Dacryocystorhinostomy – external, endonasal and transcanalicular

CONCLUSIONS

REFERENCES1. 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.

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 ofmucosal 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 obstructionwhen compared with endoscopic surgical approaches. Transcanalicular laser DCR represents one of many recentattempts to improve lacrimal surgery.

RESULTS

MILITARY INSTITUTE OF THE HEALTH SERVICES WARSAW, POLANDAndrzej Stankiewicz, Radosław Różycki, Michał Michalikº, Marek Rękas, Aleksandra Jakubaszek, Artur Maliborski*Department of Ophthalmology: Head of the Department: Professor A. Stankiewiczº Medical Ophthalmology end Laryngology Center: Head of the center: MD M. Michalik* Department of Radiology: Head of the Department: MD PhD R. Bogusławska

MATERIAL AND METHOD

131 PATIENTS38M 93 F

1st GROUP EXT DCR80 patients

2nd GROUPEndonasal DCR

8 patients

3rd GROUPLDCR

43 patients

Osteotomy Localization and incision of lacrimal sac

Removal purulence from lacrimal sac

Intubation of lacrimal duct with Crawford sonde

Local anesthesia Incision of nasal mucosa

Coagulation of bleeding vessels

Exposure of lacrimal bone crest

Lacrimal sac and nasal mucosa incision

Intubation of lacrimal duct with Crawford sonde

Joining nasal and lacrimal sac flaps

Closing skin incision with suture

Skin incision Exposure of lacrimal bone crest

Removal lacrimal bone

Osteotomy

Tissue vaporisation Intubation of lacrimal duct with Crawford sonde

Osteotomy after procedure

Cooperation ophthalmologist and laryngologist

Putting eye – shield Local anesthesia Placement of laser energy

Transcanalicular placement of a light pipe

POSTOPERATIVE CARETopical 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 laserprocedures were performed with patients under local anesthesia, EXT DCR under general anesthesia.

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

136 procedures

EXT DCR80 patients

Endonasal DCR8 patients

SUCCESS 72 (90%) SUCCESS 5 (62,5%)

L DCR48 patients

SUCCESS 40 (83,3%)

PARTIAL 2 (25%) PARTIAL 6 (12,5%) PARTIAL 8 (10%)

FAILURE 0 (0%) FAILURE 2 (4,2%) FAILURE 1 (12,5%)

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, neitherTranscanalicular 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, andgreater laser availability, will likely bring this simple approach to the forefront of lacrimal surgery.

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 diodelaser 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 lacrimaldrainage 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 wasremoved.

DCRext ECL EDCR35

40

45

50

55

60

65

70

75

80

85

90

Age

Mean Mean±SD Mean±SE

Age Mean SD P

DCRext 58,5 16,9

0.072ECL 68,0 14,2

EDCR 62,4 21,7Intaoperative 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.

EPIPHORA