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ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 3  |  Page : 105-109

Surgical results of transcaruncular dacryocystorhinostomy


1 Center for Sight, Delhi, India
2 Department of Ophthalmology, Punjab Institute of Medical Sciences, Jalandhar, Punjab, India

Date of Submission14-Jul-2018
Date of Acceptance16-Mar-2019
Date of Web Publication11-Dec-2019

Correspondence Address:
Yashi Bansal
87, SAS Nagar Extension, Wadala Road, Jalandhar - 144 003, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_61_18

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  Abstract 


Purpose: The objective of the study is to evaluate the effectiveness of the transcaruncular approach of dacryocystorhinostomy (DCR) in the management of the cases of chronic dacryocystitis. Materials and Methods: A prospective study was conducted on 30 patients presenting in the outpatient department with chronic dacryocystitis at a tertiary eye care center. Intraoperative parameters were observed and noted at the time of surgery. Patients were followed up for a minimum period of 6 weeks and interviewed for subjective improvement of symptoms. Outcome measures were anatomical patency, epiphora, esthetic outcome, and presence of any complications. Results: Thirty patients of chronic dacryocystitis with nasolacrimal duct obstruction comprising 22 females and 8 males with a mean age of 43.8 years were operated by transcaruncular modification of external DCR. The surgical success rate of 90% was achieved after a follow-up period of 6 weeks. Postoperative complications included periorbital edema, mild nasal bleeding, and section leak which resolved by day 7 postoperatively. The procedure was associated with minimal intraoperative complications. One patient (3%) had significant intraoperative bleeding, and two patients (7%) had canalicular injury and both the patients were managed with canalicular intubation. Conclusions: Transcaruncular DCR is a cost-effective and esthetic approach not requiring the use of any endoscope or lasers and provides the benefits of external approach without a skin incision. It is associated with minimal intraoperative and postoperative complications. The surgical success rate of the procedure is comparable to the other conventional methods of DCR.

Keywords: Dacryocystitis, dacryocystorhinostomy, nasolacrimal, syringing, transcaruncular


How to cite this article:
Garg M, Bansal Y, Singh G. Surgical results of transcaruncular dacryocystorhinostomy. J Clin Ophthalmol Res 2019;7:105-9

How to cite this URL:
Garg M, Bansal Y, Singh G. Surgical results of transcaruncular dacryocystorhinostomy. J Clin Ophthalmol Res [serial online] 2019 [cited 2020 May 31];7:105-9. Available from: http://www.jcor.in/text.asp?2019/7/3/105/272710



In patients with acquired nasolacrimal duct obstruction (NLDO), dacryocystorhinostomy (DCR) is the treatment of choice.[1] DCR has traditionally been performed for nasolacrimal duct obstruction through an external approach.[2] It aims to create a surgical fistula in order to allow passage of tears from lacrimal sac into the nasal cavity. The lacrimal sac is exposed by applying a skin incision, and osteotomy is done using a bone drill or burr. The success rate of external DCR is high. The complications of external DCR include an external scar, danger of injury to the medial canthal structures, incidence of cerebrospinal fluid leak, and failure of the ostium. Various modifications of the procedures have come up including suturing the edges of nasal mucosa to lacrimal sac mucosal flaps, adjunctive use of wound healing inhibitor like mitomycin-C,[3],[4],[5] or placements of lacrimal stents. Other latest modality of treatment includes endoscopy with or without lasers. The main advantages of endoscopic DCR are that it provides better esthetic results with no external scar, allows a one-stage procedure to correct associated nasal pathology that may be the cause, avoids injury to medialcanthus, preserves the pumping action mechanism of orbicularis oculi muscle and can be done even during acute infection of lacrimal system. It is especially superior to external approach in revision surgery. It is much less bloody and messy than the external approach.

Various esthetic surgical techniques to avoid externally visible scar at the medial canthal area have been reported. In 2003, Adenis and Robert published a series of 11 patients where they described a retrocaruncular approach and achieved successful outcome in 82% (9/11) with no residual facial scar.[6] A subciliary approach to external DCR was described by Dave et al. in 16 patients with 88% of patients grading the surgical scar to be invisible or faintly visible.[7] In 2011, Kaynak-Hekimhan and Yilmaz described external transconjunctival DCR with no visible facial scar.[8] A more recently published larger series by the same group showed a 92.6% (25/27) success.[9] Kaynak-Hekimhan and Yilmaz had to convert in 18.2% (6/33) of patients to external transcutaneous DCR.

The aim of all the modifications in DCR has been to achieve long-time results comparable to or better than external approach with better cosmetic results by avoiding any skin incision that leads to scar formation. The surgical approach should have minimal complication rate, and it should be simple so it can be done at normal health-care conditions.

Transcaruncular modification in external DCR is aimed at providing the benefits of external approach without a skin incision and hence avoiding any disfiguring scar formation. It approaches the lacrimal apparatus from the posterior lacrimal crest and avoids damage to anterior structures such as the canaliculus providing a rapid access to the surgical site through an avascular plane. In addition, it creates gravity-aided drainage of tears through the surgical fistula in the postoperative period.

This approach has been described previously for orbital decompression in the treatment of Graves' ophthalmopathy,[10] for surgical decompression of frontoethmoidal mucoceles.[11] The goal of our study was to establish the surgical success rate of this method and to find special complications of the procedure if any.


  Materials and Methods Top


A prospective study was conducted at a tertiary eye care center. A total of 30 patients diagnosed with chronic dacryocystitis with nasolacrimal duct obstruction were enrolled during the study.

All the patients were examined by an ophthalmologist at presentation. The diagnosis of blocked nasolacrimal dust was established by preoperative lacrimal sac syringing. Nasal examination was done to rule out any nasal pathology leading to NLDO. Patients having bleeding disorders or severe systemic illness, patients with other pathologies such as tuberculosis causing chronic dacryocystitis, and pediatric patients were excluded from the study. Informed written consent was obtained from all the patients, and clearance was obtained from the ethics committee of the institution. Patients not willing to be the part of the study were excluded. Patients' preoperative data were collected as per the master table.

The patients underwent the procedure transcaruncular DCR in the Department of Ophthalmology. All the surgeries were performed by the same surgeon. Patients were followed up for the minimum period of 6 weeks, and the data were collected.

The procedure was done under local anesthesia (infratrochlear block). The nasal cavity was prepared by lignocaine nasal spray 10 min before surgery. With a needle radiofrequency cautery, a 12-mm vertical incision was created through the lateral one-third of the caruncle [Figure 1]. The condensed fibrous layer just deep to the caruncle was incised in the direction of the posterior lacrimal crest. A narrow malleable retractor was used to palpate the posterior lacrimal crest. The posterior lacrimal crest was identified, and the lacrimal fascia with lacrimal sac was separated from lacrimal fossa by blunt dissection. The sac was retracted using the retractor [Figure 2]. Osteotomy was done in the most inferior part of the fossa with bone punch. Surgical site bleeding was controlled by direct pressure with adrenaline-soaked gauge with continuous aspiration or by application of bone wax. The adequate amount of nasal mucosa was removed to avoid granulation tissue formation postoperatively. No mucosal flaps were created. Posterior wall of lacrimal sac was tented with the help of lacrimal probe passed through lower canaliculus. Incision was applied on the posterior wall of the sac and the contents of the sac drained. The posterior wall of the sac was excised. The residual sac was positioned back. Patency of stoma was checked by sac syringing and confirming the free flow of fluid into the nasopharynx. The caruncular incision was closed with the help of fibrin glue. Intraoperative parameters recorded were total time taken for surgery, any difficulty in exposure of the lacrimal sac and fossa, bleeding from operative site or injury to the lids or canaliculi.
Figure 1: Site of incision

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Figure 2: Transcaruncular approach

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The patient's eye was not patched to allow a frequent check of vision for vision-threatening orbital hemorrhage. All patients were prescribed systemic antibiotics, analgesics, and serratiopeptidase preparation in the postoperative period. All patients were instructed to take antibiotic eye drops and nasal decongestants. The patients were discharged on the 1st postoperative day after examination and lacrimal syringing. Periorbital edema, nasal bleed, and any signs of injury to the lid or adnexa, especially the canalicular region, were noted.

Patients were followed at day 4, day 7, 2 weeks, 4 weeks, and then at 6 weeks postoperatively in the outpatient department. Parameters studied postoperatively were subjective improvement of the patient, condition of the lid and adnexa, and periorbital edema. At each visit, syringing was done to confirm the patency of surgical fistula. Nasal examination was done and any crusts if present were removed. All the data were recorded as per the pro forma.

The surgery was classified as successful if the patient was free of subjective symptoms and was found to be patent on lacrimal syringing at the end of 6-week follow-up. The patients who were not found to be patent on syringing on any of the follow-up visits or if there was no improvement of epiphora after 4 weeks the surgery were reoperated. Endoscopic nasal examination was done peroperatively to determine the cause of failure. At the end of the study, the data were statistically analyzed for calculating the success rate of the surgical procedure.

The youngest patient was 19 years old and the oldest 67 years old, with a maximum number of patients (10) in the age group of 31–40 years. Mean age at presentation was 43.8 years. The study consisted of 30 patients, 8 males (26.67%) and 22 females (73.33%). Females outnumbered males in ratio of 2.25:1. All the patients in the study had unilateral complaints. While 16 patients (53%) had right-sided involvement, 14 patients (47%) had left-sided involvement. All the patients had epiphora as the presenting complaint. Twenty-seven patients had discharge from the medial canthus either spontaneous or on applying pressure over the lacrimal sac area. Nineteen patients had associated medial canthus swelling. Pain was present in only five patients, and three patients complained of redness of the eyes. During the surgery, the negligible amount of bleeding was observed in 25 patients. Four patients had a moderate amount of bleeding requiring continuous suction at the surgical site. One patient had severe bleeding requiring nasal packing additionally at the end of surgery.

Canalicular injury during retraction for exposure of the surgical site was noted in two patients. Both the patients were managed by canalicular intubation with silicone tube. The tube was left in situ for 6 weeks and was removed 6 weeks postoperatively. Both the patients had surgical success indicated by patent surgical fistula on syringing at the end of follow-up period.

In the follow-up period, mild nasal bleeding was noted in eight patients on day 1. None of these patients required intervention other than nasal decongestant drops. Twelve patients were noted to have periorbital edema on the 1st postoperative day. The edema was resolved in ten patients by the 4th postoperative day and in all patients by 1 week [Figure 3].
Figure 3: Trend of periorbital edema postoperatively

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One patient had the surgical site leakage on the 1st postoperative day. The patient was managed by repair of the incision with 6–0 vicryl suture.

Of the 30 surgeries in our study, 27 (90%) were found to be successful at the end of follow-up of 6 weeks. The criteria for success were subjective improvement in epiphora and patency on syringing.


  Discussion Top


Dacryocystitis leading to obstruction of nasolacrimal passage is a common medical problem in India. Although it is not associated with mortality in the antibiotic era, there is significant morbidity, and symptoms are often socially embarrassing to the patient.

Patients with complaints such as epiphora, purulent discharge secondary to infection, and obstruction of nasolacrimal passage presenting to the ophthalmologist were treated with external DCR. The cosmetic blemish produced by external scar has led to the preference of esthetic techniques by patients. The endonasal DCR avoids external scar and offers comparable outcome as external technique, but it could not gain much popularity among ophthalmologists due to their lack of knowledge of nasal anatomy, expensive instrumentation, and larger learning curve.[12] Transcaruncular approach is aimed at achieving all the benefits of external DCR without any disfiguring facial scar.

It was noted that of the 30 cases included, the disease was more common in females (n = 22, 73%) than in males (n = 8, 27%). Our study group had female preponderance in the ratio of 2.75:1. Most descriptions of chronic dacryocystitis state a female preponderance. The most acceptable explanation for this observation is that females have a higher nasal index (width × 100/height), and the bony lacrimal canal is narrower, which favors the development of obstruction of lacrimal passage.

This is in accordance with a study conducted by Tsai et al. on probing with the use of adjunctive mitomycin-C for nasolacrimal duct blockage in adults who found females to be predominantly affected in the ratio of 1.42:1, with a mean age of 58 years.[13] Most of the patients in our study (60%) were in their fourth and fifth decades of life, with a mean age being 43.8 years. All the patients in our study group had unilateral symptoms. The right side was involved more commonly (53%) than the left side (47%). The age and sex distribution of the patients and laterality followed general trends known to be associated with the condition, and no deviation was noted. No relation was noted between the duration of the disease and the time of presentation of the patient.

No significant perioperative complication occurred in the study. Two patients suffered injury to the lacrimal canaliculi during retraction of the sac to expose the lacrimal fossa. Both of them were managed with canalicular intubation with lacrimal tube. The lacrimal tubes were removed 6 weeks postoperatively. Significant nasal bleeding occurred in one patient only. Bleeding was controlled with nasal packing alone and did not require any additional intervention.

In our study, fibrin glue was used to seal the caruncular incision. The role of fibrin glue has been suggested in many other ophthalmic procedures such as sutureless lamellar keratoplasty,[14] pterygium excision,[15] and glaucoma filtration surgery.

Liao et al. while describing transcaruncular incision have suggested suturing of transcaruncular incision rather than to apply fibrin glue.[10] In their study, it was suggested that careful edge-to-edge closure of the incision decreases the postoperative caruncular scar tissue and formation of conjunctival granuloma. None of these complications were encountered in our study. One patient had postoperative section site leakage on syringing on day 1. The case was managed with closure of the incision with 6–0 vicryl sutures. In all the patients, the section site was healed by the third postoperative visit on day 7. No long-term complications were seen in any of the patients. Thus, the use of fibrin glue was found to be a rapid and adequate method of wound closure to seal the incision site.

Bartley highlighted the advantage of endonasal laser DCR in comparison with external DCR including limitation of tissue injury to the discrete fistula site, avoidance of skin incision, excellent hemostasis, ability to be performed as an outpatient procedure with quick rehabilitation and decreased overall health-care expense.[16] All these advantages are achieved in our procedure without the expense of laser or endoscope. No special training is required as in maneuvering of endoscopes and laser safety. Ophthalmic surgeons are better trained and comfortable with anatomy of the lacrimal area from orbital approach, so the learning curve for the procedure is small.

In postoperative period, periorbital edema was noted in 40% (n = 12) cases but resolved by the time of second follow-up visit at day 4 in most of the patients. At the most, edema was seen to last for a week (third follow-up visit) in two cases. Mild bleeding from the nasal cavity was noted in 27% of patients (n = 8). The bleeding was in the form of mild blood-stained mucosal discharge and was managed with nasal decongestant drops only, not requiring any other intervention. The bleeding was resolved in all the patients by day 4 postoperatively.

Subjective improvement in epiphora and patency on lacrimal syringing at the end of follow-up of 6 weeks was seen in cases (n = 27). The success rate using this surgery was 90%. Remaining three cases had developed recurrence of symptoms during that time frame. All three patients were reoperated, and a nasal endoscope was used to determine the cause of failure of surgery. All the cases were successful after repeat surgery.

Very few comparative studies are available for transcaruncular approach to DCR. Adenis and Robert reported a similar technique using retrocaruncular approach which is adjacent to the globe and the incision in their study healed without scarring with 82% success rate.[6] The lower success rate as compared to the present study could be due to the inclusion of patients with various etiological factors such as dry eye, orbital fracture, and sinus surgery trauma. Kaynak et al. reported a success rate of 92.5% at the 2nd year follow-up using the transconjunctival approach. The success rate was comparable with the present study.[9]


  Conclusions Top


The surgical results are comparable to the studies on different other approaches of DCR with an acceptable rate of complications.

Limitations of transcaruncular incision approach for DCR include inadequate visualization of intranasal anatomy, and intranasal causes of DCR failure cannot be concomitantly dealt as in endoscopic DCR. No comparative studies are at present available on the use of this method in different types of dacryocystitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dolman PJ. Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy. Ophthalmology 2003;110:78-84.  Back to cited text no. 1
    
2.
Patel BC. Management of acquired nasolacrimal duct obstruction: External and endonasal dacryocystorhinostomy. Is there a third way? Br J Ophthalmol 2009;93:1416-9.  Back to cited text no. 2
    
3.
Tabatabaie SZ, Heirati A, Rajabi MT, Kasaee A. Silicone intubation with intraoperative mitomycin C for nasolacrimal duct obstruction in adults: A prospective, randomized, double-masked study. Ophthalmic Plast Reconstr Surg 2007;23:455-8.  Back to cited text no. 3
    
4.
Deka A, Bhattacharjee K, Bhuyan SK, Barua CK, Bhattacharjee H, Khaund G. Effect of mitomycin C on ostium in dacryocystorhinostomy. Clin Exp Ophthalmol 2006;34:557-61.  Back to cited text no. 4
    
5.
Dolmetsch AM, Gallon MA, Holds JB. Nonlaser endoscopic endonasal dacryocystorhinostomy with adjunctive mitomycin C in children. Ophthalmic Plast Reconstr Surg 2008;24:390-3.  Back to cited text no. 5
    
6.
Adenis JP, Robert PY. Retrocaruncular approach to the medial orbit for dacryocystorhinostomy. Graefes Arch Clin Exp Ophthalmol 2003;241:725-9.  Back to cited text no. 6
    
7.
Dave TV, Javed Ali M, Sravani P, Naik MN. Subciliary incision for external dacryocystorhinostomy. Ophthalmic Plast Reconstr Surg 2012;28:341-5.  Back to cited text no. 7
    
8.
Kaynak-Hekimhan P, Yilmaz OF. Transconjunctival dacryocystorhinostomy: Scarless surgery without endoscope and laser assistance. Ophthalmic Plast Reconstr Surg 2011;27:206-10.  Back to cited text no. 8
    
9.
Kaynak P, Ozturker C, Karabulut G, Celik B, Yilmaz OF, Demirok A. Transconjunctival dacryocystorhinostomy: Long term results. Saudi J Ophthalmol 2014;28:61-5.  Back to cited text no. 9
    
10.
Liao SL, Chang TC, Lin LL. Transcaruncular orbital decompression: An alternate procedure for graves ophthalmopathy with compressive optic neuropathy. Am J Ophthalmol 2006;141:810-8.  Back to cited text no. 10
    
11.
Lai PC, Liao SL, Jou JR, Hou PK. Transcaruncular approach for the management of frontoethmoid mucoceles. Br J Ophthalmol 2003;87:699-703.  Back to cited text no. 11
    
12.
Preechawai P. Results of nonendoscopic endonasal dacryocystorhinostomy. Clin Ophthalmol 2012;6:1297-301.  Back to cited text no. 12
    
13.
Tsai CC, Kau HC, Kao SC, Hsu WM, Liu JH. Efficacy of probing the nasolacrimal duct with adjunctive mitomycin-C for epiphora in adults. Ophthalmology 2002;109:172-4.  Back to cited text no. 13
    
14.
Kaufman HE, Insler MS, Ibrahim-Elzembely HA, Kaufman SC. Human fibrin tissue adhesive for sutureless lamellar keratoplasty and scleral patch adhesion: A pilot study. Ophthalmology 2003;110:2168-72.  Back to cited text no. 14
    
15.
Karalezli A, Kucukerdonmez C, Akova YA, Altan-Yaycioglu R, Borazan M. Fibrin glue versus sutures for conjunctival autografting in pterygium surgery: A prospective comparative study. Br J Ophthalmol 2008;92:1206-10.  Back to cited text no. 15
    
16.
Bartley GB. Acquired lacrimal drainage obstruction: An etiologic classification system, case reports, and a review of the literature. Part 1. Ophthalmic Plast Reconstr Surg 1992;8:237-42.  Back to cited text no. 16
    


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