Endoscopic endonasal dacryocystorhinostomy (END-DCR) has increased as a valid alternative to the classic external approach to treat distal lacrimal obstruction. Different surgical varieties of the END-DCR approach have been proposed with no clear understanding of the best surgical technique.
Data Source
A comprehensive research was performed in PubMed, Embase, SCOPUS, and Cochrane databases with a final search on March 2020.
Review Methods
The aim of this search was to identify relevant END-DCR procedures performed with mechanical (Mecn-END-DCR) and powered (Pow-END-DCR) approaches to compare their functional success rate. In addition, the influence of mucosal flaps was evaluated. Articles were selected only if they were published later than 2000 and had at least 50 single-clinician surgical procedures performed. Excluded articles included acute infections, cancers, mixed cohort study, and revision cases.
Results
A total of 11,445 publications were identified and 2741 reviewed after screening; 15 articles were included after full-text review (0.6% of the initial articles reviewed). The mean success rate was 91.34% (95% CI, 87.1%-94.3%) for Pow-END-DCR and 89.5% (95% CI, 86.5%-91.9%) for Mecn-END-DCR with no significant difference between the surgical approaches (P = .43). For mucosal flaps performed during END-DCR, the mean success rate was 89% (95% CI, 86%-91%) if mucosal flaps were used and 92% (95% CI, 88%-95%) if they were not used, with no statistical difference present (P = .14).
Conclusions
Our analyses suggest that there are no differences in outcomes between mechanical and powered approaches in END-DCR and that mucosal flap preservation is not essential to achieve a superior END-DCR outcome.
WoogJJ.The incidence of symptomatic acquired lacrimal outflow obstruction among residents of Olmsted County, Minnesota, 1976-2000 (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2007;105:649-666.
2.
Al-QahtaniKHAl AsiriMTunioMA, et al. Nasolacrimal duct obstruction following radioactive iodine 131 therapy in differentiated thyroid cancers: review of 19 cases. Clin Ophthalmol. 2014;8:2479-2484.
BerlucchiMTomenzoliDTrimarchiMLombardiDBattagliaGNicolaiP.Dacryocystocele in the adult: etiology, diagnosis and treatment [in Italian]. Acta Otorhinolaryngol Ital. 2001;21:100-104.
5.
AliMJ.Iodine-131 therapy and nasolacrimal duct obstructions: what we know and what we need to know. Ophthalmic Plast Reconstr Surg. 2016;32:243-248.
6.
KrishnaYCouplandSE.Lacrimal sac tumors—a review. Asia Pac J Ophthalmol (Phila). 2017;6:173-178.
7.
WormaldPJ.Powered endoscopic dacryocystorhinostomy. Otolaryngol Clin North Am. 2006;39:539-549.
8.
WormaldPJKewJVan HasseltA.Intranasal anatomy of the nasolacrimal sac in endoscopic dacryocystorhinostomy. Otolaryngol Head Neck Surg. 2000;123:307-310.
GreenRGohilRRossP.Mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review. Clin Otolaryngol. 2017;42:514-520.
13.
SobelRKAakaluVKWladisEJBilykJRYenMTMawnLA.A comparison of endonasal dacryocystorhinostomy and external dacryocystorhinostomy: a report by the American Academy of Ophthalmology. Ophthalmology. 2019;126(11):1580-1585.
14.
VinciguerraANonisAGiordano RestiABussiMTrimarchiM.Best treatments available for distal acquired lacrimal obstruction: a systematic review and meta-analysis. Clin Otolaryngol. 2020;45(4):545-557.
15.
LiberatiAAltmanDGTetzlaffJ, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100.
16.
AliMJPsaltisAJMurphyJWormaldPJ.Outcomes in primary powered endoscopic dacryocystorhinostomy: comparison between experienced versus less experienced surgeons. Am J Rhinol Allergy. 2014;28:514-516.
LeeJJLeeHMLimHBSeoSWAhnHBLeeSB.Learning curve for endoscopic endonasal dacryocystorhinostomy. Korean J Ophthalmol. 2017;31:299-305.
19.
DekkersOMEggerMAltmanDGVandenbrouckeJP.Distinguishing case series from cohort studies. Ann Intern Med. 2012;156:37-40.
20.
GuyattGHOxmanADVistGE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924-926.
21.
HowickJChalmersIGlasziouP, et al. The 2011 Oxford CEBM levels of evidence (introductory document). Oxford Centre for Evidence-Based Medicine. Published 2011. https://www.cebm.net/index.aspx?o=5653
22.
MathesTPieperD.Clarifying the distinction between case series and cohort studies in systematic reviews of comparative studies: potential impact on body of evidence and workload. BMC Med Res Methodol. 2017;17:107.
23.
HigginsJPAltmanDGGotzschePC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
24.
SlimKNiniEForestierDKwiatkowskiFPanisYChipponiJ.Methodological Index for Non-randomized Studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73:712-716.
25.
MunkPLLinDTMorrisDC.Epiphora: treatment by means of dacryocystoplasty with balloon dilation of the nasolacrimal drainage apparatus. Radiology. 1990;177:687-690.
26.
R Core Team. R: a language and environment for statistical computing. R Foundation for Statistical Computing. Published 2018. https://www.R-project.org/
27.
BalduzziSRuckerGSchwarzerG.How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health. 2019;22:153-160.
28.
Al-QahtaniAS.Primary endoscopic dacryocystorhinostomy with or without silicone tubing: a prospective randomized study. Am J Rhinol Allergy. 2012;26:332-334.
29.
AyoobMMahidaKQurat ulADawoodZ.Outcome and complications of endoscopic dacryocystorhinostomy without stenting. Pak J Med Sci. 2013;29(5):1236-1239.
30.
BeshayNGhabrialR.Anatomical and subjective success rates of endonasal dacryocystorhinostomy over a seven-year period. Eye (Lond). 2016;30:1458-1461.
31.
CiğerEBalciMKArslanoğluSErenE.Endoscopic-powered dacryocystorhinostomy without stenting: long-term outcomes of 120 procedures. Am J Rhinol Allergy. 2018;32:303-309.
32.
DoJRLeeHBaekSLeeTSChangM.Efficacy of postoperative mitomycin-C eye drops on the clinical outcome in endoscopic dacryocystorhinostomy. Graefes Arch Clin Exp Ophthalmol. 2016;254:785-790.
33.
Erfanian SalimRMohammadiS. Results of endoscopic endonasal dacryocystorhinostomy: necessity of teamwork and patient selection. Med Hypothesis Discov Innov Ophthalmol. 2015;4(3):114-119.
34.
KarimRGhabrialRLynchTTangB.A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Clin Ophthalmol. 2011;5:979-989.
35.
LeeJLeeHLeeHKChangMParkMBaekS.Effectiveness of synthetic polyurethane foam as a nasal packing material in endoscopic endonasal dacryocystorhinostomy. J Craniofac Surg. 2015;26:2207-2211.
36.
MakSTIoIYWongAC.Prognostic factors for outcome of endoscopic dacryocystorhinostomy in patients with primary acquired nasolacrimal duct obstruction. Graefes Arch Clin Exp Ophthalmol. 2013;251:1361-1367.
37.
ParkJLeeJJangS, et al. Effectiveness of sodium hyaluronate (Protad) application in endoscopic endonasal dacryocystorhinostomy. Can J Ophthalmol. 2017;52:192-197.
38.
ShinHYPaikJSYangSW.Clinical results of anti-adhesion adjuvants after endonasal dacryocystorhinostomy. Korean J Ophthalmol. 2018;32:433-437.
39.
SuPY.Comparison of endoscopic and external dacryocystorhinostomy for treatment of primary acquired nasolacrimal duct obstruction. Taiwan J Ophthalmol. 2018;8:19-23.
40.
TrimarchiMGiordano RestiABelliniCFortiMBussiM.Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy. Eur Arch Otorhinolaryngol. 2009;266:1747-1752.
41.
TrimarchiMGiordano RestiAVinciguerraADaneGBussiM.Dacryocystorhinostomy: evolution of endoscopic techniques after 498 cases. Eur J Ophthalmol. 2020;30(5):998-1003.
42.
WuWCannonPSYanWTuYSelvaDQuJ.Effects of Merogel coverage on wound healing and ostial patency in endonasal endoscopic dacryocystorhinostomy for primary chronic dacryocystitis. Eye (Lond). 2011;25:746-753.
43.
AliMJPsaltisAJAliMHWormaldPJ.Endoscopic assessment of the dacryocystorhinostomy ostium after powered endoscopic surgery: behaviour beyond 4 weeks. Clin Exp Ophthalmol. 2015;43:152-155.
44.
KingdomTTBarhamHPDurairajVD.Long-term outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation. Laryngoscope. 2020;130:12-17.
45.
CodereFDentonPCoronaJ.Endonasal dacryocystorhinostomy: a modified technique with preservation of the nasal and lacrimal mucosa. Ophthalmic Plast Reconstr Surg. 2010;26:161-164.
46.
RazaviMENoorollahianMEslampoorA.Non-endoscopic mechanical endonasal dacryocystorhinostomy. J Ophthalmic Vis Res. 2011;6:219-224.
47.
ChangDJ.The “no-drill” technique of anterior clinoidectomy: a cranial base approach to the paraclinoid and parasellar region. Neurosurgery. 2009;64(3)(suppl):ons96-ons105.
48.
PradhanPBhardwajAMandalSMajhiS.Double posterior based flap technique in primary endoscopic dacryocystorhinostomy with and without using powered instrument. Indian J Otolaryngol Head Neck Surg. 2017;69:474-479.
49.
MannBSWormaldPJ.Endoscopic assessment of the dacryocystorhinostomy ostium after endoscopic surgery. Laryngoscope. 2006;116:1172-1174.
50.
MuellerSKFreitagSKLefebvreDRBleierBS.Endoscopic DCR using bipedicled interlacing mucosal flaps. Laryngoscope. 2018;128:794-797.
51.
WangDFangPZhaoY.Assessment of long-term outcomes associated with a lobulated pedicled nasal mucosa flap technique for endoscopic dacryocystorhinostomy without stenting. Ear Nose Throat J. Published online January8, 2020. doi:10.1177/0145561319900025
52.
TrimarchiMBelliniCFabianoBGereviniSBussiM.Multiple mucosal involvement in cicatricial pemphigoid. Acta Otorhinolaryngol Ital. 2009;29:222-225.
53.
HodgsonNBrattonEWhippleK, et al. Outcomes of endonasal dacryocystorhinostomy without mucosal flap preservation. Ophthalmic Plast Reconstr Surg. 2014;30:24-27.
54.
LenziRMuscatelloL.Comment on: mucosal and lacrimal flaps for endonasal dacryocystorhinostomy: a systematic review. Clin Otolaryngol. 2018;43:393-394.
55.
RamakrishnanVRHinkEMDurairajVDKingdomTT.Outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation. Am J Rhinol. 2007;21:753-757.
56.
ZlotoOKovalTYakirevichA, et al. Endoscopic dacryocystorhinostomy with and without mucosal flap-is there any difference?Eye (Lond). 2020;34(8):1449-1453.
57.
KhalifaMARagabSMSaafanMEEl-GuindyAS.Endoscopic dacryocystorhinostomy with double posteriorly based nasal and lacrimal flaps: a prospective randomized controlled trial. Otolaryngol Head Neck Surg. 2012;147:782-787.
58.
IngEBBediHHussainA, et al. Meta-analysis of randomized controlled trials in dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol. 2018;53:466-470.
59.
KangMGShimWSShinDKKimJYLeeJEJungHJ.A systematic review of benefit of silicone intubation in endoscopic dacryocystorhinostomy. Clin Exp Otorhinolaryngol. 2018;11:81-88.
60.
KimDHKimSIJinHJKimSHwangSH.The clinical efficacy of silicone stents for endoscopic dacryocystorhinostomy: a meta-analysis. Clin Exp Otorhinolaryngol. 2018;11:151-157.
61.
SarodeDBariDACainACSyedMIWilliamsAT.The benefit of silicone stents in primary endonasal dacryocystorhinostomy: a systematic review and meta-analysis. Clin Otolaryngol. 2017;42:307-314.
62.
XieCZhangLLiuYMaHLiS.Comparing the success rate of dacryocystorhinostomy with and without silicone intubation: a trial sequential analysis of randomized control trials. Sci Rep. 2017;7:1936.
63.
ChengSMFengYFXuLLiYHuangJH.Efficacy of mitomycin C in endoscopic dacryocystorhinostomy: a systematic review and meta-analysis. PLoS One. 2013;8:e62737.
64.
FengYFYuJGShiJLHuangJHSunYLZhaoYE.A meta-analysis of primary external dacryocystorhinostomy with and without mitomycin C. Ophthalmic Epidemiol. 2012;19:364-370.
65.
NairAGAliMJ.Mitomycin-C in dacryocystorhinostomy: from experimentation to implementation and the road ahead—a review. Indian J Ophthalmol. 2015;63:335-339.
66.
QianZZhangYFanX.Clinical outcomes of dacryocystorhinostomy with or without intraoperative use of mitomycin C: a systematic review and meta-analysis. J Ocul Pharmacol Ther. 2014;30:615-624.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
