Outcome of Endoscopic Endonasal Dacryocystorhinostomy

1
Outcome of Endoscopic Endonasal
Dacryocystorhinostomy
R. Suryanarayanan, A. Kinshuck, A. C. Swift ENT
Department, University hospital of Aintree
Introduction Endoscopic dacryocystorhinostomy
(DCR) is a well established procedure to relieve
naso lacrimal duct obstruction. Endonasal
approach to lacrimal sac surgery was first
introduced by Caldwell1 in 1893, but the
visibility into nasal cavity was very poor.
Subsequently high resolution endoscopes were
introduced in 1980s, which improved the
visualisation of the nasal cavities enabling
endonasal DCR. In our centre, the senior author
is performing endoscopic DCR operation since
early 1990s. The aim of this study is to report
the clinical outcome of the operations.
Results of primary operations 56 (68) sides
improved with 45 sides getting complete relief
and 11 sides improving considerably (partial
relief). The outcome was better in patients with
obstruction at the level of sac or the
nasolacrimal duct (83) than those with common
canalicular or more proximal obstruction (57) .

Results of primary endoscopic DCR in 82 eyes
Method This is a retrospective study. Initial
assessment of the patient was performed by
ophthalmologist, who then referred the patient to
the senior author. Obstruction of the
nasolacrimal system was diagnosed with
nasolacrimal syringing. Radiologic imaging was
not used routinely. These patients underwent full
endoscopic evaluation of the nasal cavity in the
ENT clinic. The operation was performed under
GA mostly. Nose was prepared using moffats
solution. The lower punctum was dilated and a
suitable sized lacrimal probe was inserted and
advanced into the lacrimal sac. Its position was
visualised in the nasal cavity with a 0 degree
rigid endoscope. Lacrimal fistula was created
surgically and enlarged with a bone ronguer, if
necessary. Odonoghue silicone tube was then
inserted and secured in the nose by a loose knot
and a ligaclip. Post operatively patients
received ciprofloxacin eye drops for a week. The
tube stayed for variable length of time, with a
median of 3 months (1 to 10 months). The
operation was considered successful if the
patient became asymptomatic (complete relief) or
if symptoms improved significantly (partial
relief). .
Results of revision DCR 23 operations were
revision of our own cases. 18 operations were
revisions following primary surgery performed by
others.
Results of revision DCR

• Factors associated with failure
• No difference in the side operated, age or sex
  incidence
• Aetiology of NL obstruction included infection
  (12), trauma (2) and sarcoidosis (1)
• Common canalicular block (9)
• Intranasal adhesion (3)
• Post operative infection (2)
• Physiological failure (2)

Discussion Endoscopic DCR has become an accepted
technique for the management of NL obstruction
and gives outcome similar to external DCR.2
Success rate for the endoscopic technique range
from 70 to 953-6. These results are similar to
those achieved with external DCR.7,8 Endoscopic
DCR performed with laser appears to be less
effective, with success rates ranging from 64 to
85,4,3,8 than cold steel procedure that has a
success rate of about 85 to 96.5,6,9 However
confounding factors such as mucocele, infection,
intranasal adhesion and connective tissue
disorder such as sarcoidosis can impair a
successful outcome, as shown in our study as well
as by others10. Level of naso lacrimal
obstruction seems to be another major factor that
influences the final outcome. We found better
outcome in patients with obstruction at the sac
or NL duct than in those with more proximal
obstruction, a finding also reported in the
literature.11 The procedure of endoscopic DCR
does need training. Otolaryngologist are a
valuable part of the surgical team, as nearly a
third of the patients (as seen in our study) with
lacrimal obstruction also have intra nasal
pathology that need to be dealt with
concurrently. Careful patient selection,
meticulous technique at operation, appropriate
treatment of any intra nasal pathology and
regular follow up seem to be the key to
successful outcome.
Result 127 operations were performed on 77
patients. 100 sides (eyes) were operated. The
median age of the patients was 65 (33-89 years).
51 were females. 56 right sides and 44 left sides
were operated. The follow up of these patients
varied from 2 months to 7 years with a mean of 15
months and a median of 9 months. All operations,
but four, were performed under general
anaesthesia. Out of the total of 127
operations, three records were unavailable and
one operation was abandoned as the puncta could
not be cannulated. Of the remaining 123
operations, 82 were primary operations with 41
revision procedures.

• Endoscopic DCR
• Avoids a facial scar
• Limits the tissue injury to the fistula site
• Avoids disruption of the medial canthus
• Day case procedure, can be done under LA
• Intra nasal pathology dealt with at the same
  time
• Particularly suitable for revision cases, where
  the scar tissue can make external DCR difficult.

• Points to remember about endoscopic DCR
• The procedure needs training
• Results are better for NLD/Sac obstruction than
  for common canalicular blockage
• Associated intranasal pathology can impair a
  successful outcome
• Outcome is generally good but the success rate
  may not always be similar to published results.

Reference 1. Caldwell GW. Two new operations for
obstruction of the nasal duct. N Y J Med.
189357581582. 2. Hartikainen J, Antila, J,
Varpula, M. Prospective Randomized Comparison of
Endonasal Endoscopic Dacryocystorhinostomy and
External Dacryocystorhinostomy 108(12), December
1998, pp 1861-1866. 3. Hehar SS, Jones NS, Sadiq
A, Downes RN. Endoscopic holmium YAG laser
dacryocystorhinostomy is safe and effective as a
day-case procedure. J Laryngol Otol 1997 111
1056 1059. 4. Metson R, Woog JJ, Puliafito CA.
Endoscopic laser dacryocystorhinostomy.
Laryngoscope 1994 104 269 274. 5. Sprekelsen
MM, Barberan MT. Endoscopic dacryocystorhinostomy
surgical technique and results. Laryngoscope
1996 106 187 189. 6. Weidenbecher M, Hosemann
W, Buhr W. Endoscopic endonasal
dacryocystorhinostomy results in 56 patients.
Ann Otol Rhinol Laryngol 1994 103 363 367. 7.
Welham RA, Wulc AE. Management of unsuccessful
lacrimal surgery. Br J Ophthalmol 1987 71 152
157. 8. Hartikainen J, Grenman R, Puukka P, Seppa
H. Prospective randomized comparison of external
dacryocystorhinostomy and endonasal laser
dacryocystorhinostomy. Ophthalmology 1998 105
1106 1113. 9. Wormald, PJ Powered Endoscopic
DacryocystorhinostomyVolume 112(1), January 2002,
pp 69-7. 10. Ressiniotis T, Voros GM, Kostakis
VT, Carrie S, Neoh C. Clinical outcome of
endonasal KTP laser assisted dacryocystorhinostomy
BMC Ophthalmol. 2005 5 2. 11. Yung MW,
Hardman- Lea S. Analysis of the results of
surgical endoscopic dacryocystorhinostomy effect
of the level of obstruction. Br J Ophthalmol
2002 86 792 - 794