Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy

PURPOSE: To compare the success rates of a new mechanical endonasal dacryocystorhinostomy (MENDCR) technique and the conventional external dacryocystorhinostomy technique (Ext-DCR). METHODS: A prospective, nonrandomized interventional comparative case series of 31 consecutive MENDCRs and 24 Ext-DCRs performed from January 1999 to December 2000. Patients with anatomic nasolacrimal duct obstruction were included in the study; previous lacrimal surgery and functional nasolacrimal and canalicular obstruction were exclusion criteria. Two surgeons performed the MENDCRs, using a standardized operative technique, which involved creation of a large bony ostium and mucosal flaps between the lacrimal sac mucosa and nasal mucosa. One surgeon performed all Ext-DCRs. RESULTS: Twenty-seven patients (8 men, 19 women) underwent 31 MENDCRs. The average age of the patients was 62.9 years (range, 15 to 86 years; SD, 19.1 years). In 11 cases (35.4%), a septoplasty was required at the time of surgery, and in 6 cases (19%), further endoscopic sinus surgery was performed. In the Ext-DCR group, 23 patients (7 men, 16 women) underwent 24 DCRs. The average age was 59.6 years (range, 22 to 86 years; SD, 18.5 years). No other nasal procedures were performed at the time of surgery in this group. The average follow-up time was 13 months for the MENDCR group and 12.4 months for the Ext-DCR group. Success was defined as relief of symptoms and by anatomic patency, which was assessed by history, fluorescein flow on nasal endoscopy, and lacrimal syringing. In the MENDCR group, surgery was successful in 29 of 31 DCRs (93.5%); 1 of 2 failed cases was anatomically patent but symptomatic, yielding an anatomic patency rate of 96.8%. In the Ext-DCR group, the success rate was 95.8% (23/24 DCRs); the failed case was anatomically patent but symptomatic, giving an anatomic patency rate of 100%. The differences in overall success and anatomic patency were not statistically significant (P = 0.6 and P = 0.56, 1-tailed Fisher exact test). CONCLUSIONS: The success rate of MENDCR (93.5%) compares favorably with that of standard external DCR (95.8% in this study). MENDCR relies on the creation of a large ostium and mucosal flap apposition. A larger, randomized prospective trial is needed to fully assess the efficacy of this new technique.     

Mechanical endonasal dacryocystorhinostomy with mucosal flaps

AIMS: To describe and assess the efficacy of mechanical endonasal dacryocystorhinostomy (MENDCR). This is a new technique that involves creation of a large rhinostomy and mucosal flaps. The study involved a prospective non-randomised interventional case series with short perioperative follow up. METHOD: A prospective series of 104 consecutive endonasal DCRs performed from January 1999 to December 2001 were entered into the study. Patients included in the study had nasolacrimal duct obstruction and had not had previous lacrimal surgery. The technique involved anastomosis of nasal mucosal and lacrimal sac flaps and a large bony ostium. Surgery was performed by two surgeons (AT/PJW). Follow up assessment included nasoendoscopy as well as symptom evaluation. Success was defined as anatomical patency with fluorescein flow on nasoendoscopy and patency to lacrimal syringing. The average follow up time was 9.7 months (range 2-28, SD 6.7 months). RESULTS: There were 104 DCRs performed on 86 patients (30 male, 56 female). The average age of the patients was 59 years (range 3-89, SD 24.1 years). Common presentations were epiphora (77%) and/or mucocele (19%). Septoplasty (SMR) was required in 48 DCRs (46%) and 13 DCRs (12.5%) needed other endoscopic surgery in conjunction with the lacrimal surgery. The surgery was successful in 93 cases (89%). Of the 11 cases that were classified as a failure six patients was anatomically patent but still symptomatic and another two had preoperative canalicular problems. The anatomical patency with this new technique was thus 95% (99 of 104 DCRs). CONCLUSION: MENDCR involves creation of a large ostium and mucosal preservation for the construction of flaps. The anatomical success is 95% and is similar to external DCR and better then other endonasal approaches. The authors suggest that creation of a large ostium as well as mucosal flaps improves the efficacy of this endonasal technique.     

External versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center

Purpose

To study the duration of surgery, outcomes, adverse events and success rates of external versus endonasal dacryocystorhinostomy (DCR) surgery in a specialized lacrimal surgery center.

Methods

Prospective, interventional case series. Standard external DCR technique was performed. Mechanical endonasal DCR was performed with enlargement of the ostium and full length opening of the lacrimal sac. Surgical time, duration of intubation, incidence of hemorrhage, infection, wound dehiscence; follow-up duration and functional success at the end of follow up were recorded.

Results

Functional success and symptomatic relief were equivalent in both procedures. Endonasal DCR surgery was found to be quicker to perform than external DCR surgery. The follow-up duration was comparable in both groups (mean 9 months). Patient satisfaction was significantly higher in the endonasal DCR group (9.3 versus 8.6).

Conclusion

Endonasal DCR surgery offers a very attractive alternative to the well established technique of external DCR surgery for the treatment of primary acquired nasolacrimal duct obstruction with equivalent success rates, shorter surgical time and higher patient satisfaction.     

The value of nasal endoscopy after dacryocystorhinostomy

PURPOSE To determine the value of office nasal endoscopy after dacryocystorhinostomy (DCR). METHODS A prospective clinical observational study of consecutive adult patients after primary external or endonasal surgical DCR, both with intubation for nasolacrimal duct obstruction. Nasal endoscopy was used at the time of tube retrieval and six months after surgery to evaluate nasal pathology and ostium function. RESULTS Sixteen patients were examined. 5/16 (31%) had surgically induced nasal synaechiae; in 2/5 patients transnasal synaechiae occluded the ostium. Granuloma adjacent to the ostia in 2/16 (12.5%) did not impair function. There was no difference in the incidence of synaechiae or granuloma after endonasal compared to external DCR. In 3/16 (19%) endoscopy aided retrieval of tubes concealed by transnasal synaechiae or a narrow nasal space. Six months after surgery ostium function was positive in 12/16 (75%) using the functional endoscopic dye test; 13/16 (81%) patients had relief of epiphora with patent syringing; one had an alternative drainage route. CONCLUSIONS Nasal endoscopy after DCR i) identifies surgically induced nasal mucosal pathology, ii) assists in difficult retrieval of tubes and iii) assesses ostium function using the functional endoscopic dye test. The information obtained is adding much to our understanding of the effects of DCR at the lacrimal / sinus / nasal interface.     

The value of nasal endoscopy after dacryocystorhinostomy

PURPOSE To determine the value of office nasal endoscopy after dacryocystorhinostomy (DCR). METHODS A prospective clinical observational study of consecutive adult patients after primary external or endonasal surgical DCR, both with intubation for nasolacrimal duct obstruction. Nasal endoscopy was used at the time of tube retrieval and six months after surgery to evaluate nasal pathology and ostium function. RESULTS Sixteen patients were examined. 5/16 (31%) had surgically induced nasal synaechiae; in 2/5 patients transnasal synaechiae occluded the ostium. Granuloma adjacent to the ostia in 2/16 (12.5%) did not impair function. There was no difference in the incidence of synaechiae or granuloma after endonasal compared to external DCR. In 3/16 (19%) endoscopy aided retrieval of tubes concealed by transnasal synaechiae or a narrow nasal space. Six months after surgery ostium function was positive in 12/16 (75%) using the functional endoscopic dye test; 13/16 (81%) patients had relief of epiphora with patent syringing; one had an alternative drainage route. CONCLUSIONS Nasal endoscopy after DCR i) identifies surgically induced nasal mucosal pathology, ii) assists in difficult retrieval of tubes and iii) assesses ostium function using the functional endoscopic dye test. The information obtained is adding much to our understanding of the effects of DCR at the lacrimal / sinus / nasal interface.     

Outcome of patients with nasolacrimal polyurethane stent implantation: do they keep tearing?

PURPOSE: To evaluate the results of nasolacrimal polyurethane stent implantation for the treatment of primary acquired nasolacrimal duct obstruction and the effects of obstructed nasolacrimal stent on subsequent dacryocystorhinostomy (DCR). METHODS: This study was designed as a nonrandomized, prospective clinical trial. Stent implantation was attempted in 53 obstructed lacrimal drainage systems of 47 patients. Stent placement was performed in a retrograde fashion through the external nare over a guide wire, which was introduced from the upper punctum. Occluded stents were removed either with nasal endoscopy or during DCR. External DCR surgery with silicone intubation was performed in cases with stent failure. RESULTS: The mean follow-up period was 23.4 months. The success rate of stent implantation was 60.4%, 37.5%, and 31.2% at 6-, 12-, and 18-month follow-up, respectively. Stent obstruction developed in 33 eyes. Twenty underwent external DCR with silicone intubation. During DCR surgery, varying degrees of chronic inflammatory reaction were detected in the lacrimal sac and nasolacrimal duct. The mean follow-up period after DCR was 10.3 months. Epiphora was relieved with DCR in all but one eye. CONCLUSIONS: The success rate of nasolacrimal polyurethane stent implantation for the treatment of primary acquired nasolacrimal duct obstruction is low and may induce inflammation and fibrous tissue formation. Although this may cause further difficulties in subsequent lacrimal surgery, epiphora could be relieved with meticulous technique.     

Agger nasi cell mucosal autograft for lacrimal sac reconstruction during endonasal dacryocystorhinostomy

A mucosal autograft composed of agger nasi cell mucosa was used to reconstruct the lacrimal sac mucosa in a young woman with a cicatrised lacrimal sac and obstructed nasolacrimal system. The patient had undergone a previous external dacryocystorhinostomy (DCR), dacryocystectomy and revision mechanical endonasal DCR. There was persistent epiphora and at further mechanical endonasal (MEN) DCR it was noted that only a small cuff of lacrimal sac mucosa around the common canaliculus was present. To achieve a mucosal anastomosis, the agger nasi cell mucosa was removed from the cell and placed as a free mucosal graft around the common canalicular opening. Apposition with the nasal mucosa was completed with flaps from the lateral nasal wall mucosa. Postoperatively, the patient is asymptomatic with a freely draining ostium at 18 months of follow-up.     

Corrective techniques of lacrimal obstruction in the vertical system

PurposeTo describe current surgical techniques of dacryocystorhinostomy (DCR) and to compare their effectiveness by analysing the advantages and disadvantages between external, endonasal and transcanalicular surgery.Patients and methodsA total of 91 DCRs were analysed using a retrospective, cross-sectional and multicentre study in 75 patients who had symptoms of nasolacrimal duct obstruction. Of these, 28 were operated using external DCR, 31 endonasal technic, and 32 transcanalicular DCR with diode laser. Outcomes were evaluated subjectively using patient symptoms for the grade of epiphora and the results from the syringing before and after surgery.ResultsExternal DCR was performed in 28 cases, with 19 cases asymptomatic (67.85%), and 20 patients had a patent tract (71.42%). Endonasal DCR was performed in 31 cases, of which 19 cases were asymptomatic (61.29%), and 21 showed patency of the nasolacrimal duct (67.74%). A transcanalicular technique was performed in 32 cases, with absence of epiphora in 24 patients (75%), and the syringing was successful in 24 of them (75%).ConclusionsAny of these 3 surgery techniques would be an adequate treatment for lacrimal obstruction, due to the significant development of endonasal and transcanalicular techniques in recent decades. With improvement, we could use either endonasal or transcanalicular techniques with diode laser with the same lever of effectiveness as the classic external approach, with the advantages of minimally invasive surgery.     

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

PURPOSE: Comparison of surgical times for dacryocystorhinostomy (DCR) by three different approaches: (1) external, (2) endoscopic endonasal surgical (EES), and (3) endoscopic endonasal laser (EEL) using the holmium:YAG laser. The merits and limitations of each approach are considered and surgical throughput predicted. METHODS: Prospective study of adult patients undergoing primary DCR surgery for nasolacrimal duct obstruction. Surgical times were recorded. Subjective and objective outcomes were assessed at a minimum of 6 months. RESULTS: A total of 48 patients undergoing 51 DCR procedures were studied. The mean surgical time for primary external (n=20), EES-DCR (n=16), and EEL-DCR (n=15) was 41.1+/-10.3, 39.6+/-13.8, and 20.9+/-7.8 min, with symptomatic success achieved in 95, 88, and 60%, respectively. Follow-up was 6-36 months, mean 8 months. It was calculated that if six EEL-DCR, four EES-DCR, or three external DCRs are performed per list for 45 lists per annum, this equals a total of 270 EEL-DCR, 180 EES-DCR, and 135 external DCRs. Of these, 108 EEL-DCR, 22 EES-DCR, and seven external DCRs will fail. If 75% of these have redo surgery using the same technique, an extra 13.5 (EEL-DCR), four (EES-DCR), and two (external DCR) lists are needed. CONCLUSIONS: There was no significant difference between the time taken to do EES-DCR compared to external DCR, and their clinical outcomes. Only EEL-DCR was significantly faster (P<0.001). However, its lower success rate negates the apparent benefit from the greater surgical throughput.     

Functional and anatomic results after two types of endoscopic endonasal dacryocystorhinostomy: surgical and holmium laser

PURPOSE: To determine subjective and objective outcomes after two types of endoscopic endonasal dacryocystorhinostomy (DCR) and to evaluate the use of the functional endoscopic dye test (FEDT). DESIGN: Prospective, nonrandomized trial. PARTICIPANTS: Sixty-nine consecutive adult patients with primary acquired nasolacrimal duct obstruction. METHODS: Patients underwent primary endonasal surgical or laser (Holmium:yttrium-aluminum-garnet [YAG]) DCR with temporary silicone intubation. MAIN OBJECTIVE MEASURES: Data were collected 6 months after surgery (at least 3 months after removal of tubes). Subjective results were based on the patients' symptoms of epiphora. Objective results consisted of (1) lacrimal system irrigation, (2) FEDT-this test is positive when dye placed in the conjunctival fornix is observed to enter the nasal space via the DCR rhinostomy, and (3) rhinostomy appearance. RESULTS: Thirty-six patients had endosurgical and 33 had endolaser (Holmium:YAG) DCR. Symptomatic success was 83% after endosurgical and 71% after endolaser DCR. Lacrimal irrigation was a good test after surgery for identifying patients with successful or unsuccessful outcome (sensitivity, 98%; specificity, 87%). The FEDT had a few false negatives and small number of false positives (sensitivity, 83%; specificity, 91%). CONCLUSIONS: Endoscopic endonasal DCR performed surgically had better results than those achieved with Holmium:YAG laser alone (but did not reach statistical significance). The FEDT is useful in assessing rhinostomy patency and understanding the effects of surgery but was not as good as lacrimal irrigation in predicting symptomatic success.     

Success rate and complications of endonasal dacryocystorhinostomy with unciformectomy

Background

Endonasal dacryocystorhinostomy (DCR) has been widely used to treat nasolacrimal duct obstruction. Here, we evaluated the anatomical advantages of the uncinate process as a landmark and to study the effect of unciformectomy on success rate and complications of endonasal DCR .

Methods

In total, 288 eyes of 265 adult patients who underwent endonasal DCR between January 2003 and February 2010 were reviewed retrospectively. The eyes were classified into two groups, according to whether unciformectomy was performed or not. All surgical procedures and surgical indications were the same except unciformectomy and endonasal DCR was performed by one surgeon. Unciformectomy was performed by resecting the anterior part of uncinate process.

Results

One hundred and eighty-six eyes of 168 patients received endonasal DCR with unciformectomy, and 102 eyes of 97 patients received endonasal DCR alone. The average success rate of endonasal DCR with unciformectomy was 97.8?% and that of endonasal DCR alone was 90.2?%, with statistically significant difference (Student's t-test, p-value?<?0.05). There were 14 eyes with post-operative nasolacrimal obstruction, caused by granuloma in five eyes, intranasal synechia in two eyes, membranous obstruction in six eyes, and canalicular stenosis in one eye. There were no serious complications such as orbital fat prolapse, cerebrospinal fluid leak, or delayed hemorrhage.

Conclusions

Anterior resection of the uncinate process gives improved access to the lacrimal bone by exposing the medial aspect of the lacrimal fossa and forming the precise location of the osteotomy on the lacrimal bone during endonasal DCR. Thus, the uncinate process can be used as an anatomical landmark for endonasal DCR. The unciformian endonasal DCR improves operation success rate by allowing access to the large space of the nasal cavity and reducing the synechiae of the nasal cavity.     

Paediatric endoscopic endonasal dacryocystorhinostomy in congenital nasolacrimal duct obstruction

Objectives The objectives of this study were to report a series of paediatric patients who underwent endoscopic endonasal dacryocystorhinostomy (DCR) for primary congenital nasolacrimal duct obstruction (NLDO).Methods This is a retrospective, noncomparative review of all consecutive cases in two lacrimal clinics between January 1999 and October 2004. The main outcome measures were patients’ demographics, previous treatments, clinical presentation, operative and postoperative complications, postoperative follow-up and resolution of epiphora.Results Twenty-one patients (15 males) with a mean age of 6±3.5 years (range, 2–14 years) underwent 26 endoscopic DCR operations for congenital NLDO. Sixteen cases were unilateral, and five were bilateral. In 13 cases (50.0%), there was a history of epiphora and chronic dacryocystitis with or without a mucocele. Two cases (7.7%) presented with acute dacryocystitis, and 11 (42.3%) had only a history of epiphora. Previous procedures included probing and irrigation in 25 cases (96.2%) and insertion of Crawford tubes in 19 cases 973.1%). During a mean postoperative follow-up period of 18±8 months, the anatomical success rate (free flow of fluorescein sodium and patency of ostium on nasal endoscopy) was 100%, and the clinical success rate (resolution of epiphora) was 92.3%.Conclusion Endoscopic endonasal DCR is an effective treatment modality for congenital NLDO that compares favourably with the reported success rates of external DCR.     

Pediatric endonasal dacryocystorhinostomy: A multicenter series of 116 cases

We report our experience with pediatric endonasal dacryocystorhinostomy (DCR). Multicenter, retrospective, noncomparative study. Cases of pediatric endonasal DCR during 2006–2011 were included from six oculoplastic units. Patients over the age of 16 years were excluded. The outcomes of pediatric endonasal DCR are presented. Indication for surgery, demographics, previous interventions, intraoperative or postoperative complications, follow-up duration, and success rate (defined as significant improvement of epiphora) were evaluated. In total, 116 endonasal DCRs were performed for 103 patients. The mean follow-up period was 8 months (range 3 months to 4 years), with 1 patient lost to follow-up. There were 48 males (mean age 5 years and 9 months) and 50 females (range of 4 months to 16 years), with a total of 98 cases of congenital nasolacrimal duct obstruction (CNLDO) (84.5%) and 18 cases of acquired nasolacrimal duct obstruction (ANLDO) (15.5%). Previous interventions included probing 75.9% (88/116), massaging 43.1% (50/116), and intubation 39.7% (46/116). There were no intraoperative complications. There was one case of postoperative pyogenic granuloma. There were no cases of postoperative infection and postoperative hemorrhage. Ninety percent of procedures were considered successful. Complete symptom resolution was observed in 78% (90/116), significant improvement in 12% (14/116), partial improvement in 2% (2/116), and no improvement in 8% (9/116). In our series, we demonstrated that endonasal DCR is a safe operation and has an overall success rate of 90% for pediatric NLDO.     

Primary external dacryocystorhinostomy versus primary endonasal dacryocystorhinostomy: a review

This paper aims to compare the efficacy, mean operative time and adverse effects of primary external dacryocystorhinostomy (DCR) versus primary endonasal DCR in treating acquired nasolacrimal duct obstruction. Searches were performed for studies comparing the two procedures. Two reviewers independently extracted data from 14 eligible studies. A random effects model was used to analyse the studies. Outcome measures were defined as patency of the nasolacrimal canal and mean operative time, and adverse effects as cutaneous scarring and bleeding. Both procedures were comparable in efficacy in terms of full success, partial success and anatomic patency. Subgroup analysis showed no significant difference between prospective and retrospective studies as well as between non‐laser endonasal DCR versus external DCR and laser endonasal DCR versus external DCR. Endonasal DCR had a significantly shorter mean operative duration, be it laser endonasal DCR (mean difference: 37.65 min, 95% confidence intervals: 3.54–71.75 min, P: 0.03) or non‐laser endonasal DCR (mean difference: 19.22 min, 95% confidence intervals: 2.15–36.28 min, P: 0.03). The odds of postoperative bleeding was not significantly different between the two procedures, whereas postoperative cutaneous scarring was unique to external DCR and occurred in 50 out of 402 (12.44%) external DCRs recorded. Endonasal DCR has comparable success rates with external DCR and has a shorter operative time and no cutaneous scar. However, drawbacks include the steep learning curve and higher costs.     

Long-term outcomes of revision endoscopic dacryocystorhinostomy aided by 4-mm coronary balloon catheter dacryoplasty

Our purpose was assess the long-term efficacy of 4-mm coronary balloon catheter dacryoplasty in revision endoscopic dacryocystorhinostomy (RevEnDCR). This retrospective interventional case-series was performed for patients who underwent RevEnDCR aided by a 4-mm coronary balloon catheter (CBC) dacryoplasty. The indications for the surgery were previously failed DCRs by external or endoscopic approach where the ostium showed near total cicatrization with or without the presence of organized granuloma threatening the internal common opening (ICO). The coronary balloon (4 × 10 mm, SPALNO, Cardiomac, Haryana, India) with the guidewire was used and a minimum of >12 months of follow-up was considered for analysis. Ten lacrimal systems of eight patients with mean age of 48.8 years underwent CBC-assisted revision endoscopic DCR. Of the 10 failed DCRs, 6 had a previous external approach DCR and 4 were endoscopic DCRs. Grossly stenosed ostium with near total cicatricial closure were noted in half of the patients (50%, 5/10) while the remaining half, in addition, showed organized granulomas threatening the ICO. The surgical technique using CBC was found to be minimally invasive, easy to perform with multiple advantages like uniform clearance of the area in front of ICO and more predictable lacrimal sac flaps. At a mean follow-up of 20 months, anatomical and functional success were achieved in 90% (9/10) of the eyes. We conclude that coronary balloon catheter-assisted revision endoscopic DCR is a minimally invasive and viable alternative in select group of patients of failed DCR with near total cicatrisation or organized granulomas threatening ICO.     

Lacrimal intubation during dacryocystorhinostomy utilizing the STENTube

The traditional use of the Crawford tube for lacrimal intubation during dacryocystorhinostomy (DCR) carries several drawbacks. We describe the use of the STENTube for DCR intubation and detail its advantages. Retrospective, noncomparative, interventional case series; 313 patients with nasolacrimal duct obstruction (NLDO) underwent 339 DCRs (216 external, 123 endonasal) with the STENTube from January 2007 – June 2013 by 5 surgeons (RS, QN, TS, SB, TN) across 3 institutions (SUNY Downstate Medical Center, Texas Oculoplastics Consultants, and Moorfields Eye Hospital). Study outcome measures included patient demographics, surgical complications, and epiphora improvement/resolution. 206 (66%) females and 107 (34%) males had a mean age of 63 years (range 2–94 years). Distribution of diagnoses included: 314 complete idiopathic acquired NLDO, 20 partial idiopathic acquired NLDO, and 5 congenital complete NLDO. 316 (93%) were primary DCRs and 23 (7%) were revisions. Epiphora improved in 312 (92%) cases with 294 (86%) experiencing resolution with patent lacrimal irrigation at a mean last follow-up of 9.4 months. Twenty-eight (8%) patients experienced surgical complications with 16 (5%) experiencing tube prolapse, and 20 (6%) requiring re-operation. The STENTube represents a simple method for lacrimal intubation during external or endonasal DCR at a comparable cost to the Crawford tube. It allows for low prolapse rates without the need for additional endonasal fixation procedures, resulting in a simple and comfortable post-operative extraction without risk of lacrimal trauma. The STENTube is our preferred intubation technique during DCR, and should be considered by oculofacial surgeons performing DCR with intubation.     

Clinicopathologic findings after nasolacrimal polyurethane stent implantations

PURPOSE: To evaluate the results of nasolacrimal polyurethane stent implantations for the treatment of primary acquired nasolacrimal duct obstruction, and to determine the effects of various surgical procedures, including stent removal, in subsequent nasolacrimal duct obstruction. METHODS: This study included 15 patients who had nasolacrimal polyurethane implantations for the treatment of primary acquired nasolacrimal duct obstruction. Occluded stents were removed either by nasal endoscopy or during dacryocystorhinostomy (DCR). Cultures and biopsies were performed on the removed stents, and the results of the secondary DCR were analyzed for a 6-month follow-up period. RESULTS: During stent removal surgery, various degrees of chronic inflammatory reaction and fibrous tissue formation were detected in the lacrimal sac and nasolacrimal duct. Formations of granuloma and fibrous tissue were found in 15 eyes, and culture-positive reaction were found in nine of the 15 eyes. Conventional dacryocystorhinostomy surgery was performed in nine of the 15 eyes and a silicone tube was located at the canaliculi. Subjective and objective outcome were favorable in 13 of the 15 eyes. CONCLUSIONS: The success rate of nasolacrimal polyurethane stent implantation for the treatment of primary acquired nasolacrimal duct obstruction is low. This may result from a chronic inflammatory reaction. Despite the low success rate of nasolacrimal polyurethane stent implantation, the success rate of endonasal DCR as a subsequent surgery is favorable.     

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

AIM: One of the main factors in determining success rate of lacrimal surgery is the level of obstruction in the lacrimal drainage system. There are only few reports which quantify this, and none on endoscopic dacryocystorhinostomy (DCR). METHODS: A case series of patients who had endoscopic DCR for anatomical obstruction of the lacrimal drainage system was performed. All patients who had lacrimal blockage referred to a district general hospital, irrespective of the level of blockage, had endoscopic DCR as the initial treatment by the authors. A total of 191 endoscopic DCRs were performed between 1994 and 1999. No other forms of lacrimal surgery were performed during this period. The level of the obstruction was assessed by the ophthalmologist before the operation and confirmed at surgery. All cases were followed up for a minimum of 6 months, and 96 cases were also reviewed 12 months after surgery. The outcome of the endoscopic DCR operation for each eye was categorised into complete cure, partial cure, or no improvement according to the degree of symptomatic relief following the operation. RESULTS: Complete relief from epiphora was achieved in 89% of cases overall at 6 months. The success rate in cases with lacrimal sac/duct obstruction (93%) or common canalicular blockage (88%) was comparable. In canalicular obstruction, however, the complete cure rate was lower at 54%. The benefit of the operation was maintained at 12 months. CONCLUSION: This study demonstrates that the success rate of surgical (non-laser) endoscopic DCR is comparable to that reported for external DCR. Moreover, the technique is appropriate for initial treatment of patients with common canalicular or even canalicular obstruction.     

Safety and efficacy of adjunctive intranasal mitomycin C and triamcinolone in endonasal endoscopic dacryocystorhinostomy

One of the common causes of failure in dacryocystorhinostomy for nasolacrimal duct obstruction (NLDO) is mucosal scarring and fibrosis around the ostium. Steroid and mitomycin C (MMC) can potentially reduce scarring by their action on the inflammatory and proliferative phase of wound healing, respectively. The purpose of this study is to evaluate the safety and efficacy of combined usage of adjunctive MMC and intranasal triamcinolone (TA) in endonasal endoscopic dacryocystorhinostomy (EE-DCR). This is a retrospective interventional case series. All patients underwent mechanical EE-DCR in two regional hospitals in Hong Kong from January 2005 to December 2006 were included. All received intraoperative MMC application for 5 min and gelfoam soaked with TA onto the ostium. Main outcome measures include the anatomical and functional success rate at follow-up at least 6 months after operation. Other outcomes include complications occurred during and after operation. A total of 73 EE-DCR were performed in 69 patients. Three patients had simultaneous bilateral DCR; one had sequential DCRs for both sides. At the last follow-up, anatomical success was achieved in 68 cases (93 %) and both anatomical with functional success in 67 cases (92 %). No major complication was observed. Minor complications included asymptomatic mucosal adhesion between the nasal septum and lateral nasal wall in one patient and moderate secondary hemorrhage in another. EE-DCR with adjunctive MMC and TA is a safe and successful procedure for the treatment of NLDO.     

Complications of standardized endonasal dacryocystorhinostomy with unciformectomy

PURPOSE: To report the nature and frequency of complications occurring with endonasal dacryocystorhinostomy (DCR) based on routine unciformectomy. DESIGN: Prospective, noncomparative interventional consecutive case series study. PARTICIPANTS: Endonasal DCR was performed on 300 patients with complete nasolacrimal stenosis. METHODS: The uncinate process was resected (unciformian endonasal DCR), except when the lacrimal fossa was anterior to its insertion (23 cases [7.7%]). Preoperative clinical assessment and computed tomography scans, intraoperative endoscopic video recording, and postoperative clinical and endoscopic follow-ups were analyzed for reported endonasal DCR failure and complications. The mean follow-up was 13+/-12.6 months (range, 1-57). MAIN OUTCOME MEASURES: Failure rate, nature, frequency, and time of intraoperative and postoperative complications. RESULTS: Of the 300 patients treated, 39 (13%) suffered from residual epiphora and no passage upon irrigation; there was secondary canalicular stenosis in 2 cases (0.6%), sump syndrome in 4 cases (1.2%), a distal stenosis from progressive healing closure of the ostium in 21 cases (7.0%), a recurrence of lacrimal mucocele in 5 cases (1.7%), and adhesions between the ostium and septum in 2 cases (0.6%). Access to the surgical site required an anterior middle turbinectomy in 103 cases (34.3%) and a septoplasty in 1 case (0.3%). Intraoperative bleeding was minor in 183 (60.6%), moderate in 82 (27.3%), and severe in 35 cases (11.6%). Postoperative bleeding occurred in 4 cases, and was controlled by packing. Transient frontal sinusitis (n = 1), nasal mucosa burn (n = 1), cacosmia (n = 8), phlebitis (n = 1), and maxillary pain (n = 8) also occurred. Orbital fat prolapse, cerebrospinal fluid leaking, cutaneous scarring, diplopia, and loss of vision did not occur. CONCLUSION: Complications from unciformian endonasal DCR may be less frequent or severe than with maxillary endonasal DCR, and comparable to or less frequent than those for external DCR.