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.

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.

The influence of microorganisms on early relapses after external dacryocystorhinostomy.

PURPOSE: Understanding the influence of microorganisms in patients with acquired nasolacrimal duct obstruction (NLDO) and investigating their effect on recurrence after external dacryocystorhinostomy (DCR). METHODS: This prospective study included 50 patients. Evaluations were made before, on the first postoperative day and monthly after DCR. Nasolacrimal silicon tubes (NST) were removed after three months. Before the DCR, swab samples were taken from both hands and lower conjunctival fornices and from the lacrimal sac during the first DCR and from the relapsed cases during the second DCR. RESULTS: Growth was observed in 90 (45%) cultures out of 200 and a total of 23 different strains were identified altogether. Staphylococcus aureus (40%) and Streptococcus pneumoniae (28%) were dominantly isolated which were all resistant to penicillin, tetracycline and erythromycin. Lacrimal syringing (LS) was successful in patients (100%) on the first postoperative day. After three months, before NST removal, purulent discharge from the punctum was observed in five patients, and blockage was detected by LS. S. pneumoniae was isolated from all five patients' obstructed side conjunctival cultures. Additionally, from their lacrimal sac, S. pneumoniae (4 patients), Capnocytophaga gingivalis, and Candida spp. (1 patient) strains were isolated. S pneumoniae was isolated in four out of five patients from the ipsilateral conjunctival and lacrimal sac cultures which obtained from the subsequent DCR. CONCLUSION: Our results showed that S. pneumoniae was an isolated and persistent strain in cases with early recurrence even after a successful DCR.

Use of Dermaflage®, a silicone-based skin camouflage product, for treatment of medial canthal fistula.

Medial canthal fistulas present a therapeutic challenge, given that the risk factors for development of this and similar complications also contribute to their difficulty to treat. Following surgical, chemotherapy and radiation treatment of a poorly differentiated sinonasal carcinoma, a 61 year old man failed internal and external rotational flap repair and declined further operative procedures; he was satisfied with a novel conservative treatment. This report describes use of Dermaflage®, a silicone-based skin camouflage and topical cutaneous filler product, to both resolve the symptoms of tearing and discharge through the fistula and mask the defect from the casual observer.

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.

Comparing outcomes of pediatric and adult external dacryocystorhinostomy in Nepal: Is age a prognostic factor?

We determine whether age is a prognostic factor for surgical outcomes of external dacryocystorhinostomy (Ex-DCR). This retrospective cohort study conducted at Tilganga Institute of Ophthalmology (Kathmandu, Nepal) compared pediatric Ex-DCR procedures (age ≤ 15 years) to adult Ex-DCR procedures (age > 15 years) and was performed between January 2013 and December 2013, with a minimum follow-up period of 6 months. Primary outcome measure was rate of success, defined as complete resolution of subjective symptom(s) of epiphora (subjective success), combined with patent lacrimal passage on syringing (anatomical success) at last follow-up visit. Other outcome measures included clinical presentation, diagnosis, intraoperative complications and post-operative complications. In total, 154 Ex-DCR procedures were included, with an age range of 8 months to 81 years (mean age 36.4 ± 21.0 years). In all, 38 pediatric Ex-DCR procedures were compared to 116 adult procedures. Success rates were 97% in the pediatric group and 95% in the adult group, with no clinically or statistically significant difference in success rate or complication rate between groups (p > 0.05). Our study yielded high success rates of Ex-DCR in both pediatric and adult age groups suggesting that Ex-DCR remains an optimal treatment choice for all age groups. With no difference in surgical outcomes between pediatric and adult patients, including complication rate, we conclude that age is not a prognostic factor for Ex-DCR failure. We do not recommend adjuvant therapy for pediatric patients.

Prevention of re-obstruction in watery eye treatment: three-flap technique in external dacryocystorhinostomy.

PURPOSE: To examine the surgical outcome of three-flap external dacryocystorhinostomy (3-flap ex-DCR) based on the most common site of granulation occurrence in no-flap endonasal DCR (no-flap en-DCR). METHODS: This was a retrospective observational study. We first examined the location of granulation occurrence in the osteotomy site using nasal endoscopy after no-flap en-DCR on 53 sides of 37 patients (5 male, 32 female) with nasolacrimal duct obstruction. Based on the results of this surgery, we performed 3-flap ex-DCR on 70 sides of 61 patients (18 male, 43 female) with nasolacrimal duct obstruction. Anatomical success was defined as no reflux under lacrimal irrigation and a patent osteotomy site under nasal endoscopic examination at postoperative 12 months. Functional success was defined as no symptoms of watery eyes over the same period. RESULTS: In the no-flap en-DCR patients, the granulation was formed in 42 sides (79.2 %): 18 sides (34.0 %) on the superior portion, 9 sides (17.0 %) on the inferior portion, 35 sides (66.0 %) on the anterior portion, and only 1 side (1.9 %) on the posterior portion, which was very small. Based on these results, we performed the 3-flap ex-DCR with the anterior, superior, and inferior flaps. Anatomical success with this technique was achieved in all sides (100 %), and functional success was obtained in 66 of 70 sides (94.3 %). CONCLUSIONS: The 3-flap ex-DCR did not cause recurrent nasolacrimal duct obstruction, rendering it a very useful technique in terms of quality of life and medical economics.

Meta-analysis of the adjunctive use of mitomycin C in primary and revision, external and endonasal dacryocystorhinostomy.

PURPOSE: To determine whether application of the anti-proliferation agent, mitomycin C (MMC), to the osteotomy site during dacryocystorhinostomy (DCR) surgery increases surgical success rates. METHOD: We conducted a comprehensive meta-analysis of randomised controlled clinical studies relating to the adjunctive use of MMC in primary and revision, as well as external (EX-DCR) and endonasal DCR (EN-DCR). RESULTS: 15 studies met our inclusion criteria with a total of 850 DCR procedures. The mean concentration of MMC used was 0.3 mg/ml (range 0.02-0.75 mg/ml) and mean duration of application 18 min (range 2-30 min). MMC significantly reduced the failure rate of primary EX-DCR (risk ratio, RR, 0.51; 95% confidence interval, CI, 0.31-0.86) and revision EN-DCR (RR 0.43; 95% CI 0.21-0.89). The adjunctive use of MMC in primary EN-DCR, however, did not confer a significant reduction in failure rate compared with control (RR 0.94; 95% CI 0.44-2.04). We found a deficiency of evidence regarding the potential benefit of MMC in revision EX-DCR. Only two cases of adverse effects relating to the use of MMC were reported among the studies, both of which related to delayed wound healing. CONCLUSIONS: Application of MMC to the osteotomy site is a safe and effective way of increasing surgical success rate in primary EX-DCR and revision EN-DCR, but does not provide any significant benefit in primary EN-DCR. Further studies are required to evaluate the potential effect of MMC in revision EX-DCR.

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.

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.

Endoscopic and External Dacryocystorhinostomy: Long Term Result from a Tertiary Center in Portugal.

Dacryocystorhinostomy is the gold-standard for distal lacrimal obstructions. This study aims to report the demography, clinical presentation, influence of agger nasi opening, uncinectomy and septoplasty, the use of silicone stent tubes, complications and success of endoscopic and external dacryocystorhinostomy over a period of 11 years. Retrospective review of clinical records, from January 2012 to December 2022, at a tertiary center in Portugal. A total of 249 procedures, 6 external and 243 endoscopic, were performed, including 39 revision cases. There was a female predominance (79.9%) with a mean age at diagnosis of 66.4 years. Recurrent acute dacryocystitis, reported by 33.3%, was associated with higher success (p = 0.053). Agger nasi opening, uncinectomy and septoplasty were performed in 17.7%, 6.0% and 15.3% respectively, although associated with higher success rates, no statistically significant difference was found. Minor complication rates for both external and endoscopic approach was 33.3% and 32.1% respectively. Functional and anatomical success was 100% and 83.3%, respectively, for external dacryocystorhinostomy, and 91.4% and 85.1%, respectively, for endoscopic dacryocystorhinostomy. Revision surgery was associated with a worse anatomical success (p = 0.05). Endoscopic dacryocystorhinostomy is an effective and safe alternative to the external approach. Minor procedures can increase the success rate, but multicentre studies need to be performed for a statistically significant result.

Enhancing Precision: A Visual Guide to Drill-Assisted External Dacryocystorhinostomy Surgery.

This technical report aims to provide a visual guide to the drill-assisted external dacryocystorhinostomy (DCR) technique with silicone intubation. Through a step-by-step video demonstration, it addresses inherent documentation challenges and highlights crucial considerations. A critical aspect of the procedure's success lies in creating a clear space around the drilling area to prevent thermal burns and soft tissue wrapping around the burr. Additionally, it emphasizes the careful use of smaller burr diameters and the importance of drilling techniques, advocating for minimal perpendicular drilling while maintaining rotational polishing movements to minimize the risk of rapid penetration and potential nasal mucosal injury. The thermal cauterization of perforating nutrient vessels during bone drilling offers a significant advantage in reducing the risk of bleeding. A review of existing limited studies comparing drill-assisted and conventional external DCR reveals advantages such as shorter surgical duration, lower intraoperative hemorrhage rate, more regular osteotomy edges, increased ostomy patency, and potential prevention of soft tissue or mucosal injuries. Nonetheless, achieving these benefits necessitates enhanced hand and foot coordination. However, despite these benefits, a noticeable gap exists in the literature concerning comprehensive studies and comparative analyses. Furthermore, exploring the associated cost and learning curve of adopting this surgical technique is essential. This report aims to fill the existing gap in the literature and serve as a visual reference for surgeons interested in adopting drill-assisted external DCR.

Intravenous Tranexamic Acid for Control of Bleeding during External Dacryocystorhinostomy under General Anesthesia: A Randomized Clinical Trial.

Purpose: To investigate the effect of intravenous tranexamic acid administered prior to external dacryocystorhinostomy (DCR) surgery to decrease intraoperative bleeding under general anesthesia. Methods: This was a double-blinded randomized placebo-controlled trial. A total of 70 patients (35 intervention and 35 control) with nasolacrimal duct obstruction (NLDO) who were selected for DCR surgery between September 2021 and September 2022 were included. After clinical examinations and laboratory tests, patients were randomly classified into intervention and control groups. The intervention group received 10 mg/kg intravenous tranexamic acid to a maximum dose of 1 gr 30 minutes before the surgery. Controls received normal saline solution as a placebo. The amount of intraoperative bleeding and surgical time were compared between the two groups. Results: The intervention group included 21 men (60%) and 14 women (40%), while the control group included 19 men (54.3%) and 16 women (45.7%). The mean ages of the participants were 55.46 ± 10.8 years and 58.06 ± 11.28 years in the intervention and control groups, respectively. A significant difference was observed between the two groups in the surgical time analysis (control group: 37.74 ± 9.52 minutes vs intervention: 26.03 ± 10.5 minutes; P < 0.001). Additionally, there was a significant difference in the bleeding volume between the intervention (70.66 ± 48.19 ml) and control (47.74 ± 60 ml) groups (P < 0.001). Conclusion: Intravenous tranexamic acid administration before the DCR procedure can successfully control bleeding during the surgery.

Success Rate of External Dacryocystorhinostomy With and Without Stent.

Dacryocystorhinostomy (DCR) is a procedure that bypasses an obstruction in the nasolacrimal duct system. DCR can be categorized into two primary techniques: external and endoscopic. This review aims to assess the success rate of external DCR procedures, both with and without the use of a stent. This study compared the outcomes of primary DCR with and without silicone intubation in multiple studies. The reviewed studies consistently showed that silicone intubation significantly improves the success rates of DCR, with success rates ranging from 80% to 95%. The involved studies suggest that silicone intubation offers specific advantages in complex cases involving distant and common canaliculus blockages and recurrent DCR surgeries. This review emphasizes that multiple studies have documented higher success rates of external dacryocystorhinostomy (DCR) when silicone tubes are utilized as stents. Furthermore, external DCR has been identified as the preferred procedure among medical professionals.

Surgical Outcomes in Congenital Nasolacrimal Duct Obstruction After Probing Failure: A One-Stage Approach.

Objectives: This study evaluates the outcomes of a one-stage obstruction-based strategy for congenital nasolacrimal duct obstruction (CNLDO) in children who have prior probing failure. The objective is to assess the success rates of probing, balloon dacrioplasty (BDP), monocanalicular intubation (MCI), and external dacryocystorhinostomy (external DCR) performed in the same anesthesia session. Methods: A retrospective analysis included 55 eyes (45 patients, aged 12-120 months) with initial probing at another center. Procedures involved probing, probing plus BDP, MCI, and external DCR. For membranous obstruction (MO), the procedure concludes after probing; for incomplete complex obstruction (ICO) it includes BDP or MCI; and for complete complex obstruction (CCO), external DCR is performed. Success rates were assessed based on obstruction types and age groups, with improvement in symptoms and signs as the measure of success. Statistical analysis utilized Kruskal-Wallis, Fisher's exact test, and logistic regression. Results: The overall success rate for all procedures was 72.7%. Success rates were 77.8% for MO, 66.7% for ICO, and 100% for CCO, introducing a promising perspective for the management of different CNLDO types. External DCR exhibited a 100% success rate, highlighting its effectiveness in cases of CCO. Success rates for interventions were 77.8% for probing, 61.5% for probing plus BDP, and 73.1% for MCI, emphasizing the feasibility and success of one-stage obstruction-based treatments. Age did not significantly correlate with success rates. Conclusion: The one-stage obstruction-based approach, which demonstrated favorable success rates in treating CNLDO and introduced a paradigm shift in the treatment strategy after probing failure, underscores the importance of tailoring interventions to the specific obstruction type. The study also highlights the feasibility and cost-effectiveness of performing multiple BDP, MCI, or external DCR procedures concurrently during the same anesthesia session, further emphasizing the crucial role of customizing treatments based on the nature of the obstruction.

A randomized control trial on the role of tranexamic acid in preventing intraoperative bleeding during external dacryocystorhinostomy.

Purpose: To evaluate the role of tranexamic acid in controlling intra-operative and immediate post-operative bleeding during external dacryocystorhinostomy. Methods: This was a double-blinded randomized placebo-controlled trial. All patients diagnosed with primary acquired nasolacrimal duct obstruction presenting between June 2018 to December 2019 were included in the study. All patients in the study group received a single dose of 1 gm tranexamic acid injection intravenously 30 minutes before the surgery, whereas the patients from group B (placebo) received normal saline. The effect of the injection was measured in terms of duration of the surgery, surgical field grading, amount of total blood loss during the surgery, and the need for postoperative nasal packing. Results: A total of 96 patients were included, of whom 45 were males and 51 were females. The study group (Group A) included 51 patients (27 males and 24 females) and the control group (Group B) included 45 patients (18 males and 27 females). There were no statistically significant differences between the two groups in terms of the duration of surgery (48.43 ± 20.01 minutes vs. 53.38 ± 19.8 minutes, P = 0.228), view of the surgical field (P = 0.084), the amount of intraoperative blood loss (88.63 ± 69.34 mL vs. 88.89 ± 51.93 mL, P = 0.984) and requirement of postoperative nasal packing (54.9% vs 62.2%, P = 0.471). Conclusion: There seems to be little to justify the role of preoperative intravenous tranexamic acid injection in controlling intra-operative and immediate postoperative bleeding during external dacryocystorhinostomy.

Management of chronic dacryocystitis cases after failed external dacryocystorhinostomy using endoscopic technique with a novel lacrimal ostium stent.

AIM: To demonstrate the outcomes of endoscopic endonasal dacryocystorhinostomy (En-DCR) with an novel lacrimal ostium stent (LOS) which was performed in patients with recurrent epiphora after failed external dacryocystorhinostomy (Ex-DCR) and analyze the causes of failed Ex-DCR. METHODS: From September 2015 and December 2017, the clinic data of 29 cases suffered from recurrent epiphora after failed Ex-DCR was reviewed. The LOS were implanted into the ostium at the end of the revisional surgery. The causes of failed Ex-DCR were analyzed before revisional surgeries. Outcome of revisional surgeries with the new device were evaluated as well. RESULTS: The major causes of failure of the external approach were synechiae formation in the nasal ostium (29/29), followed by inadequate removal of the bony wall (21/29), nasal synechiae formation between lateral wall of nose and middle turbinate (11/29), and the bone opening was not in good location (7/29). The rate of success after revisional surgery was 82.76%. Re-obstruction of the ostiums were found in 5 failed cases. CONCLUSION: Endoscopic approach with a novel LOS may be an effective procedure to manage recurrent epiphora after previous failed Ex-DCR surgery. Synechiae formation in the nasal ostium and inadequate removal of the bony wall were the major causes of failure of Ex-DCR.

A glued technique of external dacryocystorhinostomy.

PURPOSE: Fibrin glue was used for anastomosis of lacrimal sac and nasal mucosal flaps and was compared with the conventional suture technique in external dacryocystorhinostomy. METHODS: A prospective interventional randomized control study in which 50 consecutive patients of primary acquired nasolacrimal duct obstruction (PANDO) were equally allocated into two groups. The case group underwent glued technique of external dacryocystorhinostomy (Ext DCR) in which fibrin glue was used for the apposition of the anterior lacrimal sac and nasal mucosal flaps. In the control group, conventional technique of Ext DCR was used to suture the flaps. Functional success was assessed by improvement in epiphora and fluorescein dye disappearance test (FDDT), whereas anatomical success was assessed by lacrimal irrigation and endoscopic view of the osteotomy site. RESULTS: The anatomical success in both the groups was 92%, whereas the functional success was 92% in the case group and 88% in the control group. The difference in the success rates between the two groups was statistically non-significant. CONCLUSION: Glued technique of Ext DCR is a simple and easy alternative to suturing of the flaps. Though the final outcome was comparable in both the groups, glue can be especially useful in uncooperative cases, in cases of excessive bleeding, or in situations where the flaps are very thin or have become friable.

External versus Endoscopic Dacryocystorhinostomy for Primary Acquired Nasolacrimal Duct Obstruction.

PURPOSE: The purpose of the study is to compare the surgical outcomes and success rates of external dacryocystorhinostomy (EX-DCR) versus endoscopic endonasal DCR (EN-DCR) for the treatment of primary acquired nasolacrimal duct obstruction (PANDO). METHODS: This retrospective nonrandomized study was conducted at Farabi Eye Hospital and Noor Eye Hospital, Iran. A review of electronic medical records of all patients with PANDO who underwent EX-DCR or EN-DCR between January 2016 and 2018 was carried out. RESULTS: A total of 803 patients underwent surgery, of which 618 patients (77%) were managed by EX-DCR and 185 patients (23%) by EN-DCR. The majority of cases (62%) were female. The mean age of the patients in EX-DCR and EN-DCR groups was 40.8 ± 14.2 and 34.3 ± 9.2 years, respectively. EX-DCR resulted in significantly less amount of pain compared to EN-DCR (P < 0.05). The success rate of surgery among EX-DCR and EN-DCR groups was 92.4% and 91.1%, respectively, and did not show statistically significant difference. A higher incidence of intraoperative hemorrhage requiring intervention was noted in the EN-DCR group (16.7% vs. 4.5%). Postoperative patient's satisfaction with EN-DCR and EX-DCR was 73% and 82%, respectively. CONCLUSION: Both EX-DXR and endoscopic DCR surgeries have high success rates and low incidence of failure. The choice of DCR technique should be based on the experience of the surgeon and patient's lacrimal and nasal anatomy and preferences.

The importance of clinical presentation on long-term outcomes of external dacryocystorhinostomies: Our experience on 245 cases.

PURPOSE: External dacryocystorhinostomy (EXT-DCR) is a surgical approach commonly used to treat post-canalicular acquired lacrimal obstruction whose success rate has been described, equally with endoscopic DCR, to be superior to other available treatments. METHODS: At San Raffaele Hospital, Milan (Italy), from January 2008 to December 2020, 245 EXT-DCRs were performed. All patients underwent routine pre-operative work-up including Jones tests and probing and irrigation of the lacrimal pathway; when necessary, a multidisciplinary approach with nasal endoscopy was performed. The surgical approach was followed by positioning of a bicanalicular stent which was left in place for 6 months. Success was defined as resolution of clinical signs/symptoms and free lacrimal flow on functional test. RESULTS: Of the cases enrolled, 26.9% were treated for recurrent epiphora (group 1), and 73.1% for epiphora associated with chronic dacryocystitis (group 2). After a median follow-up of 71 months, group 1 had success at T0 (1 month) and T1 (long-term) of 81.8% and 60.6%, respectively, compared to 93.8% and 77.7% in group 2. Statistical analysis showed a significant association with surgery both at T0 (p = 0.018) and T1 (p = 0.012) with group 2 showing better outcomes. Additionally, the cosmetic outcome of the external scar was defined as invisible in 91.8% of cases and slightly visible in 8.2%. CONCLUSIONS: External dacryocystorhinostomy provides long-term reliable results particularly in case of chronic dacryocystitis. Moreover, the optimal esthetic outcome of the external scar should be no longer considered the only guiding principle of treatment modality, particularly in the elderly.