Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population.

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

Comparison of Piezosurgery and Hammer-Chisel in Endoscopic Dacryocystorhinostomy.

BACKGROUND: In this study, we compared the advantages and disadvantages of piezosurgery and hammer-chisel used in endoscopic dacryocystorhinostomy (EDCR). MATERIAL AND METHODS: Between January 2012 and January 2016, 10 women and 8 men in whom piezosurgery was used (group 1) and 11 women and 7 men in whom hammer-chisel was used (group 2) during EDCR operations were compared retrospectively. Recurrence, operation time, postoperative bleeding, and operative cost were evaluated in patients who were followed for an average of 11.8 months. In addition, visual analogue scale (VAS) was used to assess pain at 6 hours postoperatively. RESULTS: No recurrence was observed in group 1, but recurrence was observed in 2 patients in group 2 (P = 0.685). There was no postoperative bleeding in both groups. The mean duration of operation was 30.6 ±â€Š8.2 minutes in group 1 and 46.8 ±â€Š9.5 minutes in group 2 (P = 0.038). The VAS score in group 1 was 2.7 ±â€Š1.4 and the VAS score in group 2 was 5.8 ±â€Š2.2 (P = 0.01). Piezosurgery costs an additional $325 for each patient while the use of the hammer-chisel does not incur additional costs. CONCLUSION: Piezosurgery causes shorter operation time, less recurrence, and less pain when compared with hammer-chisel.

Endoscopically assisted Crawford tube placement results in shorter general anesthesia times in pediatric patients.

BACKGROUND: Crawford tube placement is commonly used to achieve patency of nasolacrimal ducts for epiphora secondary to nasolacrimal duct obstruction. The nasal passages of pediatric patients are narrower than adults, and the result is a relatively higher risk of intranasal complications (e.g., synechiae, bleeding) with Crawford tube placement. There is evidence that general anesthesia may negatively affect the neurocognitive function and behavioral development of children, which prompts efforts to decrease operation times for potential health benefits and also potentially to reduce health care costs. Analysis of research reports supports the use of nasal endoscopy to reduce intranasal complications with Crawford tube placement; however, no publications currently address the effect of nasal endoscopy concurrent with Crawford tube placement on operative times on pediatric patients or the resulting effects on health care costs. OBJECTIVE: To determine the difference in procedure time and cost between Crawford tubes placed traditionally and those placed with endoscopic assistance in pediatric patients. METHODS: A chart review was performed from January 1, 2011 to December 31, 2016 for cases using CPT codes 68815 or 31231. Within this group of patients, the patient in whom nasal endoscopy was performed were placed in the "endoscopic" group and the patients without endoscopy were placed in the "traditional" group. Procedure times were noted, and the t-test was performed to examine for any statistically significant difference in operative times. Estimates of anesthesia cost savings were made. We identified 24 patients in the traditional group and 7 patients in the endoscopic group. RESULTS: The average operative time for the traditional group was 27.3 minutes compared with 14.0 minutes for the endoscopic group (p = 0.02). The cost comparison data revealed no significant difference with the traditional group averaging $9369 per procedure and the endoscopic group averaging $8891 (p = 0.51). CONCLUSION: An endoscopically assisted Crawford tube placement resulted in patients who had less time under general anesthesia compared with the traditional technique at no difference in cost.

Probing for congenital nasolacrimal duct obstruction.

BACKGROUND: Congenital nasolacrimal duct obstruction (NLDO) is a common condition causing excessive tearing in the first year of life. Infants present with excessive tearing or mucoid discharge from the eyes due to blockage of the nasolacrimal duct system, which can result in maceration of the skin of the eyelids and local infections, such as conjunctivitis, that may require antibiotics. The incidence of nasolacrimal duct obstruction in early childhood ranges from 5% to 20% and often resolves without surgery. Treatment options for this condition are either conservative therapy, including observation (or deferred probing), massage of the lacrimal sac and antibiotics, or probing the nasolacrimal duct to open the membranous obstruction at the distal nasolacrimal duct. Probing may be performed without anesthesia in the office setting or under general anesthesia in the operating room. Probing may serve to resolve the symptoms by opening the membranous obstruction; however, it may not be successful if the obstruction is due to a bony protrusion of the inferior turbinate into the nasolacrimal duct or when the duct is edematous (swollen) due to infection such as dacryocystitis. Additionally, potential complications with probing include creation of a false passage and injury to the nasolacrimal duct, canaliculi and puncta, bleeding, laryngospasm, or aspiration. OBJECTIVES: To assess the effects of probing for congenital nasolacrimal duct obstruction. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register (2016, Issue 8); MEDLINE Ovid (1946 to 30 August 2016); Embase.com (1947 to 30 August 2016); PubMed (1948 to 30 August 2016); LILACS (Latin American and Caribbean Health Sciences Literature Database; 1982 to 30 August 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), last searched 14 August 2014; ClinicalTrials.gov (www.clinicaltrials.gov), searched 30 August 2016; and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), searched 30 August 2016. We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared probing (office-based or hospital-based under general anesthesia) versus no (or deferred) probing or other interventions (observation alone, antibiotic drops only, or antibiotic drops plus massage of the nasolacrimal duct). We did not include studies that compared different probing techniques or probing compared with other surgical procedures. We included studies in children aged three weeks to four years who may have presented with tearing and conjunctivitis. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion and independently extracted data and assessed risk of bias for the included studies. We analyzed data using Review Manager software and evaluated the certainty of the evidence using GRADE. MAIN RESULTS: We identified two RCTs and no ongoing studies; one of the included RCTs was registered. The studies reported on 303 eyes of 242 participants who had unilateral or bilateral congenital nasolacrimal duct obstruction. For both included studies, the interventions compared were immediate office-based probing to remove the duct obstruction versus deferred probing, if needed, after 6 months of observation or once the child reached a certain age.The primary outcome of the review, treatment success at 6 months, was reported partially in one study. Treatment success was not reported at this time point for all children in the immediate probing group; however, 77 of 117 (66%) eyes randomized to deferred probing had resolved without surgery 6 months after randomization and 40 (34%) eyes did not resolve without probing. For children who had unilateral NLDO, those randomized to immediate probing had treatment success more often than those who were randomized to deferred probing (RR 1.41, 95% CI 1.12 to 1.78; 163 children; moderate-certainty evidence). Treatment success for all children was assessed in the study at age 18 months; as an ad hoc analysis in the included study, results were presented separately for children with unilateral and bilateral NLDO (RR 1.13, 95% CI 0.99 to 1.28 and RR 0.86, 95% CI 0.70 to 1.06, respectively; very low-certainty evidence).In the other small study (26 eyes of 22 children), more eyes that received immediate probing were cured within one month after surgery compared with eyes that were randomized to deferred probing and analyzed at age 15 months (RR 2.56, 95% CI 1.16 to 5.64). We considered the evidence to be low-certainty due to imprecision from the small study size and risk of bias concerns due to attrition bias.One study reported on the number of children that required reoperation; however, these data were reported only for immediate probing group. Nine percent of children with unilateral NLDO and 13% with bilateral NLDO required secondary procedures.One study reported cost-effectiveness of immediate probing versus deferred probing. The mean cost of treatment for immediate probing was less than for deferred probing; however, there is uncertainty as to whether there is a true cost difference (mean difference USD -139, 95% CI USD -377 to 94; moderate-certainty evidence).Reported complications of the treatment were not serious. One study reported that there were no complications for any surgery and no serious adverse events, while the other study reported that bleeding from the punctum occurred in 20% of all probings. AUTHORS' CONCLUSIONS: The effects and costs of immediate versus deferred probing for NLDO are uncertain. Children who have unilateral NLDO may have better success from immediate office probing, though few children have participated in these trials, and investigators examined outcomes at disparate time points. Determining whether to perform the procedure and its optimal timing will require additional studies with greater power and larger, well-run clinical trials to help our understanding of the comparison.

Simultaneous Bilateral Endonasal Endoscopic Dacryocystorhinostomy: A Low Cost, Fast, and Successful Method.

The etiology of primary nasolacrimal duct obstruction is largely unknown, and this disease may occur bilaterally in a small percentage of patients. In this retrospective study, the authors aimed to discuss the cost, operation time, complications, and success rate of simultaneous bilateral endonasal endoscopic surgery. Twenty-eight patients (16 female, 12 male) were enrolled in this study, with a mean age of 55 years old (range: 43-76). The success rate was 91% (51/56), and the mean operation time was 44 minutes. Only minor and transient complications were observed in 2 of the patients. Overall, the authors believe that a bilateral endoscopic dacryocystorhinostomy would be useful in a single session, based on its advantages of low morbidity, low cost, and high success.

Nasolacrimal duct office probing in children under the age of 12 months: Cure rate and cost evaluation.

INTRODUCTION: Controversy exists regarding the treatment of infants with symptomatic nasolacrimal duct obstruction. One philosophy advocates "early" nasolacrimal duct probing, generally in the office - a relatively common approach in France, while others prefer to wait until the age of 12 months to offer a procedure under general anesthesia. The goal of this study is to report results of immediate office probing for congenital nasolacrimal duct obstruction (CNLDO) under age 1 year in terms of efficacy and cost. METHODS: A retrospective study was performed on 329 patients (443 eyes) treated by probing for CNLDO under the age of 12 months age. A single probing was performed at the first visit in the office under topical anesthesia without sedation. In order to determine the factors associated with failure of probing, univariate analysis was performed using the Student t-test, Pearson's, homogeneity Chi(2) or Fisher's exact tests. For cost evaluation, hypothetical estimates of spontaneous resolution month by month were used according to data in the literature, along with health insurance reimbursement data. RESULTS: The ages of the patients ranged from 2 to 11 months (mean 7.0 ± SD 2.3). The overall success rate for cure by immediate office probing was 76.7%. Unilateral CNLDO had an 80.4% success rate whereas bilateral CNLDO had a 73.2% success rate for each eye (P=0.09). Discharge during probing was associated with failed probing (P=0.02). The cost for the spontaneous resolution strategy was 1.56 times higher than for the immediate probing strategy. A strategy which would apply the spontaneous resolution strategy for children ≤ 5 months and the probing strategy to children>5 months would be the most cost-effective. CONCLUSIONS: Immediate office probing between the ages of 5 to 12 months is a safe, effective method to relieve CNLDO and is the most cost-effective.

Cannula dacryocystorhinostomy: a simple, innovative and cost-effective method of lacrimal surgery.

To compare our innovative, cost-effective method of lacrimal surgery with other methods. A prospective cohort study. The study included 80 eyes of 80 consecutive patients who presented to our clinic between January 2009 and December 2011. The patients underwent surgery using a new technique with a specially designed cannula and were followed according to our protocol. Patency on irrigation. Of the 80 cases enrolled, the procedure was successful in 52.5 % with a mean follow-up of 247.2 days. The success rate was significantly affected by the preoperative conditions (p = 0.001) and follow-up duration (p = 0.006). This simple innovative technique was cost-effective and the results were comparable with those of other techniques.

A comparison of external and endonasal dacryocystorhinostomy in regard to patient satisfaction and cost.

BACKGROUND: Definitive treatment of nasolacrimal duct obstruction is with external or endonasal dacryocystorhinostomy (DCR). Recent trials suggest surgical equivalency between techniques. We sought to compare alternative outcomes of DCR techniques in terms of quality of life and cost. METHODS: This study was a multicentre prospective nonrandomized case series comparing adult patients treated with external or endonasal DCR. Groups were allocated according to DCR technique. Participation did not affect treatment choice. The Glasgow Benefit Inventory (GBI) was utilized to compare postoperative quality of life, and an activity-based costing (ABC) method used to estimate costs of the two techniques. Surgical data were also collected. A minimum of 3 months follow-up was observed. RESULTS: Seventy-seven patients were included--37 external and 40 endonasal. Both techniques resulted in positive health status change, with mean GBI scores of +16.1 for external DCR and +24.1 for endonasal (p = 0.18). Using an ABC method, the operative costs of external DCR were less than endonasal at $715.79 AUD and $932.52 AUD respectively. CONCLUSIONS: This trial suggests that external and endonasal DCR produce comparable outcomes in terms of postoperative quality of life, with external DCR resulting in lower operative costs.

Efficacy of endonasal dacryocystorhinostomy, using 'cold steel' instruments without stenting, in treatment of distal nasolacrimal duct obstruction.

OBJECTIVE: To assess the efficacy of an endonasal dacryocystorhinostomy technique using conventional instruments, without the use of any adjunctive techniques. STUDY DESIGN: Prospective, non-randomised, cohort study. METHODS: Patients diagnosed with nasolacrimal duct obstruction between January 2006 and December 2008 were included in the study. Seventy-eight endonasal dacryocystorhinostomies (primary or revision) were performed with conventional 'cold steel' instruments. The technique involved complete exposure and marsupialisation of the lacrimal sac. No adjunctive procedures were used. Success was defined as complete resolution of epiphora and a patent lacrimal system, evaluated by lacrimal irrigation and endoscopy, one year post-operatively. RESULTS: Seventy-four of the 78 cases were symptom-free after a minimum follow up of 12 months, giving an overall success rate of 94.9 per cent. The success rates for primary and revision cases were 95.5 and 90.9 per cent, respectively. CONCLUSION: Meticulous surgical technique can ensure high success rates with the use of conventional cold steel instruments, without the use of adjunctive procedures, making endonasal dacryocystorhinostomy a cost-effective, reliable procedure.

Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation.

BACKGROUND/AIMS: The aim of the study was to compare surgical outcomes of external dacryocystorhinostomy (DCR) with and without silastic intubation for treatment of primary uncomplicated nasolacrimal duct obstruction (NLDO). DESIGN: The study was a prospective randomised trial conducted at the Tilganga Eye Centre (Kathmandu, Nepal). METHODS: One-hundred consecutive patients with uncomplicated primary NLDO were randomly assigned into two groups (44 underwent DCR with silastic intubation and 56 underwent DCR without intubation). Patients were re-assessed at 1 week, 6 weeks and 6 months after surgery. Success was defined objectively by irrigation of the puncta without regurgitation and subjectively by the absence of epiphora or discharge. RESULTS: The success rate at 6 months was 90% for DCR with silastic intubation and 87% for DCR without silastic intubation. There was no statistically significant difference between the two groups (p = 0.77). No complications were encountered in either group. Silicone tubes increased surgical cost by 20% at the Tilganga Eye Centre. CONCLUSION: DCR without silastic intubation is less expensive than DCR with silastic intubation in primary uncomplicated NLDO, and has a similar success rate. DCR with silastic intubation may create increased burden for patients in the form of more post-surgical follow-up visits. In cases of uncomplicated primary NLDO, the use of silastic intubation in DCR may be unnecessary.

Prolene: a novel, cheap, and effective material in dacryocystorhinostomy.

CONCLUSION: Prolene is cheap, effective, and readily available in almost all operating theaters. It might be used successfully in endoscopic dacryocystorhinostomy and is promising as an alternative to silicone stent intubations, especially in settings with limited resources. OBJECTIVE: To evaluate the clinical efficacy and results of stenting with polypropylene (Prolene; Ethicon, Inc.) suture material instead of silicone tube in endoscopic dacryocystorhinostomy. PATIENTS AND METHODS: Forty-two endoscopic dacryocystorhinostomy operations were performed in 36 patients (11 men and 25 women; mean age 34.7 + or - 9.5 years, range 16-60 years) between 2007 and 2008. After creating an aperture in the medial wall of the lacrimal sac, 2/0 Prolene was inserted through the canaliculi into the sac. The Prolene was left in the lacrimal sac for 3 months. The patients were followed up for between 6 and 18 months (mean 8.1 + or - 3.6 months). The improvement in the complaint of epiphora was grouped as very good, good, or no change. RESULTS: The improvement in 34 eyes (81%) was reported as very good, whereas improvement was noted as good in 5 eyes (11.9%), and there was no change in 3 eyes (7.1%). We observed granulation tissue formation around the Prolene in two patients.

Cost-efficiency of endoscopic and external dacryocystorhinostomy.

BACKGROUND: In most centres in the United Kingdom, endoscopic dacryocystorhinostomy is currently undertaken as a joint operation between ophthalmologists and otolaryngologists. The addition of an extra surgeon, the use of endoscopic equipment and the relatively lower success rate of this procedure made us compare endoscopic dacryocystorhinostomy and external dacryocystorhinostomy with regards to costs and income for our hospital. METHODS: All 38 primary endoscopic dacryocystorhinostomy cases performed in our centre in 2001-2003 were retrospectively compared with the 49 external dacryocystorhinostomy cases performed in 1993-2000. Cost-income calculations were made based on: rate of local anaesthesia, success rate, rate of day case admission, hospital reference cost for dacryocystorhinostomy, and the income per case extracted from national tariffs (based on the Health Resources Group). Also, the average number of cases per session was used to calculate the income gained per session for each method. RESULTS: The following rates between the endoscopic and the external dacryocystorhinostomy were found: local anaesthesia, 29 vs 6 per cent, respectively; day-case operation, 95 vs 12 per cent, respectively; and success rate, 87 vs 94 per cent, respectively. The average number of endoscopic dacryocystorhinostomy cases conducted in a single theatre session was twice that of external dacryocystorhinostomy cases. Endoscopic dacryocystorhinostomy generated approximately twice the income of external dacryocystorhinostomy (6585 pounds vs 3292 pounds, respectively). CONCLUSION: Endoscopic dacryocystorhinostomy is more cost-effective than external dacryocystorhinostomy, despite having a lower success rate and greater usage of resources, as the endoscopic procedure generates more income. This is mainly due to the higher number of cases per session and the higher rates of local anaesthesia and day case operations possible.

[Cost efficiency study of lacrimal canal obstruction treatment]. / Etude coût-efficacité du traitement de l'obstruction du canal lacrymal.

OBJECTIVE: To compare three methods used to clear the lacrimal canal. PATIENTS AND METHODS: A total of 32 files (20 for the dacryocysto-rhinostomy by endoscopic way, 5 for the dacryocysto-rhinostomy by external way and 7 cases of percutaneous stenting) were reviewed. For each, costs of performed interventions were reviewed. An average of the total cost per patient was calculated for all three methods and was then correlated to the initial efficiency of the method. RESULTS: Results show that the average cost for stenting is up to 1,366.80 EUR, for the endoscopic way is up to 2 001.53 EUR and for the external way is up to 2,220.46 EUR. ANOVA (Analysis of Variance) gives significant results when comparing stent to endoscopic way (p=0.000007) and to the external way (p =0.02). The analysis of sensitivity concerning the success rate of various treatments shows that the stent was potentially the most cost-effective and that a failure rate of 35.1% is rather acceptable by comparison to the endoscopic method. If the stent is considered as an outpatient intervention, then, a failure rate of 50% is acceptable. CONCLUSION: If the failure rate stays under 35.1%, the stent may be considered as a short-term cost-effective method.

The otologic T-tube: a cost effective dacryocystorhinostomy stent.

Endoscopic endonasal dacryocystorhinostomy (EDCR) has established itself as a popular means of relieving post-saccal obstruction of the naso-lacrimal ducts. Soft tissue stenosis of the rhinostomy is a significant cause of long-term failure. We describe the technique of using a standard otological T-tube as a cheap and easy self-retaining stent to ensure a patent rhinostomy following EDCR.

External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost.

BACKGROUND: External dacryocystorhinostomy (DCR) is the standard treatment for nasolacrimal duct obstruction, with success rates consistently above 90%. This study reviews the demographics, success, cost, efficiency, and patient satisfaction in external DCR. This information will be useful as comparison criteria for evaluating new surgical techniques. METHODS: Records of 169 external DCR procedures performed over an 8.7-year period were reviewed. All patients had preoperative symptoms of tearing and/or dacryocystitis with a component of nasolacrimal obstruction. Patient demographics, history, examination findings, surgical and anesthesia information, postoperative success, complications, and follow-up course were recorded. Patient satisfaction and long-term success were evaluated by telephone survey. RESULTS: External DCR often required middle turbinectomy (17%), exposure of ethmoid sinuses (17%), and removal of dacryoliths (14%). Most patients (90%) underwent silicone intubation, with the tubes removed at an average of 3.7 weeks after surgery. A patent system was established in 95% of procedures, whereas 92% remained asymptomatic. Postoperative complications included hemorrhage (3.9%) and scarring (2.6%). Of the surveyed patients, 87% denied continued or recurrent symptoms; 97% rated their incision "good" to "excellent" in appearance; and all patients stated they would recommend the procedure to others. CONCLUSION: External DCR is highly successful, requires limited follow-up, and is a cost-effective procedure. Complications are uncommon, and patient satisfaction is high. New lacrimal surgical techniques must be evaluated against the long-proven success of the external approach.