Introduction
The most common cause of epiphora in adults is primary acquired nasolacrimal duct obstruction and is more common in females1, 2 whereas in children the most common cause is congenital nasolacrimal duct obstruction.3 The standard treatment for nasolacrimal duct obstruction is dacrocystorhinostomy performed either externally or endonasally. It is performed using a skin incision followed by a removal of lacrimal and maxillary bones and forming a passage between nasal and lacrimal mucosa.4 External Dacrocystorhinostomy was first described by Toti in 19045 was later modified to form an epithelium lined fistula by suturing of nasal and lacrimal mucosal flaps.6 And Endonasal dacryocystorhinostomy was introduced in 1893 by Sir Cadwell7 and later modified. The primary success rates with both the procedures are well documented in literature. It is about 63-97%.7, 8 Major complications include scar formation, infection, disruption of medial canthal ligament and epistaxis.9
During the last decade several new techniques such as Silicon tube intubation introduced by Gibbs has been widely used in conjunction with lacrimal duct surgery.10 Silicone intubation has both functional and mechanical effects on epiphora. Silicone intubation is said to enhance lacrimal pump function by supporting position of the punctum and apposition during process of blinking. 11 It is also believed to increase tear drainage by preventing blockage of ostium.12, 13
The most common complications associated with silicon tube intubation are slitting of canaliculi or punctum, and granuloma formation in the nose and lacrimal fossa14, 15 and with prolonged intubation infections with pseudomonas aeruginosa are common.16
In literature, although success rates of dacryocystorhinostomy with silicone tube intubation have been widely studied, but there is paucity of data regarding comparative studies. Hence, we evaluated the outcome of silicone intubation in external dacryocystorhinostomy patients with nasolacrimal duct obstruction in comparison with endoscopic endonasal dacryocystorhinostomy.
Materials and Methods
This is a prospective randomized comparative study conducted at department of Ophthalmology at Vydehi Institute of Medical Sciences and Research Center, a tertiary care teaching hospital, Bangalore on patients with lacrimal drainage system disorders attending the outpatient department between a study periods of December 2010 to December 2019.
Exclusion criteria
Cases with entropion or ectropion
Cases with noticeable lid laxity
Cases of congenital malformations of lacrimal apparatus and craniofacial anomalies
Cases of tumours of the lacrimal apparatus and nasal cavity
Cases of acute dacrocystitis, lacrimal abscess and lacrimal fistula
Cases with canalicular and punctual obstruction
Method of collection of data
An informed consent before surgery was obtained from all patients included in the study. A detailed history was collected from the study subjects;
Thorough Ophthalmological examination included following:
Visual assessment
Anterior segment examination under slit lamp
Examination of posterior segment
Lacrimal syringing to confirm obstruction of nasolacrimal duct
ENT examination to rule out sinusitis, DNS and concha bullosa
Dacrocystorhinostomy under general anesthesia
By simple random sampling technique all registered cases requiring surgery were operated for external dacrocystorhinostomy, external dacrocystorhinosyomy with silicon tube intubation and endonasal DCR under general anaesthesia.
Postoperative follow-up
All patients were given systemic antibiotics and analgesics for a period of 5 days.
Nasal pack was removed after 24 hours in majority of the cases.
First dressing was done after 24 hours in all, the cases.
Suture removal was done on 5th day.
All patients were followed up over a week, after 6months and over 3 years.
In every follow-up routine ophthalmological examination was done, incision area was inspected, patency of lacrimal passage was assessed
Also presence or absence of discharge was assessed.
Any complication detected was dealt immediately.
Results
41 patients were involved in the study, 25patients managed with external dacrycystorhinostomy, 26 patients managed with external dacryocystorhinostomy with silicone tube intubation and 18 patients with endoscopic endonasal dacryocystorhinostomy. Study was conducted over 9years with follow-up
Table 1
Distribution ofPatients among groups
| Group | No. of Patients(n) | Percent(%) |
| I | 25 | 36.23 |
| II | 26 | 37.68 |
| III | 18 | 26.08 |
| Total | 69 | 100.0 |
Table 1 showing patient distribution among the study group. 36% patients belonged to GroupI(External DCR), 38% patients belonged to Group II(External DCR with silicone tube intubation) and 26% belong to Group III(Endonasal DCR).
Table 2
Age-Distribution of Patients among groups
| Age-Group | I | II | III | |||
| N | % | N | % | N | % | |
| 6-15 | 2 | 8 | 3 | 6.7 | 2 | 11.1 |
| 16-25 | 1 | 4 | 0 | 0 | 0 | 0 |
| 26-35 | 7 | 28 | 7 | 33.3 | 10 | 55.5 |
| 36-45 | 9 | 36 | 10 | 26.7 | 6 | 33.33 |
| 46-55 | 6 | 24 | 6 | 33.3 | 0 | 0 |
Table 2 showing age distribution among the study group.
Group I: 8% patients belonged to 6-15 years, 4% patients belonged to 16-25 years. 28% patients belonged to 26-35 years, 36% to 36-45 years and 24% to 46-55 years.
Group II: 6.7% patients belonged to 6-15years, 33.33% patients belonged to 26-35years, 26.7% to 36-45 years and 33.33% to 46-55 years.
Group III: 11.1% patients belonged to 6-15years, 55.5% patients belonged to 26-35 years, 33.3% to 36-45years.
Table 3
Comparison of in both the Groups
| Age | N | Mean | SD | Standard Error of mean | t-statistic | p-value |
| Group I | 25 | 39.9 | 11.55 | 2.203 | -0.718 | |
| Group II | 26 | 36.69 | 11.77 | 2.308 | -0.718 | 0.385 |
| Group III | 18 | 34.44 | 10.53 | 2.720 |
Table 4
Gender distribution of patients among groups
| Gender | I | II | III | |||
| N | % | N | % | N | % | |
| Female | 13 | 52.0 | 13 | 50.0 | 10 | 55.5 |
| Male | 12 | 48.0 | 13 | 50.0 | 8 | 44.4 |
| Total | 25 | 100.0 | 26 | 100.0 | 18 | 100.0 |
Table 4 represents age distribution among the study group. The distribution of females n=13 (52%) was more than males n=12(48%) among Group I, Equal gender distribution was noted among Group II(n=13 50%) and distribution offemales n=10(55.5%) was higher than males n=8(44.4%) among Group III.
Table 5
Syringing Distribution of Patients among thestudy groups
| Syringing | I | II | III | |||
| N | % | N | % | N | % | |
| LE regurgitation | 12 | 48 | 12 | 46.15 | 11 | 61.1 |
| RE regurgitation | 13 | 52 | 14 | 53.8 | 7 | 38.8 |
| Total | 25 | 100.0 | 26 | 100.0 | 18 | 100.0 |
Table 5 represents the syringing among the study group. Involvement of right eye (52%) was more than left eye (48%) among Group I, Group II{RE 53.8% and LE 46.15%} but involvement of left eye(61.1%) was more than right eye(38.8%) among Group III.
Table 6
Complications of Patients among the study group
| Complications | I | II | III |
| Bleeding | 0 | 0 | 2 |
| Lid edema(immediate) | 0 | 0 | 2 |
| Infection | 0 | 0 | 1 |
| Lid edema on POD3 | 1 | 1 | 1 |
| Synechiae formation | 0 | 0 | 2 |
| Tube displacement | 0 | 1 | 0 |
| NIL | 24 | 24 | 10 |
Table 6 represents the distribution of complications among the study group. Group III presented with complications such as bleeding (n=2), lid edema(n=2), infection(n=1), lid edema on POD3(n=1), Synechiae formation(n=2).
With respect to Group II 24 patients had no complications although two patients had lid edema and tube displacement noted and was treated accordingly. Group I had only one patient presenting with lid edema and remaining patients had no complications.
Discussion
The aim of the present study was to prospectively evaluate and compare the clinical outcome with external dacryocystorhinostomy with silicone tube intubation and endonasal DCR in patients with nasolacrimal duct obstruction.
DCR is the treatment of choice for patients with epiphora in cases of obstruction distal to common canaliculi, performed externally or endonasally. At the turn of century external DCR has been a gold standard treatment for nasolacrimal duct obstruction. The procedure offers a high predictability of success and better visualization of lacrimal anatomy. Although the disadvantages are scar formation, CSF rhinorrhea and risk of injury to medial canthal tendon structures. 17
Endonasal DCR modified in the year 1990,18 and has shown equally promising results. Complications include restenosis of the opening, epistaxis, corneal abrasion and canalicular erosion, recurrent infections. 19, 20
A breakthrough modification in lacrimal surgeries is the silicone tube introduction. It has been combined with DR to prevent adhesions of nasolacrimal mucosa during the process of healing and to ensure patency of the nasolacrimal duct after its removal. Despite these advantages, common complications associated are punctual/canalicular laceration, tube replacement or loss, inter-punctual symblepharon, pyogenic granuloma and conjunctival irritation.21, 22
In our study, the demographic characteristics of our patient population were similar to those described by others. Nasolacrimal outflow obstruction is much more common in women than in men and is associated with advanced age. In our study, we analyzed 69 surgically treated cases of lacrimal drainage system disorders. From the general data, the majority of treated patients (were female than male among the study group. The distribution of females n=13 (52%) was more than males n=12(48%) among Group I, Equal gender distribution was noted among Group II(n=13 50%) and distribution of females n=10(55.5%) was higher than males n=8(44.4%) among Group III. A similar female preponderance was also shown by Mortimore et al. (74%), Unlu et al. (76%), and Soler Machin et al. (73.91%). 23, 24, 25 With respect to age mean age in group I was 39.9years and group II was 36.69years and 34.4 years among Group III. Similar results were noted in a study by Cokkeser Y et al where the mean age noted was 39.6 years in group undergoing external DCR with silicone tube intubation and 34.8 years in group treated with endonasal DCR.26
The surgery was considered successful by objective demonstration of a patent lacrimal duct system through syringing. Of total 69 patients studied patency was achieved in 92.3% patient’s treated with external DCR and external DCR with silicone tube intubation and 55.5% patients treated with endonasal DCR. The difference was statistically significant (Table 6). The complication incidence was high in patients who underwent endonasal DCR. Postoperative hemorrhage was noted in 2 (11.1%) patients who underwent endoscopic endonasal dacryocystorhinostomy but absent in patients who underwent external DCR. This postoperative hemorrhage was either nasal bleeding or wound bleed. All of them were treated conservatively and hemostasis was achieved without any intervention. Synechiae formation was noted in 2(11.%) who were treated with endoscopic DCR and tube displacement was noted in one patient who underwent External DCR with Silicone tube intubation. There was no documentation of orbital emphysema, medial rectus paresis, and orbital fat herniation. Refer5forpostoperativeresultsandcomplicationsstratifiedbyDCRsurgeryexternalendonasal endoscopicapproach.
With respect to surgical success rates in patients with silicone tube, various studies have proved that success rates are higher in patients with silicone intubation. In 2009 study by Kakariki et al 27 which included 166 patients with surgical outcome was (95.1%) higher compared to silicone tube free subjects (85.7%).Similar success outcome (90%) over a follow-up was noted in a study by Sajju et al. 28 26 patients who underwent external DCR with silicone tube intubation only 1patient had tube displacement. In our study group tubes were retained over -2-3months. Although the concept of this tube retention is controversial. A study by Kong et al 29 suggested tube removal before 8weeks prevents granuloma formation but a study by Boush et al[32] suggested that there exists a direct relationship between tube retention and surgical success. The revision of primary external DCR with endoscopic technique is prove to be successful in literature but success of endoscopic revision of Endoscopic endonasal surgery has been doubtful. In our cases 2 endoscopic DCR failures external DCR with silicone tube intubation was done and 100% patency was achieved.
This study suggests that External DCR with silicone tube intubation has better success rate and best outcome compared to endonasal DCR. The results were comparable and significant. Endonasal DCR has a steeper learning curve compared to External DCR. There are studies which have drawn a comparison between external DCR and endonasal DCR. But there a few/no studies which have compared outcome of external DCR with silicone tube intubation and endoscopic DCR. The advantages with silicone tube usage overweighs the drawbacks such as cost factor and duration of surgery. Thus throwing light upon an inference that silicone tube intubation improves the outcome of surgery and aids in improving quality of life especially in pediatric group.
Conclusion
The outcome of both external dacrocystorhinostomy with silicon tube intubation and endonasal dacrocystorhinostomy were comparable, although complications were high in endonasal dacryocystorhinostomy with two requiring revision procedure due to failure and results were statistically significant. Therefore external dacrocystorhinostomy with silicon tube intubation can be considered as a primary procedure in patients with epiphora for better success rates and improvement in quality of life in pediatric cases.
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