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| ORIGINAL ARTICLE |
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| Year : 2001 | Volume
: 49
| Issue : 3 | Page : 169-172 |
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Comparison of external dacryocystorhinostomy and 5-fluorouracil augmented endonasal laser dacryocystorhinostomy. A Retrospective review
Patrick Watts, A Raghu Ram, Ranjit Nair, Huw Williams
Department of Ophthalmology, Royal Glamorgan Hospital, South Wales, United Kingdom
Correspondence Address:
Patrick Watts
Department of Ophthalmology, Royal Glamorgan Hospital, South Wales
United Kingdom
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 15887724 
Purpose: To compare the success rates of external dacryocystorhinostomy (EXT-DCR) with 5-fluorouracil (5-FU) augmented endonasal laser dacryocystorhinostomy (ENL-DCR) and to record the complications associated with 5-FU augmented ENL-DCR
Materials and Methods: This was a retrospective non-randomised study. Forty-one patients with primary acquired nasolacrimal duct obstruction underwent an EXT-DCR (19 patients) or an ENL-DCR (22 patients) over a 3-year period. A Holmium YAG laser (Ho:YAG) was used in the latter group of patients. Silicone tubes intubated in all patients were removed at three months. 5-FU was applied intraoperatively at the site of the ostium in the ENL-DCR patients. The median follow-up was 12 months (range 3-24 months) for the ENL-DCR group and 22 months (range 6-28 months) for the EXT-DCR group. The patency of the lacrimal system and the severity of epiphora were assessed at a final-review.
Results: The median age of the EXT-DCR group was 77 years (range 53-87) and that of the ENL-DCR group was 71 years (range 23 to 84). There were 12 female patients in the former group and 19 in the latter. The percentage of success in the EXT-DCR group was 94.7% (95% confidence interval (CI) = 75.4-99.1) = ), and 63.6% in the ENL-DCR group (95% CI= 43.0-80.3). The confidence interval for the difference of 31.1% was 5.6-52.2. There was a statistically significant difference between the two groups, p=0.024 (Fisher exact test).
Conclusions: These data suggest that EXT-DCR provides better results than 5-FU augmented ENL-DCR. However, ENL-DCR is the procedure of choice in certain circumstances such as in elderly, frail or medically unfit patients. Our results of 5-FU augmented ENL-DCR compare favourably with other published series.
Keywords: Dacryocystorhinostomy, 5-Fluorouracil, endonasal laser
How to cite this article:
Watts P, Ram A R, Nair R, Williams H. Comparison of external dacryocystorhinostomy and 5-fluorouracil augmented endonasal laser dacryocystorhinostomy. A Retrospective review. Indian J Ophthalmol 2001;49:169-72 |
 | EXT-DCR - CONVENTIONAL SKIN INCISIONAL DACRYOCYSTORHINOSTOMY; ENL-DCR - ENDOSONAL LASER DACRYOCYSTORHINOSTOMY; 5-FU - 5-FLUOROURACIL
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| EXT-DCR - CONVENTIONAL SKIN INCISIONAL DACRYOCYSTORHINOSTOMY; ENL-DCR - ENDOSONAL LASER DACRYOCYSTORHINOSTOMY; 5-FU - 5-FLUOROURACIL
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The surgical management of epiphora due to primary acquired nasolacrimal duct obstruction (PANDO) has revolved around creating a dacryocystorhinostomy (DCR) with either an external skin incisional approach [1,2] (EXT) or endoscopically through the nasal mucosa (ENL).[3] Endoscopic nasal surgery may be carried out surgically or with a laser.[4] Similar success rates of 95% and 94.7% following EXT-DCR[5] and endonasal surgical DCR[6] (ENS-DCR) have been reported. However the success rate of ENL-DCR falls short of these established procedures, falling between 58 and 83%.[7-9] A number of lasers such as Argon,[10] CO2,[11] Potassium Titanyl phosphate (KTP),[11] Neodymium Yttrium Aluminium Garnet(Nd:YAG),[12] and Holmium YAG (Ho:YAG)[13] have been successfully employed to create an ostium. Currently the Ho:YAG laser with its superior haemostatic and bone ablating properties is the most frequently utilised laser. [14,15]
Desptite its lower success rates, ENL-DCR continues to be popular in some centres as it enjoys certain advantages over the established incisional procedures. It avoids a facial scar without disturbing the medial canthal ligament or the lacrimal pump anatomy. Haemostasis is easily achieved and hypotensive anaesthesia is avoided, with patients electing to have a local anaesthetic. With experience the operating time of this procedure has been halved with most cases performed as out-patient procedures.[14]
Saddiq et al[7] in1997 noted that the cause of failure of ENL-DCR was probably due to scarring at the mucosal or submucosal level, and suggested that prevention of this healing response may be the key to improving the success rates. Hence we decided to perform ENL-DCR with 5-FU application intraoperatively at the site of the ostium to offset the closure of the anastomosis by the scarring process. We report our results over a 24-month period and compare these to our results of the EXT-DCR procedure performed during the same period.
| Material and Methods | |  |
This was a retrospective study carried out between 1996 and 1999. From the surgery log book, we identified 44 patients who had undergone surgery for PANDO. After the H0:YAG laser had been introduced in our service patients were offered either an EXT-DCR or an ENL-DCR. Informed consent was obtained for either procedure after a discussion of the relative advantages, disadvantages and current success rates from published reports. The patient selection was non-randomised.
We included all those patients with a nasolacrimal duct block confirmed clinically with syringing. A technetium 99 scintigraphy was performed on all patients. If a common canalicular block was found on scintigraphy, a contrast dacryocystogram was performed as per local protocol, to differentiate a functional obstruction from a true one at the level of common canaliculus. Only those with a functional block were considered suitable for ENL-DCR.
The EXT-DCR patients were admitted as in-patients and had conventional surgery under a general anaesthesia as described by Duprey-Dutemps and Bourget with intubation of silicone tubes (Crawford DCR tubes, 20g, Visitec, UK). They were discharged the following day. A consultant ophthalmologist or an associate specialist performed the surgery. They were followed up a week later and the skin sutures were removed. The tubes were removed after 3 months.
The ENL-DCR patients were operated as day cases under a local anaesthetic. A nasal pack soaked in 6% cocaine [Moffat's solution combination of cocaine 2ml, adrenaline (1:1000) 1ml and sodium bicarbonate 2ml] was inserted onto the nose for 10 minutes and removed at the time of surgery. The nasal mucosa at the site of the proposed ostium was also injected with 2% Xylocaine with 1:200 000 adrenaline. Following cannalicular dilation a 20-gauge vitreoretinal light pipe was inserted into the nasolacrimal sac through the upper canaliculus. With the help of an endoscope, HO:YAG laser was aimed at the area of nasal mucosa transilluminated with the light pipe. An area 10x10 mm was ablated using energy of 0.6J at 10Hz frequency for the mucosa and 1.0J for the bone. The light pipe was used to tent the nasolacrimal sac mucosa before it was ablated to avoid collateral damage. At this stage a microsponge (Alcon, UK) soaked in 5-FU (25mg/ml) was inserted with the help of the endoscope at the site of the ostium for 4 minutes. This was followed by a thorough irrigation with normal saline. Crawford lacrimal intubation tubes (Visitec, UK) were inserted and either secured with a Watzke sleeve or with Liga clips.
A consultant ophthalmologist and consultant ENT surgeon (ARR and HW) carried out all the laser procedures. Intravenous cefuroxime (750mgs) was administered at completion of the procedure followed by a 7-day oral regimen. Postoperatively the patients were instructed to carry out a nasal douche every day for the first week and were prescribed local betamethasone nasal drops to be used four times daily for four weeks. The patient's first postoperative visit was at two weeks. The tubes were removed at 3 months. At the review appointment patients were asked about their symptoms of watering. They also had the nasolacrimal passages syringed on the side of the operation.
Of the 44 patients, 22 had undergone EXT-DCR and the remaining 22 ENL-DCR. The patient's notes were reviewed and they were invited to attend a follow=up appointment to assess their symptoms and the patency of the nasolacrimal system with syringing. A total of 41 patients attended the final review, all 22 of those who had undergone ENL-DCR and 19 of those who had undergone EXT-DCR.
| Results | | |
Forty-one patients attended the final review. In the EXT-DCR group (n=19) there were 12 female patients; 10 patients were operated on the left side and the median follow up was 22 months (range 6-28 months). The median age in this group was 77 years (range 53-87 years). The tubes were removed at a median interval of 3 months (range 0.5-6 months). Two tubes fell out spontaneously at one month and one patient's tubes fell out at 2 weeks (Table).
In the 5-FU augmented ENL-DCR group (n=22), there were 19 females, and 14 patients were operated on the left side. The median follow-up was 12 months (range 3-24 months). The median age was 71 years (23 to 84 years). The mean laser energy used was 0.6 ± 0.21 J. The median time interval for tube removal in this group was 3 months (range 0.5-4 months). The tubes spontaneously extruded in 3 patients, two at one month and one at 2 weeks (accidentally removed by the patient). In addition, two patients had their tubes displaced into the conjunctival fornices which were repositioned in the nose with the endoscope.
In the EXT-DCR group 18 of 19 patients had a patent nasolacrimal duct on syringing [success rate: 94.7% (95% CI: 75.4%-99.1%)]. The only failure was in a patient who had her tubes removed at 6 months and noticed the symptoms recur at this stage. In the ENL-DCR group 14 of 22 patients had patent nasolacrimal duct on syringing [success rate: 63.6% (95% CI: 43%-80.3%)]. Though 8 patients were considered anatomical failures due to non-patency of the nasolacrimal duct system (syringed through upper and lower puncta), 5 volunteered that their symptoms were better following surgery.
There was a significant difference in the success rate between the two groups; 31.1% with 95% CI for the difference of these independent proportions +5.6% to +52.2% (Fisher exact test = 0.024). The patients were well matched for age and laterality; however, there were more females in the laser group (p= 0.14, Fisher exact test) and the follow-up was longer in the EXT-DCR group (p=0.0001, Mann Whitney U test).
| Discussion | | |
The success rate in the EXT-DCR group (94.7%) was significantly (P = 0.024) higher than in the 5-FU augmented ENL-DCR group (63.6%). There was no significant difference between the age groups, gender and laterality. There was a longer follow up in the EXT-DCR group, as 5 FU augmented ENL-DCRs were performed in the last two years of this retrospective review.
In comparison to the established EXT-DCR approach, our results with 5 FU augmented ENL-DCR were not encouraging. However it is still the preferred choice among individuals anxious to avoid a surgical scar, elderly frail patients who need to be rehabilitated rapidly, and inpatients for whom hypotensive anaesthesia is not advisable. In addition, the procedure may be repeated with an improved success rate in those that have failed. [8,12] In our series, one patient needed a repeat procedure to establish nasolacrimal duct patency. However, this was not included in the data analysis as the success was measured after a single laser procedure. This patient had a large mucocoele and a sump syndrome following the first surgery, as the surgical fistula was not in the dependent position. Among the remaining 7 failures five reported that their symptoms were better despite the nasolacrimal system not being patent on syringing through either puncta. None of these patients elected to have further surgery. The other main surgical advantages are the lack of significant blood loss due to the haemostatic properties of the laser and the reduced surgical time. The average time for an ENL-DCR was 20 minutes and it was 45 minutes for an EXT-DCR. Revision of the failed cases through an endonasal approach is easily accomplished as the fibrous scar at the ostium can be dealt with using minimal laser energy.
These results may reflect the effect of a learning curve associated with the introduction of a new procedure. However, there was no difference in the success rate of those performed early in the study as compared to those performed later. Our results for the 5-FU-augmented ENL-DCR however compare favourably with other reported series of ENL-DCR. At 12 months' follow-up Sadiq et al[7] reported a success rate of 61% of those patients who were intubated. In a randomised prospective study comparing EXT-DCR with ENL-DCR, Hartikanen et al[16] reported a success rate of 63 % in the ENL-DCR group with a 12-month follow-up. In the latter series the success rate improved to 94% after minor secondary intervention.[17] All patients who failed in the ENL-DCR group complained of epiphora within the first three months of surgery. However, due to the retrospective nature of the study it was not possible to predict the exact timing of failure in either group. The test for patency was carried out only at the final follow-up. While the success rate in this study compares with other studies with a similar length of follow-up, [7,16] it is possible that with a longer follow-up additional failure in the ENL-DCR group may show up.
Antimetabolitic agents like 5-FU and mitomycin C (MMC) have been shown to inhibit human Tenon's capsule fibroblast proliferation.[18] Single intraoperative application of 5-FU prolongs the survival of filtering surgery as it inhibits scarring.[19] As the cause of failure of ENL-DCR is due to the scarring response at the internal ostium,[7] intraoperative 5-FU was used to try and offset this process and improve upon the success rates.
Although there was no control group in our series the application of 5-FU did not seem to improve the results compared to the success rates reported in other series. In a small series (n = 14) of patients undergoing EXT-DCR, Kao et al[20] reported a larger ostium size in those patients randomly assigned to receive intraoperative MMC. The success was 100% at 6 months' follow-up. In contrast, in a larger series of patients (n = 40) undergoing endonasal surgical DCR, with a longer follow up (9-27 months), Zilelioglu et al[21] did not find benefit in the adjunctive use of MMC. As far as we are aware the role of MMC is not well established in ENL-DCR.
In all our ENL-DCR patients the largest ostium possible was created. It may be argued that the size of the internal ostium created at the time of surgery determines the outcome. However, based on the examinations of internal ostium in EXT-DCR Linberg et al[22] did not find a direct correlation between size of ostium and success of procedure. It may also be hypothesised that the endonasal laser may induce a greater healing response; the healing is by secondary intention, and could lead to lower success rate. It was not possible in our series to report the postoperative endoscopic appearance in the failed cases for lack of documentation. As MMC is a more potent inhibitor of healing response after filtering surgery than 5-FU,[23] a larger randomised control study of it use in ENL-DCR may demonstrate an improvement in the success rate of this procedure.
In conclusion, though the success rates for ENL-DCR in our small series at present do not compare with those of EXT-DCR, it still has a place in the therapeutic armoury of PANDO. It may be the only procedure possible in an elderly, frail, or medically unfit patient. Given the choice, despite the difference in success rate, patients still opt to avoid a surgical scar of EXT-DCR. Additionally, ENL-DCR may be used successfully to revise the EXT-DCR failures[12]. Also with minor secondary intervention the success rates may be comparable to EXT-DCR.[17] In our small nonrandomised series we could not demonstrate a higher success rate of ENL-DCR, when augmented with 5-FU compared to published reports of ENL-DCR without antimetabolites. Where resources are limited, the shorter operating time of this procedure, combined with the fact that it can be performed on an outpatient basis, will no doubt add to its popularity as an alternative to EXT-DCR.
It is accepted that the practice of a general anaesthetic for an EXT-DCR is not the norm. In addition, it is acknowledged that the surgical time of an EXT-DCR may well be inversely related to the experience of the surgeon and may ultimately be reduced to approach the time required for an ENL-DCR.
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