considered as an initial treatment of patients with distal or common canalicular obstructions.

A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation

OBJECTIVE

To examine possible differences in success rates of primary dacryocystorhinostomy (DCR) with and without silicone intubation, and to find out whether the use of silicone tubes is beneficial.

DESIGN

A literature search was conducted in the PubMed, EMBASE, and Cochrane Controlled Trials Register to identify potentially relevant controlled trials.

METHODS

Language was restricted to English. The surgical techniques were categorized into external DCR (EX-DCR), endonasal laser-assisted DCR (LA-DCR), and nonlaser endoscopic endonasal DCR techniques (EN-DCR). The main outcome measure was success rates after DCR-with and DCR-without silicone intubation. The statistical analysis was carried out using a RevMan 5.0 software.

RESULTS

Of 188 retrieved trials from the electronic database, 9 trials (5 randomized controlled trials and 4 cohort studies) involving 514 cases met our inclusion criteria. There was no statistically significant heterogeneity between the studies. The pooled risk ratio was 0.99, with a 95% confidence interval (0.91-1.08). There was no significant difference in the success rates between the DCR with and without silicone intubation (p = 0.81). Sensitivity analysis and subgroups analyses suggested that the result was comparatively reliable.

CONCLUSIONS

Based on this meta-analysis that included 5 randomized controlled trials and 4 cohort studies, no benefit was found for silicone tube intubation in primary DCR. Further well-organized, prospective, randomized studies involving larger patient numbers are required.

Mitomycin C in Revision Endoscopic Dacryocystorhinostomy: A Prospective Randomized Study

Background

Endoscopic dacryocystorhinostomy (EN-DCR) is an effective and safe procedure when treating saccal and postsaccal nasolacrimal duct obstruction. However, sometimes scarring of the rhinostomy site caused by fibrosis may occur, particularly in revision operations. The application of intraoperative mitomycin C (MMC), an antiproliferative agent, has been introduced as one possible technique to improve the outcome. We conducted a prospective, randomized study to evaluate if the use of MMC improves the success in endonasal revision DCR procedure.

Methods

Thirty revision EN-DCR procedures were performed during 2004–2010. The patients were randomized into two study groups, according to whether the intraoperative MMC was used or not. The technique of EN-DCR procedure in both groups was the same, but in the MMC group, at the end of the procedure a piece of tampon soaked in MMC (0.4 mg/mL) was placed into the rhinostoma for 5 minutes. No silicone stents were inserted. The surgical outcome at the 6-month follow-up visit was considered successful if the lacrimal sac irrigation succeeded and if the patients’ symptoms were relieved.

Results

The success rate after revision EN-DCR with MMC was 93% and without MMC was 60%. The overall success rate was 77%. The difference between the two groups was not statistically significant (p = 0.08). The relief of the symptoms between groups in both the Nasolacrimal Duct Obstruction Symptom Score and ocular symptoms was statistically significant (p = 0.007 and p = 0.02, respectively).

Conclusion

The results of our study indicate that the application of intraoperative mitomycin C may improve the outcome in revision EN-DCR.

Paediatric powered endonasal dacryocystorhinostomy

Dacryocystorhinostomy (DCR) is indicated in children with persistent nasolacrimal duct obstruction (NLDO). Endoscopic endonasal DCR has been successfully performed in both adults and children, with success rates similar to that of external DCR. This paper aims to evaluate the outcomes of paediatric patients undergoing endonasal endoscopic DCR at a district general hospital. A retrospective review of all patients attending a joint lacrimal clinic undergoing endonasal endoscopic DCR between October 2001 and December 2008 was performed. Sixteen children (17 eyes) aged between 2 and 14 were analysed. The main outcome measure was resolution of symptoms. Fourteen cases (82%) presented with epiphora with or without stickiness. Three cases had recurrent dacryocystitis. Three patients had Down syndrome. There were no operative complications. During a mean post-operative period of 12 months, all but one case showed an improvement of symptoms. While 60% of the patients had a complete resolution of symptoms, the remaining were minimally symptomatic. Of those with residual symptoms, two had Down syndrome. Endonasal DCR is a safe and effective intervention for children with persistent NLDO. Success is higher in children with no craniofacial abnormality. Joint care under a consultant Oculoplastic and ENT surgeon provides optimum care for these patients.

Analysis of Functional and Anatomic Success following Endonasal Dacryocystorhinostomy

Objectives:

The aim of this study was to assess the concomitant perioperative procedures, the causes of nasolacrimal duct obstruction, the success rate, and the complications associated with endonasal dacryocystorhinostomy (ENDCR).

Methods:

In this single-center retrospective study, 98 patients underwent 104 ENDCRs between January 1994 and February 2006. There were 78 patients with 84 nasolacrimal duct obstructions who were included in this study.

Results:

The overall functional success rate with improvement in symptoms was 94.9% for primary surgery (59 of 84 obstructions) and 63.6% for salvage surgery after failure of primary surgery performed in another hospital (25 of 84 obstructions). The mean follow-up time was 36.8 ± 17.11 months. Primary surgery showed better results, with a complete success rate of 93.2%, than did salvage surgery, with a success rate of only 68%. Persistent symptoms, despite an open rhinostomy, were found in 1.7% of patients with primary surgery and in 12% of those with salvage surgery. Failure of ENDCR was observed in 3.4% of patients after primary surgery and in 20% after salvage surgery. We encountered only minimal perioperative complications, and these were essentially related to lacrimal intubation.

Conclusions:

Because of the possibility of treating concomitant sinonasal disorders, the cosmetic advantages, and the excellent results, ENDCR represents the procedure of choice for treating nasolacrimal duct obstructions. The main challenge lies in the exact preoperative assessment, as well as postoperative evaluation in case of failure.

Strong expression of HSP47 in metaplastic nasal mucosa may predict a poor outcome after primary endoscopic dacryocystorhinostomy: a prospective study

PURPOSE

Dacryocystorhinostomy (DCR) is an effective and safe procedure for patients with post-saccal obstruction of the nasolacrimal pathway. The aim of DCR is to relieve symptoms by creating a bypass between the lacrimal sac and the nasal cavity. The most common reason for failure is stenosis caused by a fibrotic process at the rhinostomy site. In this prospective study we assessed the expression of heat shock protein 47 (HSP47), a regulator of fibrosis, in the biopsies of nasal mucosa isolated from patients undergoing primary endoscopic DCR (EN-DCR).

METHODS

Thirty consecutive primary EN-DCR procedures in 30 patients were performed using the powered instrumentation technique. The nasal mucosa specimens over the rhinostomy site were collected for histological analysis at the beginning of the operation and the expression of HSP47 was evaluated by immunohistochemistry. The outcome of EN-DCR was estimated in follow-up visits at 1 week, 2 months and 6 months after surgery.

RESULTS

At the 6-month follow-up, the overall success rate after primary EN-DCR was 83%. A metaplastic change and strong expression of HSP47 in nasal mucosa were associated with EN-DCR failure (p = 0.009).

CONCLUSIONS

HSP47 may be regarded as a novel marker to predict impaired EN-DCR outcome.

Endonasal versus external dacryocystorhinostomy for nasolacrimal duct obstruction

BACKGROUND

Dacryocystorhinostomy (DCR) procedures can be performed using external or endonasal approaches. The comparative success rates of these procedures are unknown.

OBJECTIVES

To compare the success rates of external and endonasal approaches to DCR.

SEARCH STRATEGY

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 11), MEDLINE (January 1950 to December 2010), EMBASE (January 1980 to December 2010), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (December 2010), ClinicalTrials.gov (www.clinicaltrials.gov) (December 2010) and Web of Science Conference Proceedings Citation Index- Science (CPCI-S) (January 1990 to December 2010). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 7 December 2010. We requested or examined relevant conference proceedings for appropriate trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing external and endonasal dacryocystorhinostomies.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and assessment of quality with a predefined form. We contacted investigators to clarify the methodological quality of the studies.

MAIN RESULTS

We identified one trial that fulfilled the inclusion criteria. This trial compared 64 DCR procedures (32 external and 32 endonasal procedures). Endonasal DCR was four times more likely to fail compared to external DCR. This was statistically significant (95% confidence interval (CI) 1.25 to 12.84).

AUTHORS' CONCLUSIONS

The only trial included in the review provides evidence that endonasal DCR has statistically higher risk of failure compared to external DCR. However, this conclusion is limited by paucity of RCTs, small number of participants and lack of clarity of the methodological process. Well conducted RCTs with sufficient power are required to answer the research question.

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.

Sleeve technique to maintain a large mucosal ostium during endoscopic dacryocystorhinostomy

Currently, many surgeons use bicanalicular silicone tubes as a stent to keep the intranasal mucosal ostium patent when they perform endoscopic dacryocystorhinostomy. The authors describe the sleeve technique using bicanalicular silicone tubes. After inserting the bicanalicular silicone tube, a sleeve is passed over it. The sleeve prevents the nasal mucosa from obstructing the intranasal mucosal ostium and enlarges the mucosal ostium. In primary acquired nasolacrimal duct obstruction, the sleeve technique was applied to 61 cases (group 1); the other 75 cases (group 2) were intubated by bicanalicular silicone tube only. The overall success rate was 95.1% in group 1 and 90.7% in group 2 (P = .51), and the average mucosal ostium at 6 months postoperatively was 3.2 ± 1.1 and 1.9 ± 1.0 mm (P = .04), respectively. The authors believe that the sleeve technique has the advantage of maintaining a larger intranasal mucosal ostium.

Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is a well-established alternative to external approaches in the treatment of nasolacrimal canal obstruction. From July 2004 to December 2008, 92 endoscopic DCRs were performed on 88 patients at the Department of Otorhinolaryngology, San Raffaele Hospital, Milan. All patients were affected by chronic dacryocystitis with epiphora. Preoperative work-up included Jones tests, lacrimal pathways irrigation, nasal endoscopy, and imaging evaluation by computed tomography. The technique involved anastomosis of nasal mucosal, lacrimal sac flaps and a large bony ostium. A silicone tube was inserted in all patients that remained for a period of 3 months. The first endoscopic intervention was successful in 91.30% of patients. After a second revision endoscopic DCR, the overall success rate raised to 95.65%. Anastomosis of nasal mucosal between lacrimal sac flaps plays a key role in endoscopic DCR with a high success rate both in primary nasolacrimal obstructions and in revision cases.

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.

A novel stenting technique in endoscopic dacryocystorhinostomy

The objective of our study was to evaluate in a prospective noncomparative case series, the clinical efficacy and the results of modified T-tube insertion instead of silicone tube in endoscopic dacryocystorhinostomy (EDCR). Following ophthalmologic examinations, 22 patients (16 female, 6 male) suffering from recurrent chronic epiphora with postsaccal stenosis for whom DCR was indicated, underwent EDCR at Dumlupinar University Hospital by an otorhinolaryngologist and an ophthalmologist between the years 2006 and 2007. Instead of inserting a classic silicone tube passed through canaliculi and knotted inside the nose, a modified T-tube was used, without passing it through punctum, and was placed to stoma with a less traumatic endonasal endoscopic technique. The medial wall of the sac was incised vertically and the T-tube was placed horizontal to the incision. Postoperatively, the patients were evaluated by endoscopic controls in the first, third, sixth, and twelfth months to evaluate T-tube localization and rhinostomy opening site. The success was defined as resolution of epiphora with patent ostium after evaluation by irrigation and nasal endoscopy. Eighteen patients (82%) showed complete resolution of epiphora at 12-months of follow-up. Re-stenosis was observed only in four cases, one in the sixth and the other in the ninth postoperative months. Granulation tissue formation near the rhinostomy site was seen in one patient, which did not cause any functional problem. The success rate was calculated as 82%. We conclude that modified T-tube placement in EDCR seems to be a practical and less traumatic technique. This is also a cheaper method besides being less traumatic and easier to perform than canalicular stenting. It can be considered as a useful alternative to the classic silicon tubes in cases of epiphora resulting from the postsaccal stenosis.

Otologic T-tube in endonasal dacryocystorhinostomy: a new approach

CONCLUSION

Otologic T-tubes had a success rate of 73% if implanted during endoscopic dacryocystorhinostomy (DCR). We suggest that they can be used successfully in endoscopic DCR, and are promising as an alternative to silicone stent intubations.

OBJECTIVE

To evaluate the efficacy of endoscopic DCR using otologic T-tube.

MATERIALS AND METHODS

Twenty patients (22 eyes) with nasolacrimal duct obstruction underwent endoscopic DCR. After creating an aperture in the medial wall of the lacrimal sac, the otologic T-tube (1.15 mm diameter, Invotec, Jacksonville, FL, USA) was inserted into the sac transnasally. The T-tube was left in the lacrimal sac for between 3 and 6 months. The patients were followed up for between 6 and 24 months (mean 12.4 months). The improvement in patients' epiphora complaint was grouped as very good, good, or no change.

RESULTS

Eleven eyes (50%) proved to be 'very good', whereas five eyes (23%) were good, and six eyes (27%) had no change. Of six eyes that were reported to have no change after the operation, three experienced spontaneous tube loss in the early period, one eye was a recurrent case, and the other two were primary cases.