Best treatments available for distal acquired lacrimal obstruction: A systematic review and meta‐analysis

Abstract

BackgroundEpiphora is a common clinical sign whose primary cause is post‐canalicular lacrimal obstruction. Treatment is both surgical and non‐surgical. In the literature, there is some evidence to suggest that some treatments are superior to others, but there are no direct comparative data in this regard.Objective of reviewTo analyse the success rates of all available treatments to resolve post‐canalicular acquired lacrimal obstruction.Type of review:Systematic review and meta‐analysis.Search strategy:A literature search was conducted in the US National Library of Medicine (PubMed), EMBASE, SCOPUS and Cochrane databases with a final search performed in January 2020.Evaluation method:The search strategy identified articles published later than 2000 with at least 50 procedures performed both surgically (external dacryocystorhinostomy [EXT‐DCR], endoscopic dacryocystorhinostomy [END‐DCR] and transcanalicular laser dacryocystorhinostomy [TCL‐DCR]) and non‐surgically (balloon dacryoplasty [DCP], probing‐stenting [SP] and polyurethane stent [PoS]). The primary outcome was functional success, defined as symptom resolution or less than MUNK 2 scale; in addition to this, the influence of adjunctive treatments, such as application of mitomycin C and post‐procedural silicone stenting, was evaluated.ResultsIn total, 14 958 papers were selected, 440 of which were reviewed after screening; 55 were included after full‐text review, which involved 9337 procedures. Mean success rate was 48.9% (35.7%‐62.3%) for DCP, 54.4% (41.8%‐66.5%) for SP, 73.6% (59.7%‐84%) for PoS, 80% (75.1%‐84%) for TCL‐DCR, 89.8% (83.3%‐93.9%) for EXT‐DCR and 89.5% (87.2%‐91.5%) for END‐DCR. Among all procedures, a difference was noted between DCP and END‐DCR (P < .001), DCP and EXT‐DCR (P < .001), SP and END‐DCR (P < .001), SP and EXT‐DCR (P < .001), END‐DCR and PoS (P = .016), and END‐DCR and TCL‐DCR (P = .001); no differences were noted between END‐DCR and EXT‐DCR (P = 1.00), EXT‐DCR and PoS (P = .121) and EXT‐DCR and TCL‐DCR (P = .223). Considering surgical procedures, no differences were seen if a silicone stenting was applied, whereas, due to heterogeneity of the literature data, no statistical analysis was feasible for application of mitomycin C.ConclusionsOur analyses suggest that, among all procedures available, END‐DCR and EXT‐DCR should be considered as treatments of choice to resolve distal acquired lacrimal obstruction.

Impact of Post-Surgical Therapies on Endoscopic and External Dacryocystorhinostomy: Systematic Review and Meta-Analysis

“…External and endoscopic endonasal dacryocystorhinostomy have gained, over the past several years, increasing relevance in the treatment of distal acquired lacrimal obstruction. 12,13 However, when considering the success rates of these procedures, few authors have analysed the importance and influence of post-surgical therapies that may potentially influence surgical outcomes. At present, to the best of our knowledge, the present study is the first attempt to analyse the influence of adjunctive medical therapies on both EXT-DCR and END-DCR.…”

“…In fact, as already demonstrated, laser END-DCR and balloon catheter dacryoplasty have been considered inferior compared to END-DCR and EXT-DCR. 12 Conversely, EXT-DCR has not demonstrated to have a superior surgical approach so that any specific surgical variations were included.…”

“…In a recent review, it was pointed out, based on the functional success rates, that external dacryocystorhinostomy (EXT-DCR) and endoscopic endonasal dacryocystorhinostomy (END-DCR) can be considered as the treatments of choice. 12 However, given the lack of robust data, even if EXT-DCR has been considered the gold-standard procedure over the past decades, it is unclear if one of these two procedures is superior to the other. 13 Independently of the surgical approach used, different post-surgical medical treatments, such as topical ocular steroids, topical nasal steroids, topical nasal antibiotics, topical ocular antibiotics, nasal vasoconstrictors and oral antibiotics, are available and currently used to improve surgical outcomes and prevent local infection.…”

“…In a recent review, it was pointed out, based on the functional success rates, that external dacryocystorhinostomy (EXT-DCR) and endoscopic endonasal dacryocystorhinostomy (END-DCR) can be considered as the treatments of choice. 12 However, given the lack of robust data, even if EXT-DCR has been considered the gold-standard procedure over the past decades, it is unclear if one of these two procedures is superior to the other. 13…”

Multidisciplinary approach to lacrimal system diseases

“…Primary acquired and secondary, nononcologic, diseases have several treatments available, both surgical and non-surgical, that can be performed by different clinicians. Among all, a recent review has pointed out that external dacryocystorhinostomy (EXT-DCR) and END-DCR present higher functional success rates compared to other techniques, and should be considered as treatments of choice 27 . In these cases, the collaboration between ophthalmic plastic and ENT surgeons is necessary because, if a END-DCR is performed, management of the proximal lacrimal pathway is required and needs the presence of the ophthalmologist (Fig.…”