Sage Journals: Discover world-class research

Abstract

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.

Keywords

Endoscopic DCR external DCR EE-DCR DCR learning curve

Introduction

It is well established that the gold standard treatment of epiphora due to primary acquired nasolacrimal duct obstruction is dacryocystorhinostomy (DCR). Success rates documented for this procedure range between 80–95%.¹ The external approach is performed by a cutaneous incision to access the lacrimal sac.^1–3 This procedure became widely accepted due to its efficacy and minimal complication rates.^1–3 The endonasal technique was impractical when first introduced in 1893 by Caldwell, until 1989 with the advent of endoscopes and illuminators allowing visualization of endonasal anatomy.^1–3 Endoscopic endonasal DCR (EE-DCR) has slowly gained acceptance due to the comparable success rates, absence of skin scarring and shorter recovery periods.¹

The challenge with EE-DCR however is learning and mastering this technique while operating on unfamiliar topography using monocular endoscopic views that ophthalmologists are unaccustomed to.⁴ This is compounded by the initial steep learning curve and the need for expensive instrumentation.^1–4

Both approaches have been modified several times over the years.⁵ The aim of this study is to build on current literature by surveying a sample of oculoplastic surgeons to determine their preference for DCR, patient selection criteria for EE-DCR, EE-DCR technique as well as barriers to adoption of EE-DCR.

Material and methods

This cross-sectional study was conducted from May-December 2021. The Institutional Review Board at King Khalid Eye Specialist Hospital approved this study, and study procedures followed the tenets of the Declaration of Helsinki.

The survey was developed by the study investigators. It included 38 questions mainly on demographic characteristics such as age, geographic location, duration in practice (years), and type of clinical practice (academic university, academic non-university, private multispecialty group, private single-specialty group, private solo) (see Appendix 1).

The sampling method was a convenient sampling employing the snowball technique; therefore, estimated response rate could not be generated. The aim was to reach a large number of participants. We used multiple platforms, including data from the global educational forum from King Khalid Eye Hospital, and we contacted each society through a representative from the co-authors, namely, the Saudi Oculoplastic and Orbit Group SOOG through (HS), American Society of Oculoplastic and Reconstructive Surgery ASOPRS (RA), European Society of Plastic and Reconstructive Surgery ESOPRS (DS), Brazilian Oculoplastic Surgery Society BOSS (SS), Asia Pacific Society of Ophthalmic Reconstructive Surgery APSOPRS and Hong Kong Society of Ophthalmic Plastic and Reconstructive Surgery HKSOPRS (HY).

The technique preferences were correlated with type of training (formal training in oculoplastic vs. non formal training), duration of training (2 years or less), period of training (70 s,80 s,90 s,2000 and after), exposure to DCR cases during training (external, endoscopic endonasal, non-endoscopic endonasal DCR) and the volume of cases.

Low volume was defined as less than 2 cases/week, moderate as 3–5 cases/week and high volume as more than 6 cases/ week. Respondents were classified as new in practice (10 years or less) or established in practice (>10 years).

We inquired about oculoplastic surgeons’ preferences for dacryocystorhinostomy (DCR) including the use of stent, duration of stent retention, use of antimetabolites, and patient selection criteria. Finally, barriers and facilitators to the adoption of endoscopic DCR were reviewed.

Statistical analysis

Chi-squared and Fisher exact tests, as deemed appropriate, were used to summarize categorical data. Statistical analysis was performed using paired t tests, with threshold for significance set at p < 0.05. All analyses were performed using Stata statistical software (version 14, StataCorp, College Station, TX).

Results

Demographics

A total of 245 respondents completed the online survey. Demographic characteristics, including age, gender, region, area, and type of practice, are summarized in table 1.

Table 1.

Summary of the demographic characteristics, area, type of practice and volume of DCR cases.

Demographics
Region of practice: - North America - South America - Asia - Middle East - Europe	(106) 43.3% (67) 27.3% (26) 10.6% (24) 9.8% (20) 8.2%
Age - 30–39 years - 40–49 years - 50–59 years - >60 years	(73) 29.8% (85) 34.7% (56) 22.9% (31) 12.65%
Gender - Males - Females	(138) 56% (107) 43.7%
Area of practice: - Urban - Suburban - Rural	(206) 84% (35) 14.3% (4) 1.6%
Type of practice - Public sector - Private practice	(81) 33% (162) 66%
- Academic - Nonacademic	(118) 48% (127) 52%
- Specialized Eye Center - Multispeciality hospital - Solo practice	(88) 43,3% (106) 35.9% (51) 21%
Volume of DCR cases - 2 or less than 2 cases/week - 3–5 cases/week - 6–10 cases/week - 11–20 DCR cases/week - >20 cases of DCR/week	(189) 77% (46) 18.8% (7) 2.9% (1) 0.4% (2) 0.8%

training

Table 2 summarizes characteristics of training, including the country where the training was performed, type of training, duration, period of training, techniques exposed, and the number of cases performed during training.

Table 2.

Summary of training characteristics and DCR exposure during training.

Training
Area of training - North America - South America - Asia - Middle East - Europe	(119) 48.6% (64) 26% (19) 7.8% (22) 8.9% (19) 7.8%
Period of training - Before 90's - 90s - 2000 and later	(23) 9% (40) 16% (182) 74.3%
DCR exposure - exposed to external DCR only - trained in both external and endoscopic DCR - external, endoscopic and endonasal DCR - endoscopic endonasal only	(111) 45% (108) 44% (21) 8.6% (3) 1.22%
Type of training - Formal training in oculoplastics - Non formal training in oculoplastic - Formal training in both oculoplastics and ENT	(228) 93% (9) 3.7% (6) 2.5%
Duration of formal training - 1–6 months - 7–12 months - 13–18 months - 19–24 months - More than 2 years - Didn’t receive formal training	(8) 3.27% (47) 19% (29) 11.8% (113) 46% (41) 17% (7) 2.8%
Number of Endoscopic endonasal operated cases - None - < 20 cases - 20–40 case - >40 case	(103) 42% (89) 36% (25) 10.20% (28) 11.4%
Number of Non Endoscopic endonasal operated cases - None - < 20 cases - 20–40 case - >40 case	(150) 61.22% (51) 20.8% (17) 6.9% (27) 11%
Number of operated external DCR cases - None - < 20 cases - 20–40 case - >40 case	(3) 1.22% (48) 19.6% (70) 28.6% (124) 50.6%

Practice

The pattern of practice, preferences and factors influencing the decision to perform endoscopic DCR are summarized in table 3.

Table 3.

Patterns of practice and factors influencing the decision to perform endosopic DCR.

Practice
Duration of practice - < 5years years - 5–10 years - >10 years	(48) 19.6% (53) 21.6% (144) 58.9%
First line procedure of choice in nasolacrimal duct obstruction - External DCR - Endonasal DCR - No preference	(149) 61% (78) 32% (17) 7%
Factors influencing surgeon decision to perform endonasal surgery - Patient request - Endonasal exam - Gender - Age - All cases are done as Endonasal Endoscopic DCR - Other factors: Known keloid or hypertrophic scar, revision of external DCR, presence of good assistant	(91) 37.3% (79) 32.38% (35) 14.34% (52) 21.3% (17) 7% (35) 14.34%
Endosopic endonasal is performed - Alone as a main surgeon - Main surgeon with the assistance of ENT - ENT does the endoscopic part, I do the intubation - Not applicable	(101) 41.2% (12) 4.9% (60) 23.49% (72) 29.4%
Use of Mitomycin C in endonasal DCR - Yes - No - Re-do only	(28) 16% (80) 46% (64) 37.6%
Use of Mitomycin C in external - Yes - No - Re-do only	(11) 5% (114) 50% (101) 44.6%
Use of stent in endonasal DCR - Yes - No - Re-do only	(161) 94% (5) 2.9% (7) 4%
Use of stent in external DCR - Yes - No - Re-do only	(211) 90.9% (8) 3,4% (13) 5.6%
In endonasal surgery, Stent kept in place for - One month - 2 months - 3 months - 6 months - One year - Variable - Not applicable	(27) 11.02% (62) 25.3% (70) 28.6% (11) 4.5% (1) 0.41% (9) 3.67% (65) 26.5%
In external DCR surgery, Stent kept in place for - One month - 2 months - 3 months - 6 months - One year - Variable - Not applicable	(30) 12.24% (66) 26.94% (97) 39.59% (14) 5.71% (2) 0.82% (12) 4.9% (24) 9.8%

According to the respondents, the most common factor to affect their decision to operate was patient's request followed by endonasal exam. Other factors are summarized in table (3).

Barriers and potential facilitators for endoscopic DCR adoption:

Most respondents (45%) reported lack of experience as a barrier to not performing endoscopic endonasal DCR. 42% were not trained during the fellowship. The following factors also influenced the respondents’ decision: investment to acquire instruments for surgery is very high for a small number of procedures available (31%), steep learning curve (29.9%), concern about the surgical outcome (27%), limited visibility of endoscopic DCR (25.4%) and lack of resources (25.3%). 52% consider endoscopic DCR to have a similar success rate to external DCR. 44% find that endoscopic DCR is more challenging to perform.

The most worrisome complication for most of our respondents was failure of the procedure (48%), followed by bleeding (30.3%) and Injury to the skull base (7.8%). 22.5% are satisfied with their results in external DCR and not interested in learning endoscopic DCR

81% believe surgical mentorship and supervision during initial cases would facilitate endoscopic DCR learning. Other facilitators include high surgical volume to improve the learning curve (62.4%), initial training with an ENT surgeon to become familiar with nasal anatomy and the endoscope (44.9%), wet lab experience (44.5%) and surgical simulators to improve endoscopic maneuvering skills (40%).

We observed that participants who were trained in 1990 onwards had preference for EE-DCR over external procedure. However, this was not statistically significant (P = 0.082)

Working in a multidisciplinary hospital where ENT could be involved, did not have an impact on the type of procedure or the decision to perform endonasal surgery P = 0.129

EE-DCR is found to be the first choice of treatment among those who operated more than 40 cases of endoscopic DCR during their training (P < 0.001).

We found an association between moderate to high surgical volume (>3 cases/week) and the tendency to perform EE-DCR Table 4.

Table 4.

Comparison between external and endoscopic DCR performers.

Characteristics	Preferred Technique		P value
Characteristics	External (n = 149)	Endoscopic (n = 78)	P value
Area of training			0.2
North America	(74) 50%	(35) 45%
South America	(36) 24%	(25) 32%
Europe	(14) 9%	(4) 5%
Middle east	(15) 10%	(4) 5%
Asia/asia-pacific	(8) 5%	(10) 13%
Africa	(1) 1%	0
Australia	(1) 1%	0
Period of training			0.082
70s	(3) 2%	0
80s	(15) 10%	(3) 4%
90 s	(19) 13%	(17) 22%
2000 and after	(112) 75%	(58) 74%
Exposure to external DCR technique during training			<0.001
None	(1) 1%	(2) 3%
<20 cases	(18) 12%	(28) 36%
20–40 cases	(44) 30%	(18) 23%
>40 cases	(86) 58%	(30) 38%
Exposure to non endoscopic endonasal DCR technique during training			0.3
None	(97) 65%	(41) 53%
<20 cases	(27) 18%	(20) 26%
20–40 cases	(9) 6%	(7) 9%
>40 cases	(16)11%	(10) 13%
Exposure to endoscopic endonasal DCR technique during training			<0.001
None	(74) 50%	(24) 31%
<20 cases	(59) 39%	(23) 29%
20–40 cases	(13) 9%	(8) 10%
>40 cases	(3) 2%	(23) 30%
Surgical volume in current practice			0.06
2 cases or less per week	(121) 81%	(53) 68%
3–5 cases/ week	(21) 14%	(22) 28%
6–10 cases/ week	(5) 3%	(2) 3%
11–20 cases/ week	(1) 1%	0
>20 cases/ week	(1) 1%	(1) 1%
Type of current practice			0.13
Multi-specialty hospital	(45) 30%	(34) 44%
Specialized eye center	(69) 46%	(30) 38%
Solo (private clinic)	(35) 24%	(14) 18%

Discussion

External DCR was first described in 1904 by Adeo Toti.⁵ It underwent several modifications until it reached the final external DCR known today. Caldwell described the first intranasal DCR in 1893.⁶ However, it was considered impractical due to the difficult visualization of the endonasal anatomy with the instrumentation at that time. After the introduction of rigid nasal endoscopes, endoscopic endonasal DCR was described by McDonogh and Meiring in 1989.⁷ Both external and endoscopic DCR have a good prognosis. However, endoscopic DCR has several advantages over external DCR, including the absence of an external scar and better visualization as a result of the development of the endoscopic monitor system.

In this survey, more than half of the respondents perform external DCR as a first-line procedure for primary nasolacrimal duct obstruction. Previous surveys about DCR preferences also reported a higher preference for external DCR.^8,9 We also observed that those who preferred external DCR were trained to perform only this technique during their training. This could explain why they are more comfortable performing external DCR. The majority of endonasal DCR performers were trained in the 90 s. Also, a higher percentage of endonasal DCR performers have been in practice less than 10 years, indicating that endonasal DCR performers (both endoscopic and non-endoscopic) are relatively new practitioners. There is an increased interest in learning endonasal DCR. This is consistent with previous studies.^8–10

Exposure to endoscopic endonasal DCR during training positively affected practitioners adopting this technique. More than half of participants who preferred this technique reported they received training on endonasal surgeries and two-thirds performed more than 20 cases during their fellowship. Furthermore, about 40% of participants received training on non-endoscopic endonasal DCR. However, no difference was noticed in their preferred technique, external vs endonasal. We found no statistically significant difference in the preferred technique based on where the surgeon work (academic vs. non-academic). However, there is a trend that more endonasal cases are performed in the academic sector (p-value = 0.07)

Endonasal DCR surgery requires a thorough knowledge of the intranasal anatomy since anatomical variations inside the nasal cavity are likely to affect the outcome of the EE-DCR surgery.¹¹ The presence of ENT specialist back up in the hospital would increase the number of surgeons performing EE-DCR as this might be useful to refer difficult patients with nasal pathologies and to manage post operative complications if present. However, our data showed that working in a multidisciplinary hospital with ENT backup available did not affect the decision to perform endonasal surgery.

Many factors influence the success rate of endoscopic DCR including age and presence of nasal pathology^12,13 . In this survey, the decision to proceed with endoscopic DCR was mainly influenced by the patients’ request, followed by the endonasal exam. Gender of the patient did not affect the decision to perform endonasal surgery as stated by almost 85% of respondents. Barmettler et al also reported the patient's preference as the highest-ranked reason to perform EE-DCR.⁸

21% consider the age of the patient before performing endonasal surgery. This consideration may be based on the concern for a noticeable scar in younger patients. Another consideration is that older age has been associated with a higher failure rate with external DCR. It has been postulated that this higher failure rate in older patients is due to a weak orbicularis muscle affecting the lacrimal pump¹² .Recent studies have demonstrated compromise of the facial nerve with external DCR incisions, which may further affect the lacrimal pump.¹⁴ An advantage of an endoscopic DCR is the potential decreased risk to these branches of the facial nerve.

Regarding surgeon's preferences in DCR, 46% of participants do not use mitomycin C in first-time endoscopic DCR. This is in agreement with multiple level-1 evidence studies that demonstrate no benefit of MMC in terms of symptomatology and ostial patency for primary EE-DCR.¹³ A small percentage of respondents use MMC in primary external DCR. MMC has been shown to be safe and effective in increasing surgical success rate in primary external DCR¹⁵ . Gonzalvo et al studied the effects of intraoperative MMC on the clinical evolution and osteotomy size following an external DCR with helical computed tomography and reported that intraoperative MMC may increase the success rates over the traditional DCR.¹⁶ Furthermore, a meta-analysis published in 2014 supported these studies. It concluded that intraoperative application of MMC increases the success rate in primary External DCR and revision EE-DCR, but does not provide any significant benefit in primary EE-DCR.¹⁷

A stent helps keep the osteotomy site patent in the initial stages of healing and thus decreases the chance of early failure. Vishwakarma et al performed a prospective study on 272 patients to assess the effect of silicone stenting on the outcome of endoscopic dacryocystorhinostomy and found a higher success rate using a silicone stent.^18,19 However, several studies have found no significant difference in surgical success between DCR done with stents and those done without.^18,20–22 Even with the evidence that stent-free surgery results in good outcomes in DCR surgery, most of the performers of EE-DCR prefer placing a stent. An Indian survey showed that practitioners with less than 10 years of experience were more likely to place stents.⁹ This could be due to the feared risk of mucosal adhesions or lack of awareness of these recent studies. Malhorta 2015 suggested that stenting during the early adoption period of endoscopic DCR may be of value as mucosal adhesions are anticipated.²¹

Regarding barriers and potential facilitators for endoscopic DCR adoption, the lack of experience was the most common barrier to not performing endoscopic DCR. 42% of participants were not trained to perform endonasal surgery during their fellowship. Other barriers were limited visibility of the endonasal endoscope and difficulty manoeuvring instruments in a confined space. Giving more surgical training time to trainees and familiarizing them with nasal anatomy may help overcome these barriers.

Almost a quarter of participants reported that the lack of support and backup from an experienced oculoplastic surgeon or ENT specialist is a barrier to performing endoscopic DCR. Complications can be encountered during surgery, and thorough knowledge and experience are required.

Although surgeons with lower surgical volumes and limited technical proctorship might have concerns about being able to overcome the learning curve of endoscopic DCR, previous research shows that the initial learning curve may be overcome relatively easily after 30 cases of experience of endoscopic surgeries^3,23 . This is consistent with our study which showed that those who performed 40 cases of EE-DCR during fellowship were more likely to perform this procedure after training.

Previous studies reported good success rates with a safety profile and efficacy equivalent to the traditional external approach.²⁴ The endoscopic DCR is also known to have a shorter operative time and a relatively lower complication rate.²⁴ However, concern for complications is one of the main obstacles encountered in the adoption of endoscopic DCR. Among the difficulties, the most problematic was risk of failure. This is followed by the risk of bleeding, injury to intraorbital structures, and injury to the skull base. Improving trainees’ awareness of these complications and providing guidance in the OR may help overcome this.

Most respondents agreed that mentorship and supervision are important facilitators for the adoption of endoscopic DCR. This was followed by initial training with ENT. Our study showed that those who were not trained to do endoscopic DCR during their fellowship were unlikely to perform endonasal surgery later. Kamal et al. recommended a structured training program through knowledge of nasal anatomy, clear demonstration of surgical steps, and supervision by experienced surgeons to result in efficient skills transfer.⁴ The use of virtual reality simulators can create a computerized environment in which the anatomy is reproduced and interaction with endoscopic handling and realistic haptic feedback is possible. Moreover, scenarios can be presented that improve trainees’ skills and confidence. Wais et al found that the trainee pretrained on the cadaveric endoscopic sinus surgery (ESS) tasks performed better than the nonintervention (no pretraining) group.²⁵

Almost a quarter of participants believe video-based performance assessment would facilitate endoscopic DCR learning. Video-based coaching is an educational modality that is known to be beneficial as it targets intraoperative judgment, technique, and teaching.²⁶ Reviewing surgery footage can be useful in identifying areas of difficulty and minimizing repeating the same mistakes. Posture training, instrument handling, avoiding multiple entries, and paying special attention to the superiorly placed bone overhanging the ostium are some of the feedback points that Malhotra et al. have enumerated in their list of tips for the trainee and trainer in En-DCR.²¹

Limitations and future studies

Survey-based studies have inherent limitations. The cross-sectional study design is also a limitation. The length of the survey might have affected the response rate. Poor participation from the Eastern countries might been due to language barrier. Future studies using simulators among oculoplastic surgeons and the efficacy of video-based teaching may be beneficial.

Conclusions

Exposure to and learning endoscopic DCR early during fellowship training dramatically impacts the adoption of the procedure. Thorough knowledge of the nasal anatomy and supervision by an experienced surgeon is essential in learning the technique and overcoming the learning curve. Implementing video-assisted training and simulators may have a positive role in learning the procedure.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Walaa Alturkistany

Aysha Aloqab

Silvana Schellini

Diego Strianese

DCR preferences among Oculoplastic Surgeons

We appreciate the time you are taking out of your busy schedule to fill out this questionnaire.

*Required

Do you agree to participate in this study? * Mark only one oval.

Yes

Part A: Personal Data

1- Age: *

30–39

40–49

50–59

60 and plus

2- Gender: *

Male

Female

3- Region of practice: * Mark only one oval.

North America

South America

Europe

Africa

Middle East

Asia/ Asia-Pacific Australia

Other: ……………………………Please Specify the country: *

4- Area of practice: * Mark only one oval.

Urban

Suburban

Rural

5- Type pf practice: * Mark only one oval.

Governmental hospital

Public Private hospital/ Clinic

Charity Hospital

6- You are working in. ……… * Mark only one oval.

Academic sector

Non-academic sector

7- Where are you practicing oculoplastic* Mark only one oval.

Multi-speciality hospital or clinic (general hospital)

Specialized eye centre

Solo (private clinic)

8- How do you describe the surgical volume in your hospital? * Mark only one oval.

2 or less than 2 cases of DCR/week

3–5 DCR cases/week

6–10 DCR cases/week

11–20 DCR cases/week

>20 DCR cases/week

Part B: Training

9- Type of training after residency: * Mark only one oval.

Formal training (fellowship in Oculoplastics)

Formal training in Rhinology

Formal training both (Oculoplastic and Rhinology)

Non-formal training in Oculoplastics

Non-formal training in Rhinology

Non-formal training in both (Oculoplastic and Rhinology) Other:

10- Area of training: * Mark only one oval.

North America

South America

Europe

Africa

Middle East

Asia/ Asia-Pacific

Australia

11- Duration of training: * Mark only one oval.

1–6 months

7–12 months

13–18 months

19- 24 months

more than 24 month

Didn't receive formal training

12- Period of training: * Mark only one oval.

70's

80's

90's

2000 and later

13- Exposure to DCR cases during training: * Mark only one oval.

External DCR only

Endoscopic Endonasal DCR only

Non-Endoscopic Endonasal DCR

Both External and Endoscopic

External, Endoscopic and Non-Endoscopic endonasal No DCR exposure

14- During your training, how many cases of Endoscopic Endonasal DCR did you perform? (total) *

<20 cases

20- 40 cases

>40 cases

none

15- During your training, how many cases of Non-Endoscopic Endonasal DCR did you perform? (total) *

<20 cases

20- 40 cases

>40 cases

none

16- During your training, how many cases of External DCR did you perform? (total) *

<20 cases

20- 40 cases

>40 cases

none

Part C: Practice

17- Since when are you practicing Oculoplastic(years after residency) * Mark only one oval.

<5y

5–10y

>10y

18- In your practice, which technique do you consider as first line procedure to manage nasolacrimal obstructions? * Mark only one oval.

External DCR

Non-Endoscopic Endonasal DCR Endoscopic Endonasal DCR

No preference

I don't perform DCR

19- Among all DCR cases, what is the percentage of endonasal DCR surgeries performedMark only one oval.

1–25%

26–50%

51–75%

76–100%

I don't perform endonasal surgeries

20- Since when are you performing External DCR? * Mark only one oval.

<10 years

10 years and more

I don't perform external DCR

21- Since when are you performing Endoscopic Endonasal DCR? * Mark only one oval.

< 10 years

10 years and more

I don't perform endoscopic DCR

22- Since when are you performing Non-Endoscopic Endonasal DCR? * Mark only one oval.

< 10 years

10 years and more

I don't perform non-endoscopic endonasal DCR

23- Your decision to perform Endoscopic DCR is based on: * Tick all that apply.

Gender of patient

Age of the patient

Patient request

Endonasal exam

I don't perform endoscopic DCR

Other: …………….

24- Do you perform endonasal surgeries: * Mark only one oval.

Alone as a main surgeon

I am the main surgeon with the assistance of the ENT

The ENT does the endoscopic part and I do the lacrimal probing and intubation

Not applicable

25- Do you use mitomycin when performing endonasal DCR? * Mark only one oval.

Yes

Only in re-do cases

Not applicable

26- Do you use mitomycin when performing external DCR? * Mark only one oval.

Yes

Only in re-do cases Not applicable

27- Do you use stent when you perform an endonasal DCR surgery? * Mark only one oval.

Yes

Only in re-do cases Not applicable

28- Do you use stent when you perform an external DCR surgery? * Mark only one oval.

o o Yes

• No

• Only in re-do cases Not applicable

29- If your answer to the previous question was “yes, I use stent in endonasal DCR,” how lon after surgery the stent is removed? * Mark only one oval.

One month

Two months

Three months

Six months

One year

Variable

Not applicable

30- If your answer to the previous question was “yes, I use stent in external DCR,” how long after surgery the stent is removed? * Mark only one oval.

One month

Two months

Three months

Six months

One year

Variable

Not applicable

31- If you routinely use both techniques, which one do you feel results in a better outcome? Mark only one oval.

External

Endoscopic

Both similar

Not applicable

32- If you are performing External and Endonasal DCR, with which one do you feel you face more complications? * Mark only one oval.

External

Endoscopic

Both similar

Not applicable

Part D: Barriers for not performing endoscopic DCR

33- Are the facilities for performing Endonasal DCR available at your hospital? * Mark only one oval.

Yes

34- In your opinion, which one of the following is considered as a barrier for not performing endonasal DCR? (Tick all that apply) *

Insufficient time to learn

Insufficient resources/support

Lack of experience

Steep learning curve

Worried about complications

Limited visibility of endoscopic DCR

Worried about the surgical outcome

Was not trained during fellowship

No courses in my region

Investment to acquire instruments for surgery very high for a small number of procedures availab

Facilities for performing endoscopic DCR are not available in my place

Lack of experienced back up

Difficulty achieving dexterity and instruments maneuvering within the confined space of nasal cavity.

I am not interested in endoscopic DCR because my results with external are good.

Other: ………………………..

35- In your opinion, the surgical success rate of endoscopic DCR compared to external DCR Mark only one oval.

higher

lower

equal

36- Compared to external DCR, I find endoscopic DCR: * Mark only one oval.

easier than external DCR more difficult

same

not applicable

37- What are the complications you are worried about when performing Endoscopic DCR? Mark only one oval.

Bleeding

Failure / non patent lacrimal system

Silicon tube displacement

Injury to the orbital structures

Injury to skull base

Other: ………………….

Part E: Facilitators to performing endoscopic DCR

38- In your opinion, which of the following facilitate endonasal DCR training? (Tick all that apply) *

Surgical mentorship/ supervision during initial cases

High surgical volume to improve the learning curve

Initial training with an ENT (ear, nose, and throat) surgeon to familiarize with nasal anatomy and endoscope

Additional data to highlight non-inferiority of endoscopic compared to external DCR

Surgical simulation for improving endoscopic DCR skills

Wet lab / Cadaveric session

Video-based performance assessment (self assessment or by experts)

I have no interest in endoscopic surgery

Other: …………………………..

References

Ozer

. Endoscopic vs external dacryocystorhinostomy-comparison from the patients’ aspect. Int J Ophthalmol 2014; 7: 689–696.

Karim

Ghabrial

Lynch

, et al. A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Clin Ophthalmol 2011; 5: 979–989.

Lee

Lim

, et al. Learning curve for endoscopic endonasal dacryocystorhinostomy. Korean J Ophthalmol 2017; 31: 299.

Kamal

Ali

Nair

. Outcomes of endoscopic dacryocystorhinostomy: experience of a fellowship trainee at a tertiary care center. Indian J Ophthalmol 2016; 64: 648.

Hughes

. The history of lacrimal surgery. Adv Ophthalmic Plast Reconstr Surg 1986; 5: 139–168.

Caldwell

. Two new operations for obstruction of the nasal duct, with preservation of the canaliculi and an incidental description of a new lacrimal probe. NY Med J 1893; 57: 581–582.

McDonogh

Meiring

. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989 Jun; 103: 585–587.

Barmettler

Erlich

Lelli

. Current preferences and reported success rates in dacryocystorhinostomy amongst ASOPRS members. Orbit 2013 Feb; 32: 20–26.

Nair

Kamal

Agarwal

. Indian Survey on practice patterns of lacrimal and eyelid disorders (iSUPPLE) report 2: mitomycin-C and lacrimal stents in dacryocystorhinostomy. Journal of Craniofacial Surgery 2016 Nov; 27: 2015–2019.

10.

Chen

Liang

. Practice patterns in endoscopic dacryocystorhinostomy: survey of the American rhinologic society: practice patterns in endoscopic DCR. Int Forum Allergy Rhinol 2016 Sep; 6: 990–997.

11.

Acharya

Jethani

Nene

, et al. Transition from external to endonasal endoscopic dacryocystorhinostomy: learning curve of an oculoplasty surgeon. J Clin Ophthalmol Res 2015; 3: 19.

12.

Tanigawa

Sasaki

Nonoyama

, et al. Outcomes of endoscopic endonasal dacryocystorhinostomy for intractable lacrimal dacryostenosis and associated factors. Int J Ophthalmol 2016; 9: 1471–1475.

13.

Nomura

Arakawa

Sugawara

, et al. Factors influencing endoscopic dacryocystorhinostomy outcome. Eur Arch Otorhinolaryngol 2017 Jul; 274: 2773–2777.

14.

Solyman

Tharwat

El Sabbagh

, et al. Eyelid blink lagophthalmos and blinking velocity changes after external transcutaneous dacrocystorhinostomy: a prospective study. Am J Ophthalmol 2022 Sep 6; 245: 81–85.

15.

Feng

Shi

, et al. A meta-analysis of primary external dacryocystorhinostomy with and without mitomycin C. Ophthalmic Epidemiol 2012 Dec; 19: 364–370.

16.

Gonzalvo Ibáñez

Fuertes Fernández

Fernández Tirado

, et al. External dacryocystorhinostomy with mitomycin C. Clinical and anatomical evaluation with helical computed tomography. Arch Soc Esp Oftalmol 2000; 75: 611–617.

17.

Xue

Mellington

Norris

. Meta-analysis of the adjunctive use of Mitomycin C in primary and revision, external and endonasal dacryocystorhinostomy. Orbit 2014 Aug; 33: 239–244.

18.

Jahan

Eldanfur

Ghuzi

. Role of silicone stenting in endoscopic dacryocystorhinostomy. Int J Otorhinolaryngol Head Neck Surg 2020 Jan 24; 6: 248.

19.

Vishwakarma

Singh

Ghosh

. A study of 272 cases of endoscopic dacryocystorhinostomy. Indian J Otolaryngol Head Neck Surg 2004 Oct; 56: 259–261.

20.

Chong

KKL

Lai

FHP

, et al. Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction. Ophthalmology 2013 Oct; 120: 2139–2145.

21.

Malhotra

Norris

Sagili

, et al. The learning curve in endoscopic dacryocystorhinostomy: outcomes in surgery performed by trainee oculoplastic surgeons. Orbit 2015 Nov 2; 34: 314–319.

22.

Kang

Shim

Shin

, et al. A systematic review of benefit of silicone intubation in endoscopic dacryocystorhinostomy. Clin Exp Otorhinolaryngol 2018 Jun 1; 11: 81–88.

23.

Vatansever

Aydın

Dinç

, et al. Endoscopic endonasal dacryocystorhinostomy learning curve. Arq Bras Oftalmol 2022; May-Jun; 85: 223–228. Available from: http://aboonline.org.br/details/6188/en-US/endoscopic-endonasal-dacryocystorhinostomy-learning-curve. [cited 2022 Nov 16].

24.

Coumou

Genders

Smid

, et al. Endoscopic dacryocystorhinostomy: long-term experience and outcomes. Acta Ophthalmol 2017 Feb; 95: 74–78.

25.

Wais

Ooi

Leung

, et al. The effect of low-fidelity endoscopic sinus surgery simulators on surgical skill. Int Forum Allergy Rhinol 2012 Jan; 2: 20–26.

26.

Peyre

Arriaga

, et al. Postgame analysis: using video-based coaching for continuous professional development. J Am Coll Surg 2012 Jan; 214: 115–124.

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

Abstract

Objective

Method

Results

Conclusions

Keywords

Introduction

Material and methods

Statistical analysis

Results

Demographics

training

Practice

Barriers and potential facilitators for endoscopic DCR adoption:

Discussion

Limitations and future studies

Conclusions

Footnotes

Declaration of conflicting interests

Funding

ORCID iDs

DCR preferences among Oculoplastic Surgeons

References