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

Abstract

Background Epiphora is a common ophthalmologic sign that is most commonly caused by distal acquired lacrimal obstruction. Recent data have demonstrated that external dacryocystorhinostomy (EXT-DCR) and endoscopic endonasal dacryocystorhinostomy (END-DCR) can be considered the treatments of choice. However, different post-surgical medical therapies are available and are currently used to improve surgical outcomes, although no direct comparison has been performed. Objective To analyse the influence of post-surgical medical treatments on END-DCR and EXT-DCR outcomes. Methods A structured search was conducted using the U.S. National Library of Medicine (PubMed), EMBASE, SCOPUS, and Cochrane databases with a final search performed in May 2020. The research identified papers published later than 2000 with at least 50 single clinician procedures performed in EXT-DCR and END-DCR. Articles that studied acute infections, revision cases, mixed cohort studies of acquired and congenital obstruction, and tumour were excluded. The influence of systemic antibiotic/steroids, local application of mitomycin C, nasal/ocular antibiotic, nasal/ocular steroids and nasal decongestants was analysed. Results In total, 11,445 papers were selected, 2,741 of which were reviewed after screening, and 18 included after full text review (0.6% of the initial articles reviewed) which involved 3,590 procedures. Considering the low number of publications on EXT-DCR, statistical analysis of post-surgical therapy was not feasible. In END-DCR, the analyses were performed only for nasal steroids (p = 0.58), oral antibiotics (p = 0.45) and nasal decongestant (p = 0.27), which demonstrated no meaningful influence. Given the variable association between adjunctive medical therapies, pharmacologic molecular heterogeneity and modality/concentration of application, these results should be considered critically. Additionally, no differences were seen for application of silicone stenting, whereas, no statistical analysis was performed for mitomycin C. Conclusions Given the high success rate of EXT-DCR and END-DCR and the heterogeneity of literature data, the effective influence of post-surgical medical therapy is difficult to identify. Future large prospective randomized studies could help in detecting the optimal adjunctive therapy for these surgeries.

Multidisciplinary approach to lacrimal system diseases

“…Following proper treatment, several post-surgical medical therapies are available, and, seem particularly useful in case of non-oncologic DALO. However, with the available data, the actual influence of adjunctive medical therapies is difficult to demonstrate 31 , and endoscopic visualization of the healing process associated with nasal medication Figure 2. Endoscopic dacryocystorhinostomy surgical procedure.…”

Long-term results of a balloon-assisted endoscopic approach in failed dacryocystorhinostomies

“…Finally, considering post-surgical therapy, different possibilities have been discussed in the literature, both for postoperative medical therapy and bicanalicular stenting. Nevertheless, with the current data available regarding END-DCR, no difference is noted regarding either lacrimal stenting [34][35][36] or medical therapies (e.g., mitomycin C, oral antibiotics (ABT), nasal steroids or ocular steroids) [37][38][39][40]. As a result, in our series, we do not apply mitomycin C, but we do prescribe post-operative oral ABT and antibiotic-steroid eye drops; bicanalicular stenting was placed in only selected patients (2/14) in which extensive fibrosis was noted as failure of the primary surgical approach.…”

Editorial

“…Other studies that are impactful in the realm of endoscopic surgery, includes a cadaver study by Li et al 14 on surgical techniques to access the medial intraconal space (MIS) and a meta-analysis by Vinciguerra, et al 15 on two treatments options for Epiphora: external vs endoscopic approaches. In the first study, Li et al 14 compared the advantage and disadvantage of transethmoidal and prelacrimal approaches to access the medial intraconal space (MIS), and reported that while both approaches are capable to assess MIS, each approach has its own advantages for assessing different zones within the MIS.…”

“…In the first study, Li et al 14 compared the advantage and disadvantage of transethmoidal and prelacrimal approaches to access the medial intraconal space (MIS), and reported that while both approaches are capable to assess MIS, each approach has its own advantages for assessing different zones within the MIS. The 2nd study 15 attempted to examine different post-surgical medical therapies that may improve surgical outcomes of external dacryocystorhinostomy (EXT-DCR) and endoscopic endonasal dacryocystorhinostomy (END-DCR). Limited analyses showed that nasal steroids, oral antibiotics nasal decongestant and silicone stenting may have no meaningful influence.…”

“…14 on surgical techniques to access the medial intraconal space (MIS) and a meta-analysis by Vinciguerra, et al. 15 on two treatments options for Epiphora: external vs endoscopic approaches. In the first study, Li et al.…”