Endoscopic Dacryocystorhinostomy: A Comprehensive Review of Surgical Techniques and Clinical Outcomes.

Dacryocystorhinostomy (DCR) stands as an essential surgical procedure for addressing the persistent challenge of dacryocystitis-a condition marked by inflammation of the lacrimal sac due to nasolacrimal duct obstruction. A hospital-based retrospective study was conducted in a tertiary care hospital, spanning the years 2018 to 2023, involving 34 patients who underwent Endoscopic Dacryocystorhinostomy. The study involved the examination of their clinical presentations, surgical techniques employed, and resulting outcomes along with causes of failure. Our study included 34 patients who had presented with persistent watering of eyes. The maximum number of cases was in the age group of 46-60 years (38%), with a minimum age of 7 years and a maximum age of 68 years. Among those 34 patients, 5 underwent a revision DCR. Fifteen patients underwent stenting. Thirteen of the fifteen patients, who underwent stenting came for regular postoperative follow up and stent removal was done 6 to 8 weeks later. The two patients who were lost to follow-up presented after 4 years of their initial surgery with persistent symptoms. The success rate of endoscopic DCR was 94% in our study. Endoscopic Dacryocystorhinostomy has emerged as a practical solution for addressing nasolacrimal duct obstruction. Despite numerous surgical modifications documented over time, the endoscopic DCR technique consistently demonstrates excellent outcomes with minimal patient morbidity. This study underscores the significance of thorough preoperative assessment, making informed decisions regarding stenting during both the preoperative and intraoperative period, employing proper surgical techniques, and recognizing the importance of regular post-operative follow-up.

An Unusual Case of Dacryocystitis After Dacryocystectomy: Is It Still Possible to Perform a Dacryocystorhinostomy?

This is a rare case of a patient who developed a relapse of dacryocystitis and maxillary sinusitis although previous dacryocystectomy. We decided to perform an external dacryocystorhinostomy to remove the scar and the residual part of the lacrimal sac combined with endoscopic sinus surgery (ESS) to solve the symptoms.

Dacryocystitis: Is Dacryocystorhinostomy Always the Solution?

Background/Objectives: The aim of the study was to compare dacryocystectomy (DCT) versus dacryocystorhinostomy (DCR) in patients with dacryocystitis in terms of tearing complaints. Methods: We conducted a retrospective and comparative study on 19 patients. The main outcome measure was defined as an improvement by 1 point of the Munk score postoperatively. Results: A total of 19 patients were included with 10 in the DCR group and 9 in the DCT group. The primary endpoint was reached in 7 (70%) and in 6 (67%) patients in the DCR and DCT groups, respectively (p > 0.999). All DCR procedures were performed under general anesthesia (GA), while almost all DCT procedures were performed under local anesthesia (LA) (p < 0.001). There was a higher need for hospitalization in the DCR group (p < 0.001). Conclusions: Our preliminary results indicate that DCR is not always the solution in the case of dacryocystitis. DCT is a viable surgical procedure, especially in elderly patients without any tearing complaint and with underlying dry eye disease.

Dacryocystitis Secondary to Orbital Mesh Implant Impingement: A Rare Etiology.

A 22-year-old male patient reported swelling in relation to the right eye and developed recurrent purulent discharge and epiphora following a reconstructive traumatic orbital floor fracture repair two years ago. Radiographic investigation and surgical exploration reveal obstruction of the lacrimal apparatus at the lacrimal sac level due to over-extension/migration of the orbital floor mesh. The migration of the mesh was probably due to the extension of the mesh medially into the paranasal region.

Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter study in China.

AIM: To report the clinical profile, endoscopic dacryocystorhinostomy (En-DCR) management, and acute dacryocystitis (AD) outcomes in China. METHODS: Clinical data of 554 adult AD patients (554 eyes) who presented in 7 tertiary eye care centers for 10y from Jan 2010 to Mar 2020 were retrospectively analyzed. Clinical profile, En-DCR management, and outcomes of all cases were recorded. The anatomical and functional success were evaluated for 12mo post-operation. RESULTS: The analysis included 149 males and 368 females with a median age of 55.2y (range: 18-84y). There were 459 eyes with a history of epiphora or purulent secretion. The time between a symptom of lacrimal duct obstruction and acute onset was 1 to 540 (66.1±58.2)mo. Fifty-nine eyes had a history of the previous acute attack. Seventy-four eyes developed a cutaneous fistula, while 11 eyes had post septal cellulitis pre-operation. En-DCR with an anatomical success of 91.7% and functional success of 90.1%. The success rate of the patients with a history of acute episodes and the preoperative fistula was lower than the overall success rates. CONCLUSION: En-DCR can be performed during an acute episode in AD with a success rate of over 90%.

Treatment of acute dacryocystitis by translacrimal canalicular drainage and D-silicone intubation.

AIM: To demonstrate the outcomes of translacrimal canalicular drainage using a lacrimal probe and intranasal drainage by D-silicone intubation for acute dacryocystitis (AD). METHODS: This retrospective study included 23 patients with AD and had undergone abscess decompression with the use of lacrimal probe and intranasal drainage by D-silicone intubation between January 2019 and December 2022. Patients received abscess decompression and systemic antibiotic-corticosteroid from the time of diagnosis. D-silicone tube was inserted within 10d after diagnosis and removed 3-6mo after intubation. The procedure and outcomes of this method were evaluated. RESULTS: All patients showed improvement of signs and symptoms of AD within 72h. No intraoperative and postoperative complications were observed. No recurrence of lacrimal sac abscesses occurred after D-silicone tube removed. CONCLUSION: Lacrimal probe and D-silicone intubation appear to be a feasible, minimally invasive, safe, and effective method, which could be a reasonable choice in the treatment of AD.

Endoscopic endonasal dacryocystorhinostomy: impact of long-standing disease on surgical outcomes.

PURPOSE: To assess whether the duration of disease may influence the surgical success of Endonasal Endoscopic DCR (EE-DCR) in patients affected by nasolacrimal duct obstruction (NLDO). METHODS: Single-center observational retrospective analysis on EE-DCR via posterior trans-ethmoidal approach. Consecutive patients were enrolled in 2021-2024 and evaluated with proper questionnaires; resolution of epiphora and dacryocystitis were analyzed after 1 (T1) and 6-months (T2) from surgery. Surgical success was defined as anatomical (patency at irrigation, no recurring dacryocystitis) or complete (zeroing of Munk score). Also, patients were asked to complete the Hospital Anxiety and Depression Scale (HADS) at each timepoint. The sample was divided based on the duration of disease (group A: ≤ 24 months, group B: > 24 months). RESULTS: Ninety-one patients were included. At baseline no differences were observed between the two groups. At both timepoints, Munk score was significantly lower in Group A compared to Group B, while a difference in dacryocystitis rate was observed only at T2. Anxiety scores differed significantly at T2, although no differences were observed for depression. At paired analysis, all groups improved significantly at T1 compared to baseline, whereas no further improvement was observed between T2 and T1. A significantly higher improvement was observed in group A for the Munk and HADS-A scores over timepoints, whereas there was no significance for dacryocystitis rate and HADS-D. Also, group A showed a higher complete success rate compared to group B (p = 0.041). Finally, linear regression confirmed a positive relationship between Munk and anxiety scores and the duration of disease at T2. CONCLUSIONS: Our findings showed that long-lasting NLDO symptoms may be associated with worse EE-DCR surgical outcomes.

Chronic dacryocystitis: An insight into bacteriology and antimicrobial sensitivity pattern.

CONTEXT: Adequate management of chronic dacryocystitis is an essential prerequisite before any intraocular surgery owing to a grave risk of endophthalmitis. The knowledge of bacteriology of chronic dacryocystitis would accentuate the choice of effective antimicrobial agents and thus help in reducing the irrational use of antimicrobial agents and subsequent development of drug resistance. AIMS: We aimed to identify the causative bacterial flora and study the antimicrobial sensitivity and resistance pattern in cases of chronic dacryocystitis. SETTINGS AND DESIGN: This was a cross-sectional observational study. SUBJECTS AND METHODS: Conjunctival swabs were obtained from both eyes from 102 patients with clinical evidence of chronic dacryocystitis. Specimens for microbiological analysis were obtained, either from the conjunctival cul-de-sac and everted puncta by applying pressure over the lacrimal sac area or from the refluxing material after irrigating the lacrimal sac with sterile saline. The specimens were sent for culture and sensitivity in the department of microbiology. Ethical approvals were duly obtained. STATISTICAL ANALYSIS USED: Percentage assessment was used for statistical analysis. RESULTS: The cultures showed the presence of Staphylococcus aureus in 50% of bacterial isolates obtained from the involved eyes, followed by coagulase-negative Staphylococcus in 11.53% of isolates and Enterococcus also in 11.53% of isolates. It was observed that cefoxitin was the most sensitive antibiotic against Gram-positive organisms, followed by vancomycin and clindamycin, whereas maximum resistance was seen for penicillin and ofloxacin. For Gram-negative organisms, imipenem was found to be most sensitive, followed by gentamicin and co-amoxiclav, whereas maximum resistance was seen for ciprofloxacin. CONCLUSIONS: It was concluded that Gram-positive bacteria predominantly S. aureus was the most commonly isolated bacteria in cases of chronic dacryocystitis as compared to Gram-negative bacteria and cefoxitin was found to be the overall most effective antibiotic for Gram-positive bacteria.

Computed Tomography Signs of Sinonasal Inflammation in Patients with Acute Dacryocystitis.

BACKGROUND: Nasal and paranasal sinus abnormalities may be related to nasolacrimal duct obstructive disease but are strongly debated. Data of acute disease stage are lacking. OBJECTIVE: The purpose of this study was to determine if there are correlations between radiologic signs of sinus inflammation and acute dacryocystitis (AD). METHODS: This cross-sectional controlled study was conducted at Wenzhou, Zhejiang Province, China from February 2021 to November 2023. Forty-four consecutive patients with AD and 50 consecutive patients with orbital tumors (the control group), who completed preoperative computed tomography scans, were enrolled to evaluate the extent of their inflammatory sinonasal disease by the modified Lund-Mackay score system. RESULTS: The inflammation signs of the paranasal sinuses (total mean sinus scores, 95% CI [0.00, 2.00]; P < 0.001), namely the anterior ethmoid sinus(95% CI [0.00, 1.00]; P < 0.001), the posterior ethmoid sinus(95% CI [0.00, 0.00]; P = 0.003), the frontal sinus (95% CI [0.00, 0.00]; P = 0.02), and the ostiomeatal complex (P < 0.001) were more extensive in patients with AD when compared with the controls. The disease course was negatively correlated with the anterior ethmoid (P = 0.03) and frontal scores (P = 0.01). The symptom of eyelid swelling was positively correlated with the anterior ethmoid (P = 0.03), ostiomeatal complex (P = 0.004), and total sinus scores (P = 0.005). CONCLUSION: Inflammatory sinus disease was found to be more frequent in patients with AD, which was gradually alleviated with the prolongation of the disease course. The mutual spread of inflammation particularly in the acute course may play an important role in lacrimal duct obstructive disease.

Acute dacryocystitis secondary to Burkholderia cepacia and Sphingomonas paucimobilis mixed infection: A novel case report.

Acute dacryocystitis caused by Burkholderia Cepacia and Sphingomonas Paucimobilis is uncommon. To the best of our knowledge, presence of mixed pathogens Burkholderia Cepacia and Sphingomonas Paucimobilis causing acute dacryocystitis in immunocompetent patients never been described. Burkholderia Cepacia and Sphingomonas Paucimobilis been reported only as a single microorganism causing other ocular infections in immunocompromised patients. Middle age, medically free female patient, presented to the emergency department at our hospital, with a history of nasolacrimal duct obstruct (NLDO) complaining of inferior preocular swelling associated with localized pain diagnosed as acute dacryocystitis. She was on oral Amoxicillin/clavulanic acid, oral Nitroimidazole antimicrobial and topical Tobramycin from elsewhere. However, no improvement had been noticed. We kept the patient on the same medications and swaps taken for culture and sensitivity. Patient presented to the first follow-up appointment with no improvement on her status. Culture and sensitivity revealed 2 pathogens: Burkholderia Cepacia and Sphingomonas Paucimobilis. We have changed the antibiotic to oral Trimethoprim/ Sulfamethoxazole as it showed positive sensitivity to the pathogens based on the sensitivity chart. Second follow-up appointment patient's condition improved.

Primary diffuse large B-cell lymphoma of the lacrimal sac with involvement of maxillary sinus: a case report and review of literature.

Primary lacrimal sac lymphoma is a rare condition, often presenting with nasolacrimal duct obstruction. Herein, we present a unique case of diffuse large B-cell lymphoma (DLBCL) involving the lacrimal sac, maxillary sinus, and infraorbital nerve. Prompt diagnosis via biopsy is essential for timely treatment and the prevention of tumor progression. A 66-year-old female presented with intractable epiphora, infraorbital nerve hypesthesia, and medial canthal swelling. Imaging revealed a soft tissue mass in the right maxillary sinus extending into the right inferior orbit and nasal cavity. A biopsy confirmed DLBCL, prompting systemic chemotherapy. Residual disease prompted high-dose involved-site radiation, resulting in tumor regression. To our knowledge, this is the first case of primary DLBCL of the lacrimal sac with concurrent involvement of the maxillary sinus and infraorbital nerve. This case underscores the significance of lacrimal sac biopsy in refractory dacryocystitis or unilateral sinus disease and the effectiveness of multimodal treatment approaches in managing DLBCL.

Dacryocystitis in a Patent Nasolacrimal Drainage System: A Literature Review.

INTRODUCTION: Acute dacryocystitis is an acute infection and the lacrimal sac secondary to pathogenic microorganism growth within the stagnant fluid in the lacrimal sac secondary to nasolacrimal duct obstruction. METHODS: A literature review was conducted on the PubMed database using the following search terms "dacryocystic retention" and "dacryocystitis" or "dacryolith" or "lacrimal duct" or "pseudo-dacryocystitis". RESULTS: The literature review suggests that dacryocystitis in a patent nasolacrimal drainage system can stem from diverse causes including the mechanical impaction by dacryoliths, viral infections and anatomical variations. It is believed that these causes lead to transient obstruction to the nasolacrimal excretory system predisposing to secondary infections. Idiopathic temporary dacryocystic retention is also highlighted in this review. CONCLUSIONS: This review broadens the understanding of dacryocystic retention and highlights the need for careful diagnosis and tailored treatment plans, particularly in cases deviating from the traditional etiological pathways.

Microbiology of acute bacterial dacryocystitis: a tertiary institutional experience in South Australia.

PURPOSE: To provide a comprehensive microbiological profile of bacterial dacryocystitis in South Australia. By identifying the specific microorganism and antibiotic susceptibility, this study intends to aid ophthalmologists in choosing appropriate empirical antibiotic therapies and development of evidence-based clinical guidelines. METHOD: A retrospective study was conducted at the Royal Adelaide Hospital (RAH) over five years (2018-2023) of patients with acute dacryocystitis. The study included 43 patients, and data encompassed demographic information, clinical presentation, microbiological analysis, management, and outcomes. Patients with chronic dacryocystitis were excluded. RESULTS: Among the 43 patients included in the study (female 28 (65%), mean age: 64 years old), the most common clinical features were pain (74%) and swelling (70%). Organisms were identified in 49% of patients, with the predominant bacteria being Staphylococcus aureus (42%), Streptococcus species (19%), and Escherichia coli (8%). Aggregatibacter species (8%), Morganella morganii (4%), Enterobacter cloaceae (4%), Hafnia alvei (4%), mixed anaerobes (4%), E coliforms (4%) and Pseudomonas aeruginosa (4%) were also identified. The most frequently prescribed empirical antibiotics were amoxicillin-clavulanic acid (50%), flucloxacillin (33%) and cefalexin (18%). CONCLUSION: The microbiological trends of acute dacryocystitis have largely remained consistent, with a predominance of Gram positive organisms. This is the most recent profile analysis of acute dacryocystitis in South Australia and will help form evidence-based clinical guidelines.

Lacrimal sac Aspergillosis Masquerading as Malignancy: A Rare Case Report.

Invasive fungal infections are uncommon in an immunocompetent host and pose a real diagnostic dilemma. As they have a propensity for locoregional destruction, clinic-radiological findings can mislead to a faulty diagnosis of a malignancy. Here we present a case of Primary Aspergillus dacryocystitis in an immunocompetent individual initially thought to be an orbital malignancy until the histopathological examination.

Langerhans cell histiocytosis mimicking acute dacryocystitis.

Langerhans cell histiocytosis (LCH) is a myeloid neoplasm characterized by clonal neoplastic proliferation of Langerhans-type dendritic cells associated with an inflammatory infiltrate predominantly composed of lymphocytes and eosinophils. In this article, we present an unusual case of LCH with significant swelling in the left lacrimal sac region in a 3-year-old child, clinically mimicking acute dacryocystitis. Microscopically, it showed intense inflammatory infiltrate and histiocytes with irregular nuclei. The tumor cells were positive for S-100 protein, CD1a, and CD207 (langerin). Molecular study was positive for the V600E/E2/D mutation (EXON 15). This case emphasizes the importance of careful clinical, radiographic, and microscopic evaluation, as some neoplasms may mimic common benign lesions.

Primary Dacryocystorhinostomy for Acute Dacryocystitis: A Systematic Review.

INTRODUCTION: Acute dacryocystitis is a common condition occurring secondary to nasolacrimal duct obstruction. We aim to assess the efficacy of primary dacryocystorhinostomy for the management of acute dacryocystitis. METHODS: A systematic search of the databases PubMed/MEDLINE, Embase, and CENTRAL was performed to December 2023. Data extraction and risk of bias analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Fourteen articles fulfilled inclusion criteria. The results demonstrated that for the treatment of acute dacryocystitis, primary dacryocystorhinostomy (DCR) is anatomically and functionally efficacious, with low complication rates and minimal risk of recurrence. The anatomical success rates for primary endonasal DCR (EnDCR) were 81.8-100%, 83.8-87.5% in delayed EnDCR and 66-100% in delayed external DCR (ExDCR). Functional success was generally defined as a subjective absence of epiphora, which was achieved in 86.4-92.0% of primary EnDCR, and 0-89.5% of the delayed ExDCR cohorts. Two randomized controlled trials established equivalent rates of functional success between primary versus delayed EnDCR (87.5% vs 87.5% and 91.3% vs 92.3%). Increased perioperative bleeding was recorded in 27.8% of primary EnDCR cases in 1 study. ExDCR was infrequently associated with postoperative fistula and scar formation and cicatricial punctal ectropion. The mean length of admission trended to be shorter when the procedure was performed closer to the acute presentation. The admission time for all primary EnDCR cases varied between 1 and 7 days. CONCLUSION: Primary dacryocystorhinostomy is an efficacious and safe management option for acute dacryocystitis. Further analyses of health-economics are required.

External dacryocystorhinostomy: A critical overview of the current evidence.

PURPOSE: External dacryocystorhinostomy (ext-DCR) is still considered the gold standard in the treatment of distal lacrimal duct obstruction. Despite an overall high success rate, some patients do relapse after surgery and the ideal perioperative management has not been identified yet. The purpose of this study is to critically discuss the published evidence in the last five years on the medical and surgical management of external dacryocystorhinostomy. Furthermore, the drawbacks of the available literature and the perspectives in this field will be also highlighted. METHODS: Systematic review of the literature in the last 5 years by using PubMed and Google Scholar. RESULTS: A total of 64 articles were included. Many technical modifications and surgical refinements have been proposed but a formal comparison among the various techniques is hampered by methodological heterogeneity. The use of local anesthesia, and the perioperative adjunctive techniques to reduce the risk of restenosis are also gaining popularity but the level of evidence remains weak. CONCLUSION: Ext-DCR offers satisfactory clinical outcomes even though there are many gray areas that need to be addressed in future high-quality studies.

16S rRNA sequencing in chronic dacryocystitis.

CLINICAL RELEVANCE: The pathogenesis of chronic dacryocystitis (CDC) is associated with a variety of bacteria. Investigating microflora has the potential to provide a theoretical basis for preventing and treating CDC. BACKGROUND: 16S rRNA sequencing is a sequence-based bacterial analysis. The application of 16S rRNA sequencing in CDC is rarely reported. METHODS: A case-control study of infected and healthy eyes diagnosed as CDC patients was conducted. Seventy-eight patients were divided into A (conjunctival sac secretions from healthy eyes), B (conjunctival sac secretions from affected eyes), and C (lacrimal sac secretions from affected eyes) groups. The flora of samples was analysed with 16S rRNA sequencing, and the data was analysed using QIIME, R, LefSE and other software. The potential functions were analysed by PICRUSt. RESULTS: A total of 1440 operational taxonomic units (OTUs) were obtained, 139 specific to group A, 220 specific to group B, and 239 specific to group C. There was no significant difference in α index between the three groups. The beta diversity and grouping analysis data indicated that the three groups of flora were similar in species richness and diversity, but there were some differences in composition. In group A, the abundance of Pseudomonadaceae, Chlorobacteria, Moraceae, Staphylococcaceae, Bacillariophyceae, Immunobacterium spp. and Bacillus spp. was higher; in group B, the abundance of Burkholderiaceae, Sphingomonas, Rhizobia, Stalked Bacteria, Sphingomonadaceae, Enterobacteriaceae, Shortwaveomonas spp. was higher; in group C, the abundance of Streptococcus digestiveis, Propionibacterium, Enterobacteriaceae, Anaerobacteriaceae, Propionibacteriaceae, Bacillus spp. Neisseria spp. and Shortactomonas spp. was higher. Six pathways were identified to assess the potential microbial functions. CONCLUSION: Alterations in the microbiota of the conjunctiva and lacrimal sac are associated with the pathogenesis of CDC, which may provide certain guidance for antibiotic treatment of CDC.

Misplaced Intracystic Lacrimal Implant- An Unusual Cause of Failed External Dacryocystorhinostomy.

Background: Various techniques of dacryocystorhinostomy (DCR) by an external or endonasal endoscopic approaches are in practice of ophthalmologists and otorhinolaryngologists. The purpose of this paper is to report a case of misplaced intracystic implant in the orbit following external DCR leading to persistence of watering, diplopia and visual diminution. Case Report: A thirty nine year old female patient presented with recurrent left eye pain, swelling over medial side of the left eye, watering, progressive blurring of vision and diplopia after revision external DCR. The ophthalmology examination revealed bilateral decreased vision, left side restricted extraocular eye movements, sub capsular cataract. The computed tomography dacryocystograph (CT-DCG) revealed tubular foreign body in the extra-conal space abutting the medial rectus with proximal block in the nasolacrimal duct. Conclusion: This is the first reported case of misplaced implant following external DCR in the literature. It may be suggested that patients undergoing intracystic larimal implant shall be on close follow up for such an occurrence later for timely intervention.

Early Endonasal Dacryocystorhinostomy for Acute Dacryocystitis: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this meta-analysis is to compare the outcomes of early endonasal dacryocystorhinostomy (DCR) with delayed DCR in the treatment of acute dacryocystitis (AD). METHODS: A comprehensive electronic search of PubMed, Embase, Web of Science, and the Cochrane Library databases was conducted up to November 11, 2023. Data synthesis was performed using Review Manager 5.4, and forest plots were generated for each outcome measure. Potential publication bias was assessed using funnel plots and Egger's test. RESULTS: Six studies involving 288 patients were included in the meta-analysis. Overall, the success rate of early endonasal DCR was comparable to that in the delayed DCR group (odds ratio [OR] = 1.52, 95% confidence interval [CI]: 0.81-2.85, P = .19). Furthermore, in comparison with the delayed DCR group, early endonasal DCR significantly reduced the time for medial canthus swelling resolution (mean differences [MD] = -4.92, 95% CI: -5.46 to 4-.37, P < .00001) and complete resolution of symptoms (MD = -17.70, 95% CI: -23.88 to -11.52, P < .00001). CONCLUSION: Primary early endonasal DCR seems to be a promising and favorable approach for managing AD with comparable efficacy and faster relief of symptoms compared to conventional delayed DCR.