Lasers in Surgery and Medicine 46:275–280 (2014)
Comparison of Transcanalicular Diode Laser Dacryocystorhinostomy and External Dacryocystorhinostomy in Patients with Primary Acquired Nasolacrimal Duct Obstruction Arzu Tas¸kıran C ¸ o¨mez, MD,1 Onur Karadag˘, MD,2 Sedat Arıkan, MD,1 Baran Gencer, MD,1 and Selc¸uk Kara, MD1 1 Department of Ophthalmology, Canakkale Onsekiz Mart University, School of Medicine, 17020, C ¸ anakkale, Turkey 2 Eye Clinic, Kocaeli Darıca Farabi State Hospital, 41900, Kocaeli, Turkey
Background and Objective: To compare the success, complication, and patient discomfort rates of transcanalicular diode laser dacryocystorhinostomy (TCDL-DCR) and external dacryocystorhinostomy (EX-DCR) surgeries performed in patients with primary acquired nasolacrimal duct obstruction. Materials and Methods: Eighty consecutive patients were included in the study, and groups were assigned according to DCR technique. Thirty-four (42.5%) patients received TCDL-DCR (Group A) and 46 (57.5%) patients (Group B) received EX-DCR with temporary silicone stent intubation. The success of surgery was determined by the relief of epiphora, patient satisfaction, endoscopic evaluation of ostium patency, and lacrimal system syringing. Pearson Chi-Square test, Fisher’s Exact test, and Student’s t-test were used for statistical analyses. Results: Group A included 22 females and 12 males with a mean age of 49.1 15.1 years, Group B included 35 females and 11 males with a mean age of 50.8 11.7 years. There was no difference between groups in terms of age and gender (P ¼ 0.905 and P ¼ 0.167, respectively). The duration of the operation was 22.2 4.8 minutes for Group A, while it was 56.3 15.7 minutes for group B (P ¼ 0.0001). In two patients in Group A, injury in the medial turbinate was recorded, and in Group B, 14 patients experienced mild to severe perioperative bleeding. The perioperative complication rate was significantly different between the groups (P ¼ 0.004). Success in relieving symptoms was 79.4% for Group A and 89.1% for Group B. The difference in the success rates was not statistically significant (P ¼ 0.229). Conclusions: Although EX-DCR success rate was higher than that achieved with TCDL-DCR, the latter, with its shorter duration of surgery, lower perioperative complication rate, and a similar success rate, may be a good and acceptable surgical alternative in treatment of primary acquired nasolacrimal duct obstruction. Lasers Surg. Med. 46:275–280, 2014. ß 2014 Wiley Periodicals, Inc. Key words: dacryocystorhinostomy; diode; external; laser; nasolacrimal; transcanalicular ß 2014 Wiley Periodicals, Inc.
INTRODUCTION External dacryocystorhinostomy (EX-DCR) is the accepted gold standard surgical treatment for primary acquired nasolacrimal duct obstruction [1,2]. However, different approaches, including endonasal and transcanalicular techniques with or without the use of laser systems, are being developed in order to perform less traumatic DCR, with comparably high success rates [3]. Transcanalicular DCR was first reported by Jack in 1963 [4]. It is preferred both by patients and the doctors due to its less traumatic nature, absence of visible scar tissue, absence of damage to the vascular structures and medial canthal ligament, minimal risk of hemorrage and orbital morbidity, shorter operation time, and repeatability [5–11]. Different lasers with different wavelengths, including Holmium:Yttrium-Aluminum-Garnet (Ho:YAG) laser; Potassium-Tytanyl-Phosphate (KTP) laser; Neodymium: YAG (Nd:YAG) laser; Erbium:YAG (Er:YAG) laser; and diode laser have been used in the field of DCR to open osteotomy since 1993 [12–16]. A 980-nm diode laser is the topic of several current papers, and this laser seems to offer specific advantages for DCR due to lower tissue damage and adequacy of the osteotomy created [16–20]. This retrospective and comparative study, aimed at comparing the duration of the operation, success, and patient satisfaction rates of the new procedure transcanalicular diode laser dacryocystorhinostomy (TCDLDCR) with the conventional EX-DCR technique performed in C ¸ anakkale Onsekiz Mart University, Department of Ophthalmology, Canakkale, Turkey.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and have disclosed the following: [The authors have no conflicts of interest with this submission]. Correspondence to: Arzu Tas¸kıran C ¸ o¨mez, MD, Barbaros Mah. Hamidiye sitesi C/9, Merkez/Canakkale/Turkey. E-mail: [email protected] Accepted 3 February 2014 Published online 26 February 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22236
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MATERIALS AND METHODS This retrospective, noncomparative study is conducted by reviewing the data of the patients who underwent TCDL-DCR and EX-DCR procedure with the diagnosis of primary nasolacrimal duct obstruction in Canakkale Onsekiz Mart University, Department of Ophthalmology between June 2009 and September 2013. All patients underwent complete ophthalmological examination besides the fluorescein dye disappearance test lacrimal syringing, ear, nose, and throat (ENT) evaluation prior to surgery. The local ethics committtee of Canakkale Onsekiz Mart University have approved the study design. Group A included 34 eyes of 34 patients who received TCDL-DCR, whereas Group B had 46 eyes of 46 patients who had EX-DCR. In Group A, 31 patients received general anesthesia and 3 patients received regional anesthesia. In Group B, all patients received general anesthesia. In all patients, 4% lignocaine solution was sprayed into the ipsilateral nasal cavity along with an adrenalinelidocaine package placed in the nasal passage 20 minutes before the operation. In three patients with regional anesthesia, 2% lignocaine with adrenalin (Xylocaine, Astra Zeneca) was injected to block the infratrochlear and infraorbital nerves. In Group A, after dilation of the both puncti, a 980 nm wavelength solid state diode laser (Multidiode S30, OFT, Intermedic, Spain) with a 600-mm semi-rigid, silicapolyamide laser fiber optic, was used with a power range between 8 and 12 W, 350–500 ms pulsetime, and 350– 500 ms pause duration between pulses to use the lowest amount of energy sufficient to create an osteotomy (Fig. 1). The site of the osteotomy was determined by nasal endoscopic view of the transillumination of the probe at the lateral nasal wall medial to the middle turbinate. The laser probe was first repositioned in the upper and then in the lower punctum in order to create an adequate opening. Despite the impossibility of measuring the aperture dimensions, the size of the aperture was decided relative to the size of the probe, which was thought to be between approximately 5 7 mm in diameter. In the first eight patients, Mitomycin-C (Mit-C) was not used, and the remaining 26 patients in Group A received Mit-C (0.4 mg/
ml). After creation of the aperture, Mit-C-imbued sponge was placed in the aperture for 2.5 minutes. After vigorous irrigation through the punctum and the ostium bicanalicular, silicone intubation was performed. Removal of the stents was planned for 2–6 months following the operation. The follow-up times were at 1 day, 10 days, 1 month, and 3 months, as well as at the final visit for the study in September 2013. In all patients in Group B, a conventional EX-DCR procedure was performed under general anesthesia. A curvilinear incision approximately 10–15 mm in length from the medial canthus along the anterior lacrimal crest, orbicularis muscle and periosteum was made, and retracted to facilitate the exposure of the anterior crest, lacrimal fossa, and lacrimal sac. A bony aperture was created with a Kerrison punch and flaps from nasal mucosa and lacrimal sac were created. After suturing of the posterior flaps, bicanalicular silicone stent intubation was performed. Suturing of the anterior flaps was followed by subdermal and skin suturing. Nasal packing was inserted in the nose and removed the day after surgery. Mit-C was applied in 29 patients in Group B. Systemic oral antibiotics and oral anti-inflammatory medications were prescribed for 10 days, along with nasal decongestant sprays, topical antibiotics and steroids three times a day, for a period of 3 weeks. In Group A, syringing of the lacrimal passage was done on the first and tenth postoperative days to clean any crust formation in the ostium, and all patients in this group were advised to use sterile 0.9% saline solution as nasal spray at least six times a day for 4–6 weeks postoperatively. The EX-DCR patients’ skin sutures were removed after the first week. The patients were called for evaluation and syringing 7 days, 1 month, 3 months, and 6 months after surgery. At every visit, the patients were asked about their symptoms, in terms of epiphora and discharge, and they underwent syringing at all intervals. The surgery was considered unsuccessful if epiphora persisted or occurred with negative syringing at any visit. DCR surgery was defined as successful when characterized by no epiphora, no episode of postoperative dacryocystitis, and no obstruction in irrigation of the lacrimal system postoperatively. The total diode laser energy in joules used and the operation time for each case was noted. Secondary interventions performed for failed cases were EX-DCR, TCDL-DCR, and endonasal-DCR. Successful results obtained after these revision procedures were not considered successful. Early postoperative discomfort of the patients was measured with a scale ranging from 1 to 5 (none: 1; mild: 2; moderate: 3; severe: 4; extreme: 5) the day after the surgery. STATISTICAL ANALYSIS
Fig. 1. Intraoperative settings of diode laser.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software (version 15.0 for Windows). The data were given as mean standard deviation and number (percentage). Pearson Chi-Square test, and Student’s t-tests were performed for statistical analyses. A P < 0.05 is considered as significant.
LASER VERSUS EXTERNAL DACRYOCYSTORHINOSTOMY
RESULTS The demographic and clinical features of groups A and B are described in Table 1. The mean laser energy used in Group A was 390 J (ranged 265–670 J). Early epiphora was recorded in 7 (20.5%) patients after explantation of the silicone stent in Group A, and nasal endoscopy revealed white fibrous membrane occlusion of the aperture. In Group B, 5 (10.8%) patients were still symptomatic after the removal of the stents. There were no cases of thermal injury to the canaliculi or punctae in Group A. Symptomatic success was 79.4% for Group A and 89.1% for Group B at the final visit. The success rates for Group B was higher but the difference was not statistically significant (P ¼ 0.229). The features of the seven patients in Group A and five patients in Group B with unsuccessful outcomes are described in Tables 2 and 3, respectively. The cosmetic benefit, which was the main concern for patients undergoing Ext-DCR, was superior in all patients who undergone laser-assisted DCR. The postoperative appearance of both procedures is shown in Figure 2. DISCUSSION External dacryocystorhinostomy (EX-DCR) is a wellestablished and widely accepted standard surgical procedure for the treatment of primary acquired nasolacrimal duct obstruction, yielding success rates of over 90% [21,22]. Although this approach remains the gold standard, compared to the 80–85% success rates of endonasal DCR and 34–95.2% success rates of transcanalicular DCR, there is still a demand from both patients and doctors for a shorter surgery that ends without facial scarring, with less risk of bleeding, and without injury to the lacrimal pump that has a comparable success rate [3,8,20,23–28]. Currently, TCDL-DCR seems to be the missing piece of the puzzle. However, the success rates ranging widely from 34% to 95.2%, gives the patient and the doctor the sense that there is still a missing part [3,8,20,23–28]. Nuhoglu et al. has the highest success rate in the literature with a 95.2% success rate by TCDL-DCR, although it was their first time using this technique [3]. The authors report that this high success rate may be
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related to being performed by two highly experienced surgeons on EX-DCR on selected cases, in addition to the fact that the laser probe they used did not require a guide, and an appropriate light angle of the transcanalicular probe made it possible to create a larger ostium with lower energy and with less tissue damage [3]. Kutukde et al. reported success rates of 86% based on symptoms in EXDCR group and 68% for transcanalicular diode laser group, with no statistically significant difference. The authors did not mention Mit-C usage in any of the groups [25]. Kaynak et al. [20], in their recent article evaluating the success rate of 980 nm transcanalicular diode laserassisted dacryocystorhinostomy with a follow-up time of 24.29 months reported that, at the third month follow-up, 85.4% of cases had complete resolution of their symptoms. However, the functional success rate decreased to 67.7% at 6 months, to 63.3% at 1 year, and to 60.3% at 2 years, while the patency of the lacrimal drainage system was restored in 93.1%, 74.6%, 69.5%, and 68.2% of the cases, respectively [20]. Basmak et al. [28] reported a 66% functional success with a follow-up period of 12.8 months with TCDLDCR, suggesting that the success rate could be raised to 86% by routinely adding mechanical enlargement of the neo-ostium and concomitant endoscopic turbinectomy to improve the access to the lacrimal sac and to decrease the incidence of postoperative adhesions between the lateral nasal wall and middle turbinate synechia [28]. Our success rate was 89.1% for EX-DCR and 79.4% for TCDL-DCR. The higher success rate of our study may be related to the use of adjunctive Mit-C, which we used in most of our patients. Basmak and Kutukde did not use MitC in their study [25,28]. Yeniad et al. reported a relatively higher success rate for eyes with EX-DCR compared to eyes with TCDL-DCR, but again the difference was not statistically significant [27]. The healing process in the new ostium is the main challenge in either DCR procedure. Besides the known and expected risk of fibrosis of the new ostium in both procedures, neither the amount, strength and duration of the laser that should be applied, nor the periostial tissue response to the laser can be predicted in the laser-assisted
TABLE 1. The Demographic and Clinical Features of Groups A and B
Female/male Mean age (years) Mean follow-up time (months) Mean surgery time (minutes) Perioperative complication Silicone stent explantation time (months) Mitomycin-C application Symptomatic success Early postoperative discomfort
Pearson Chi-square test. Student’s t-test.
Group A
Group B
P value
22/12 49.1 15.1 16.0 4 22.2 4.8 2 (middle turbinate injury) 4.3 1.7 26 (76.4%) 79.4% (n ¼ 27) 1.4 0.8
35/11 50.8 11.7 15.6 7.6 56.3 15.7 14 (bleeding) 4.2 1.6 29 (63%) 89.1% (n ¼ 41) 3.0 1.1
0.167 0.905 0.761 0.0001 0.004 0.702 0.200 0.229 0.0001
63
29
51
70
42
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
F
M
M
F
F
M F
GA
GA
LA
LA
GA
GA GA
12
14
17
14
13
14 13
23
17
32
34
22
35 21
8 0 3 3 7 4
6
þ þ þ
þ
51
63 28 36
39
Patient 1
Patient 2 Patient 3 Patient 4
Patient 5
Age
F
M F F
M
Sex
GA
GA GA GA
GA
Anesthesia
15
18 21 6
26
Follow-up time (months)
45
105 95 55
70
Operation duration (minutes)
Bicanalicular tube explantation time (month) 4 6 6 2 3
Mit-C þ þ þ þ
TABLE 3. Characteristics of Patients With Unsuccessful Outcome in Group B
GA, General anesthesia; LA, Local anesthesia.
50 53
Patient 1 Patient 2
Reason for failure
þ (bleeding) þ (bleeding)
þ (bleeding)
Granuloma formation in the ostium Granuloma formation in the ostium Granuloma formation in the ostium
Reason for failure
Synechia with middle turbinate þ concha bullosa Granuloma and fibrosis of the ostium
Synechia with middle turbinate Crust in the ostium þ granuloma formation in the ostium Granuloma formation in the ostium Sump syndrome of the lacrimal sac Synechia with Middle turbinate
Perioperative complication
Bicanalicular Follow-up Operation tube explantation Perioperative duration time time (month) complication (minutes) Mit-C Age Sex Anesthesia (month)
TABLE 2. Characteristics of Patients With Unsuccessful Outcome in Group A
did not operation did not operation
Endonasal-DCR
EX-DCR TCDL-DCR Endonasal-DCR
EX-DCR
Secondary intervention
EX-DCR
Patient want Patient want
Patient did not want operation EX-DCR
Re-TCDL-DCR Re-TCDL-DCR
Secondary intervention
Open
Closed Open Open
Closed
Final ostium
Closed
Closed
Closed
Open
Closed
Open Open
Final ostium
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Fig. 2. Postoperative appearance of both procedures. A: The scarring in the medial canthal area in external-DCR. B: No scarring in the transcanalicular diode laser-assisted DCR.
group. Moreover, individual responses to the tissue healing process are also an important factor for a successful DCR surgery. There is not an accepted consensus about the amount and the duration of Mit-C application. Some authors apply Mit-C [19] while some do not [26]. Different doses 0.05 [19,29], 0.2 [20,30], 0.4 [19,30], and 0.5 mg/ml [2,31] for 2 minutes [29], 2.5 minutes [31] or 5 minutes [19,30], applied once, or multiple times [32] are reported in the literature. It is difficult to compare success rates between EX-DCR and TCDL-DCR as there are no comparative studies with standard settings and standard outcome measures. Each study has a different number of cases, different follow-up times, minor modifications in the DCR technique such as Mit-C application and/or silicone stents implantation, differences in the Mit-C concentration, application time and differences in outcome measures, with some studies defining success as patency to irrigation while others define as symptom resolution. These differences make it difficult to compare these results. The surgery time for EX-DCR depends on the experience of the surgeon, intraoperative bleeding, and the use of adjunctive procedures such as Mit-C and bicanaliculer stent implantation. In a study by Khan et al., the mean surgery time for EX-DCR was reported to be 54.3 5.6 minutes [33], similar to our surgery time (56.3 15.7 minutes). Hartikainen et al. concluded that the average duration for external DCR was 78 minutes [34]. Saha found that the mean surgery time for EX-DCR was 119.6 minutes [35]. The surgery time for transcanalicular laser DCR surgery has been reported in the literature to range between 8 and 25 minutes [3,16,27,36]. Our mean surgery time in the TCDL-DCR group was 22.2 minutes after the induction of the general anesthesia, which was significantly lower than the EX-DCR group. When considering that these patients have surgery under general anesthesia, this time difference is quite important for the risk and morbidity of general anesthesia. The shorter operation time for TCDLDCR under either local or general anesthesia allows the older patients with systemic diseases to have surgery with less morbidity.
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When comparing the perioperative complication rates, we had no bleeding in Group A; however, we had two inadvertent injuries of the middle turbinate with laser shooting. Due to protection of the nasal structures with Freer elevator, no synechia or closure of the ostium in either of these two patients was observed. There was no bleeding complication recorded perioperatively in the laser group, although in 14 (30.4%) patients, mild to severe bleeding was recorded in the EX-DCR group. Two patients with uncontrolled hypertension had to remain hospitalized for three nights due to uncontrolled, mild but continuous bleeding from the nose and required cauterization in the operating room, facilitated with the help of the Ear Nose and Throat surgeons. In most patients, bleeding could be controlled with conservative treatment without any major risk or life threatening complications; however, it may lengthen the surgery time and subsequently prolong the hospitalization and recovery time. The mean laser energy used in the current study is (mean 390 J), higher than Drnovsek and Beltram [16], (mean 245 J) similar to Cintra and Anselmo-Lima [37] (mean 392 J), and lower than Kaynak et al. [20], (1322.7 J). Kaynak et al., attribute the lower success rate in their study to the high level of energy used [20]. All of the patients in Group A reported a none to mild (mean 1.4 [range 1–5] points) discomfort postoperatively and were able to leave the hospital on the day of the surgery, while in Group B all patients stayed the first night in the hospital and rated their discomfort as moderate to severe (mean 3.0 points [range 1–5]). The difference between the discomfort scales of the both groups was significant (P ¼ 0.0001). The eyelid swelling and bruising was also less in the TCDL-DCR group than in EX-DCR. Our results showed that symptomatic success rates of TCDL-DCR were comparable to EX-DCR but statistical analyses were not significant due to inadequate sample size. The 980 nm TCDL-DCR is a minimally invasive and quick procedure, with a low perioperative complication rate and a similar success percentage, yielding results comparable to classic DCR. It enables rapid patient recovery and avoidance of skin scarring. With these qualitative benefits (minimally invasive, patient preference, cosmetics), TCDL-DCR seems to be a promising technique in the surgical treatment of primary acquired nasolacrimal duct obstruction and may be a good and acceptable surgical alternative to the external approach; however, comparative studies with more patients and longer follow-up times should be planned. Additionally, standardization of laser energy amount and duration and standardization on mitomycin-C application should be performed to enhance the efficacy of this technique. REFERENCES 1. Yazici B, Akova B. Simultaneous bilateral external dacryocystorhinostomy. Acta Ophthalmol Scand 2007;85(6):667– 670. 2. Hartkainen J, Gernmen R, Puukka P, Seppa H. Prospective randomized dacryocystorhinostomy. Ophthalmology 1998;114: 1106–1113.
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21. Tarbet KJ, Custer PL. External dacryocystorhinostomy: Surgical success, patient satisfaction and economic cost. Ophthalmology 1995;102:1065–1070. 22. Welham RA, Henderson PH. Results of dacryocystorhinostomy: Analysis of causes for failure. Trans Ophthalmol Soc UK 1973;93:601–609. 23. Mandeville JT, Woog JJ. Obstruction of the lacrimal drainage system. Curr Opin Ophthalmol 2002;13:303–309. 24. Shun-Shin GA, Thurairajan G. External dacryocystorhinostomy-an end of an era? Br J Ophthalmol 1997;81:716–717. 25. Derya K, Demirel S, Doganay S, Orman G, Cumurcu T, Gunduz A. Endoscopic transcanalicular diode laser dacryocystorhinostomy: Is it an alternative method to conventional external dacryocystorhinostomy? Ophthal Plast Reconstr Surg 2013;29:15–17. 26. Joshi RS. Conventional dacryocystorhinostomy in a failed transcanalicular laser-assisted dacryocystorhinostomy. Indian J Ophthalmol 2011;59:383–385. 27. Yeniad B, Uludag G, Kozer-Bilgin L. Assessment of patient satisfaction following external versus transcanalicular dacryocystorhinostomy with a diode laser and evaluation if change in quality of life after simultaneous bilateral surgery in patients with bilateral nasolacrimal duct obstruction. Curr Eye Res 2012;37(4):286–292. 28. Basmak H, Caklı H, Sahin A, Gursoy H, Ozer A, Altun E, Yildirim N. Comparison of endocanalicular laser dacryocystorhinostomy with and without endonasal procedures. Graefes Arch Clin Exp Ophthalmol 2011;249(5):737–743. 29. Deka A, Bhattacharjee K, Bhuyan SK, Barua CK, Bhattacharjee H, Khaund G. Effect of mitomycin C on ostium in dacryocystorhinostomy. Clin Experiment Ophthalmol 2006;34(6):557–561. 30. You YA, Fang CT. Intraoperative mitomycin C in dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2001;17:115–119. 31. Ugurbas SH, Zilelioglu G, Sargon MF, Anadolu Y, Akiner M, Akturk T. Histopathologic effects of mitomycin C on endoscopic transnasal dacryocystorhinostomy. Ophthalmic Surg Lasers 1997;28:300–304. 32. Henson RD, Cruz HL, Henson RG Jr, Ali MJ, Kakizaki H. Postoperative application of mitomycin-C in endocanalicular laser dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2012;28(3):192–195. 33. Khan MK, Hossain MA, Hossain MJ, Al-Masud A, Rahman MZ. Comparative study of external and endoscopic endonasal dacryocystorhinostomy for the treatment of chronic dacryocystitis. JAFMC Bangladesh 2011;7:15–17. 34. Hartikainen J, Antila J, Varpula M, Puukka P, Seppa¨ H, Gr enman R. Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy. Laryngoscope 1998;108(12):1861–1866. 35. Saha R, Sinhi A, Phukan JP. Enndoscopic versus external approach dacryocystorhinostomy: A comparative analysis. Niger Med J 2013;54(3):165–169. 36. Gupta SK, Kumar A, Agarwal S, Pandey P. Transcanalicular laser dacryocystorhinostomy using low energy 810 nm diode laser. Oman J Ophthalmol 2012;5(3):171–174. 37. Cintra PP, Anselmo-Lima WT. Endocanalicular diode laser assisted dacryocystorhinostomy. Otolaryngol Head Neck Surg 2008;139:159–161.
Comparison of Transcanalicular Diode Laser Dacryocystorhinostomy and External Dacryocystorhinostomy in Patients with Primary Acquired Nasolacrimal Duct Obstruction Arzu Tas¸kıran C ¸ o¨mez, MD,1 Onur Karadag˘, MD,2 Sedat Arıkan, MD,1 Baran Gencer, MD,1 and Selc¸uk Kara, MD1 1 Department of Ophthalmology, Canakkale Onsekiz Mart University, School of Medicine, 17020, C ¸ anakkale, Turkey 2 Eye Clinic, Kocaeli Darıca Farabi State Hospital, 41900, Kocaeli, Turkey
Background and Objective: To compare the success, complication, and patient discomfort rates of transcanalicular diode laser dacryocystorhinostomy (TCDL-DCR) and external dacryocystorhinostomy (EX-DCR) surgeries performed in patients with primary acquired nasolacrimal duct obstruction. Materials and Methods: Eighty consecutive patients were included in the study, and groups were assigned according to DCR technique. Thirty-four (42.5%) patients received TCDL-DCR (Group A) and 46 (57.5%) patients (Group B) received EX-DCR with temporary silicone stent intubation. The success of surgery was determined by the relief of epiphora, patient satisfaction, endoscopic evaluation of ostium patency, and lacrimal system syringing. Pearson Chi-Square test, Fisher’s Exact test, and Student’s t-test were used for statistical analyses. Results: Group A included 22 females and 12 males with a mean age of 49.1 15.1 years, Group B included 35 females and 11 males with a mean age of 50.8 11.7 years. There was no difference between groups in terms of age and gender (P ¼ 0.905 and P ¼ 0.167, respectively). The duration of the operation was 22.2 4.8 minutes for Group A, while it was 56.3 15.7 minutes for group B (P ¼ 0.0001). In two patients in Group A, injury in the medial turbinate was recorded, and in Group B, 14 patients experienced mild to severe perioperative bleeding. The perioperative complication rate was significantly different between the groups (P ¼ 0.004). Success in relieving symptoms was 79.4% for Group A and 89.1% for Group B. The difference in the success rates was not statistically significant (P ¼ 0.229). Conclusions: Although EX-DCR success rate was higher than that achieved with TCDL-DCR, the latter, with its shorter duration of surgery, lower perioperative complication rate, and a similar success rate, may be a good and acceptable surgical alternative in treatment of primary acquired nasolacrimal duct obstruction. Lasers Surg. Med. 46:275–280, 2014. ß 2014 Wiley Periodicals, Inc. Key words: dacryocystorhinostomy; diode; external; laser; nasolacrimal; transcanalicular ß 2014 Wiley Periodicals, Inc.
INTRODUCTION External dacryocystorhinostomy (EX-DCR) is the accepted gold standard surgical treatment for primary acquired nasolacrimal duct obstruction [1,2]. However, different approaches, including endonasal and transcanalicular techniques with or without the use of laser systems, are being developed in order to perform less traumatic DCR, with comparably high success rates [3]. Transcanalicular DCR was first reported by Jack in 1963 [4]. It is preferred both by patients and the doctors due to its less traumatic nature, absence of visible scar tissue, absence of damage to the vascular structures and medial canthal ligament, minimal risk of hemorrage and orbital morbidity, shorter operation time, and repeatability [5–11]. Different lasers with different wavelengths, including Holmium:Yttrium-Aluminum-Garnet (Ho:YAG) laser; Potassium-Tytanyl-Phosphate (KTP) laser; Neodymium: YAG (Nd:YAG) laser; Erbium:YAG (Er:YAG) laser; and diode laser have been used in the field of DCR to open osteotomy since 1993 [12–16]. A 980-nm diode laser is the topic of several current papers, and this laser seems to offer specific advantages for DCR due to lower tissue damage and adequacy of the osteotomy created [16–20]. This retrospective and comparative study, aimed at comparing the duration of the operation, success, and patient satisfaction rates of the new procedure transcanalicular diode laser dacryocystorhinostomy (TCDLDCR) with the conventional EX-DCR technique performed in C ¸ anakkale Onsekiz Mart University, Department of Ophthalmology, Canakkale, Turkey.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and have disclosed the following: [The authors have no conflicts of interest with this submission]. Correspondence to: Arzu Tas¸kıran C ¸ o¨mez, MD, Barbaros Mah. Hamidiye sitesi C/9, Merkez/Canakkale/Turkey. E-mail: [email protected] Accepted 3 February 2014 Published online 26 February 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22236
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MATERIALS AND METHODS This retrospective, noncomparative study is conducted by reviewing the data of the patients who underwent TCDL-DCR and EX-DCR procedure with the diagnosis of primary nasolacrimal duct obstruction in Canakkale Onsekiz Mart University, Department of Ophthalmology between June 2009 and September 2013. All patients underwent complete ophthalmological examination besides the fluorescein dye disappearance test lacrimal syringing, ear, nose, and throat (ENT) evaluation prior to surgery. The local ethics committtee of Canakkale Onsekiz Mart University have approved the study design. Group A included 34 eyes of 34 patients who received TCDL-DCR, whereas Group B had 46 eyes of 46 patients who had EX-DCR. In Group A, 31 patients received general anesthesia and 3 patients received regional anesthesia. In Group B, all patients received general anesthesia. In all patients, 4% lignocaine solution was sprayed into the ipsilateral nasal cavity along with an adrenalinelidocaine package placed in the nasal passage 20 minutes before the operation. In three patients with regional anesthesia, 2% lignocaine with adrenalin (Xylocaine, Astra Zeneca) was injected to block the infratrochlear and infraorbital nerves. In Group A, after dilation of the both puncti, a 980 nm wavelength solid state diode laser (Multidiode S30, OFT, Intermedic, Spain) with a 600-mm semi-rigid, silicapolyamide laser fiber optic, was used with a power range between 8 and 12 W, 350–500 ms pulsetime, and 350– 500 ms pause duration between pulses to use the lowest amount of energy sufficient to create an osteotomy (Fig. 1). The site of the osteotomy was determined by nasal endoscopic view of the transillumination of the probe at the lateral nasal wall medial to the middle turbinate. The laser probe was first repositioned in the upper and then in the lower punctum in order to create an adequate opening. Despite the impossibility of measuring the aperture dimensions, the size of the aperture was decided relative to the size of the probe, which was thought to be between approximately 5 7 mm in diameter. In the first eight patients, Mitomycin-C (Mit-C) was not used, and the remaining 26 patients in Group A received Mit-C (0.4 mg/
ml). After creation of the aperture, Mit-C-imbued sponge was placed in the aperture for 2.5 minutes. After vigorous irrigation through the punctum and the ostium bicanalicular, silicone intubation was performed. Removal of the stents was planned for 2–6 months following the operation. The follow-up times were at 1 day, 10 days, 1 month, and 3 months, as well as at the final visit for the study in September 2013. In all patients in Group B, a conventional EX-DCR procedure was performed under general anesthesia. A curvilinear incision approximately 10–15 mm in length from the medial canthus along the anterior lacrimal crest, orbicularis muscle and periosteum was made, and retracted to facilitate the exposure of the anterior crest, lacrimal fossa, and lacrimal sac. A bony aperture was created with a Kerrison punch and flaps from nasal mucosa and lacrimal sac were created. After suturing of the posterior flaps, bicanalicular silicone stent intubation was performed. Suturing of the anterior flaps was followed by subdermal and skin suturing. Nasal packing was inserted in the nose and removed the day after surgery. Mit-C was applied in 29 patients in Group B. Systemic oral antibiotics and oral anti-inflammatory medications were prescribed for 10 days, along with nasal decongestant sprays, topical antibiotics and steroids three times a day, for a period of 3 weeks. In Group A, syringing of the lacrimal passage was done on the first and tenth postoperative days to clean any crust formation in the ostium, and all patients in this group were advised to use sterile 0.9% saline solution as nasal spray at least six times a day for 4–6 weeks postoperatively. The EX-DCR patients’ skin sutures were removed after the first week. The patients were called for evaluation and syringing 7 days, 1 month, 3 months, and 6 months after surgery. At every visit, the patients were asked about their symptoms, in terms of epiphora and discharge, and they underwent syringing at all intervals. The surgery was considered unsuccessful if epiphora persisted or occurred with negative syringing at any visit. DCR surgery was defined as successful when characterized by no epiphora, no episode of postoperative dacryocystitis, and no obstruction in irrigation of the lacrimal system postoperatively. The total diode laser energy in joules used and the operation time for each case was noted. Secondary interventions performed for failed cases were EX-DCR, TCDL-DCR, and endonasal-DCR. Successful results obtained after these revision procedures were not considered successful. Early postoperative discomfort of the patients was measured with a scale ranging from 1 to 5 (none: 1; mild: 2; moderate: 3; severe: 4; extreme: 5) the day after the surgery. STATISTICAL ANALYSIS
Fig. 1. Intraoperative settings of diode laser.
Data were analyzed using the Statistical Package for Social Sciences (SPSS) software (version 15.0 for Windows). The data were given as mean standard deviation and number (percentage). Pearson Chi-Square test, and Student’s t-tests were performed for statistical analyses. A P < 0.05 is considered as significant.
LASER VERSUS EXTERNAL DACRYOCYSTORHINOSTOMY
RESULTS The demographic and clinical features of groups A and B are described in Table 1. The mean laser energy used in Group A was 390 J (ranged 265–670 J). Early epiphora was recorded in 7 (20.5%) patients after explantation of the silicone stent in Group A, and nasal endoscopy revealed white fibrous membrane occlusion of the aperture. In Group B, 5 (10.8%) patients were still symptomatic after the removal of the stents. There were no cases of thermal injury to the canaliculi or punctae in Group A. Symptomatic success was 79.4% for Group A and 89.1% for Group B at the final visit. The success rates for Group B was higher but the difference was not statistically significant (P ¼ 0.229). The features of the seven patients in Group A and five patients in Group B with unsuccessful outcomes are described in Tables 2 and 3, respectively. The cosmetic benefit, which was the main concern for patients undergoing Ext-DCR, was superior in all patients who undergone laser-assisted DCR. The postoperative appearance of both procedures is shown in Figure 2. DISCUSSION External dacryocystorhinostomy (EX-DCR) is a wellestablished and widely accepted standard surgical procedure for the treatment of primary acquired nasolacrimal duct obstruction, yielding success rates of over 90% [21,22]. Although this approach remains the gold standard, compared to the 80–85% success rates of endonasal DCR and 34–95.2% success rates of transcanalicular DCR, there is still a demand from both patients and doctors for a shorter surgery that ends without facial scarring, with less risk of bleeding, and without injury to the lacrimal pump that has a comparable success rate [3,8,20,23–28]. Currently, TCDL-DCR seems to be the missing piece of the puzzle. However, the success rates ranging widely from 34% to 95.2%, gives the patient and the doctor the sense that there is still a missing part [3,8,20,23–28]. Nuhoglu et al. has the highest success rate in the literature with a 95.2% success rate by TCDL-DCR, although it was their first time using this technique [3]. The authors report that this high success rate may be
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related to being performed by two highly experienced surgeons on EX-DCR on selected cases, in addition to the fact that the laser probe they used did not require a guide, and an appropriate light angle of the transcanalicular probe made it possible to create a larger ostium with lower energy and with less tissue damage [3]. Kutukde et al. reported success rates of 86% based on symptoms in EXDCR group and 68% for transcanalicular diode laser group, with no statistically significant difference. The authors did not mention Mit-C usage in any of the groups [25]. Kaynak et al. [20], in their recent article evaluating the success rate of 980 nm transcanalicular diode laserassisted dacryocystorhinostomy with a follow-up time of 24.29 months reported that, at the third month follow-up, 85.4% of cases had complete resolution of their symptoms. However, the functional success rate decreased to 67.7% at 6 months, to 63.3% at 1 year, and to 60.3% at 2 years, while the patency of the lacrimal drainage system was restored in 93.1%, 74.6%, 69.5%, and 68.2% of the cases, respectively [20]. Basmak et al. [28] reported a 66% functional success with a follow-up period of 12.8 months with TCDLDCR, suggesting that the success rate could be raised to 86% by routinely adding mechanical enlargement of the neo-ostium and concomitant endoscopic turbinectomy to improve the access to the lacrimal sac and to decrease the incidence of postoperative adhesions between the lateral nasal wall and middle turbinate synechia [28]. Our success rate was 89.1% for EX-DCR and 79.4% for TCDL-DCR. The higher success rate of our study may be related to the use of adjunctive Mit-C, which we used in most of our patients. Basmak and Kutukde did not use MitC in their study [25,28]. Yeniad et al. reported a relatively higher success rate for eyes with EX-DCR compared to eyes with TCDL-DCR, but again the difference was not statistically significant [27]. The healing process in the new ostium is the main challenge in either DCR procedure. Besides the known and expected risk of fibrosis of the new ostium in both procedures, neither the amount, strength and duration of the laser that should be applied, nor the periostial tissue response to the laser can be predicted in the laser-assisted
TABLE 1. The Demographic and Clinical Features of Groups A and B
Female/male Mean age (years) Mean follow-up time (months) Mean surgery time (minutes) Perioperative complication Silicone stent explantation time (months) Mitomycin-C application Symptomatic success Early postoperative discomfort
Pearson Chi-square test. Student’s t-test.
Group A
Group B
P value
22/12 49.1 15.1 16.0 4 22.2 4.8 2 (middle turbinate injury) 4.3 1.7 26 (76.4%) 79.4% (n ¼ 27) 1.4 0.8
35/11 50.8 11.7 15.6 7.6 56.3 15.7 14 (bleeding) 4.2 1.6 29 (63%) 89.1% (n ¼ 41) 3.0 1.1
0.167 0.905 0.761 0.0001 0.004 0.702 0.200 0.229 0.0001
63
29
51
70
42
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
F
M
M
F
F
M F
GA
GA
LA
LA
GA
GA GA
12
14
17
14
13
14 13
23
17
32
34
22
35 21
8 0 3 3 7 4
6
þ þ þ
þ
51
63 28 36
39
Patient 1
Patient 2 Patient 3 Patient 4
Patient 5
Age
F
M F F
M
Sex
GA
GA GA GA
GA
Anesthesia
15
18 21 6
26
Follow-up time (months)
45
105 95 55
70
Operation duration (minutes)
Bicanalicular tube explantation time (month) 4 6 6 2 3
Mit-C þ þ þ þ
TABLE 3. Characteristics of Patients With Unsuccessful Outcome in Group B
GA, General anesthesia; LA, Local anesthesia.
50 53
Patient 1 Patient 2
Reason for failure
þ (bleeding) þ (bleeding)
þ (bleeding)
Granuloma formation in the ostium Granuloma formation in the ostium Granuloma formation in the ostium
Reason for failure
Synechia with middle turbinate þ concha bullosa Granuloma and fibrosis of the ostium
Synechia with middle turbinate Crust in the ostium þ granuloma formation in the ostium Granuloma formation in the ostium Sump syndrome of the lacrimal sac Synechia with Middle turbinate
Perioperative complication
Bicanalicular Follow-up Operation tube explantation Perioperative duration time time (month) complication (minutes) Mit-C Age Sex Anesthesia (month)
TABLE 2. Characteristics of Patients With Unsuccessful Outcome in Group A
did not operation did not operation
Endonasal-DCR
EX-DCR TCDL-DCR Endonasal-DCR
EX-DCR
Secondary intervention
EX-DCR
Patient want Patient want
Patient did not want operation EX-DCR
Re-TCDL-DCR Re-TCDL-DCR
Secondary intervention
Open
Closed Open Open
Closed
Final ostium
Closed
Closed
Closed
Open
Closed
Open Open
Final ostium
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LASER VERSUS EXTERNAL DACRYOCYSTORHINOSTOMY
Fig. 2. Postoperative appearance of both procedures. A: The scarring in the medial canthal area in external-DCR. B: No scarring in the transcanalicular diode laser-assisted DCR.
group. Moreover, individual responses to the tissue healing process are also an important factor for a successful DCR surgery. There is not an accepted consensus about the amount and the duration of Mit-C application. Some authors apply Mit-C [19] while some do not [26]. Different doses 0.05 [19,29], 0.2 [20,30], 0.4 [19,30], and 0.5 mg/ml [2,31] for 2 minutes [29], 2.5 minutes [31] or 5 minutes [19,30], applied once, or multiple times [32] are reported in the literature. It is difficult to compare success rates between EX-DCR and TCDL-DCR as there are no comparative studies with standard settings and standard outcome measures. Each study has a different number of cases, different follow-up times, minor modifications in the DCR technique such as Mit-C application and/or silicone stents implantation, differences in the Mit-C concentration, application time and differences in outcome measures, with some studies defining success as patency to irrigation while others define as symptom resolution. These differences make it difficult to compare these results. The surgery time for EX-DCR depends on the experience of the surgeon, intraoperative bleeding, and the use of adjunctive procedures such as Mit-C and bicanaliculer stent implantation. In a study by Khan et al., the mean surgery time for EX-DCR was reported to be 54.3 5.6 minutes [33], similar to our surgery time (56.3 15.7 minutes). Hartikainen et al. concluded that the average duration for external DCR was 78 minutes [34]. Saha found that the mean surgery time for EX-DCR was 119.6 minutes [35]. The surgery time for transcanalicular laser DCR surgery has been reported in the literature to range between 8 and 25 minutes [3,16,27,36]. Our mean surgery time in the TCDL-DCR group was 22.2 minutes after the induction of the general anesthesia, which was significantly lower than the EX-DCR group. When considering that these patients have surgery under general anesthesia, this time difference is quite important for the risk and morbidity of general anesthesia. The shorter operation time for TCDLDCR under either local or general anesthesia allows the older patients with systemic diseases to have surgery with less morbidity.
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When comparing the perioperative complication rates, we had no bleeding in Group A; however, we had two inadvertent injuries of the middle turbinate with laser shooting. Due to protection of the nasal structures with Freer elevator, no synechia or closure of the ostium in either of these two patients was observed. There was no bleeding complication recorded perioperatively in the laser group, although in 14 (30.4%) patients, mild to severe bleeding was recorded in the EX-DCR group. Two patients with uncontrolled hypertension had to remain hospitalized for three nights due to uncontrolled, mild but continuous bleeding from the nose and required cauterization in the operating room, facilitated with the help of the Ear Nose and Throat surgeons. In most patients, bleeding could be controlled with conservative treatment without any major risk or life threatening complications; however, it may lengthen the surgery time and subsequently prolong the hospitalization and recovery time. The mean laser energy used in the current study is (mean 390 J), higher than Drnovsek and Beltram [16], (mean 245 J) similar to Cintra and Anselmo-Lima [37] (mean 392 J), and lower than Kaynak et al. [20], (1322.7 J). Kaynak et al., attribute the lower success rate in their study to the high level of energy used [20]. All of the patients in Group A reported a none to mild (mean 1.4 [range 1–5] points) discomfort postoperatively and were able to leave the hospital on the day of the surgery, while in Group B all patients stayed the first night in the hospital and rated their discomfort as moderate to severe (mean 3.0 points [range 1–5]). The difference between the discomfort scales of the both groups was significant (P ¼ 0.0001). The eyelid swelling and bruising was also less in the TCDL-DCR group than in EX-DCR. Our results showed that symptomatic success rates of TCDL-DCR were comparable to EX-DCR but statistical analyses were not significant due to inadequate sample size. The 980 nm TCDL-DCR is a minimally invasive and quick procedure, with a low perioperative complication rate and a similar success percentage, yielding results comparable to classic DCR. It enables rapid patient recovery and avoidance of skin scarring. With these qualitative benefits (minimally invasive, patient preference, cosmetics), TCDL-DCR seems to be a promising technique in the surgical treatment of primary acquired nasolacrimal duct obstruction and may be a good and acceptable surgical alternative to the external approach; however, comparative studies with more patients and longer follow-up times should be planned. Additionally, standardization of laser energy amount and duration and standardization on mitomycin-C application should be performed to enhance the efficacy of this technique. REFERENCES 1. Yazici B, Akova B. Simultaneous bilateral external dacryocystorhinostomy. Acta Ophthalmol Scand 2007;85(6):667– 670. 2. Hartkainen J, Gernmen R, Puukka P, Seppa H. Prospective randomized dacryocystorhinostomy. Ophthalmology 1998;114: 1106–1113.
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