Endonasal Laser Dacryocystorhinostomy Research Articles

Prospective Comparison of Conventional External Dacryocystorhinostomy and Endonasal Laser Dacryocystorhinostomy

Background:Epiphora, a common manifestation of chronic dacryocystitis, requires definitive treatment through dacryocystorhinostomy (DCR), a surgical procedure aimed at creating an alternative fluid drainage pathway.This study aimed to assess how effective both external dacryocystorhinostomy (Ex-DCR) and endonasal dacryocystorhinostomy (Endo-DCR) are in managing chronic dacryocystitis, with a specific focus on surgical duration, complication rates, and treatment outcomes. Methods: In this study, sixty participants were prospectively enrolled and evenly divided into two groups. Thirty patients were assigned to the first group and underwent En-DCR surgery, while the second group, also comprising thirty patients, underwent Ex-DCR surgery. Both groups were monitored for a duration of 9 months and assessed for surgical duration, perioperative and postoperative complications, and eventual surgical outcomes. Results: The distribution of patients across age groups and sexes was similar between the two groups (p>0.05). Clinical features such as epiphora, epiphora with discharge, and epiphora with swelling were comparable between groups. En-DCR group demonstrated significantly less intraoperative bleeding (mean:13.5 ml vs 50 ml; p<0.0001) and shorter operative durations (mean: 20 mins vs 37.5 mins; p<0.0001) compared to Ex-DCR group. Complications such as nasal bleeding and hematoma were minimal in both groups, with no significant differences noted. The final outcome, categorized as success (En-DCR vs Ex-DCR: 76.7% vs 83.3%) or failure (23.3% vs 16.7%), did not show a statistically significant difference between the two groups (p>0.05). Conclusion:Both surgical techniques offer feasible alternatives for addressing issues related to nasolacrimal obstruction. J Bangladesh Coll Phys Surg 2024; 42: 355-362

A Comparison of Endonasal Dacryocystorhinostomy and External Dacryocystorhinostomy: A Report by the American Academy of Ophthalmology

To assess the efficacy of endonasal dacryocystorhinostomy (DCR) compared with external DCR. A literature search was conducted in the PubMed database in March 2016 and updated in October 2017 and February 2019. The search strategy was designed to update the first Ophthalmic Technology Assessment on endonasal DCR from 2001 by identifying new peer-reviewed human studies reported since 2000 in the English language that compare results of endonasal DCR with those of external DCR. The searches yielded 169 articles. Of these, 13 met the inclusion criteria and were assigned a level of evidence rating. Six of the 13 studies included in this assessment were rated level II and 7 were rated level III. Three of the 13 studies drew conclusions based on statistically significant results, but all of these were level III evidence. Two of these significant studies demonstrated lesser efficacy of endonasal laser DCR (63%-64%) compared with external DCR (94%; P= 0.0002, 0.024). The third study reported that nonlaser endonasal DCR was superior to external DCR (84% vs. 70%; P=0.03). The remainder of the studies did not find statistically significant differences in success rates between the 2 techniques. Limited data suggest that laser endonasal DCR may be less effective than external DCR. Existing data are inadequate to draw conclusions about whether endonasal DCR is superior to, equivalent to, or inferior to the gold standard external DCR.

Experience in navigation system use in surgical treatment of the traumatic dacryocystitis recurrence (clinical case)

The article presents a clinical case of surgical of a recurrent chronic purulent dacryocystitisof traumatic etiology. Under endoscopic control, the patient underwent a revisional endonasal laser dacryocystorhinostomy with bicanalicular silicone stent. All surgical steps were controlled on the navigation system display. Navigation equipment was used to accurately visualize the structures of the nasal cavity and lacrimal pathways, because the anatomy of this area was changed as a result of the midface trauma and preliminary unsuccessful surgical procedures. During surgery, the functional and anatomical patency of the lacrimal pathways was achieved. Thus, the navigation system is a useful supplementary equipment that allows identifying the lacrimal sac in complex surgical situations, to monitor the state of lacrimal passages and surrounding nasal structures, which ultimately increases the effectiveness and safety of the procedure.

The return of the jedi: comparison of the outcomes of endolaser dacryocystorhinostomy and endonasal dacryocystorhinostomy

External dacryocystorhinostomy (DCR) is considered to be the gold standard treatment of primary acquired nasolacrimal duct obstruction. A better understanding of the endoscopic anatomy of the lacrimal sac has increased the success rate of endonasal DCR. Laser DCR has become popular in recent years and has a success rate comparable with those of other endonasal techniques. The aim of this study was to compare the surgical results of endonasal DCR (EDCR) and endonasal laser DCR (ELDCR). Fifty-four patients treated with ELDCR and 42 patients treated with EDCR for nasolacrimal duct obstruction from 2009 to 2012 with at least 1.5 years of follow-up were retrospectively enrolled in this comparative study. Lack of patient complaints and irrigation testing were used as subjective and objective assessment tools, respectively. Both groups were similar in terms of age and sex. ELDCR had a success rate of 85.2%, and EDCR had a success rate of 92.9%. The difference between the 2 procedures was not statistically significant. ELDCR had a significantly shorter operative time than did EDCR (16.9 vs 24.4 minutes, respectively; p < 0.001). Endonasal procedures have the advantage of no scar formation and do not disturb the pumping mechanism of the lacrimal sac. Their success rates are comparable with those of external DCR. Surgery is quicker, and with use of a laser, even less time is spent in the operating room. In selected cases, ELDCR can be a good alternative method with a high success rate.

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

Purpose Endonasal dacryocystorhinostomy is known as an increasingly attractive and effective approach for the surgical treatment of nasal duct obstruction with minimal complications and best cosmetic consequences. In a relatively large-scale case-series study over a 5-year period, we describe the surgical technique and 12-month follow-up results of microscopic laser dacryocystorhinostomy with particular regard to the effect of various pre-/postoperational factors (ie, patients' sex, age, symptoms chronicity, previous interventions, duration of silicone intubation) on the surgical outcome. Materials and methods A total of 162 cases in 151 patients with chronic epiphora, mucocele, or recurrent episodes of dacryocystitis were included in the study. Endonasal laser dacryocystorhinostomy was performed using a surgical microscope with transcanalicular lacrimal sac illumination. The laser types used were potassium-titanyl-phosphate and neodymium:yttrium-aluminum-garnet for ablation of nasal mucosa and application to bone, respectively. Patients were evaluated 6 months and 1 year later. Data were analyzed by χ 2 tests. Results There were no major complications during or after the operations. Complete cure occurred in 89.5% (after 6 months) and 74.2% (after 1 year) of the cases. Anatomical patency was shown by lacrimal system irrigation with fluorescein in 81.5% of the cases after the 12-month follow-up. It was found that patients younger than 55 years, with symptoms lasting less than 1 year, and without history of nasal problems, had significantly higher surgical success rates ( P < .05). Moreover, rates of failure were significantly lower in cases whose canaliculi were intubated for 5 to 6 months ( P < .05). Conclusions Endonasal microscopic laser dacryocystorhinostomy is a safe and minimally invasive procedure with reasonable results. It has many advantages over external or other conventional approaches. Successful results could be further enhanced by more wisely selecting the patients and by silicone extubation after 6 months.

Implante de ducto nasolacrimal de poliuretano: relato de caso

Epiphora (watering eye) is generally caused by insufficient drainage of tears. The most common cause of epiphora in adults is idiopathic inflammatory obstruction of the nasolacrimal duct. The traditional surgical treatment of nasolacrimal duct obstruction is an external dacryocystorhinostomy, which has an 85% to 95% success rate. To eliminate cutaneus wounds and scarring some techniques were introduced, for example the endonasal laser dacryocystorhinostomy and the nasolacrimal stent. The aim of this report was to evaluate the first case of nasolacrimal stent implantation in Brazil. The procedure was performed in the "Hospital das Clínicas" of the University of São Paulo - USP. A female patient with tearing of the right eye and secretion was submitted to a nasolacrimal stent implantation, with fluoroscopic guidance. The stent used in this procedure was the polyurethane Tearleader stent set. (Dr. Wilhelm type-PBN MEDICALS - Denmark). After 3 months, the patient started complaining of tearing, so the stent was removed and the patient was submitted to an external dacryocystorhinostomy. At present the patient does not have any symptoms or complaints. This procedure is less invasive and simple, causes no facial scars and avoids surgical trauma, but the long term success rates achieved using polyurethane nasolacrimal stents are low as compared with the external dacryocystorhinostomy. In addition, the patients usually complaint of tearing even having patent lacrimal system. In summary, long-term studies are needed to resolve some complications. Maybe a new stent design and new methods of unblocking the stent in situ would improve in the near future the levels of patency that currently are modest.

Endoscopic endonasal laser versus endonasal surgical dacryocystorhinostomy for epiphora due to nasolacrimal duct obstruction: prospective, randomised, controlled trial

Rhinostomy patency is a problem in all forms of dacryocystorhinostomy. Laser-assisted procedures are potentially fast and result in excellent haemostasis. However, they may induce more fibroblastic activity, resulting in excessive scarring and stenosis of the rhinostomy, compared with non-laser dissection. The objective of this study was to compare subjective outcomes following dacryocystorhinostomy conducted with endoscopic endonasal laser and with endonasal surgical techniques. Prospective, randomised, controlled trial comparing potassium titanyl phosphate endonasal laser dissection with endonasal surgical techniques, for dacryocystorhinostomy to treat epiphora due to primary, acquired nasolacrimal duct obstruction. One hundred and twenty-six adult patients with chronic epiphora due to primary, acquired nasolacrimal sac or duct obstruction. INTERVENTIONS comprised endonasal dacryocystorhinostomy, performed using potassium titanyl phosphate laser or surgical dissection, in order to open the lacrimal sac into the nasal cavity. These were: symptom score and symptom relief of epiphora (at three and 12 months post-procedure); duration and ease of procedure; and duration of hospital stay. Sixty patients underwent endonasal laser dacryocystorhinostomy and 66 underwent endonasal surgical dacryocystorhinostomy. Symptomatic success was 82 per cent at three months and 68 per cent at 12 months in the laser group, and 76 per cent at three months and 74 per cent at 12 months in the surgical group. A two-point reduction in the symptom score was associated with symptomatic success at three and 12 months. Eight patients randomised to the laser group required additional instrumentation in order to remove thick bone over the lacrimal sac. At three months, endonasal laser dacryocystorhinostomy had better results than endonasal surgical dacryocystorhinostomy. However, at 12 months, the surgical procedure had better results than the laser procedure. There was no statistically significant difference between the two groups at three or 12 months with regard to symptomatic outcome. The ease of procedure (on a scale of zero to 10) was 4.5 for the laser procedure and 4.1 for the surgical procedure. The average times for the procedures were 25 minutes in the laser group and 20 minutes in the surgical group. No statistical difference was found when comparing: symptom score improvement for local anaesthetic vs general anaesthetic; ages over and under 70 years; laterality; or operating surgeon. Change in the symptom score was a useful indicator of symptomatic success.

Long-term results of endonasal laser dacryocystorhinostomy

To determine the long-term success rate of endonasal laser dacryocystorhinostomy (DCR) in our unit. This was a retrospective study including all the consecutive cases of endonasal laser DCR (ELDCR) between November 1996 and December 1999. Patients who underwent revision DCR were excluded. The absence or improvement of symptoms as reported by the patients was defined as successful outcome. Conversely, recurrence of epiphora was considered as failure. The results were reviewed at 1 year in the clinic and at further 3 years and 5 years by telephone consultation. There were 65 patients (73 procedures) in the study cohort, with a mean follow-up period of 74 months (range, 60-97). Early failure was noted in 13 patients at 1 year. Only 28 patients (of the possible 50) were free from epiphora after 5 years postsurgery. We found that the success rate of ELDCR has gradually declined over the years to 56% (confidence interval, 38-69) in patients who had at least 5 years of postoperative data. We do not advocate the use of laser in endonasal DCR for patients with epiphora. C-4.

Endonasal laser dacryocystorhinostomy in outpatient clinic

The endonasal laser dacryocystorhinostomy (DCR) was performed in five patients with obstruction after conventional external DCR. The surgery was performed in an outpatient setting with local anesthesia. After intranasal superficial anesthesia with gauze impregnated with 4% lidocaine hydrochloride diluted with 5000-fold epinephrine, 0.5% lidocaine hydrochloride was injected. A 20-gauge light probe, originally developed for vitrectomy, was inserted from the upper punctum. The obstructed region was illuminated using the light probe and was observed intranasally with the endoscope. The KTP laser was delivered through a 0.4-mm quartz fiber that was passed through the hand-piece for nasal surgery. The mucosa surrounding proposed rhinostomy was vaporized by the laser (continuous wave, 5 to 8 W, near-contact mode). The obstructed region was then opened and the desired rhinostomy size was achieved. Bicanalicular silicone tube intubation of the surgical ostium was performed. No complications occurred during and after surgery. The ostium continued to be patent, and the patients were free of symptoms. We concluded that the endonasal laser DCR is useful for reconstruction after conventional DCR.

Intraoperative Fluorouracil in Endonasal Laser Dacryocystorhinostomy

Although endonasal laser dacryocystorhinostomy (ELDCR) offers many advantages compared with conventional techniques, postoperative scarring leading to occlusion of the rhinostomy is more common with ELDCR. To investigate whether fluorouracil applied to the rhinostomy site intraoperatively has an effect on the outcome. We randomly allocated 155 consecutive patients (201 procedures) to a control group and a fluorouracil group. Patients and investigators were masked to the choice of treatment. All patients underwent ELDCR. A pledget soaked in isotonic sodium chloride solution or 0.5-mg/mL fluorouracil, randomly allocated by the pharmacy, was applied to the rhinostomy site for 5 minutes at the time of surgery. Patients were followed up for 12 months and their symptoms were assessed at each visit. Among patients followed up for 12 months or longer, ELDCR procedures performed with topical application of fluorouracil to the rhinostomy site were successful in 65 (76%), compared with 52 (63%) for the control group. This was not statistically significant when patients who failed to attend follow-up at or after 12 months were not counted as successfully treated (P =.21, chi(2) test). Even if those who failed to attend for follow-up were counted as successes, the effect of fluorouracil did not reach significance at the.05 level (P =.08, chi(2) test). The topical application of fluorouracil failed to increase the patency rates in ELDCR.

Local anaesthetic endonasal endoscopic laser dacryocystorhinostomy: analysis of patients' acceptability and various factors affecting the success of this procedure.

Endonasal endoscopic laser dacryocystorhinostomy is now a well established, effective approach to relieve nasolacrimal duct obstruction. Whereas attempts have been made to comment on the efficacy of the procedure, no study has been conducted to evaluate the acceptability of this procedure by those at the receiving end, ie, the patients. An attempt has been made in the present study to critically evaluate the procedure from the point of view of patients' acceptability and also to evaluate certain factors which may influence the success rate of this procedure. Forty-six eyes from 40 patients underwent endonasal endoscopic laser dacryocystorhinostomy, performed by the same surgeon, over a period of 15 months. Various aspects of the procedure were evaluated by patients by filling out a simple questionnaire (Figure 1). In addition to recording patients' views, success of the procedure was confirmed by performing a postoperative sac washout in the clinic. Patients were also subdivided according to their age, duration of symptoms and history of previous surgical intervention. The data were statistically analysed using chi-square tests with the Yates correction. The percentage of patients who declared themselves completely cured was 65.22%. A partial resolution was felt by 23.91% of patients and no improvement was reported by 10.87% of patients. Forty-two out of the 46 eyes (91.3%) achieved anatomical success by the procedure, as shown by a postoperative sac washout performed in the clinic. Some of them, however, did not have complete resolution of their symptoms perhaps due to an additional factor of lacrimal pump dysfunction in these patients. During the procedure 60.86% of eyes felt no discomfort at all whereas 39.14% of eyes felt some discomfort at some point of time during the procedure (Table 1). When directly asked 86.12% of patients recommended the procedure (implying that the procedure had some good effect on their quality of life), 8.33% of patients did not recommend it and 5.55% of patients made no comments. Various factors affecting the success of this procedure were analysed (Table 2) and it was found that eyes which had no previous surgical intervention showed a complete cure rate which was significantly higher than that seen in eyes which had some sort of previous intervention (P = 0.0003); eyes with a short (<6 mths) duration of symptoms showed significantly higher success rates (P = 0.0098) in comparison to that shown by eyes with longer (>6 mths) duration of symptoms; and younger patients (<50 yrs) had a complete resolution rate much higher than patients over 50 yrs of age (P = 0.0309). The present study clearly shows that endonasal endoscopic laser DCR is an effective procedure, well tolerated and recommended by the patients. Discomfort during the procedure is not a major problem. Younger patients, with no previous surgical intervention and with short duration of symptoms are likely to be benefited the most. Though success rates are higher with external DCR, endonasal endoscopic laser DCR offers certain advantages over the external approach while keeping the option of external DCR open, if needed at a later date.

Local anaesthetic endonasal endoscopic laser dacryocystorhinostomy: analysis of patients’ acceptability and various factors affecting the success of this procedure

Local anaesthetic endonasal endoscopic laser dacryocystorhinostomy: analysis of patients’ acceptability and various factors affecting the success of this procedure

Endonasal Laser Dacryocystorhinostomy and External Dacryocystorhinostomy Outcome Profile in a General Ophthalmic Service Unit: A Comparative Retrospective Study

To evaluate the outcome profile of endonasal laser dacryocystorhinostomy (ENL-DCR) in comparison with external dacryocystorhinostomy (ENL-DCR) carried out as part of general ophthalmic service within the same center. Patients who have undergone external or endonasal laser DCR in the authors institute with a minimum follow-up of 9 months and at least 3 months after removal of the tubes were invited to participate in this research. We used a questionnaire and a systematic clinical examination for detecting lacrimal passage patency and function. Patients were classified into categories: complete anatomical and physiological success; anatomical success with partial relief of symptoms; anatomical success with no relief of symptoms; anatomical failure. The endoscopic view of the ostium vertical location has been classified into four levels. One hundred and ten external-DCR and 53 Endonasal-DCR procedures were evaluated. Free communication (anatomical success) was achieved in 82% undergoing Ext-DCR and in 58% undergoing ENL-DCR. A significant number of patients continued to have symptoms in spite of a patent fistula (54% for Ext-DCR and 39% for ENL-DCR). The site of the opening of the internal ostium was significantly related to the persistence of symptoms in spite of free communication (P < 0.001, chi-square test). In this series of patients undergoing DCR in a general ophthalmic unit, the standard Ext-DCR technique has a higher anatomical success rate than the endoscopic laser DCR but not necessarily with equivalent rate of relief of symptoms. An inferiorly placed ostium is more likely to result in complete relief of symptoms.

Quality of life outcomes following dacryocystorhinostomy: external and endonasal laser techniques compared

AIMS/BACKGROUND . Endonasal laser dacryocystorhinostomy (ELDCR) has recently become established as an alternative technique to conventional external DCR (EXDCR) for relief of epiphora. The aim of this study was to compare quality of life and symptomatic outcomes in patients treated by these two methods. METHODS . A postal questionnaire was sent to 204 ELDCR and 78 EXDCR patients who had undergone surgery under our care more than 6 months previously. The questionnaire included the validated 18-item Glasgow Benefit Inventory (GBI) and 5 further questions addressing ocular symptomatology. RESULTS . Fully completed questionnaires were received from 156 ELDCR and 50 EXDCR patients. Mean GBI scores of +16.8 (ELDCR) and +23.2 (EXDCR) were obtained (Mann-Whitney U test = NS). Ocular symptom scores were +33 (ELDCR) and +54 (EXDCR) (p=0.005). CONCLUSION . Patients undergoing either ELDCR or EXDCR experience significant benefit in their healthcare status as detected by the GBI. There is no significant difference between the scores obtained by the two groups of patients. There were improvements in ocular symptom scores in both groups, with patients who had EXDCR scoring significantly better than the ELDCR group.

Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy

Objective and design The introduction of endonasal laser dacryocystorhinostomy (ENL-DCR) in the early 1990s showed great promise of changing dacryocystorhinostomy into an elegant, minimally invasive procedure from the traditional external dacryocystorhinostomy (EXT-DCR). This prospective, randomized study compares these two operations, their success rates, surgical durations, and postoperative symptoms. Participants A total of 64 cases in 61 patients with primary acquired nasolacrimal sac or duct obstruction were divided into 2 subgroups by symptoms (simple epiphora and chronic dacryocystitis). These patients were randomized within both subgroups into 2 operation groups with 32 cases in each group. Intervention Altogether, 32 EXT-DCRs and 32 ENL-DCRs were performed. The silicone tube was removed at 6 months after surgery. The final follow-up visit was at 1 year after surgery. The patency of the lacrimal passage was investigated by irrigation, and patients were questioned about their symptoms. Main outcome measures The patency of the lacrimal passage to irrigation and the duration of surgery were measured. Results The success rate at 1 year after surgery was 91% for EXT-DCR and 63% for ENL-DCR after primary surgery. The difference was statistically significant ( P = 0.016). The surgical duration for ENL-DCR was three times shorter than for EXT-DCR, the average duration being 23 minutes and 78 minutes, respectively ( P < 0.0001). Conclusions The EXT-DCR, when compared with ENL-DCR, seems to provide superior operation results in primary acquired nasolacrimal duct obstruction.

Endonasal laser dacryocystorhinostomy under direct vision

We describe a method of endonasal laser dacryocystorhinostomy, using a neodynium-YAG laser, whose ease of performance should make it attractive to general ophthalmologists as an alternative to the routine external approach. A small series of 6 patients were investigated 6 months after surgery and a patent drainage system was revealed.

Transcanalicular THC:YAG Dacryocystorhinostomy

Chromium-sensitized and thulium- and holmium-doped YAG lasers (THC:YAG laser) were used to create a nasal bony ostium in the area of the lacrimal sac fossa in four fresh frozen bisected human cadaver heads. The lasers-long pulsed (300 milliseconds), compact, self-contained, and solid state--operate in the near infrared (2.1 microns). The opening was created by passing the 320-micrometer laser fiber across the canalicular system. Pulse energies of 250 to 900 mJ were used with a repetition rate of 5 to 15 pulses per second. Energy levels ranging from 1.25 to 9 W produced a full-thickness bony ostium approximately 3 to 4 mm in diameter. Silicone tubing was then threaded through the superior and inferior canaliculus system in the standard fashion. This technique may simplify conventional dacryocystorhinostomy as well as endonasal laser dacryocystorhinostomy procedures.

Translacrimal Laser Dacryocystorhinostomy-Reply

In Reply. —I thank Dr Christenbury for his kind comments regarding our original description of endonasal laser dacryocystorhinostomy (ENL-DCR) for the treatment of lacrimal outflow obstruction. I offer the following comments regarding his work. In our initial cadaver research we investigated transcanalicular passage of a 300-μm quartz fiberoptic catheter to produce a laser DCR fistula using a 16-W argon blue-green laser. The optical fiber suffered damage when used in this contact mode, causing reduced tissue cutting efficiency and increased collateral tissue damage as evidenced by post-procedure dissections. The quartz fiber described by Dr Christenbury is intended for intraocular endophotocoagulation and would be expected to present the same disadvantages. When using a transcanalicular technique, it is more difficult to control the exact site of fistula placement, and lacrimal sac mucosal damage is not directly observed. Although this route may be less cumbersome and more familiar to the ophthalmologist, the intranasal approach

Endonasal Laser Dacryocystorhinostomy

A high-powered argon blue-green laser coupled to a 300-microns quartz fiberoptic catheter was used to create intranasal dacryocystorhinostomy fistulas in fresh-frozen cadaver heads. The procedure, which we term endonasal laser dacryocystorhinostomy, is described. Cadaver specimens were examined postoperatively. Laser rhinostomies were found to involve the posteroinferior portion of the lacrimal sac fossa. Tissues surrounding the fistula site showed no signs of damage. We report on the first patient to undergo endonasal laser dacryocystorhinostomy for the treatment of nasolacrimal duct obstruction, with 10 months of follow-up. We believe endonasal laser dacryocystorhinostomy offers the following advantages over standard external dacryocystorhinostomy: (1) Tissue injury is limited to the discrete fistula site. (2) The cutaneous scar and cosmetic blemish of an external dissection are eliminated. (3) Excellent hemostasis is maintained. (4) Minimal operative and postoperative morbidity permits outpatient surgery, with faster resumption of normal daily activities and increased cost-effectiveness. (5) Patients prefer endonasal laser dacryocystorhinostomy to external dacryocystorhinostomy.