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Dacryocystorhinostomy – external, endonasal and transcanalicular MILITARY INSTITUTE OF THE HEALTH SERVICES WARSAW, POLAND Andrzej Stankiewicz, Radosław Różycki, Michał Michalikº, Marek Rękas, Aleksandra Jakubaszek, Artur Maliborski* Department of Ophthalmology: Head of the Department: Professor A. Stankiewicz º Medical Ophthalmology end Laryngology Center: Head of the center: MD M. Michalik * Department of Radiology: Head of the Department: MD PhD R. Bogusławska The history of dacryocystorhinostomy (DCR) is well known and has been retold frequently. The exceptionally successfulexternal approach1 has remained essentially unaltered since its 19th century inception, with the notable introduction of mucosal linings by Dupuy-Dutemps and Bourguet in 19212 and concurrent silicone intubation by Jones in 1962. There is little dispute that external DCR affords the greatest likelihood of resolving epiphora due to complete lacrimal duct obstruction when compared with endoscopic surgical approaches. Transcanalicular laser DCR represents one of many recentattempts to improve lacrimal surgery.

MATERIAL AND METHOD The preoperative enrolling of patients included: epiphora related to lacrimal pathway obstruction, positive fluoresein dye test, obstruction in probing. Dacryocystography was made in most cases. A small number of analyzed endoscopic surgery were due to lack of a diode laser at the moment of examination's beginning. Subjects with lacrimal sac and duct obstruction were listed for endonasal dacryocystorhinostomy or transcanalicular reconstruction of the lacrimal drainage with the use of the diode laser. Posttraumatic or canalicular lacrimal drainage obstruction was disqualified. Also anomalies in DCG (diverticulum), pathological lesion (polyps, granulation tissue, Wegener's disease) were disqualified. All lacrimal drainage systems were intubated using Crawford's sonde. 3 months after surgery Crawford's sonde was removed. 131 PATIENTS 38M 93 F 1st GROUP EXT DCR 80 patients

Skin incision

Lacrimal sac and nasal mucosa incision

Exposure of lacrimal bone crest

Removal lacrimal bone

Joining nasal and lacrimal sac flaps

Intubation of lacrimal duct with Crawford sonde

2nd GROUP Endonasal DCR 8 patients

Incision of nasal mucosa

Coagulation of bleeding vessels

Localization and incision of lacrimal sac

Removal purulence from lacrimal sac

Local anesthesia

Osteotomy

Osteotomy

Closing skin incision with suture

3rd GROUP LDCR 43 patients

Putting eye – shield

Exposure of lacrimal bone crest

Intubation of lacrimal duct with Crawford sonde

Tissue vaporisation

POSTOPERATIVE CARE

Local anesthesia

Intubation of lacrimal duct with Crawford sonde

Placement of laser energy

Transcanalicular placement of a light pipe

Osteotomy after procedure

Cooperation ophthalmologist and laryngologist

Topical antibiotic/steroid eye drop for 14 – day course, systemic antibiotics for 5 days, endoscopic inspection of surgical site after 1 month and 3 months, lacrimal irrigation to assess fistula patency once a month. Endonasal and transcanalicular with the use of the diode laser procedures were performed with patients under local anesthesia, EXT DCR under general anesthesia.

RESULTS

90

Age

Mean

SD

P

85 80 75

DCRext

58,5

16,9

70

Age

Complete therapeutic success: 1. Complete reduction of epiphora 2. Jones test positive in endoscopy 3. Osteotomy > 1.5 mm Partial therapeutic success : 1. Intermittent epiphora 2. Patent fistula during lacrimal irrigation 3. Osteotomy≤1,5 mm Failure rate: 1. Epiphora 2. Fibrosis of the osteotomy

ECL

68,0

14,2

0.072

65 60 55

EPIPHORA

50

Intaoperative and postoperative complications in DCR were: intraoperative bleeding, cicatrix, surgical emphysema, removal of intubation. Intraoperative bleeding was an intraoperative complication in endonasal DCR. In LDCR there were no complications.

EDCR

62,4

45

21,7

40 Mean 35

DCRext

Mean±SD ECL

Mean±SE EDCR

136 procedures

EXT DCR 80 patients

Endonasal DCR 8 patients

L DCR 48 patients

SUCCESS 72 (90%)

SUCCESS 5 (62,5%)

SUCCESS 40 (83,3%)

PARTIAL 2 (25%)

PARTIAL 6 (12,5%)

PARTIAL

8 (10%)

FAILURE

0 (0%)

FAILURE

1 (12,5%)

FAILURE

2 (4,2%)

CONCLUSIONS The allure of incision-sparing surgery and shortened convalescence continues to produce innovations in lacrimal surgery. Although myriad techniques and lasers have been explored, success rates for laser DCR continue to range from 50% to 85% for one procedure. Clearly, neither Transcanalicular laser DCR nor any other endoscopic technique has consistently matched the success rate established for external DCR. Continued advances in technology and technique, such as endonasally deployed ostium collars, innovative lacrimal stents, antimetabolites, and greater laser availability, will likely bring this simple approach to the forefront of lacrimal surgery.

REFERENCES 1. Jones LT. The cure of epiphora due to canalicular disorders, trauma and surgical failures on the lacrimal passages. Trans Am Acad Ophthalmol Otolaryngol 1962;66:506 –24. 2. Woog JJ, Kennedy RH, Custer PL, et al. Endonasal dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology 2001;108:2369 –77. 3. Endocanalicular Laser Dacryocystorhinostomy: Analysis of 118 Consecutive Surgeries , 08 August 2005 Jenny E. Hong, Mark P. Hatton, Martin L. Leib, Aaron M. Fay Ophthalmology September 2005 (Vol. 112, Issue 9, Pages 1629-1633) 4. Pearlman SJ, Michalos P, Leib ML, Moazed KT. Translacrimal transnasal laser-assisted dacryocystorhinostomy. Laryngoscope 1997;107:1362–5. 5. Fay AM, Michalos P, Rubin PA. Endocanalicular Nd:YAG laser dacryocystorhinostomy. Int Ophthalmol Clin 1999;39: 177–84. 6. Hartikainen J, Antila J, Varpula M, et al. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 1998; 108:1861–6. 7. Rosen N, Barak A, Rosner M. Transcanalicular laser-assisted dacryocystorhinostomy. Ophthalmic Surg Lasers 1997;28: 723–6. Hong et al Endocanalicular Laser Dacryocystorhinostomy 1633 8. Fayet B, Racy E, Assouline M. Complications of standardized endonasal dacryocystorhinostomy with unciformectomy. Ophthalmology 2004;111:837– 45. 9. Linberg JV, Anderson RL, Bumsted RM, Barreras R. Study of intranasal ostium external acryocystorhinostomy. Arch Ophthalmol 1982;100:1758–62.

Dacryocystorhinostomy – external, endonasal and transcanalicular  

Dacryocystorhinostomy – external, endonasal and transcanalicular - Andrzej Stankiewicz, Radosław Różycki, Michał Michalikº, Marek Rękas, Al...