Unlocking the secrets of success in probing for congenital nasolacrimal duct obstruction: investigating the factors that matter.

PURPOSE: The objective of this study was to analyze the impact of different factors on the success rate of probing for congenital nasolacrimal duct obstruction (CNLDO). METHODS: A retrospective analysis was conducted on 239 eyes of 202 patients who underwent probing for CNLDO between 2014 and 2019. Patients were divided into three age groups (12-24 months, 25-36 months, and over 36 months) and two groups based on the type of membranous obstruction (MO) and incomplete complex obstruction (ICO), with complete complex obstruction (CCO) cases being excluded. The study involved administering general anesthesia (GA) to all participants during the probing procedure. The patients were then monitored at scheduled intervals for up to 6 months after the surgery. Success was defined as an improvement in symptoms and signs, and logistic regression and Fisher's exact test were used for statistical analysis. RESULTS: The mean age of the patients was 25.48 ± 13.38 months, and the total success rate was 86.61%. The success rate for MO was 92.8%, 95.87%, and 97% in age groups 1, 2, and 3, respectively. The success rate for ICO was 91.17%, 80%, and 23.52% in age groups 1, 2, and 3, respectively. The success rate for MO was significantly higher than ICO in all age groups. The success rate for ICO was significantly lower in age group 3 (p = 0.009). CONCLUSION: The study found that probing performed within the first 36 months had high success rates regardless of age and type of obstruction. However, the success rate significantly decreased in patients undergoing probing for ICO at 36 months or later.

[Dacryocystorhinostomy with a counteropening in the treatment of secondary nasolacrimal duct obstruction after radioiodine therapy]. / Dakriotsistorinostomiya s nalozheniem kontrapertury pri vtorichnoi obliteratsii slezootvodyashchikh putei vsledstvie terapii radioaktivnym iodom.

Among secondary forms of nasolacrimal duct obstruction caused by radioactive iodine therapy, its distal forms localized in the area of the Hasner's valve are predominant. In this regard, during dacryocystorhinostomy (DCR) there is a high probability of developing the sump syndrome, for which the anatomical prerequisite is that the lower edge of the DCR ostium is above the level of obstruction. In such cases, we propose to supplement DCR with a counteropening in the area of the Hasner's valve. PURPOSE: This study analyzes the clinical effectiveness of dacryocystorinostomy with a counteropening. MATERIAL AND METHODS: The outcomes of 49 surgeries (49 patients) with secondary acquired nasolacrimal duct obstruction due to radioactive iodine therapy were analyzed, including 34 DCR and 15 DCR with a counteropening. The clinical outcomes were analyzed over the longest possible period after surgery. The analysis included the severity of tearing on the Munk scale, the characteristic of the formed ostium on the M. Ali scale and the height of the tear meniscus. Differences were considered significant at a confidence level of 95% (p≤0.05). RESULTS: Analysis of the results of the performed surgeries showed that DCR was clinically effective in 30 (88%) cases, DCR with a counteropening - in 15 (100%) cases. The differences were not statistically significant in the total sample, but were statistically significant when comparing the results of surgeries in patients with distal obliteration. CONCLUSION: The developed and clinically tested method of DCR with a counteropening in the area of the Hasner's valve was completely effective in 15 patients with secondary nasolacrimal duct obstruction caused by radioiodine therapy.

Long-term outcomes of modified transcanalicular diode laser dacryocystorhinostomy.

PURPOSE: The purpose of this study is to assess the long-term outcomes of modified transcanalicular diode laser dacryocystorhinostomy in a large cohort of patients affected by primary acquired nasolacrimal duct obstruction. METHODS: This study, conducted from January 17 to June 2022, encompassed 141 patients (159 procedures) who underwent modified transcanalicular diode laser dacryocystorhinostomy (MT-DCR). The procedure employed an 810-nm diode laser. Patients were monitored for at least a year after the intervention. Anatomical success was determined by ostium patency upon irrigation, while functional success referred to epiphora resolution. Parameters studied included patient demographics, procedure duration, complications, and both anatomical and functional success. Statistical analysis was performed using the Statistical Package for the Social Sciences software, with results considered significant at a 95% confidence interval (p≤0.05). RESULTS: A total of 159 lacrimal drainage systems (141 patients: 112 women and 29 men) were included in this study. Among them, 18 underwent bilateral procedures. The average patient age was 58 years (range: 34-91 years), and the average surgical duration was 24 minutes (range: 18-35 minutes). One year after the surgery, MT-DCR exhibited anatomical and functional success rates of 84.9% (135/159) and 83% (132/159), respectively. CONCLUSION: MT-DCR achieved an anatomical success rate of 84.9%, reflecting an excellent outcome. However, further extensive studies with larger sample sizes and longer follow-up periods are necessary to substantiate these findings.

Alterations of Lacrimal Sac Microbiota in Failed Dacryocystorhinostomy: The Lacriome Paper 6.

PURPOSE: To study the metagenomics of the microbes isolated from the lacrimal sac in patients with failed dacryocystorhinostomy (DCR). METHODS: A prospective study was performed on 10 consecutive patients with failed DCR. Lacrimal sac samples were obtained for metagenomic analysis during the revision endoscopic DCR. The samples were collected intraoperatively after a full-length lacrimal sac marsupialization and immediately transported on ice to the laboratory. A whole shotgun metagenome sequencing was performed on the IlluminaTM platform following DNA extraction and library preparation. The downstream analysis of the samples was performed using various software packaged in the Squeeze Metapipeline v1.3.0 and marker gene-based metagenomic phylogenetic analysis using MetaPhlAn4. RESULTS: The five major phyla identified across the samples of failed DCR include Proteobacteria, Firmicutes, Actinobacteria, Bacteroidetes, and Fusobacteria (Figure 1). The prevalent species include Stenotrophomonas maltophilia, Pseudomonas juntendi, Streptococcus pneumoniae, Acinetobacter ursingii, Citrobacter koseri, and Cutibacterium acnes (Figure 2). Among the other organisms identified, few were from genera candida and mezorhizobium. Among the viruses, the most abundant was the BeAn 58058 virus. It was interesting to note the occasional presence of plasmodium and toxoplasma species. The functional category distribution of KEGG (Kyoto encyclopedia of genes and genomes) data showed microbial metabolism to be the most involved function, followed by cellular processes. CONCLUSION: This is the first whole metagenome sequencing of the lacrimal sac contents from failed DCR patients. The organisms identified varied significantly from those isolated from patients with primary acquired nasolacrimal duct obstruction (PANDO) using similar techniques and reflect altered lacrimal microbiota in surgically unsuccessful DCRs.

Comparative study of surgical outcomes regarding tear meniscus area and high-order aberrations between two different interventional methods for primary acquired nasolacrimal duct obstruction.

PURPOSE: To compare endonasal dacryocystorhinostomy (EN-DCR) with sheath-guided dacryoendoscopic probing and bicanalicular intubation (SG-BCI) by evaluating tear meniscus area (TMA) and total high-order aberrations (HOAs) for primary acquired nasolacrimal duct obstruction (PANDO). METHOD: We retrospectively reviewed 56 eyes of 42 patients (7 men, 35 women; age, 72.7±13.1 years) who underwent EN-DCR or SG-BCI for PANDO in Toyama University Hospital from February 2020 to June 2022. In the EN-DCR and SG-BCI groups, we measured the patency of the lacrimal passage, preoperative and postoperative TMA, and HOAs of the central 4 mm of the cornea using optical coherence tomography (AS-OCT), six months postoperatively. RESULTS: There was a positive correlation between preoperative TMA and preoperative HOAs in all cases. Postoperative patency of lacrimal passage was 100% in the EN-DCR and 80.8% in the SG-BCI group. There was a significant difference in the number of passages between the two groups (p = 0.01). Preoperative TMA and HOAs showed a significant postoperative decrease in both groups (EN-DCR group: p<0.01, p<0.01, SG-BCI group: p<0.01, p=0.03, respectively). We then calculated the rate of change of preoperative and postoperative TMA and HOAs and compared them between the two groups. The rate of change was significantly higher in the EN-DCR group than that in the SG-BCI group (TMA, p=0.03; HOAs, p=0.02). CONCLUSION: Although both EN-DCR and SG-BCI are effective for PANDO, our results suggest that EN-DCR is more effective in improving TMA and HOAs.

Probing versus primary nasal endoscopy for the treatment of congenital dacryocystoceles.

PURPOSE: To compare outcomes and complications of three surgical techniques for the treatment of congenital dacryocystoceles: nasolacrimal probing and irrigation (P+I), P+I plus nasal endoscopy (NE) with intranasal cyst marsupialization, and primary NE with intranasal cyst marsupialization. METHODS: The medical records of children ≤2 years of age at a single academic center with a diagnosis of dacryocystocele from 2012 to 2022 were retrospectively identified and reviewed. The primary outcome was resolution of the dacryocystocele (ie, elimination of the medial canthal mass and resolution of tearing or discharge) after a single procedure ("primary success"). Surgical techniques were compared using exact logistic regression. RESULTS: Of 54 patients, 21 (39%) underwent P+I, 23 (43%) underwent P+I plus nasal endoscopy, and 10 (18%) underwent primary NE. Primary success was 76% for P+I and 100% for the other two cohorts. Most patients (89%) who underwent P+I received general anesthesia compared with none who underwent primary nasal endoscopy. Most complications were related to the use of general anesthesia, with a complication rate of 10% for P+I, 48% for P+I plus NE, and 0% for primary NE. Most P+I procedures required hospital admission compared to half of primary NE procedures. CONCLUSIONS: In our study cohort, primary NE provided good outcomes and was associated with a lower complication rate than P+I with or without NE.

Primary Lacrimal Sac Tumors with Extension into Vicinity: Outcomes with Endoscopy-Assisted Modified Weber-Ferguson's Approach.

PURPOSE: To evaluate the outcomes of endoscopy-assisted modified Weber-Ferguson's approach in the management of primary lacrimal sac tumors with extension into the neighboring tissues. METHODS: A retrospective interventional study was performed on all patients with lacrimal sac tumors treated with the endoscopy-assisted modified Weber-Ferguson approach between January 2010 and June 2022 at the Shanghai Ninth People's Hospital, China. Data assessed include demographics, clinical presentations, imaging features, surgical techniques, histopathology, adjuvant modalities of management, complications, and outcomes. RESULTS: A total of 13 patients were included in the analysis. Epiphora and palpable mass lesion were the presenting complaint in 84.6% (11/13) of the patients. Nearly half of the patients (46.1%, 6/13) were misdiagnosed as lacrimal duct obstruction. All the lacrimal sac tumors in the present series showed uneven enhancement on T1-weighted MRI imaging. Postoperatively, 84.6% (11/13) patients recovered well with excellent esthetics and were disease-free after a mean follow-up of 58.6 months. Two patients who underwent additional exenteration developed recurrence and succumbed (at 41 and 96 months follow up) while they were on palliative chemoradiation. CONCLUSION: The endoscopic-assisted modified Weber-Fergusson surgical approach is effective in providing better visibility and accessibility to lacrimal sac tumors with extension into neighboring tissue.

Retrograde Flow of Fluid Through the Nasolacrimal Duct System Under General Anesthesia: A Case Report.

This case report describes a rare incident of fluid exhibiting retrograde flow from the nasopharynx through the nasolacrimal duct and accumulating within the eye guard while under general anesthesia. The patient was in a steep Trendelenburg position for several hours and received multiple liters of intravenous fluid. The patient did not have a history of sinusitis, sinus surgery, cocaine use, dacryostenosis and dacryocystitis, or nasolacrimal duct irrigation and probing. This case provides insight into the potential ophthalmic implications of surgical and anesthetic management. While the patient fortunately had no complications, this case also underscores the importance of intraoperative vigilance.

Evaluation of the relationship between tear meniscus changes and quality of life outcomes after external dacryocystorhinostomy.

PURPOSE: This study aims to investigate the effects of external dacryocystorhinostomy (DCR) surgery on tear meniscus parameters and assess its relationship with improvements in quality of life (QoL) in patients with nasolacrimal duct obstruction (NLDO). METHODS: This prospective study included 30 patients diagnosed with NLDO who underwent external DCR surgery. Tear meniscus (TM) parameters, including height, depth and area, were measured using anterior segment optical coherence tomography. Lacrimal symptom questionnaire (LacQ), Munk scores and Glasgow benefit inventories (GBI) were collected. Statistical analysis was performed to evaluate the correlation between tear meniscus changes and improvements in QoL. RESULTS: TM height, depth and area decreased from preoperative median measurements (0.09 mm2, 0.37 mm, 0.56 mm) to postoperative median measurements (0.03 mm2, 0.21 mm, 0.30 mm) (p < 0.001). Lacrimal symptom scores and Munk scores showed a significant improvement at 3-month postoperatively (p < 0.001). The GBI scores also demonstrated a significant improvement, indicating a positive impact on the patients' QoL. (p < 0.001). A statistically significant correlation was found between the change in TM parameters and LacQ lacrimal symptom scores. CONCLUSION: External DCR surgery leads to significant improvements in tear meniscus parameters and quality of life outcomes in patients with NLDO. The decreased in TM height and TM area indicates improved tear film dynamics and decreased tear volume, which positively impact the patients' ocular comfort and overall well-being. This study highlights the importance of tear meniscus evaluation as a potential market for assessing the success of DCR surgery and its impact on patients' QoL.

Surgical outcomes of endoscopic dacryocystorhinostomy for eyes with nasolacrimal duct obstruction via tear meniscus height evaluation.

PURPOSE: To evaluate the association of tear meniscus height (TMH) with clinical outcomes of patients who underwent endonasal dacryocystorhinostomy. METHODS: We recruited 304 patients from two institutes. The TMH was measured using anterior segment optical coherence tomography before surgery. All patients underwent endoscopic DCR with lacrimal intubation stent insertion. The lacrimal stent was removed 2 months after surgery. The TMH was measured at 2 months and 12 months after surgery. Improvements in epiphora were assessed using a visual analogue scale (range, 0-2). Recurrence was determined based on lacrimal irrigation and endoscopic evaluation results. RESULTS: All patients experienced improvements in subjective symptoms 2 months after surgery. The mean TMH also decreased significantly compared with that before surgery. During the follow-up period, four patients experienced recurrence. The mean TMH 12 months after surgery was significantly lower than that before surgery. The rate of change in the TMH was significantly associated with the use of a dacryoendoscope during sheath-guided lacrimal stent intubation at all time points. Of the 251 patients who were followed up at 12 months after surgery, three reported recurrences, and 17 reported mild improvement of epiphora. The rate of change in the TMH was significantly associated with epiphora improvement. Height was also associated with epiphora improvement. CONCLUSIONS: Endoscopic DCR is an acceptable surgical procedure for managing nasolacrimal duct obstruction. Sheath-guided lacrimal stent intubation using a dacryoendoscope resulted in a greater reduction in postoperative TMH compared to the blind insertion technique, which may lead to favorable clinical outcomes.

Optimisation of reduction for prolapsed silicone tube after lacrimal intubation.

BACKGROUND: A common complication of bicanalicular intubation is dislocation of the silicone tube. METHODS: Eleven patients with prolapsed silicone tubes who had undergone bicanalicular nasal intubation were injected with a 2 per cent lidocaine solution to infiltrate the lacrimal duct mucosa. A memory wire probe was used to pull a 4-0 suture through the lacrimal passage retrogradely, allowing the suture to grab the silicone tube. Paraffin oil was applied to the contact part of the rope and the silicone tube, then the distal end of the silk thread was removed from the nostril until the tube was pulled into place. RESULTS: The prolapsed silicone tubes were restored by surgery in nine patients, with the drainage tube in the correct position in the eye and the lacrimal duct irrigation unobstructed. CONCLUSION: The optimisations made in this study are considered effective adjustments of reduction surgery for a prolapsed silicone tube.

Analysis of the safety and effectiveness of endoscopic nasal dacryocystorhinostomy in the remedy of chronic dacryocystitis.

To estimate the safety and effectiveness of endoscopic nasal dacryocystorhinostomy in the remedy of chronic dacryocystitis. The clinical data of 105 subjects with chronic dacryocystitis enrolled into our hospital were analyzed retrospectively. The subjects were distinguished into nasal endoscopic group (endoscopic dacryocystorhinostomy; i.e., 51 cases) according to their surgical methods and external-route group (external-route dacryocystorhinostomy; i.e., 54 cases). The therapeutic effect, lacrimal gland secretion function, tear film stability, degree of epiphora, lacrimal passage patency, complications, and recurrence rate were contrasted between the 2 groups. The nasal endoscopic group exhibited a higher effective remedy rate (98.04%) compared with the external-route group (83.33%). Three months postoperation, both groups showed improvements in lacrimal gland secretion function and tear film stability, with the nasal endoscopic group demonstrating more significant enhancement in lacrimal gland secretion function than the external-route group. Six months postoperation, a reduction in the degree of epiphora was observed in both groups, with the nasal endoscopic group displaying a more pronounced decrease in epiphora severity and a higher lacrimal passage patency rate than the external-route group. Furthermore, the nasal endoscopic group experienced lower incidences of postoperative complications and recurrence rates. Endoscopic dacryocystorhinostomy is safe and effective in the remedy of chronic dacryocystitis.

Medial lacrimal sac excision versus conventional H-shaped lacrimal sac opening in external dacryocystorhinostomy: a comparative cohort study.

PURPOSE: The external dacryocystorhinostomy (Ex-DCR) is a reliable but surgically challenging procedure to overcome a nasolacrimal duct obstruction (NLDO). The aim of this study is to describe the outcomes of a modified technique of lacrimal sac opening and to compare it with the conventional Ex-DCR. METHODS: This comparative cohort study included adult patients undergoing Ex-DCR for primary acquired NLDO by or under supervision of one surgeon. Group 1 (conventional Ex-DCR including H-shaped incision, anastomosis of the anterior mucosal flap to nasal mucosal flap and resection of the posterior sac flap) was compared with Group 2 (modified Ex-DCR including excision of the medial lacrimal sac and anastomosis of remaining anterior sac flap to nasal mucosal flap). Outcome measures included the success rate (defined as complete symptom relief or patent irrigation after three months), reoperation rate, redo-free survival within five years, and occurrence of postoperative bleeding and postoperative infection. RESULTS: 138 patients were included. The success rates were 94.7% (54/57 cases) for Group 1 and 96.3% (78/81) for Group 2 (p-value = 0.658). The redo-rate was 5.3% (3/75) in Group 1 and 2.5% (2/81) in Group 2 (p = 0.331). Two-year redo-free survival probability estimates were 89.8% for Group 1 and 96.3% for Group 2, respectively. No complications occurred in Group 2, whereas in Group 1, one patient (1.8%) suffered from postoperative bleeding and one (1.8%) from postoperative infection. CONCLUSIONS: This study showed that our modified Ex-DCR technique is equally efficacious compared with the conventional Ex-DCR technique in adult patients with NLDO.

Practice patterns in revision dacryocystorhinostomy.

PURPOSE: This study aimed to report the practice patterns while performing revision dacryocystorhinostomy (RevDCR) amongst oculoplastic surgeons from several regions across the globe. METHODS: The survey consisted of 41 specific questions sent via email that contained a link to the Google forms. The questions covered several aspects of the respondents' practice profiles, evaluation methods, pre-operative choices, surgical techniques, and follow-up preferences while dealing with patients of prior failed DCRs. Questions were answerable either as multiple choice or free text typing. The survey respondents were anonymized. The responses were collected and analyzed, and data were tabulated to understand the preferred practice trends. RESULTS: A total of 137 surgeons completed the survey. Most respondents identified themselves as experienced surgeons managing failed DCRs (76.6%, total respondents (n) = 137). The commonly preferred modalities for evaluation of a failed DCR were lacrimal irrigation (91.2%) and nasal endoscopy (66.9%). About 64% (87/137) of the respondents performed a combination of nasal endoscopy, lacrimal irrigation, and probing to localize the area of the failed DCR. A majority of the respondents used anti-metabolites (73.3%, n = 131) and stents (96.4%, 132/137) during the revision surgery. Most surgeons preferred endoscopic approach (44.5%), (61/137) for revising a failed DCR and most preferred general anaesthesia with local infiltration (70.1%, 96/137). Aggressive fibrosis with cicatricial closure was identified as the most frequently encountered cause of failure (84.6%, 115/137). The osteotomy was performed on an as-needed basis by 59.1% (81/137) of the surgeons. Only 10.9% of the respondents used navigation guidance while performing a revision DCR, mainly for post-trauma scenarios. Most of the surgeons completed the revision procedure within 30-60 minutes (77.4%, 106/137). The self-reported outcomes of revision DCRs were good (80-95%, median-90%, n = 137). CONCLUSION: A significantly high percentage of oculoplastic surgeons who responded to this survey from across the globe performed nasal endoscopy in their pre-operative evaluations, preferred endoscopic surgical approach, and used antimetabolites and stents while performing revision DCRs.

Transcutaneous (External) Dacryocystorhinostomy with Reconstruction of the Ductus nasolacrimalis. / Transkutane (externe) Dakryozystorhinostomie mit Rekonstruktion des Ductus nasolacrimalis.

BACKGROUND: Dacryocystorhinostomy (DCR) is regarded as the gold standard for the treatment of chronic dacryocystitis (CDC). Different modifications of the surgical procedure have been developed over the years. METHODS: Patients with CDC due to postsaccal lacrimal stenosis and under treatment with DCR have been included in this retrospective study. Two groups of different surgical procedures were analysed: firstly DCR without reconstruction of the ductus nasolacrimalis (DNL, group 1) and secondly patients with reopening the DNL (group 2). Criteria for success were absence of permanent epiphora, absence of inflammation of the lacrimal sac (functional success), and no recurrent surgery with free patency of the lacrimal duct (anatomical success). This was obtained by questionnaire after a follow-up of at least 12 months. The impact of gender, ectasia of the lacrimal sac, dacryoliths, and prior lacrimal surgeries was analysed. RESULTS: Overall, 248 surgeries were enrolled in this trial. Mean age in group 1 was 68 years (range: 22 to 92 years) and gender ratio was 3.2 to 1 (female : male). In that group, 68 operations could be followed up. In group 2, 62 operations on patients of a mean age of 63 years (range: 24 to 89 years) and a gender ratio of 2.9 to 1 (female : male) were observed. Complete success occurred in 75.0% in group 1 and 75.8% in group 2. Recurrent operations were necessary in one case of group 2 (1.6%) and 4 cases of group 1 (5.9%). Gender (group 1 p = 1; group 2 p = 0.115; between groups p = 0.511), ectasia of the lacrimal sac (group 1 p = 0.877; group 2 p = 0.674; between groups p = 0.878), dacryolith (group 1 p = 1; group 2 p = 0.465; between groups p = 1), and prior lacrimal surgery (group 1 p = 0.092; group 2 p = 0.051; between groups p = 0.520) did not influence the success rates in each group or between groups. Significantly more dacryoliths were found during operations of group 2 (p = 0.010). CONCLUSION: Reconstruction of the DNL during DCR is a possible and easy modification, with a slightly better success rate in curing CDC. Intraoperatively, dacryoliths might not be apparent remain in the deeper parts of the lacrimal ducts. Therefore, these segments should be inspected during surgery.

Caruncle and plica hypertrophy causing mechanical secondary acquired lacrimal duct obstruction: - SALDO update study (SUP) - paper I.

PURPOSE: To exclusively report the clinical category of mechanical secondary acquired lacrimal duct obstruction (SALDO) secondary to the caruncle and plica hypertrophy. METHODS: Prospective interventional case series involving 10 consecutive eyes with megalocaruncle and plica hypertrophy were enrolled in the study. All patients presented with epiphora secondary to a demonstratable mechanical obstruction of the puncta. All patients underwent high magnification slit-lamp photography and Fourier-domain ocular coherence tomography scans (FD-OCT) of the tear meniscus height (TMH) pre- and post-operatively at 1-month and 3-months. Caruncle and plica size, position, and their relationship to the puncta were noted. All patients underwent partial carunculectomy. Primary outcome measures were demonstrable resolution of the mechanical obstruction of the puncta and the reduction in the tear meniscus height. The secondary outcome measure was the subjective improvement of the epiphora. RESULTS: The mean age of the patients was 67 years (range: 63-72 years). The average TMH was 843.1 (range: 345-2049) microns pre-operatively and 195.1(91-379) microns at 1-month follow-up. All patients reported significant subjective improvement in epiphora at 6-months follow-up. One patient had bilateral granuloma at the surgical site at two weeks and was managed by simple excision and topical tapering steroids. Histopathology revealed hyperplastic epithelium with goblet cells with chronic inflammatory cells in the sub-epithelial region and the stroma. CONCLUSION: The role of the caruncle in the causation of mechanical SALDO needs to be carefully assessed in patients beyond the sixth decade. Excellent objective and subjective outcomes can be achieved by a partial carunculectomy and plica semilunaris excision.

DCR preferences among oculoplastic surgeons: Barriers and facilitators to adoption of endoscopic DCR.

OBJECTIVE: To determine the preference for dacryocystorhinostomy (DCR), patient selection criteria for endoscopic DCR, endoscopic DCR technique, and barriers to adoption of endoscopic DCR. METHOD: Cross-sectional study conducted from May-December 2021. A survey was sent to oculoplastic surgeons. Questions on demographic characteristics, type of clinical practice, technique preferences, barriers and facilitators to adoption of endoscopic DCR were included. RESULTS: 245 participants completed the survey. Most respondents were located at an urban site (84%), were in private practice (66%), and had been in practice for more than 10 years (58.9%). Sixty one percent perform external DCR as the first line procedure for treating primary nasolacrimal duct obstruction. The most common factor influencing the surgeon's decision to perform endoscopic DCR was the patient's request (37%) followed by endonasal exam (32%). The most common barrier for not performing endoscopic DCR was the lack of experience and lack of training during fellowship (42%). The most worrisome complication for most respondents was failure of the procedure (48%), followed by bleeding (30.3%). Eighty one percent believe surgical mentorship and supervision during initial cases would facilitate endoscopic DCR learning. CONCLUSIONS: External Dacryocystorhinostomy is the preferred technique for treating primary acquired nasolacrimal duct obstruction. Learning endoscopic DCR early during fellowship training and high surgical volume to improve the learning curve dramatically impacts the adoption of the procedure.

Antibiotic utilization in endoscopic dacryocystorhinostomy: a multi-institutional study and review of the literature.

PURPOSE: Utilization of antibiotics for endoscopic dacryocystorhinostomy (endo-DCR) is largely dependent on individual surgeon preference. This study aimed to investigate prescribing practices of pre-, peri-, and postoperative antibiotics and effects on postoperative infection rates in patients who underwent endo-DCR. METHODS: A retrospective chart review of institutional data at two academic centers of endo-DCR cases from 2015-2020 was performed. Postoperative infection rates for patients who received pre-, peri-, and postoperative antibiotics, individually or in combination, and those who did not, were compared via odds ratio and ANOVA linear regression. RESULTS: 331 endo-DCR cases were included; 22 cases (6.6%) had a postoperative infection. There was no significant difference in the infection rates between patients without an active preoperative dacryocystitis who received different permutations of peri- and postoperative antibiotics. Patients who received preoperative antibiotics within two weeks of surgery for preexisting acute dacryocystitis, but did not receive peri- or postoperative antibiotics, had a higher rate of postoperative infections (p = 008). CONCLUSIONS: Our data suggest antibiotics may be beneficial only when patients have a recent or active dacryocystitis prior to surgery. Otherwise, our data do not support the routine use of antibiotic prophylaxis in endo-DCR.

The evaluation of nasolacrimal duct injury in Le Fort I osteotomy patients.

BACKGROUND: Although Le Fort I surgeries are safe and successful procedures; nasolacrimal duct injuries may be observed due to these surgeries. The study aimed to investigate the prevalence of nasolacrimal duct injury in Le Fort I osteotomy patients. MATERIAL AND METHODS: The authors conducted a retrospective cohort study consisting of patients who underwent Le Fort I osteotomies between 2017 and 2021 in the Erciyes University Faculty of Dentistry. The primary predictor variables were the distance of the nasolacrimal canal to the outer cortex of the maxilla and the nasal floor, as well as the superior-inferior level of the superiorly positioned screw inserted in the maxilla aperture region relative to the nasolacrimal canal. The outcome variable was the presence of a nasolacrimal duct injury. Mann Whitney U test was used for quantitative variables between the two groups. A Pearson chi-squared analysis was used to compare categorical data. A p-value <0.05 was considered statistically significant. RESULTS: A total of 290 nasolacrimal canals were evaluated in 145 patients, 87 females, and 58 males. The mean age was 23.47± 6.67. There was a statistically significant relationship between screw level and nasolacrimal canal perforation (p<0,001). The distance between the most anterior border of the nasolacrimal canal and the outer cortical of the maxilla was significantly less in the perforation group (p<0,001). The fixation screw was significantly closer to the nasolacrimal canal in the perforation group (p<0,001). CONCLUSIONS: In Le Fort I surgery, nasolacrimal duct injury may occur during screw fixation to the aperture region. Superiorly positioned fixation screws in the aperture region may damage the nasolacrimal canal. In patients where the nasolacrimal canal is close to the outer cortex, care should be taken when applying the fixation screws to the aperture region to avoid damaging the canal.

Minimally Anterior Medial Maxillary Approach (MAMMA): a novel technique for a wide access to the maxillary sinus.

PURPOSE: To describe a novel endoscopic technique to approach the maxillary sinus (MS), the Modified Anterior Medial Maxillary Approach (MAMMA), preserving the inferior turbinate (IT) and the nasolacrimal duct (NLD). To perform radiological measurements and describe a case series to study the feasibility and limits of MAMMA. METHODS: Computed tomography (CT) scans (n = 150 nasal cavities) were used to calculate areas of the MAMMA to define surgical limits and extensions. Measurement of distances to critical anatomy landmarks and total area for the MAMMA were calculated. An instructional case illustrating the surgical technique and outcome was also included. RESULTS: Radiological analysis showed a mean distance from the Piriform Aperture (PA) to the anterior limit of the NLD of 1.03 ± 0.18 cm (range 0.59-1.48) and a mean distance from de PA to the posterior limit of the NLD of 1.57 ± 0.22 cm (range 1.02-2.11). The mean distance from the nasal floor to the Hasner's valve was 1.61 ± 0.27 cm (range 1.06-2.52) and the distance from the nasal floor to the insertion of the IT was 2.20 ± 0.36 cm (range 1.70-3.69). Finally, the mean total area for the MAMMA was 4.04 ± 0.52 cm2 (range 3.17-5.53). No complications or recurrence of the pathology were observed in operated patients. CONCLUSION: The MAMMA provides a wide surgical field of the MS walls comparable to more aggressive techniques, with preservation of the sinonasal and lacrimal function. MAMMA is an effective alternative to treat different MS pathologies including benign recurrent maxillary sinus tumors.