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.     

Intraoperative mitomycin C in dacryocystorhinostomy

PURPOSE: To assess the efficacy of intraoperative mitomycin C (MMC) in external dacryocystorhinostomy (EXT-DCR). METHODS: Forty-six cases (50 lacrimal drainage systems [LDS]) with nasolacrimal duct obstruction were randomized into three groups. In the control group, a standard EXT-DCR procedure was performed. In the two MMC groups, a piece of cotton soaked with 0.2 mg/ml MMC (group 1) or 0.5 mg/ml MMC (group 2) was applied to the nasal mucosa and the mucosa of the lacrimal sac in the osteotomy site for 5 minutes. RESULTS: The dacryocystorhinostomy in all patients was patent by irrigation 2 to 3 weeks postoperatively. After a mean follow-up interval of 35.2 +/- 5.3 months, the dacryocystorhinostomy was patent in 15 (83%) of 18 LDS in the control group, 16 (100%) of 16 LDS in group 1, and 15 (94%) of 16 LDS in group 2. The mean ostium sizes were 22.2 +/- 5.0 mm2 in group 1, 20.6 +/- 4.5 mm2 in group 2, and 13.2 +/- 2.7 mm2 in group 3 at the final follow-up visit; the difference between the patients treated with MMC and the control group was statistically significant. There was no statistically significant difference between the two MMC groups, however. No surgical complications occurred. CONCLUSIONS: Intraoperative MMC in DCR is a safe and effective adjuvant that helps achieve favorable long-term success rates.     

Effect of timing of external dacryocystorhinostomy on surgical outcome

PURPOSE: To present our experience with external dacryocystorhinostomy (DCR) outcome and to compare cases of early and late DCR. METHODS: Retrospective data review of all patients who had external DCR with silicone intubation in a 7-year period. Data were collected and analyzed concerning patients' preoperative and postoperative symptoms, and the lacrimal drainage system examination before, during, and after surgery. RESULTS: In all, 162 patients underwent 195 DCR surgeries for nasolacrimal duct obstruction. Success was achieved in 81% of surgeries. Success rates were higher in patients who had early DCR (tearing only or early inflammatory signs of the lacrimal sac, 84% success) than in cases that had late DCR (more than 6 months after inflammation started, 77% success). These differences were statistically insignificant. Failure of DCR was much higher in posttraumatic DCR than in DCR for other etiologies. Complications (in 9% of surgeries) were generally mild and infrequent, except 1 case of meningitis. CONCLUSIONS: In experienced hands, external DCR has good postoperative success with a low complication rate. Early DCR does not have a substantial advantage over late surgery with regard to surgical outcome.     

External dacryocystorhinostomy for the treatment of acquired partial nasolacrimal obstruction in adults

AIM: To determine the long term success of external dacryocystorhinostomy (DCR) in adults with acquired partial nasolacrimal obstruction. METHODS: A retrospective study of 50 external dacryocystorhinostomies with silicone intubation performed for partial nasolacrimal obstruction, was undertaken. Preoperative lacrimal scintigraphy divided drainage abnormalities into presac or postsac delays. Postoperative success was determined by lacrimal patency to irrigation, a positive dye test on nasal endoscopy and subjective resolution of epiphora. Statistical analysis was performed using the Fisher exact test. RESULTS: A patent DCR system to irrigation and a positive dye test was achieved in 90% of procedures. At an average of 3.6 months' follow up, subjective success was reported in 84% of cases-91% for postsac and 67% for presac delays. At 3 years' follow up success had declined to 70% overall and to 80% and 47% for postsac and presac occlusions respectively. There was a statistically significant association between a presac delay and postoperative recurrence of epiphora, p = 0.04. CONCLUSION: External DCR with silicone intubation is an effective procedure for partial nasolacrimal obstruction. Presac delays do significantly less well and further studies are necessary to evaluate the best type of surgery for these patients.     

Results of intraoperative mitomycin C application in dacryocystorhinostomy

AIMS: To evaluate the long term results of intraoperative mitomycin C application in dacryocystorhinostomy (DCR) surgery compared with results of the conventional procedure. METHODS: In this prospective randomised controlled study, a total of 88 eyes diagnosed with acquired nasolacrimal duct obstruction were randomly divided into a conventional DCR group and a mitomycin C group in which mitomycin C was used during DCR surgery. The surgical procedures in both groups were exactly the same, except that in the patients in the mitomycin C group, a piece of neurosurgical cottonoid soaked with 0.2 mg/ml mitomycin C was applied to the osteotomy site for 30 minutes. The results of the DCR surgeries were evaluated by objective findings such as irrigation and the height of tear meniscus and subjective symptoms by asking patients the condition of tearing improvement. RESULTS: Among the 44 eyes in the mitomycin C group, 95.5% of patients remained totally symptom free after 10 months of follow up; while in the conventional group, 70.5% of patients were reported to be symptom free and 18% of patients to have an improvement in their symptoms. There was a significant difference between these two groups. As far as objective findings were concerned, there were 41 eyes in the mitomycin C group classified as having a normal and one eye with moderate tear meniscus level, compared with 32 eyes and seven eyes, respectively, in the conventional group. There was also a significant difference between these two groups. The non-patency rate in the mitomycin C group is 4.5% compared with 11.4% in the conventional group. There were no complications such as abnormal nasal bleeding, mucosal necrosis, or infection except one patient with delayed wound healing. CONCLUSIONS: Intraoperative mitomycin C application is effective in increasing the success rate of DCR surgery in standard nasolacrimal duct obstruction, and no significant complications resulted from its use.     

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.     

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.     

鼻内窥镜下泪道浚通联合硅胶管植入治疗泪道阻塞的临床观察

目的:观察鼻内窥镜下泪道浚通联合硅胶管逆行植入和丝裂霉素C(MMC)应用治疗泪道阻塞的手术疗效。方法:鼻内窥镜下利用泪道浚通联合类Y形硅胶管规范泪道逆行植入和MMC应用,留置Y形管3mo,跟踪观察并统计其中106例106眼的治疗结果。结果:鼻内窥镜下泪道浚通后MMC应用,置留、拔管操作特别简单容易,创伤甚微。全部治疗在门诊完成,期间患者正常生活、工作、学习。3a以上随访治疗结果:有效以上率96.2%(102眼);显效以上率92.5%(98眼);治愈率84.9%(90眼);无效3.8%(4眼)。结论:鼻内窥镜下泪道浚通联合硅胶管逆行植入和MMC应用技术是治疗泪道阻塞的首选与补充方法,损伤小,成功率高,并发症少,手术费用低。     

Dacryocystorhinostomy for epiphora in the presence of a patent lacrimal system

Purpose : To evaluate the success rate of dacryocystorhinostomy (DCR) for epiphora in patients with a clinically patent lacrimal drainage system. Methods : A series of 51 patients, 12 men and 39 women, who underwent DCR surgery for epiphora with a clinically patent lacrimal drainage system in the background of normal eyelid examination, were evaluated. All patients underwent fluorescein dye disappearance testing and Jones 1 and 2 testing with dacryocystograms in borderline cases. A standard DCR was performed with bicanalicular silicone tubing inserted in all cases. The average time for the removal of the silicone tubes was 9.6 weeks. Results : In 48 cases (94%) there was improvement in symptoms with minimal or no significant epiphora postoperatively. Conclusions : Epiphora with a patent lacrimal drainage system obstruction can be successfully treated by DCR based on fluorescein dye disappearance tests and Jones 1 and 2 tests, with dacryocystography in borderline cases.     

改良泪囊鼻腔吻合术联合丝裂霉素C治疗慢性泪囊炎56例

目的:总结和分析改良泪囊鼻腔吻合术联合术中应用丝裂霉素C治疗慢性泪囊炎的效果。方法:随机选择56例(56眼)慢性泪囊炎患者施行改良泪囊鼻腔吻合术联合术中应用丝裂霉素C(观察组),随机对照组53例(53眼)行传统泪囊鼻腔吻合术,术后随访12mo,观察患者术后泪道通畅情况,鼻内窥镜下测量骨孔面积、观察骨孔内肉芽增生情况。结果:随访12mo,观察组手术成功率为100%,对照组手术成功率为79.2%,观察组和对照组手术成功率比较其差异有显著性意义(P<0.05)。结论:改良泪囊鼻腔吻合术联合术中应用丝裂霉素C能提高慢性泪囊炎的手术成功率,保持吻合口通畅,是值得推荐的一种手术方法。     

Mitomycin-C in dacryocystorhinostomy: From experimentation to implementation and the road ahead: A review

Dacryocystorhinostomy (DCR) is the procedure of choice in patients with epiphora due to primary acquired nasolacrimal duct obstruction. The evolution of surgical tools, fiber-optic endoscopes, effective anesthesia techniques, and the adjunct use of antimetabolites intraoperatively; namely mitomycin-C (MMC) have significantly contributed to the advancement of DCR surgery. MMC is a systemic chemotherapeutic agent derived from Streptomyces caespitosus that inhibits the synthesis of DNA, cellular RNA, and protein by inhibiting the synthesis of collagen by fibroblasts. Even the cellular changes in the human nasal mucosal fibroblasts induced by MMC at an ultrastructural level have been documented. There, however, seems to be a lack of consensus regarding MMC: The dosage, the route of delivery/application, the time of exposure and subsequently what role each of these variables plays in the final outcome of the surgery. In this review, an attempt is made to objectively examine all the evidence regarding the role of MMC in DCR. MMC appears to improve the success rate of DCR.     

Long-term results of adjunctive use of mitomycin C in external dacryocystorhinostomy

Objective To assess the long-term results of intraoperative mitomycin C (MMC) in external dacryocystorhinostomy (EXT-DCR). Methods In this prospective randomized controlled study, 35 patients (40 eyes) with primary acquired nasolacrimal duct obstruction were assigned randomly into two groups. In the control group, a standard EXT-DCR procedure was performed. In the MMC group 0.2 mg/ml MMC was applied to the osteotomy site for 30 min. The results of EXT-DCR in both groups were evaluated by both asking patients about the tearing condition and examining the patency of irrigation at one-year follow up. Results Eighteen (90%) of the 20 eyes in the MMC group remained totally symptom-free and one eye (5%) improved; while 12 (60%) of 20 eyes in the control group were reported to be symptom-free and five (25%) of the eyes to have an improvement in the tearing symptoms (P = 0.087). The success rate in the MMC group was 95% compared with 85% in the control group (P = 0.605). No surgical complications occurred. Conclusions The satisfaction and success rates of the MMC group were higher than those of the control group and no deleterious effect was noted with MMC application, however the differences did not reach statistical significance. Intraoperative MMC application seems to be a safe adjuvant that could help in increasing the success rates of EXT-DCR surgery in primary acquired nasolacrimal duct obstruction ,however further studies with larger series are needed to make definite statements.     

改良式外路泪囊鼻腔吻合术联合泪道置管治疗泪囊黏液囊肿

目的:探讨改良的外路泪囊鼻腔吻合术式联合泪道置管治疗泪囊黏液囊肿的临床疗效.方法:对23例(23眼)泪囊黏液囊肿行改良式泪囊鼻腔吻合术,并联合泪道置管,术后行泪道冲洗,并观察泪溢情况.结果:23例患者,1例术中改为泪囊摘除术,20例完成12个月的追踪观察治疗,1例术后6个月失访,1例12个月时失访.随访1个月,22例患者术后泪囊囊肿均消失,外观明显改善;随访12个月,20例患者中18例溢泪症状完全消失,所有患者泪道冲洗通畅,仅1例患者因泪溢症状对手术疗效不满意.结论:改良式外路泪囊鼻腔吻合术联合泪道置管治疗泪囊黏液囊肿,具有良好的临床效果,值得推广.     

Lacrimal drainage capacity and symptomatic improvement after dacryocystorhinostomy in adults presenting with patent lacrimal drainage systems

AIM. To determine the rate of symptomatic improvement after dacryocystorhinostomy (DCR) in patients with epiphora and insignificant obstruction to preoperative lacrimal syringing, and to measure the conductance of the postoperative lacrimal drainage anastomosis. METHODS. Retrospective cohort study of patients with symptomatic epiphora and patent tear ducts, with at least two-year follow-up after DCR. Patients underwent structured telephone interview together with clinical examination for lacrimal drainage capacity using the saline drop test.(1) RESULTS. Thirty-seven of 383 adult patients having had DCR were noted to have patent tear ducts at preoperative examination. Ten patients with previous surgery were excluded and two other patients were excluded because of other factors contributory to epiphora. Of the remaining 25 patients, 22 (aged 35-75 years at surgery; median 56 years) underwent a structured telephone interview: Of the 13 (60%) who felt that symptoms had improved, 9 (41%) were relieved of indoor epiphora and 11 (50%) thought the procedure was an overall success. Seventeen patients underwent clinical examination. The lacrimal drainage anastomosis was patent in all patients and the saline drop test result was well within the normal range in 3/4 patients who had persistent indoor epiphora. CONCLUSION. Of patients with epiphora due to minor nasolacrimal duct stenosis, open DCR produces a marked improvement or cure of symptoms in 50%. The lacrimal drainage capacity was well within the normal range in 3/4 patients with persistent postoperative lacrimal symptoms, suggesting that other factors (such as hypersecretion) may be significant in this group of patients with 'functional block'.     

Silicone intubation with intraoperative mitomycin C for nasolacrimal duct obstruction in adults: a prospective, randomized, double-masked study

PURPOSE: To assess the efficacy of intraoperative mitomycin C (MMC) during silicone intubation (SI) as a substitute for dacryocystorhinostomy (DCR) in nasolacrimal duct obstruction (NLDO). METHODS: In this prospective, double-masked study, 88 patients with complete NLD obstruction who were candidates for DCR were randomized in 2 groups. All study patients underwent SI with application of MMC or placebo in a randomized, double-masked fashion, with the former receiving 0.2 mg/mL for 2 minutes before SI. RESULTS: After a mean follow-up interval of 8 months, 25 of the 43 eyes in the MMC group and 21 of the 44 eyes in the placebo group had a successful outcome and were free of tearing and discharge. No significant difference was noted between the 2 groups (p = 0.331). In patients with simple epiphora and less than 6 months of duration, SI alone was effective in 83% of patients; however, in the same group, MMC application during SI did not show beneficial effect over SI alone. But in patients with simple epiphora of 6-months duration or longer, the application of MMC during SI resulted in better efficacy compared with SI alone. The success rates in the patients that had chronic dacryocystitis was lower (23%) compared with patients that had only epiphora (63.7%). CONCLUSIONS: SI alone could effectively substitute for a more extensive procedure such as DCR in patients with simple epiphora, particularly those with newly developed symptoms. In cases with longer duration of symptoms of epiphora, application of MMC would increase the success rate significantly.     

环形硅胶管联合丝裂霉素C治疗上泪道阻塞

目的:探讨泪道置环形硅胶管联合丝裂霉素C治疗上泪道阻塞的疗效。方法:选择在门诊治疗的上泪道阻塞89例116眼:泪点阻塞14眼、泪小管阻塞38眼、泪总管阻塞64眼。随机分成两组,对照组(A组)44例58眼:泪点阻塞6眼、泪小管阻塞20眼、泪总管阻塞32眼,观察组(B组)45例58眼:泪点阻塞8眼、泪小管阻塞18眼、泪总管阻塞32眼。材料选用硅胶泪小管,自编扩泪小管绳。在上下泪小管—鼻泪管置环形硅胶管,3～6mo拔管,若合并有鼻泪管阻塞,拨环形硅胶管后立即行鼻泪管逆植球头硅胶管术。B组与A组不同的是,将浸有0.25mg/mL丝裂霉素C的扩泪小管绳在上泪道留置3～5min,拨环形硅胶管后定期冲洗泪道。平均随访2a。结果:A组治愈率为72.4%,B组治愈率为93.1%,两组治愈率比较,差异有统计学意义(P<0.01)。结论:上泪道置环行硅胶管联合丝裂霉素C能提高手术的成功率,是治疗上泪道阻塞的较理想方法。     

Lacrimal bypass surgery in patients with sarcoidosis

PURPOSE: To examine the results of lacrimal bypass surgery in patients with sarcoidosis. METHODS: Patients with sarcoidosis who underwent dacryocystorhinostomy (DCR) or conjunctivodacryocystorhinostomy (CDCR) in two practice settings from 1986 through 1995 were identified and their medical records reviewed. RESULTS: Twelve patients, of whom eight were women, underwent bilateral DCR or CDCR to treat nasolacrimal duct obstruction associated with sarcoidosis. The initial diagnosis of sarcoidosis was established in four patients from a biopsy specimen obtained during DCR. The ages of the patients at diagnosis of sarcoidosis ranged from 39 to 64 years (mean, 49.6 years; median, 45.5 years), whereas their ages at the time of surgery ranged from 42 to 72 years (mean and median, 55 years). The average duration of postoperative follow-up evaluation was 44 months (median, 38.5 months; range, 10 to 82 months). All patients received local corticosteroids postoperatively, and nine patients (75%) were treated with prednisone. Of the 24 lacrimal procedures, 23 (95.8%) were patent to irrigation at the last follow-up examination, and all patients were asymptomatic. CONCLUSION: Lacrimal drainage obstruction may be the initial manifestation of sarcoidosis, and tissue obtained during DCR may help to establish the diagnosis. A successful surgical outcome may require intensive and occasionally long-term therapy with local and systemic corticosteroids.     

The safety and efficacy of mitomycin C in endonasal endoscopic laser-assisted dacryocystorhinostomy

PURPOSE: The adjunctive use of mitomycin C (MMC) in glaucoma and pterygium surgery has been widely published, but there has not been any large long-term study of its use in endonasal endoscopic laser-assisted dacryocystorhinostomy (ELA-DCR). The purpose of this study was to examine the safety and efficacy of the adjunctive use of MMC in this procedure. METHODS: A nonrandomized, retrospective, single-masked, interventional case-controlled study was performed wherein 123 consecutive procedures using MMC in ELA-DCR procedures, using the Holmium:YAG laser, were compared with a historical control group consisting of 48 consecutive procedures in which MMC was not used. One surgeon performed all procedures. The two groups were compared with regard to complications as well as success rate. The main outcome measures for success were the resolution of epiphora and patency with lacrimal irrigation. Success rates were analyzed using the Fisher's exact test. The main outcome determinants for complications were the presence or absence of delayed wound healing, wound necrosis, infection, or excessive bleeding. Postoperative follow-up interval ranged from 30 months to 72 months. RESULTS: There were no complications in the group receiving MMC. One case of turbino-septal synechia formation occurred in the non-MMC group. The success rate of the MMC group was 99.2% compared with 89.6% in the control group. This difference (9.6%) was statistically significant using Fisher's exact test (p = 0.007). CONCLUSION: This study supports the safety and efficacy of the intraoperative use of MMC in endonasal ELA-DCR.     

Outcome of external dacryocystorhinostomy combined with membranectomy of a distal canalicular obstruction

PURPOSE: To investigate the accuracy of the preoperative evaluation in identifying a membranous obstruction of the distal canaliculus and the success rate of an external dacryocystorhinostomy (DCR) when membranectomy of the canalicular obstruction is also performed. DESIGN: Retrospective, interventional case series. METHODS: The surgical records of the lacrimal cases operated at Moorfields Eye Hospital between January 1997 and December 1999 were reviewed. All the patients with evidence of a membranous block of the canalicular opening into the sac identified and excised during the course of a standard DCR procedure with silastic intubation and a minimum follow-up period of 12 months were selected for this study. The records were analyzed for preoperative evaluation with syringing and probing, surgical details, outcome, and complications. RESULTS: In 59 (85%) cases a functional anastomosis was established after tube removal. Additionally, 5 cases (7%) had patent system but required later ectropion repair and considered successful. Only 4 (6%) patients needed further lacrimal surgery, and one was referred to the ENT department for nasal polyps. The silastic tube was removed at a mean period of 6 weeks (SD = 4; range, 2-24 weeks), and the mean follow-up period was 13 months (SD = 3; range, 12-29 months). The preoperative evaluation failed to identify the membranous obstruction in 30 (43%) cases, which were correctly diagnosed intraoperatively. CONCLUSIONS: In our series the anatomic success rate of 92% after DCR with membranectomy is comparable to the outcome of the DCR procedure. The distal canalicular membranous obstruction is an anatomic factor that may lead to surgical failure if not identified and excised.     

Selective antibiotic use to prevent postoperative wound infection after external dacryocystorhinostomy

PURPOSE: The use of systemic antibiotic prophylaxis in lacrimal drainage surgery is controversial. Some studies have reported high rates of postoperative infection and surgical failure after lacrimal drainage surgery when systemic antibiotic prophylaxis was not routinely administered. Many ophthalmologists have traditionally used antibiotics only in selected patients undergoing dacryocystorhinostomy (DCR), and this study evaluates the success of this strategy. METHODS: This was a retrospective interventional case series of 138 consecutive patients who underwent 163 external DCR procedures. Antibiotics were given only when inflammatory signs were present in the medial canthal region or when purulent material was noted during surgery. Patients with persistent external medial canthal inflammatory signs received amoxicillin/clavulanate or cephalexin orally 3 to 7 days before and 1 week after surgery. Patients in whom purulent lacrimal sac material was noted during surgery received cefazolin intravenously. RESULTS: Postoperative results were evaluated in terms of wound infection and related complications and surgical success. Systemic antibiotics were given in 15 of 163 (9%) cases. Nine (6%) cases received intraoperative (intravenous) antibiotics; 5 (3%) cases received perioperative (oral) antibiotics; and 1 (1%) case received both. None of the patients had postoperative deep soft tissue infection (cellulitis). Skin changes compatible with superficial wound infection occurred in 2 (1%) cases and responded well to topical treatment. Surgery was successful in 157 of 163 (96%) cases. Of 6 failures, none were associated with postoperative wound infection. CONCLUSIONS: Selective use of antibiotics limited to patients with signs of lacrimal sac inflammation appears sufficient to prevent soft tissue infection after DCR.