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.

Late endoscopic evaluation of the ostium size after external dacryocystorhinostomy

OBJECTIVE

To evaluate the effect of chronicity on the size of the ostium after external dacryocystorhinostomy (DCR) with intubation.

METHODS

Design: A retrospective chart review of patients who underwent external DCR with intubation over 10 years from January 2003 at a tertiary hospital. All patients were recruited and examined with rigid nasal endoscope.

RESULTS

A total number of 66 (85 eyes) patients were included. The mean age at the time of evaluation was 53.1 years with gender distribution of 54 females (81.8 %). The mean duration ±SD between the date of surgery and the date of evaluation was 33.2 ± 33.6 (6-118 months). Our study showed an overall anatomical and functional success of 98.8% and 95.3%, respectively. The mean size of the ostium (±SD) was 23.0 (±15.7) mm² (ranging from 1 to 80.4 mm²). The size of the ostium was not a significant factor for failure (p = 0.907). No statistically significant correlation was found between the long-term duration after surgery and the size of the ostium (R: 0.025, p = 0.157).

CONCLUSIONS

Nasal endoscopy after DCR is valuable in evaluating the ostium with no observed potential correlation between the long-term follow-up after surgery and the size of the ostium.

Failure in Revision Dacryocystorhinostomy: A Study of Surgical Technique and Etiology

The aim of this study is to assess the etiologic factors of primary dacryocystorhinostomy (DCR) failure according to DCR techniques and also to determine risk factors for the prediction of failure in revision external DCR. Retrospective review was performed in patients who underwent revision external DCR for previous DCR failure between 2008 and 2018. All patients underwent full ophthalmic and intranasal examination, lacrimal probing, and irrigation. Patients were classified into following groups according to previous DCR type: external, endoscopic endonasal, and transcanalicular laser DCR. Potential etiologic factors were compared between 3 groups. Multivariate analysis was performed to identify risk factors for failure in revision external DCR. About 115 eyes from 109 patients constituted the external (50.4%), endonasal (31.3%), and laser (18.3%) DCR groups. Among 27 (23.5%) patients with intranasal pathologies, septal deviation (33.3%) is the most common finding. The commonest cause of failure was inadequate ostium size in external (37.9%), endonasal (36.1%), and laser (66.7%) DCR groups. Inadequate ostium size and cicatricial lacrimal ostium scarring were observed significantly more common in the laser (P = 0.047) and external DCR group (P = 0.043), respectively. The success rate for revision external DCR was 85.2%. Canalicular or common canalicular obstruction (P = 0.032), intranasal pathology (P = 0.003), and bilateral obstruction (P = 0.025) demonstrated a significant independent association with failure in revision external DCR. Inadequate ostium size was the most common cause of failure in primary external, endonasal, and laser DCR. Canalicular or common canalicular obstruction, intranasal pathology, and bilateral lacrimal obstruction were significant predictors of failure in revision external DCR.

Endoscopic DCR: A 10 Years Personal Experience

Endoscopic DCR is an endonasal minimally invasive procedure to bypass an obstructed nasolacrimal duct by creating a direct fistula between the lacrimal sac and the nasal cavity. This is a retrospective case series review of the author's experience in endoscopic DCR in the period from 2007 to 2017. This series included 193 adult patients with a mean age of 47 years who underwent endoscopic DCR surgery. In this study, both primary and revision cases were reviewed including non-stented primary cases and bilateral simultaneous surgeries at the same session. Causes of failure in primary surgeries were stated, and indications of secondary cases were also reviewed. As a conclusion, endoscopic DCR remains the standard procedure in treating nasolacrimal duct obstruction with its consequent symptoms of epiphora, recurrent or chronic dacryocystitis.

Revision eDCR using a superior pedicled mucosal flap

BACKGROUND

Endoscopic dacryocystorhinostomies (eDCRs) show patency rates between 81% and 94%. However, dacryocystorhinostomy (DCR) failure and the need for revision remain a significant challenge. One of the principal challenges in revision eDCR is the need to surgically identify the correct osteotomy site and maintain long-term patency in the setting of previously instrumented and potentially scarred tissue. At the same time, the surgeon must assume that the blood supply to the commonly described anterior and posteriorly pedicled flaps has been compromised.

OBJECTIVE

The objective of the study is to describe a novel flap technique for revision eDCR.

METHODS

The superior based mucosal flap is a novel technique that provides a vascularized mucosa preserving technique in revision eDCR despite previous instrumentation of the lacrimal system. This technique provides wide exposure of the revision osteotomy site while simultaneously allowing a viable mucosal flap to be replaced at the conclusion of the procedure, thereby minimizing bone exposure and cicatricial restenosis.

RESULTS

The authors have utilized this technique in 13 procedures with 100% positive identification of the lacrimal sac, a 0% complication rate, and a 100% success rate after a mean follow-up of 26.93 ± 10.33 months (range 6-35 months).

CONCLUSION

The eDCR using the superior pedicled mucosal flap provides excellent exposure of the maxillary bone and the lacrimal sac. This method preserves vascularity of the flap using a superiorly based pedicle which is typically inviolate during both open and endoscopic primary DCR. The mucosal flap can then be replaced, thereby minimizing bone exposure and optimizing patency.

Endoscopic dacryocystorhinostomy with an otologic T-type ventilation tube in repeated revision cases

BACKGROUND

To compare the frequency of appearance of complications, anatomical success and functional success after conventional endoscopic dacryocystorhinostomies (EN-DCRs) or EN-DCR with otologic T-Type ventilation tube combined with silicone tube intubation in repeated revision cases.

METHODS

Twenty-two patients who had epiphora and recurrent dacryocystitis after at least a previous failed revision DCR as well as 22 patients receiving conventional EN-DCR only were enrolled in the study between January 2008 and December 2011. Operations were performed by using an otologic T-tube combined with silicone tube intubation. Oral antibiotics, nasal steroids, oral antihistamines, and antibiotic eyedrops were given to all cases. The ventilation tubes were removed 6 to 20 weeks after surgery.

RESULTS

Of 22 cases, all cases achieved anatomical success, 19 cases were symptom free, and 3 cases had decreased continuation in complications with a functional success rate of 81.8%. The overall success rates were significantly higher than those in patients undertaking conventional EN-DCR only (P < 0.01).

CONCLUSION

The revision endoscopic DCR has a high rate of failure. The usage of a T-type ventilation tube can significantly improve the success rate of surgery.

TRIAL REGISTRATION NUMBER

ChiCTR-INR-17012160, retrospectively registered on July 27th, 2017.

Teamwork Endoscopic Endonasal Surgery in Failed External Dacryocystorhinostomy

Purpose:

The purpose of this study was to evaluate the results of a teamwork revision endoscopic dacryocystorhinostomy (DCR) in eyes with previously failed external DCR.

Methods:

This retrospective study was performed on 50 failed external DCR subjects who underwent a teamwork revision endoscopic DCR by an ophthalmologist and an otolaryngologist. Paranasal sinus CT scanning was performed for each patient before the revision surgery. During surgery, any abnormal tissue noticed before silicone intubation was sent for pathological evaluation.

Results:

Endoscopic revision DCR was performed on 50 failed external DCR subjects with one-year follow-up. Of these, 31 were female (62%). The age range of the subjects was 18-88 years (mean: 59.98 years). Sinus CT showed at least one abnormality in 94% of cases. Revision endoscopy showed septal deviation (66%), scar formation (32%), ostium problems (28%), and sump syndrome (6%). Pathologic and clinical findings showed that chronic inflammation had a significant association with scar tissue and septal synechia (P = 0.001 and 0.008, respectively). At the final follow-up, anatomical and functional success was achieved in 45 out of 50 (90%) of subjects.

Conclusion:

Endoscopic revision DCR when performed as cooperation of otolaryngologists and ophthalmologists may help resolve the endonasal problems and increase the success rate.

Etiologic analysis of 100 anatomically failed dacryocystorhinostomies

Background

The aim of this study was to assess the etiological factors contributing to the failure of a dacryocystorhinostomy (DCR).

Patients and methods

Retrospective review was performed in 100 consecutive patients who were diagnosed with anatomically failed DCR at presentation to a tertiary care hospital over a 5-year period from 2010 to 2015. Patient records were reviewed for demographic data, type of past surgery, preoperative endoscopic findings, previous use of adjuvants such as intubation and mitomycin C, and intraoperative notes during the re-revision. The potential etiological factors for failure were noted.

Results

Of the 100 patients with failed DCRs, the primary surgery was an external DCR in 73 and endoscopic DCR in 27 patients. Six patients in each group had multiple revisions. The mean ages at presentation in the external and endoscopic groups were 39.41 years and 37.19 years, respectively. All patients presented with epiphora. The most common causes of failure were inadequate osteotomy (69.8% in the external group and 85.1% in the endoscopic group, P=0.19) followed by inadequate or inappropriate sac marsupialization (60.2% in the external group and 77.7% in the endoscopic group, P=0.16) and cicatricial closure of the ostium (50.6% in the external group and 55.5% in the endoscopic group, P=0.83). The least common causes such as ostium granulomas and paradoxical middle turbinate (1.37%, n=1) were noted in the external group only.

Conclusion

Inadequate osteotomy, incomplete sac marsupialization, and cicatricial closure of the ostium were the most common causes of failure and did not significantly differ in the external and endoscopic groups. Meticulous evaluation to identify causative factors for failure and addressing them are crucial for subsequent successful outcomes.

Cause and Management of Patients With Failed Endonasal Dacryocystorhinostomy

Objectives

Endonasal dacryocystorhinostomy (DCR) is a well-established treatment method in patients with nasolacrimal duct obstruction. However, there are a few reports about the overall management of failed endonasal DCR. We investigated the causes and management strategies of failed endonasal DCR.

Methods

This retrospective review included 61 patients (61 eyes) who had undergone revision surgery by the same surgeon after failed endonasal DCR between January 2008 and December 2012. The appropriate revision method was determined after analysis of the etiology of failure by the fluorescein dye disappearance test, nasal endoscopy, lacrimal irrigation, and probing. The criteria for success of the revision surgery were defined by the passage of fluid without resistance upon lacrimal irrigation and normalization of the tear meniscus height.

Results

The mean duration between the primary endonasal DCR and revision surgery was 15.3 months. The average follow-up period after revision surgery was 12.2 months. The most common cause of endoscopic revision surgery was membranous obstruction. Endoscopic revision surgery was performed in 48 patients, while lacrimal silicone tube intubation under endoscopy was performed in 13 patients. The most common indication for lacrimal silicone tube intubation was functional epiphora. The overall success rate of the revision surgery was 89%.

Conclusion

The most common cause of failed endonasal DCR was membranous obstruction. When patients with failed endonasal DCR presented at the clinic, it is important to identify the cause of the failure. Revision surgery could increase the final success rate of endonasal DCR.

Success rates in powered endonasal revision surgery for failed dacryocystorhinostomy in a tertiary referral center

PURPOSE

To evaluate the causes of failed dacryocystorhinostomy (DCR) surgery, recommend specific endoscopic endonasal techniques in revision DCR, and report postoperative success rates.

METHODS

Retrospective case series in a tertiary referral center of 19 consecutive, endonasal revision DCR surgeries in 17 adult patients with previous failed DCR. All cases were revised endonasally by 1 surgeon. Analysis of etiology of failure and techniques of surgery were supplemented by review of surgical video and medical records. Surgical outcomes were measured functionally by resolution of epiphora and anatomically by patency of nasolacrimal duct system on syringing and positive functional endoscopic dye test.

RESULTS

The most common cause for failed DCR was a blocked ostium due to membranous scarring (74%). Multiple causes for failure were found in 9 of 19 cases. Adjunctive procedures during revision surgery included partial middle turbinectomy (53%) and anterior ethmoidectomy (21%). The serrated oscillating blade was required in 89% cases, the high-speed diamond bur in 26%. Mean follow up was 15 months (range 7-26 months). All 19 cases had an anatomically successfully outcome. Fifteen of 19 cases (79%) had a functionally successful outcome.

CONCLUSIONS

In this study, the most frequent cause of failed DCR was a scarred ostium, which is optimally visualized endonasally and precisely managed with the oscillating blade. Using the abovementioned specific endonasal techniques, the authors have demonstrated a high success rate in endonasal revision DCR surgery.

Effect of mitomycin C on success rate in dacryocystorhinostomy with silicone tube intubation and improper flaps

PURPOSE

To assess the effect of mitomycin C on surgical success rate of dacryocystorhinostomy and silicone intubation in patients with improper flaps.

METHODS

The study was a randomized clinical trial. The patients with indication for dacryocystorhinostomy surgery with silicone intubation (inappropriate lacrimal sac or nasal mucosal flaps during surgery and/or history of dacryocystitis in the past 3 months) were randomly assigned to application of mitomycin C (0.02%) on surgical flaps (group A) or a control group without mitomycin C application (group B). Main outcome measures were subjective symptomatic improvement and result of irrigation test at last follow-up visit.

RESULTS

The study enrolled 88 patients (88 eyes); there were 42 patients in group A and 46 patients in group B. There was an average follow-up of 10 months (range 6-15 months) following surgery. Significant improvement (no tearing with patent lacrimal system in irrigation) was observed in 31 patients (73.8%) in group A and 32 patients (69.6%) in group B. There was no statistically significant difference in no improvement (no change in tearing state and obstruction in irrigation test), relative improvement (decreased tearing and passage of fluid with force in irrigation test), and significant improvement rate between the 2 groups of study (p>0.05).

CONCLUSIONS

Application of mitomycin C on surgical flaps during dacryocystorhinostomy surgery with silicone intubation in patients with improper flaps has no proven beneficial effect on success rate of surgery.

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.