Current Eye Research, Early Online, 1–10, 2014 ! Informa Healthcare USA, Inc. ISSN: 0271-3683 print / 1460-2202 online DOI: 10.3109/02713683.2014.987873

RESEARCH REPORT

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Endoscopic Endonasal Dacryocystorhinostomy with Ostial Stent Intubation Following Nasolacrimal Duct Stent Incarceration Xiaopeng Wang1, Yang Bian2, Wentao Yan2, Pelaez Daniel3, Yunhai Tu2 and Wencan Wu2 1

Department of Ophthalmology, Jinhua Center Hospital, Jinhua, Zhejiang, People’s Republic of China, Department of Orbital & Oculoplastic Surgery, Eye Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China, and 3Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA 2

ABSTRACT Purpose: To study the feasibility of endoscopic endonasal dacryocystorhinostomy (EE-DCR) with novel lacrimal ostial stent (LOS) intubation for patients with chronic dacryocystitis with incarceration of a previously implanted nasolacrimal duct stent (NDS). Methods: According to surgical procedure, 166 patients (167 eyes) were divided into two groups: EE-DCR with LOS intubation was performed on 126 patients (127 eyes) in the EE-DCR group; while external dacryocystorhinostomy (E-DCR) with silicone tube intubation was performed on 40 patients (40 eyes) in the E-DCR group. The LOS or silicone tube was retained for 3–6 months. All patients were followed up for 12–36 months. Success rate of tear drainage reconstruction (TDR) and complications were retrospectively compared. Results: Excluding patients with early detachment of the LOS or the silicone tube, or with incomplete follow-up period, 117 patients (117 eyes) in the EE-DCR group and 36 patients (36 eyes) in the E-DCR group were included. The mean surgical time was 45.8 ± 11.5 min in the EE-DCR group and 68.1 ± 23.8 min in the E-DCR group (p50.001). Intraoperatively, the lacrimal sac was observed to become very small and its walls were thin, hyperemic and fragile, firmly attaching to the NDS by fibrous bands in all eyes. Upon final review, success rate of TDR was 83.8% (98/117) in the EE-DCR group, while 58.3% (21/36) in the E-DCR group (p50.01). Failure of TDR due to ostial closure by excessive fibrosis occurred in 14 out of 19 patients in the EE-DCR group, significantly less than the 11 out of 15 patients with failed TDR in the E-DCR group (2 = 6.959, p50.01). No significant difference existed in failures due to granuloma occluding the ostium or common canaliculus obstruction. Conclusion: EE-DCR with LOS intubation may be an effective procedure to manage the special subgroup of patients with chronic dacryocystitis with incarcerations of a previously implanted NDS. Keywords: Chronic dacryocystitis, dacryocystorhinostomy, endoscopic endonasal, external dacryocystorhinostomy, intubation, nasolacrimal duct stent incarceration, ostial stent

INTRODUCTION

commonly used for nasolacrimal duct obstruction (NDO) due to its simplicity and minimal invasiveness.2–15 Although various improvements have been made to its design, material and surgical techniques,

Since the Song stent was first designed and reported,1 nasolacrimal duct stent (NDS) intubation has been

Received 22 April 2014; revised 2 November 2014; accepted 9 November 2014; published online 9 December 2014 Correspondence: Professor Wencan Wu, MD, PhD, Department of Orbital & Oculoplastic Surgery, Eye Hospital of Wenzhou Medical University, No. 270 Xueyuan Xi Road, Wenzhou, Zhejiang 325027, People’s Republic of China. Tel: +86 577 88068958. E-mail: [email protected]

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the efficacy is not encouraging, especially when the implant is left in the lacrimal passage for more than 6 months.9,10,12–17 Aside from failure or recurrence, incarceration of the NDS, which cannot be removed from the nose under endoscopy, is not rare and reports of its occurrence range from 5% to 33.3% in the literature.7,8,10,13 Such patients may suffer from persistent epiphora, purulent blood secretions, canthus pain, smelly nose and/or other discomforts. For patients with failed NDS intubation or with recurrences of NDO after NDS removal, dacryocystorhinostomy (DCR) has been generally used and accepted. And, while adverse effects of the chronic inflammation resulting from the failed NDS on subsequent treatments have been documented in the literature,6,8–10,12,13–16 patients with incarcerated NDS present with much more serious chronic inflammation infiltration between the lacrimal passage and the NDS. This potentially results in worse alterations of the lacrimal passage,8–13,16,17 making it harder to prevent injury to the lacrimal sac and more challenging to correctly prepare the lacrimal sac flap when external dacryocystorhinostomy (E-DCR) is performed. Furthermore, it may be more difficult to complete the procedure of anastomosis between a smaller and more fragile lacrimal sac flap and the nasal mucosa flap in these patients.8–10 Endonasal endoscopic dacryocystorhinostomy (EE-DCR) has become increasingly popular due to its advantages over E-DCR.18–23 To the best of our knowledge, there are no specific reports on EE-DCR effectiveness on patients with chronic dacryocystitis secondary to NDS incarceration. In addition, besides the above-mentioned difficulties associated with E-DCR, both the pathological lacrimal flap and excessive fibrous and granuloma tissues around the ostium in patients with such serious chronic inflammation can increase the risk of closure of the small ostium due to subsequent contraction and remodeling following surgery.19,21,24,25 Therefore, in this study, we explored the use of EE-DCR procedure to meticulously deal with the chronic inflammation tissues infiltrated in the lacrimal passage, to remove the incarcerated NDS and to precisely and correctly complete the lacrimal sac flap procedure. Finally, we hypothesized that implantation of a lacrimal ostial stent (LOS) would be helpful to expand and support the small lacrimal flap, while preventing an unwanted ostial closure. From October 2006 to December 2013, 126 patients (127 eyes) were treated with the procedure of EE-DCR combined with intubation with a novel LOS developed by our group. By means of retrospective analysis and comparison to patient outcomes following the procedure of E-DCR combined with a silicone tube intubation, we found that its outcomes were satisfactory and present them in this study.

CLINICAL DATA AND METHODS This study was performed at the Eye Hospital of Wenzhou Medical University, Jinhua Central Hospital, Lishui Central Hospital, Quzhou people’s Hospital and Li Huili Hospital, the Second People’s Hospital of Zhengzhou, Purui Eye Hospital of Wulumuqi, Xingtai Eye Hospital from October 2006 to May 2013, in compliance with the guidelines of the Declaration of Helsinki. All 126 patients (127 eyes) were diagnosed with chronic dacryocystitis secondary to incarceration of a previously implanted NDS, as evidenced by persistent epiphora and purulent secretions, a previous history of NDS intubation and inability to withdraw the NDS under nasal endoscopy, and where the stent was located in the lacrimal sac or nasolacrimal duct shown by lipiodol dacryocystography (Figure 1).3,8,10–15,26 Patients with concomitant canaliculus (common canaliculus) stenosis or obstructions, or with significant nasal disorders, were excluded from the study. According to the surgical procedures chosen by the patients, the patients were divided into two groups: the EE-DCR group, who underwent EE-DCR combined with intubation with the novel LOS developed by our team (Figure 2); or the E-DCR group, who underwent E-DCR combined with a silicone tube intubation. The study was approved by the hospitals’ ethics committees. Written consent was obtained from all patients before surgery.

Procedure of EE-DCR with LOS Intubation The EE-DCR procedure was performed as we previously described20,21 under a 45 4.0-cm endonasal endoscope (Karl Storz, Tuttlingen, Germany). Using an angled (15 ) coarse diamond burr attached to a microdebrider (XPS3000; Medtronic Xomed, Minneapolis, MN), a bony hole of approximately 12  16 mm was created to adequately expose the

FIGURE 1 Preoperative lipiodol dacryocystography. The lipiodol dacryocystography showed a nasolacrimal duct stent (NDS) in the left lacrimal passage, and the left lacrimal sac (arrow) was much smaller than the right side. Current Eye Research

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lacrimal sac, including parts of the nasolacrimal duct. The NDS was observed to be surrounded by the mucosa of the lacrimal passage (Figure 3A). A probe was inserted into the superior lacrimal canaliculus to locate the lacrimal sac and the superior part of the NDS; meanwhile, the volume of the lacrimal sac was evaluated subjectively. The lacrimal sac wall was meticulously incised along the anterior border of the bone hole from the superior tip of the NDS to the nasolacrimal duct to expose the mushroom head and

FIGURE 2 Computer aided diagram (CAD) of the novel lacrimal ostial stent (LOS). 1 – The central hollow pipe with 6–8 mm outer diameter and 1–2 mm inner diameter (arrow) for tear drainage. 2 – Ellipse positioning plate with 18–20 mm diameter; 3 – buckles 1–2 mm in length for fixation.

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parts of the NDS (Figure 3B). Significant granuloma and fibrous tissues were inspected, detached and removed carefully; Scars adhering to the lacrimal walls around the stent were cut (Figure 3C); and then the NDS was removed (Figure 3D). In general, significant bleeding was unavoidable due to the serious chronic inflammation and infiltration in these patients. Once bleeding occurred, it was stopped carefully; great attention was paid to prevent any injury to the lacrimal sac. After removing the incarcerated NDS, the medial wall of the inferior part of the lacrimal sac was carefully and slightly lifted using the inserted lacrimal probe (Figure 4A) and then was meticulously incised with an ultrasharp 9# MVR knife (EdgePlus Trocar Blade, Alcon, Fort Worth, TX) along the anterior border of the bone hole from the inferior part of the lacrimal sac conversely to the superior part of the lacrimal sac to prepare a posterior lacrimal sac flap as large as possible and then flattened it medially and posteriorly (Figure 4B). The nasal mucosal flap was sheared in a ‘‘V’’ shape, of which the anterior section covered the naked bone anteriorly and dorsally to the bony hole and the posterior section was attached to the posterior lacrimal sac flap as we described previously27. Following this pattern, the lacrimal probe was slightly lifted medially and/or posteriorly to expand the small ostium by a surgical assistant for LOS intubation (Figure 4B). The LOS we developed consists of three parts: the central hollow pipe with 6– 8 mm in outer diameter and 1–2 mm inner diameter

FIGURE 3 Procedure of removing the incarcerated NDS by EE-DCR. (A) A 12  16 mm bony hole being created to adequately expose the lacrimal sac, the NDS (arrow) can be observed under the mucosa of the lacrimal passage. (B) The incarcerated NDS was exposed after incising the lacrimal sac. (C) The scars (arrow) and granulation tissue were carefully identified, isolated and removed. (D) The incarcerated NDS was removed after shearing the associated scar and granulation tissue. !

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FIGURE 4 Procedure of the LOS implantation. (A) The residual small lacrimal sac was identified by inserting a lacrimal probe (arrow) from the superior lacrimal canaliculus. (B) A posterior lacrimal sac flap (arrow) was prepared carefully and flattened posteriorly and medially. (C) The four silicone buckles of the LOS were placed into the lacrimal sac to expand the ostium. (D) The lacrimal fluid flowed out from the central pipe of the LOS (arrow) during the lacrimal duct rinsing, indicating the proper position of the LOS in the lacrimal sac.

for tear drainage, and ellipse positioning plate with 18–20 mm in diameter, and four buckles 1–2 mm in length for fixation (Figure 2). According to the size of the ostium, a suitable LOS was selected and the four silicone buckles were carefully cut as deemed appropriate by the surgeon, and then precisely trimmed and placed into the ostium under direct observation of the endoscope (Figure 4C). Proper placement of the LOS was determined when the irrigation fluid was observed flowing out from the central lumen of the LOS (Figure 4D). Otherwise, the LOS was adjusted and/or placed again. Finally, the positioning plate was placed between the exterior wall of the nasal cavity and the middle turbinate for fixation (Figure 4D). MeroGel (Medtronic Xomed, Minneapolis, MN) was used to seal the space between the ostial wound and LOS intubation as we described previously.21

E-DCR Combined with a Silicone Tube Intubation The procedure of E-DCR with silicone tube intubation was the same as we described previously.20 Of note, a large osteotomy (usually 16  14 mm) was created, and the lacrimal sac was adequately exposed and incised meticulously to prepare a posterior lacrimal sac flap as large as possible. The position of the NDS and its surrounding inflamed tissues were inspected,

detached and removed carefully. Much attention was paid to minimize injury to the lacrimal sac. Then, the nasal mucosa was incised to form an anterior flap and a large posterior flap. Both posterior flaps were sutured together, and a silicone tube was introduced into the lacrimal passage, guided by a soft probe as we previously described.20 The anterior nasal mucosal flap was sutured together with the periosteum. After surgery, combination antibiotic-corticosteroid eye drops were administered for 5–7 days and systemic antibiotics were administered orally for 3 days. Intranasal Rhinocort Aqua Nasal Spray (Astra Zeneca, Wilmington, DE) was used three times daily for 1 month in all subjects. The LOS or silicone tube was left in the ostium for 3–6 months and then removed. All patients were followed up at 2 weeks, 1 month, 3 months, 6 months, 12 months and then every 3–6 months, as required. At each follow-up, the patients’ epiphora and purulent secretions were recorded; lacrimal irrigation and endonasal endoscopic examinations (to evaluate intranasal ostium patency and fibriotic tissue proliferation such as scars and granulations21,28–31), and dyeing test with fluorescein application in the conjunctival fornix (functional endoscopic dye test)32 were performed and recorded. Patients with significant granuloma at the osteotomy site underwent surgical removal and the wound was covered by small amounts of MeroGel under endonasal endoscopy in the outpatient endoscopy examination theater as necessary. Failure of tear Current Eye Research

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EE-DCR for nasolacrimal duct stent incarcerated drainage reconstruction (TDR) was defined as any of the following: (1) no improvement in epiphora or any episode of postoperative dacryocystitis, (2) inability to irrigate the lacrimal system and/or (3) endonasal endoscopy verified scarring and/or granuloma occluding the lacriaml sac ostium or no dye with abnormal functional endoscopic dye test. Success of TDR was defined as the absence of epiphora and purulence postoperatively, a normal functional endoscopic dye test, free-flowing irrigation through the lacrimal system, and the presence of ostial patency with normal-appearing epithelized mucosa under endonasal endoscopy.20,21 Surgical time, success rate of TDR at the final review and complications were recorded and compared between the two interventional groups.

Statistical Analyses Statistical analyses were performed using SPSS software version 17.0 (SPSS, Inc., Chicago, IL). Group means were compared using an independent t-test. Success rates, failure causes and complications were compared with the Pearson Chi-Square test or Fisher’s exact test. Statistical significance was set at p50.05 for all tests.

RESULTS Primarily, EE-DCR procedures were completed in 126 patients (127 eyes) in the EE-DCR group and E-DCR technique completed in 40 patients (40 eyes) in the EDCR group. In the EE-DCR group, 3 patients (3 eyes) presenting early detachment of the LOS (no more than 3 months) and 6 patients (7 eyes) with an incomplete follow-up period were excluded; whereas in the E-DCR group, 2 patients with an early removal of the silicone tube (3 weeks after surgery) due to intolerance of the tube and 2 patients with an incomplete follow-up period were excluded. Therefore, a total of 117 patients (117 eyes) in the

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EE-DCR group and 36 patients (36 eyes) in the E-DCR group were recruited in this study. Between the two groups, there were no significant differences in patient age, sex, laterality of the eye, length of time the NDS remained in the lacrimal passage, postoperative follow-up period and time for LOS or silicone tube retention in the ostium (Table 1). All surgeries were completed uneventfully. Except for four patients concurrently undergoing removal of the uncinate process in the EE-DCR group during surgery, no other surgeries of nasal diseases were performed in either of the groups. The resulting mean surgical time was 45.8 ± 11.5 min (range 28–95 min) in the EE-DCR group and 68.1 ± 23.8 min (range 38–120 min) in the E-DCR group (p50.01). A total of six types of NDS with different head shapes, including diamond (65 cases), barb (29 cases), inverted umbrella (11 cases), ball (7 cases), shuttle (3 cases) and bell (2 cases), were removed in the EE-DCR group (Figure 5), and five types of NDS, including diamond (20 cases), barb (9 cases), inverted umbrella (3 cases), shuttle (3 cases) and ball (1 cases), were removed in the E-DCR group. The lacrimal sac was found to be shrunk, and its volume diminished, as confirmed by pathological examination, lipodol dacryocystography (Figure 1) and endoscopic observation (Figure 4A and B). The lacrimal sac walls became thin, hyperemic and fragile, and they were firmly attached to the stent by tough fibrous bands. Significant granuloma and fibrotic tissues were seen to be covering and intruding into the mushroom heads of the stents in all the eyes (Figure 3C). Before the LOS was removed, in the EE-DCR group none of the patients presented epiphora or lacrimal secretions, and all showed free-flowing lacrimal irrigation from the central hollow pipe of the LOS into the nose (Figure 6A). Conversely, in the E-DCR group, some patients complained of some epiphora and ocular irritation. When the LOS was removed, the ostium remained patent in all patients in the EE-DCR group (Figure 6B); whereas the ostium remained patent in 32 of 36 patients (88.9%), with the remaining four patients presenting ostial closure following

TABLE 1 Patient Characteristics in the EE-DCR group and E-DCR group. Characteristics Number (n) Mean age ± SD (years) Gender (male/female) Laterality of surgery (right/left) Mean disease course of stent implanted ± SD (months) Mean time of tube implantation ± SD (months) Mean postoperative follow-up ± SD (months) Time for surgery ± SD (min)

Total

EE-DCR

E-DCR

p Value

153 37.3 ± 10.2 43/110 68/85 14.5 ± 7.3 3.8 ± 1.2 17.1 ± 4.7

117 37.4 ± 9.5 35/82 53/64 14.2 ± 7.0 3.7 ± 1.2 16.9 ± 4.6 45.8 ± 11.5

36 37.0 ± 12.5 8/28 15/21 15.6 ± 8.0 4.0 ± 1.4 17.6 ± 5.0 68.1 ± 23.8

0.835a 0.369b 0.701b 0.316a 0.232a 0.441a 0.000a

EE-DCR: endoscopic endonasal dacryocystorhionstomy; E-DCR: external dacryocystorhinostomy; SD: standard deviation. a p analyzed by the unpaired independent samples t-test. b p analyzed by Pearson chi-square test. !

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FIGURE 5 Six different types of NDS that were removed. (A) Barb, (B) inverted triangle, (C) diamond, (D) shuttle, (E) bell and (F) balloon.

FIGURE 6 Endoscopic observations of the lacrimal sac ostia. (A) The LOS in the ostium for 1-month post-operatively, with tear flowing out from its central hollow pipe. (B) The lacrimal sac ostium remained open following LOS removal at the 6 months’ review, with a few scars (black arrow) and granulation tissue (white arrow) formation in the surrounding tissue. (C) The ostium remained open 9 months after the LOS removal. (D) The ostium remained open 12 months after removal of the LOS.

removal of the silicone tube in the E-DCR group. At the final review, 100 patients in the EE-DCR group and 23 patients in the E-DCR group retained a stillpatent ostium without obvious epithelial edema and/ or granuloma visible under the endoscope (Figure 6C and D). The success rate of TDR was 83.8% (98/117) in the EE-DCR group, significantly higher than the 58.3% (21/36) in the E-DCR group (p50.001; Table 2).

The failure of TDR due to ostial closure by excessive fibrosis occurred in 14 patients in the EEDCR group and 11 patients in the E-DCR group (2 = 6.959, p50.01; Table 2). TDR failure due to refractory granuloma occluding the ostium was seen in three patients in the EE-DCR group and two patients in the E-DCR group (p40.05). Although the ostium appeared to be open under the endoscope, Current Eye Research

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EE-DCR for nasolacrimal duct stent incarcerated failure caused by common canaliculus obstruction occurred in two patients in both groups, respectively (p40.05; Table 2). When the LOS or the silicone tube remained, seven patients (5.98%) in the EE-DCR group and three patients (8.33%) in the E-DCR group underwent isolated removal of significant granuloma causing occlusion of the ostium. When the LOS or the silicone tube was removed, 73 of 117 patients (62.4%) in the EE-DCR group exhibited scarring and/or granulation tissues 1–3 mm around the ostium (Figure 6A and B), which was significantly less than the 86.1% of patients (31/36) in the E-DCR group with the same outcome (2 = 7.114, p = 0.008; Table 3). Of these patients with scars and/or granulation tissues, 57 patients (48.7%) presented with scars alone in the EE-DCR group, which was higher than the 10 patients (27.8%) in the E-DCR group (2 = 4.904, p = 0.027); Grauloma alone, and scars with granuloma were observed in nine patients (7.7%) and seven patients (4.1%), in the EE-DCR group and E-DCR group, respectively, resulting in a statistical significant difference for this outcome among the groups (p50.05). At the final review, 64 patients in the EE-DCR group and 19 patients in the E-DCR group had scars and/or granuloma 1–3 mm around the ostia (p40.05; Figure 6C and D; Table 3); No significant statistical difference existed in the rate of scars, granuloma, and scars with granuloma between the groups (p40.05) at TABLE 2 Comparison of success rate and failures of tear drainage reconstruction in both groups. EE-DCR E-DCR Total number Success of TDR Failure due to ostial closure Failure due to granuloma obstruction of the ostium Failure due to CCO

2

p

117 98 14 3

36 21 11 2

10.298 0.001a 0.959 0.008a 0.336b

2

2

0.236b

EE-DCR: endoscopic endonasal dacryocystorhinostomy; E-DCR: external dacryocystorhinostomy; TDR: tear drainage reconstruction; CCO: common canaliculus obstruction. a p analyzed by Pearson chi-square test. b p analyzed by Fisher’s exact test.

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this time point (Table 3). Apart from lacerations of the inferior lacrimal puncta, which were seen in nine patients in the E-DCR group, and partial adhesions between the lateral wall of the nasal cavity and the turbinate in six patients in the EE-DCR and in five patients in the E-DCR groups (p40.05), no other complications were observed in either of the groups.

DISCUSSION In the case series presented here, the success rate of TDR was 58.3% (21/36) in the E-DCR group and 83.8% (98/117) in the EE-DCR group, which is not as high as some of the values reported in the literature. After treating 11 patients with failed stents by Ex-DCR with silicone intubation, Yazici et al.10 reported that only one patient failed in the TDR due to anastomotic obstruction. Lee et al.16 reported that 13 of 15 eyes, which failed in previous NDS treatment, acquired favorable outcomes after being treated by EE-DCR with silicone intubation. These studies demonstrate that patients with failed NDO after the NDS removal can be treated by Ex-DCR or EE-DCR with good outcomes. However, different from the patients in the cited studies, here we focused on a subgroup of patients who presented with difficult-to-resect incarceration of a previously implanted NDS, which makes attaining such favorable outcomes much more challenging. Consistent with our study, Pinilla et al.8 reported that 2 out of 4 patients (50%) with NDS incarcerations failed in TDR after being treated by EEDCR, compared to 1 of 2 patients 9 months after E-DCR. We believe that the difference might be due to the degree of chronic inflammation and subsequent alterations of the lacrimal passage. The pathological alterations would be expected to be more prominent in our case series than in previous similar studies. In this study, we removed a total of six different types of NDS. In each eye, the lacrimal sac shrank, and the lacrimal sac walls became very thin, hyperemic and fragile, and were firmly attached to the NDS by strong fibrous bands, accompanied by significant inflammation and granuloma tissues. The lacrimal sac became

TABLE 3 Comparison of fibrotic proliferation at different follow-up points in the EE-DCR group (117 eyes) and in the E-DCR group (36 eyes). When the LOS or silicone tube removed Group EE-DCR E-DCR 2 p

At the final review

Total

Scars

Granuloma

SG

Total

Scars

73 31 7.114 0.008a

57 10 4.904 0.027a

9 8 5.885 0.015a

7 13 21.991 0.000a

64 19 0.041 0.839a

53 11 2.459 0.117a

Granuloma

SG

4 3

7 5

0.356b

0.155b

Scars and granulation formation was examined and evaluated 1–3 mm around the intranasal ostium. EE-DCR: endoscopic endonasal dacryocystorhinostomy; E-DCR: external dacryocystorhinostomy; SG: scars and granuloma. ap analyzed by Pearson chi-square test. b p analyzed by Fisher’s exact test. !

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so small that it was very difficult to correctly prepare the lacrimal sac flap for anastomosis of the lacrimal sac flap and the nasal mucosa flap. In the case series reported by Yazici et al.10 and Lee et al.,16 they described some similar alterations of the lacrimal passage in a few case, although they did not describe the severity of the pathological alterations and did not clarify whether all the patients had NDS incarceration as in our case series. In addition, the difference in outcomes may also be associated with different standards for success rates. In the reports of Yazici et al.10 and Lee et al.,16 no detailed standard TDR success criterion was defined. Although E-DCR with silicone tube intubation might be effective for the management of patients with incarcerations of NDS,10,16 we believe that EEDCR with the novel LOS intubation might be a better choice. In this study, the success rate achieved in the EE-DCR group was of 83.8% (98/117), and significantly higher than the 58.3% (21/36) in the E-DCR group. This difference may ascribe to the procedure of EE-DCR. When E-DCR was performed, we found that it was very difficult to precisely deal with the excessive fibrotic tissues with serious chronic inflammation infiltration, and moreover, it was almost impossible to correctly prepare the lacrimal sac flap as the lacrimal sac became so small and its walls were so thin, hyperemic and fragile. Direct illumination of the endoscope with 4- to 6-fold magnification is relatively convenient and helpful to recognize and meticulously remove fibrotic tissues with minimal damage to the lacrimal sac mucosal lining, and especially convenient to meticulously prepare the lacrimal sac flaps, allowing for a precise anastomosis of the lacrimal sac and nasal mucosal flaps.16 For cases such as the ones presented in this study, fibril tissue proliferation is almost unavoidable due to the serious chronic inflammation and surgical lacerations.10,12,13,16 The excessive proliferation and subsequent contraction of the fibril tissues around the small ostium may, to a large degree, lead to ostial closure or occlusion.19,21–25 Therefore, implanting a silicone tube or a sleeve-like tear duct has been considered necessary to prevent ostial closure due to scar contraction.10,16,18–20,22,23,33–35 However, aside from side effects such as epiphora, laceration of the lacrimal punctum as occurred in our study, and ocular surface irritation, silicone tube intubation has little effect on ostial patency because it cannot expand and support the ostium.22,23,33 Similarly, the sleeve-like tear ducts cannot be inserted into the small lacriaml sac ostium. On the other hand, the LOS we developed is a smooth hollow cylinder pipe with a 6–8 mm outer diameter. The LOS can be easily inserted into the small lacrimal sac as described above under direct visualization of the endoscope. This LOS can expand and support the lacrimal flap enough to prevent it from closing. In this study, before the silicone tube was removed in the

E-DCR group, four patients already presented ostial closure. Conversely, in the EE-DCR group, the ostia remained patent in all eyes when the LOS was removed even though 73 patients had fibrous tissues proliferation 1–3 mm around the small ostium. Meanwhile, at the final review we found that the failure of TDR due to ostial closure by excessive fibrosis occurred in 11.97% (14/117) patients in the EE-DCR group; significantly less than the 30.6% (11/36) patients in the E-DCR group (2 = 6.959, p50.01). Therefore, we deem that by means of expansion and mechanical support, the intubated LOS also contributes to the higher success rate of ostial patency in the EE-DCR group than that in the E-DCR group. In addition, our LOS appears to help maintain the ostium patent by facilitating wound healing and epithelizaiton of the ositum. Originally, we believed it might promote fibrotic proliferation in the lacrimal sac ostium due to a foreign body reaction. However, to our surprise, at the point when the LOS or the silicone tube was removed, 73 of 117 patients (62.4%) exhibited some scarring and/or granuloma 1–3 mm around the ostium in the EE-DCR group, which was significantly lower than the 31 of 36 patients (86.1%) in the E-DCR group (p50.01). Seemingly, scarring alone presented in 57 patients (48.7%) in the EE-DCR group, more than the 10 patients (27.8%) in the E-DCR group. However, if scarring with granuloma is also included, no significant statistical difference exists in the scar formation around the ostium between the groups (p40.05). Though there is deficiency of comparison, the LOS intubation seemed not to induce fibril proliferation, or even prevent its formation to some degree. The wall of the central pipe of the LOS is cylindrical and smooth with 6–8 mm outer diameter. It can be well attached to the internal wall of lacrimal sac and the nasal epithelial flap, which enables the anastomosis and adhesion between both mucosal flaps. This may also work in favor of wound healing and epithelization, rather than fibril proliferation around the ostium. Meanwhile, this capability might prevent the surrounding granuloma from intruding into the ostium, as verified by endoscopic observation in our case series. When the LOS was removed, granuloma alone around the ostium was observed in nine patients (7.7%) in the EE-DCR group, much less than the eight patients (22.2%) in the E-DCR group. If scars with granuloma are also included, no significant statistical difference exists in the granuloma formation around the ostium between the groups (p40.05). Of course, we cannot exclude the potential effects of the surgical procedure itself on the wound healing and fibrotic proliferation processes described above. In addition, when compared with silicone intubation, LOS intubation has many other advantages including not hampering tear drainage through its central hollow pipe, no ocular surface irritation and no lacrimal Current Eye Research

EE-DCR for nasolacrimal duct stent incarcerated

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punctum laceration, which were observed in the E-DCR group. We acknowledge that the retrospective nature and non-randomized comparison of this study limits our findings. We also recognize that the failure to use more accurate objective criteria to evaluate the graded scarring tissues, granuloma and degree of edema weakens the results of this study. In summary, our study indicates that the procedure of EE-DCR with LOS intubation may be more effective for the treatment of a special subgroup of patients with NDS incarcerations over that of E-DCR procedure with silicone tube intubation.

ACKNOWLEDGEMENTS The authors wish to thank Dr Songping Yu (Lishui Center Hospital, Zhejiang, PR China), Fangzheng Jiang (Quzhou Peoples’ Hospital, Zhejiang, PR China), Qiao Kong (Lihuili Hospital, Ningbo, PR China), Wentao Jing (the Second People’s Hospital of Zhengzhou, Henan, PR China), Qunying Wu (Xingtai Eye Hospital, Hebei, PR China), Jiangang Dong (Purui Eye Hospital of Wulumuqi, Xinjiang, PR China) for providing and care for the study patients and collecting the clinic data.

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

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