Success rate and complications of endonasal dacryocystorhinostomy with unciformectomy

Jae Wook Yang 0 Ha Na Oh 0 0 This work was supported by the 2012 Inje University research grant Background Endonasal dacryocystorhinostomy (DCR) has been widely used to treat nasolacrimal duct obstruction. Here, we evaluated the anatomical advantages of the uncinate process as a landmark and to study the effect of unciformectomy on success rate and complications of endonasal DCR . Methods In total, 288 eyes of 265 adult patients who underwent endonasal DCR between January 2003 and February 2010 were reviewed retrospectively. The eyes were classified into two groups, according to whether unciformectomy was performed or not. All surgical procedures and surgical indications were the same except unciformectomy and endonasal DCR was performed by one surgeon. Unciformectomy was performed by resecting the anterior part of uncinate process. Results One hundred and eighty-six eyes of 168 patients received endonasal DCR with unciformectomy, and 102 eyes of 97 patients received endonasal DCR alone. The average success rate of endonasal DCR with unciformectomy was There was no financial relationship in our study, and we have no conflict of interest. It has never been presented at any other conference. All authors have full control of all primary data, and agree to allow Graefe's Archive for Clinical and Experimental Ophthalmology to review our data. - 97.8 % and that of endonasal DCR alone was 90.2 %, with statistically significant difference (Student's t-test, p-value< 0.05). There were 14 eyes with post-operative nasolacrimal obstruction, caused by granuloma in five eyes, intranasal synechia in two eyes, membranous obstruction in six eyes, and canalicular stenosis in one eye. There were no serious complications such as orbital fat prolapse, cerebrospinal fluid leak, or delayed hemorrhage. Conclusions Anterior resection of the uncinate process gives improved access to the lacrimal bone by exposing the medial aspect of the lacrimal fossa and forming the precise location of the osteotomy on the lacrimal bone during endonasal DCR. Thus, the uncinate process can be used as an anatomical landmark for endonasal DCR. The unciformian endonasal DCR improves operation success rate by allowing access to the large space of the nasal cavity and reducing the synechiae of the nasal cavity. DCR is commonly used to treat nasolacrimal duct obstruction. It is a surgical method of making an ostium at the lacrimal bone to form a shunt in the nasolacrimal pathway. During most of the previous century, external DCR was standard treatment for nasolacrimal duct obstruction because of its intraoperative approach to the lacrimal sac and the high success rate, whereas intranasal DCR has technical difficulties visualizing the surgical site and achieving effective soft-tissue and bone removal [1, 2]. However, since the development of the rigid fiberoptic endoscope, endonasal DCR has been widely used because it has significant advantages, including the avoidance of scarring, minimal postoperative hematoma, shorter postoperative recovery, preservation of the pumping action on the orbicularis oculi muscle, and concurrent correction of intranasal abnormalities, which can cause failure from synechiae formation between the ostium and the septum or the middle turbinate using the endoscope [36]. Despite these advantages, endonasal DCR has a number of factors that can lead to failure. Anatomical variation in the nasal cavity can cause difficulties for surgical correction. Insufficient size of the osteotomy [6], cicatricial closure of the ostium [79], adhesions between the ostium and the middle turbinate [10], formation of synechiae between the ostium and the nasal septum [7], and granuloma formation within the ostium [7] can cause postoperative nasolacrimal duct obstruction. Thus, resolving these factors and overcoming anatomical variations will improve the success rate of endonasal DCR. The uncinate process is a thin bony layer that extends from the anterior end of the middle meatus, and spreads downwards and backwards above the upper aspect of the maxillary sinus [5]. The anterior part of the uncinate process faces the lacrimal bone. McDonogh and Meiring [11] suggested the potential use of the uncinate process as a landmark in endonasal dacryocystorhinostomy. In our research we have experienced favorable results and prognosis in the treatment of patients with nasolacrimal duct obstruction, using endonasal DCR with unciformectomy. Here, we evaluated the anatomical advantages of the uncinate process as a landmark, and studied the effect of unciformectomy on the success rate and complications of endonasal DCR. We suggest other contributing factors that may improve the success rate in comparison with our previous study. Materials and methods In total, 265 adult patients with symptomatic nasolacrimal duct obstruction underwent endonasal DCR between January 2003 and February 2010. Patients were followed for longer than 6 months. In total, 288 eyes were included in the study; both eyes in 23 patients and a single eye in 242 patients. The eyes were classified into two groups according to whether unciformectomy was performed or not (group A : endonasal DCR with unciformectomy, group B : endonasal DCR alone). The success rate and complications of the both groups were studied. Nasolacrimal duct obstruction was confirmed prior to the operation by positive probing (bone contact) and negative irrigation. Dacryocystography was performed in some cases, by injection of contrast (Ultravist injection 370, Bayer, Germany) into the lacrimal canaliculi and lacrimal sac to show the blocked or constricted location of nasolacrimal pathway. Nasal cavity abnormalities were not considered in assessing the result of our endonasal DCR with unciformectomy. All surgical procedures and surgical indications were the same except unciformectomy and endonasal DCR was performed by one surgeon. Patients underwent general anesthesia, and gauze soaked with 1 % lidocaine and 1:1000 epinephrine mixed solution was packed into the nasal cavity to decongest the nasal mucosa after anesthesia. The upper and lower punctum were dilated. The 20-gauge vitrectomy light source tip was inserted into the lower punctum and reached the lacrimal sac. After identifying the location of the lacrimal sac by transillumination, local anesthetic was injected into the nasal mucosa of the transilluminated areas around the uncinate process. In some patients, procedures including middle turbinectomy, fracturing techniques of septal cartilage by pushing the septum and the removal of nasal polyps were performed to enlarge the nasal cavity. The mucosa on the anterior part of the uncinate process was removed via the anterior, through the insertion of the middle turbinate using a Freer elevator. The lacrimal bone was exposed after resection of the anterior of the uncinate process. Nasal mucosa and lacrimal bone were removed, and the ostium was increased in size to >8 mm diameter (...truncated)