The importance of endoscopy in lacrimal surgery

Abstract

Introduction: The utilization of endoscopy in lacrimal surgeries has been increasing in the recent past with increasing indications. With the advent of newer generation of telescopes, the practice and learning of endoscopic lacrimal surgeries is expected to improve further. Areas covered: This review provides an overview about endoscope assistance in all conditions that involve pathologies of the lacrimal drainage apparatus. The authors have reviewed recently published literature on the techniques and outcomes of endoscopic dacryocystorhinostomy (DCR) in different scenarios such as acute dacryocystitis, pediatric cases, cases with sinonasal anomalies, traumatic nasolacrimal duct obstructions (NLDO) and revision DCRs. Furthermore, promising new avenues such as the 3D endoscopes, variable viewing endoscopes, dacryoendoscopes, navigation-assisted and augmented reality endoscopic lacrimal surgeries have been discussed. Expert commentary: The aim for clinicians should now move on to addressing lacrimal pathologies with traditionally less favorable outcomes and reducing the failure rates with the technological assistance. As more ophthalmology training programs include structured training modules on endoscopic lacrimal surgery, the popularity, the safety and indications of endoscopic lacrimal surgery by ophthalmologists is expected to increase.

Multidisciplinary approach to lacrimal system diseases

“…Additionally, endoscopic instrumentation can be used post-operatively, thanks to the importance of direct visualization of the healing process. Surprisingly, it has been reported that nasal examination is not usually performed by most ophthalmologists, with potential consequences on treatment outcomes 15 . In the past, several authors have tried to identify the best clinical practice for lacrimal diseases, but no one has taken into account the role of multidisciplinary consultation between an ophthalmologist and otorhinolaryngologist in the management of lacrimal pathologies.…”

“…Such an initial diagnostic step is a non-invasive, easy and low-cost way to establish an initial diagnosis, and if the result of this examination confirms a pathology of the eyelid, lacrimal gland, ocular bulb or meibomian gland, an otolaryngologist is not always required 16 . On the contrary, clinical examination of the nasal cavities by an otolaryngologist remains of major interest in case of both functional and obstructive lacrimal pathway pathologies 15 . In fact, even if in some lacrimal pathologies, like functional diseases, the available treatments are primarily performed by an ophthalmologist, the role of an otolaryngologist remain fundamental since he can provide an endoscopic assessment of the nasal fossa, excluding any form of influencing factors 15 .…”

“…On the contrary, clinical examination of the nasal cavities by an otolaryngologist remains of major interest in case of both functional and obstructive lacrimal pathway pathologies 15 . In fact, even if in some lacrimal pathologies, like functional diseases, the available treatments are primarily performed by an ophthalmologist, the role of an otolaryngologist remain fundamental since he can provide an endoscopic assessment of the nasal fossa, excluding any form of influencing factors 15 . Similarly, in case of lacrimal obstructive pathologies, endoscopic assessment of the nose is important for diagnostic purposes (e.g.…”

“…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. 2); conversely, if an EXT-DCR is performed, endoscopic direct visualization of the surgical landmark and potential anatomic variation can be helpful in order to decrease potential influencing factors of the surgical outcome 15 . If a secondary re-stenosis of the neo-rhinostomy occurs, END-DCR seem to be the treatment of choice since it provides direct visualization of intranasal abnormalities which cause surgical failure, with no superiority demonstrated over EXT-DCR 28 .…”

“…and lacrimal pathway irrigation remain the prevalent postsurgical management tools that can positively influence the surgical outcome of all forms of DALO. In fact, the periodic washing procedure of the lacrimal pathway and endoscopic treatment of the neo-rhinostomy can allow for better healing, and thus leading to better surgical outcomes 15 . As a result, post-surgical multidisciplinary approach remains of vital importance in long-term follow-up: in fact, on one hand the ophthalmologist can perform clinical evaluation of the lacrimal pathway, and on the other the ENT can en-doscopically evaluate the neo-rhinostomy and provide additional information about the healing process (Fig.…”