For nearly a century, the gold standard for epiphora and nasolacrimal duct obstruction has been Dacryocystorhinostomy (DCR). Although the high success rate of external DCR continues to be confirmed in the literature, there have been promising advances in other modalities of treatments for DCR namely endocanalicular surgery and endonasal DCR¹_.

Dacryocystitis results from some kind of obstruction in the nasolacrimal duct. This acquired nasolacrimal duct obstruction may be primary where cause for the inflammation is not defined, whereas secondary nasolacrimal duct obstruction is due to a known cause for the inflammation. The causes may be infectious, inflammatory, neoplastic, traumatic or mechanical². Silicone intubation has been used to improve the success rate of DCR in the recent years. It has been reported to cause cheese wiring of canaliculi and granuloma formation at the ostium². We undertook this study to find out the success rate of DCR without silicone intubation.

MATERIAL AND METHODS

This study was conducted at Mardan Medical Complex Teaching Hospital (KPK) from December 2010 to December 2011. Fifty patients (31 males 19 females) were included in the study. Patients with acute dacryocystitis lacrimal abscess and stenosed canaliculi were excluded from the study. All patients were recruited from the outpatient department of Mardan Medical Complex teaching Hospital Mardan.

All patients underwent a thorough ophthalmic examination and systemic evaluation for diabetes mellitus and hypertension. Patients having anomalies of the nasolacrimal puncti, blockage of the upper and lower canaliculi or common canaliculus, previous lacrimal surgery, post-traumatic dacryocystitis and bony deformity were excluded from the study. A written informed consent was taken from all patients undergoing the procedure. Forty seven patients were operated under local anesthesia and three patients under 15 years were operated under general anesthesia.

Standard external DCR was performed on all patients, with suturing of the anterior flaps of the lacrimal sac and nasal mucosa and trimming of the posterior flaps of the lacrimal sac. The first dressing was changed after 24 hours and irrigation of the lacrimal passage was done to ascertain the patency of the newly formed ostium and to wash out any blood clots and debris in the passage. Children below 15 years were syringed under general anesthesia on the next operation day.

Patients were then followed after 7 days, one month and 6 months. Successful outcome was defined as resolution of epiphora and discharge and patency of the passage on syringing.

RESULTS

Fifty randomly selected patients were operated for DCR during the period from December 2010 to December 2011. Thirty one (62%) were females and 19 (38%) were males. The age range was between 4 to 70 years.

Forty seven patients were operated under local anesthesia while 3 patients were operated under general anaesthesia. Follow-up period was from 6 months to one year. Per-operative complications included severe bleeding in three patients (6%), controlled with pressure packing and the procedure completed successfully.

On first post-operative day all patients (above 15 years of age) the nasolacrimal passage was washed in the ward examination room. The passage was found freely patent in all the 47 patients. In three patients (below 15 years) syringing of the nasolacrimal passage was performed under general anesthesia in the next operation day i.e. on third post-operation day. The passages were found patent in these patients as well.

Subsequently the patients were followed every month. After 6 months of follow-up 49 patients 98%) were found to have patent nasolacrimal passage. Only one patient (2%), a 19 year old male patient had a blocked nasolacrimal passage to syringing.

Table 1:

Age	Male	Female	Total
4-20 Years	5	3	8
21-40 Years	5	11	16
40-70 Years	9	17	26

DISCUSSION

Dacryocystitis is defined as inflammation of the lacrimal sac usually caused by some kind of obstruction in the nasolacrimal duct¹. The condition is commonly seen in infants and people over 40 years of age. There are two types of acquired nasolacrimal duct obstructions, primary or secondary. Primary nasolacrimal duct obstruction is caused by inflammation without any known cause whereas, the secondary acquired nasolacrimal duct obstruction is caused by a known cause of inflammation or fibrosis. These causes could be infectious, inflammatory, neoplastic, traumatic or mechanical.

Galen³ originally described the anatomy, pathology of the lacrimal drainage system and etiology of tearing. His treatment for dacryocystitis was dacryocystectomy. In 1904, Toti developed the first modern external DCR. In 1921 Dupuy Dutemps and Bourguet⁴ described the methods of forming the mucosal flaps. Since that time, silicon intubation has been the only major advance in the technique.

For nearly a century the gold standard treatment for epiphora and nasolacrimal duct obstruction has been dacryocystorhinostomy (DCR). In spite of the high success rate of external DCR, there have been advances in alternative procedures like endonasal DCR and endocanalicular surgery. External DCR has the advantages of ease of performance and lower economic impact².

The success rate of dacryocystorhinostomy (DCR) has been reported from 69% to 99%⁵. Factors influencing the outcome of the procedure include the surgical approach (endonasal DCR vs. external DCR), the presence of preoperative acute dacryocystitis or postoperative soft tissue infection, a history of trauma to the lacrimal apparatus and the use of silicone tubes⁶. Other factors attributable to DCR failure include membranous occlusion of the rhinostomy site, common canalicular obstruction and an inappropriate size or location of the bony ostium. The most common cause of primary DCR failure, according to many authors, is the soft tissue scarring at the rhinostomy site⁷.

External DCR is a technically challenging procedure. It needs considerable experience and atraumatic handling of the soft tissues, careful dissection of the lacrimal sac, proper size and location of the osteotomy for a successful outcome⁸.

We operated on 50 patients (31 females and 19 males) having chronic dacryocystitis. Patients with lacrimal abscess in the recent past, stenosed canaliculi, were excluded from the study. Chronic dacryocystitis was more common in females 31 (62%) in our study as compared to males 19 (38%). Similar female preponderance has been noted by other observers as well^1,7,8.

We followed the technique of Dutemps and Bourguet¹⁰, suturing only the anterior flaps of the lacrimal sac and the nasal mucosa. The posterior flaps were trimmed only like other surgeons^11,12. Some surgeons¹², suture the posterior flaps as well. We did not use silicone tube in any patient.

To enhance the success rate of the procedure and prevent postoperative cellulitis, we routinely use systemic antibiotics in all patients. It has been observed that there is a significant reduction in postoperative cellulitis after DCR with either intra-operative intravenous antibiotics or postoperative oral antibiotics compared with intra-operative saline wash without antibiotics^13,14,15. The cellulitis rate was approximately 1% in both antibiotic groups compared with 18 % in the non antibiotic group.

Raj Kumar Advani et al¹⁶, has reported a success rate of 95 % in their series without intubation. Gibbs¹⁷ in 1967 described a technique of inserting a silicone rubber tube when performing DCR, however, there is no significant difference between the success rates of routine external DCR irrespective of silicone intubation¹⁸.

Silicone intubation may be beneficial in complicated cases with distal and common canaliculus obstruction and repeat DCR procedures¹⁹. We achieved a success rate of 98% in our patients after one year of follow-up. In one patient, a 19 years old male, the passage remained patent for two months and reported with epiphora 5 months after the operation. In experienced hands, external dacryocystorhinostomy is a highly successful procedure without silicone tubes even in children^14,15. Saiju et al in their prospective randomized study found no statistically significant difference in the success rate between the groups of patients undergoing DCRs with and without silastic intubation. Silicone tubes increased the surgical cost by 20% in their study²⁰. Based on the meta-analysis that included 5 randomized controlled trials and 4 cohort studies, no benefit was found for silicone tube intubation in primary DCR²¹.

Author’s Affiliation

Prof. Zia Muhammad

Prof. and Head Dept. of Ophthalmology

Bacha Khan Medical College

Mardan

Dr. Muhammad Tariq

Assistant Prof. of Ophthalmology

Bacha Khan Medical College

Mardan

Dr. Mubashir Jalis

Associate Prof. of Ophthalmology

Islamabad Medical and Dental College

Islamabad

Dr. Anjum Khalid

Community Ophthalmologist

Mardan Medical Complex, Mardan.

Role of Authors

Prof. Zia Muhammad

Operating on some of the selected patients. Writing and composing the article.

Dr. Muhammad Tariq

Searching the literature and collecting the references.

Dr. Mubashir Jalis

Proof reading and editing the paper.

Dr. Anjum Khalid

Operating on the selected patients and follow-up

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