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ORIGINAL ARTICLE
Year : 2013  |  Volume : 106  |  Issue : 4  |  Page : 230-234

A novel technique to improve the results of conventional dacryocystorhinostomy


Department of Ophthalmology, Zagazig University, Zagazig, Egypt

Date of Submission10-Apr-2013
Date of Acceptance05-Jun-2013
Date of Web Publication28-Apr-2014

Correspondence Address:
Salah M El-Sayed Al-Mosallamy
MD, 6 st. Elsadaka, Eltawaniabuilding, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2090-0686.131562

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  Abstract 

Purpose
The objective of this study was to evaluate the results of the use of dried lyophilized amniotic membrane to increase the survival of external dacryocystorhinostomy (EX-DCR) with respect to the efficacy and complications.
Patients and methods
This was a prospective controlled study that included 22 eyes of 20 patients. All had nasolacrimal duct obstruction and were selected from the outpatient clinic; they were classified into two groups, 11 patients each. The first group patients were treated by EX-DCR using dried lyophilized amniotic membrane (group I) that was wrapped around the silicon tube after its implantation in the lacrimal passage (between the lacrimal passage and nasal cavity). The second group (II) patients were treated by the standard EX-DCR only, which served as the control group.
Results
The study included 22 eyes of 20 patients: 13 were female patients (65%) and seven (35%) were male patients, with mean age of 50.8 ± 6.5 and 48.2 ± 7.1 for groups I and II, respectively. Demographic characteristics showed insignificant difference between both groups. With respect to the success rate, all patients in both groups showed 100% subjective (symptomatic relief) and objective success rate (on examination) at 3-month follow-up (at the time of removal of silicon tube), but at the end of follow-up (8 months) the success rate decreased to 90.9% in the first group and 72.7% in the second group, and this difference was statistically significant (P = 0.0288). One of the complications encountered in this study was epistaxis in five patients (45.4%) in group I and in six patients (54.5%) in group II. Other complication was periorbital ecchymosis in two patients in each group. In one patient in group I, the lower punctum was slit and opened (cheese wiring) using a silicon tube. The complication rate was statistically insignificant between the two groups (P = 0.897).
Conclusion
The use of amniotic membrane with EX-DCR was effective in improving the results and increasing the survival of the ostium between the sac and the nasal cavity, with no added complications. However, larger multicenter studies with longer follow-up are needed before establishment of this treatment strategy.

Keywords: Epistaxis, amniotic membrane, ex-dcr


How to cite this article:
El-Sayed Al-Mosallamy SM. A novel technique to improve the results of conventional dacryocystorhinostomy. J Egypt Ophthalmol Soc 2013;106:230-4

How to cite this URL:
El-Sayed Al-Mosallamy SM. A novel technique to improve the results of conventional dacryocystorhinostomy. J Egypt Ophthalmol Soc [serial online] 2013 [cited 2020 Dec 3];106:230-4. Available from: http://www.jeos.eg.net/text.asp?2013/106/4/230/131562


  Introduction Top


Epiphora or abnormal tearing occurs because of blockage in the lacrimal drainage system. Nasolacrimal duct obstruction results in infection of the lacrimal sac, thereby leading to lacrimation and ocular discharge. Lacrimal sac infection, recurring despite medication, can be surgically treated with external dacryocystorhinostomy (EX-DCR) that is performed by creating an anastomosis between the lacrimal sac and the nasal mucosa. External DCR is considered the gold standard in primary cases, with high rates of success [1],[2]. Toti (1904, Italy) [3] first described the technique of external DCR.

Dupuy-Dutemps and Baerrget (1921, France) [4] described the modern external flap DCR technique.Since then, DCR has been proved to be a reliable operation strategy for obstruction beyond the common canalicular opening. Although double flap DCR is the toughest of anastomoses, it produces excellent results with skilled, experienced hands [5]. Although DCR is widely accepted as the procedure of choice for surgical correction of the lacrimal drainage system obstruction, the success rate has been reported to range from 63 to 99% [4],[5]. EX-DCR failure has been attributed to membranous occlusion of the rhinostomy site caused by soft tissue scarring. More recently, use of mitomycinC (MMC) at a concentration of 0.2 mg/ml has been described in lacrimal drainage surgery. The beneficial effect of MMC as a surgical adjunct is thought to be related to its potent inhibition of fibroblast proliferation [6].

Most of the studies found that intraoperative MMC application seems to be an effective adjuvant that could reduce the closure rate of the osteotomy site after primary EX-DCR, but some patients showed delayed healing of the external skin wound when MMC was used [7].

The use of amniotic membrane to promote re-epithelializationis well recognized; however, the additional property of suppressionof inflammation and inhibition of scarringis also beneficialwhen dealing with the tissues that may undergo inflammation and scarring [8]. Amniotic membrane transplantation has been used in the reconstruction of the ocular surfaceafter pterygium excision [9], in nonhealing corneal epithelial defects [10],[11],[12], in cicatrizingconjunctival diseases [13],[14], to retard cornealneovascularization in patients with limbal stem cell deficiency [15], and in glaucoma filtering surgery aiming at reconstruction of the bleb and prevention of subconjunctival fibrosis, giving results comparable with that of the use of MMC without serious complications [16]. This study was conducted to evaluate the use of dried lyophilized amniotic membrane for further improvement in the results of external DCRwith respect to the efficacy and safety.


  Patients and methods Top


This was a prospective controlled study that included 22 eyes of 20 patients who were selected from outpatient clinic of Zagazig University Hospital during the period from September 2009 to January 2010; all patients were suffering from primary acquired nasolacrimal duct obstruction (NLDO) (the positive regurgitation test). After thorough ophthalmic and ENT examinations that includeda detailed history taken from every patient, thorough clinical examinations were performed. Preoperatively, irrigation and probing were performed, the fluorescein disappearance test was performed, tear meniscus height was measured in each patient, and also all patients showed negative Jones dye test. Informed consent was obtained for bothprocedure after a discussion of the relative advantages, disadvantages, and current success rates from published reports.

Exclusion criteria

Patients with external lacrimal fistula in chronic dacryocystitis, congenital patients, patients with previously failed DCR, and traumatic patients were excluded from the study.

All patients showed anepiphora score of 4 or 5 according to the Munk score [17] preoperatively.Theywere divided into two groups: the first group (I) was treated by EX-DCR with wrapping of the silicon tube by dried lyophilized AMM before suturing the anterior flab and the second group(II) was treated by the standard EX-DCR without an adjuvant and served as the control group.

Surgical technique

All operations were conducted under general anesthesia. With the patients under anesthesia, the nasalcavity of the operable side was decongested for 10min with cotton pledges soaked with adrenaline (1:200000).

A curved 11-mm skin incision was placed 3.5 mm nasal to the medial canthus. Next, the orbicularis muscle was bluntly dissected, and the anterior limb of the medial canthal tendon and periostium was exposed. The skin and the orbicularis muscle were then raisedmedially and laterally using two cats-paw forceps.

The exposed periostium was incised parallel to the anteriorlacrimal crest,andan osteotomy of 12 × 12-mm wide was created with Citelli's bone punch.Then, the anterior and posterior flaps of the lacrimal sac and exposed nasal mucosa in the middle meatus were created. The posterior flaps of the lacrimal sac and nasal mucosa were sutured if accessible with 6-0 polyglycolic acid (vicryl) suture. Thereafter, a metal-guided silicon lacrimal tube was introduced through both puncti, passing through the osteotomy and emerging from the nose. After that, a loop of the double-armed silicon tube was withdrawn from the wound, wrapped with dried lyophilized amniotic membrane after making it wet by saline for 3-4 min [National Centre for Radiation Research and Technology, (NCRRT)], sterilized by gamma ray, and distributed by Matrex healthcare S.A.E. A stitch of 6-0 vicryl suture was tied over AMM, helping to anchor it over the tube and preventing its slippage. The tube was then stretched from the nose so that the wrapped part of the tube lies in the ostium between the lacrimal sac and the nasal cavity [Figure 1], [Figure 2],[Figure 3] and [Figure 4].Thereafter, the operation was completed as usual. Deep planes of the wound (orbicularis oculi muscle) were approximated using twovicryl sutures. The skin wound was closed with continuous 6-0 vicryl sutures, and the tube was tied with a knob using 3/0 silk sutures and cut short in the nose. Postoperatively, ciprofloxacin 500 mg tablets twice daily, 0.025% xylomethazoline two drops in each nostril thrice daily, and ofloxacine 0.3% eye drop four times daily were prescribed for 7 days.
Figure 1:

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Figure 2:

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Figure 3:

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Figure 4:

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Amniotic membrane preparation

The amniotic membrane was obtained under sterile conditions after elective cesarean delivery from a seronegative donor. Donors at risk for HIV, hepatitis B virus, hepatitis C virus, and Creutzfeldt-Jakobdisease were excluded. The placenta was first washed free of blood with balanced physiologic saline containing 50 μg/ml penicillin, 50 μg/ml streptomycin, 100 μg/ml neomycin, and 2.5 μg/ml amphotericin B. The inner amniotic membrane was separated from the rest of the chorion by blunt dissection through the potential spaces between these tissues. The membrane was then flattened onto a nitrocellulose paper, with epitheliumbasement membrane surface toward the upper side. The membrane with the paper was cut into 4 × 4-cm pieces and placed in a sterile vial containing Dulbecco's modified Eagle's medium and glycerol at a ratio of 1:1. The vials were frozen at −80°C. The membrane was defrosted immediately before use by warming the container to room temperature for 10 min [18].

Follow-up examinations were scheduled on the first and 10th postoperative day and after 1, 3, 6, and 8 months from the date of surgery. Subjective epiphora, if any, was evaluated with the Munk score [Table 1] [17]. Criteria for failure were nonpatency on irrigation or tear meniscus height greater than or equal to 2 mm during the postoperative period and also very subjective epiphora beyond the Munk score. Fibrous scar tissue formation at the ostium site was also noted using endonasal endoscopy during ENT examination of the patients, which was performed at 2 week, 3 months, and 8 months postoperatively. The silicon tube was removed 3months postoperatively [Table 2].
Table 1: Munk's score of epiphora [17]

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Table 2: Demographic and characteristics of patient included in the study

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Statistical analysis

Data were collected, tabulated, and statistically analyzed for the detection of significant values. This was carried out using Microsoft Excel 2010. The F-test and the Student paired t-test were carried out forthe detection of significant values between the two groups, and the unpaired test was carried out for the detection of P values within the same group. P values greater than 0.05 was considered statistically nonsignificant, whereas P value less than 0.05 was considered statistically significant.


  Results Top


The study included 22 eyes of 20 patients:13 were female patients (65%) and seven (35%) were male patients, with mean age of 50.8 ± 6.5 and 48.2 ± 7.1 for groups I and II, respectively. All demographic characteristics showed insignificant difference between both groups (P > 0.05; [Table 1]).

With respect to the success rate, all patients showed 100% subjective (symptomatic relief) and objective success rate (on examination) in both groups at 3-month follow-up (at the time of removal of silicon tube), but at the end of follow-up (8 m) the success rate decreased to 90.9% in the first group and 72.7% in the second group, and this difference was statistically significant (P = 0.0288) [Table 3].
Table 3: Success rate in both groups (N = 11 patients in each group)

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The treatment failed in four patients (one in group I and three in group II); all of them showed fibrous tissue occlusion at the site of the ostium as seen byendonasal endoscopy during ENT examination.Hence, they underwent surgical revision of the ostium with silicon intubation and MMC application intraoperatively using microsponge soaked with 0.2mg/ml MMC. No recurrence occurred in these patients.

The most common complication encountered in this study was epistaxis,which occurred in five patients (45.4%) in group I and in six patients (54.5%) in group II; all complications occurred within the first 3 postoperative days, most of them ceased spontaneously and only two patients required nasal pack.

Other complication wasperiorbital ecchymosis (two patients); in each group,it was resolved with the use of hot fomentation for 3-5 days. In one patient in group I,the lower punctumwas slit opened (cheese wiring) using a silicon tube. The complication rate was statistically insignificant between the two groups (P = 0.897; [Table 4]).
Table 4: Postoperative complications encountered in both groups

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  Discussion Top


NLDO is the most frequent form of lacrimal obstruction. Its prevalence gradually increases at the age of 40.With respect toetiology, the most frequent cause of NLDO is an evolutionary stenosis in the elderly and an idiopathic stenosis in young people and adults. The usual treatment is DCR with various approaches, external DCR being utilized typically with successful results in ˜90-95% of patients. Other approaches such as endonasal endoscopic DCR or laser endocanalicular DCR are alternatives to external approaches [19]. The rates of failure after the primary operation were reported to range between 0 and 23% [20],[21]. The most common reasons for recurrence, as shown by endoscopic endonasal examination, included a closure of the bone window by the hypertrophic nasal mucosa and granulation tissue and fibrous tissue formation at the osteotomy site. To increase the success rate in cases of DCR, combined MMC and intubation by silicone tubing may be performed [22]. This study aimed to study the novel use of amniotic membrane as an adjuvant to EX-DCR with respect to the efficacy and safety.

The results revealed that, of the 22 eyes of 20 patients included in the study, 13 werefemale patients (65%) and seven (35%) were male patients, with mean age of 50.8 ± 6.5 and 48.2 ± 7.1 for groups I and II, respectively. All demographic characteristics showed insignificant difference between both groups with respect to the success rate; all patients showed 100% subjective (symptomatic relief) and objective success rates (on examination) in both groups at 3-month follow-up (at the time of removal of silicon tube), but at the end of follow-up (8m) the success rate decreased to 90.9% in the first group and 72.7% in the second group.This difference was statistically significant (P = 0.0288) and reflected the value of the use of amniotic membrane as an adjuvant to EX-DCR because of its properties of reconstruction of the ostium, promoting its epithelialization with inhibition and prevention of fibrosis and granulation tissue formation. The most common complication encountered in this study was epistaxis,which occurred in five patients (45.4%) in group I and in six patients (54.5%) in group II. Other complication wasperiorbital ecchymosis,which was found in two patients in each group. In one patient in group I, lower punctumwas slit opened using a silicon tube. The complication rate was statistically insignificant between the two groups (P = 0.897). In a short-term study conducted by Choi et al. [23], they placed amniotic membrane-coated Merocel nasal pack in the ostium after endonasal DCR and found an overall success rate of 93.3% compared with 86.7% when amniotic membrane was not used,even after follow-up at 6 months.

In agreement with our results was the study by Delaney and Khooshabeh [24] who foundan overall EX-DCR success rate of 84% that declinedto 70% after 3 years.They attributed this to postsac idiopathic inflammatory reaction that leads to membranous formation at the ostium. In addition, Deka [25] found 98% success rateof EX-DCR after a follow-up of 13 months, without decline in the success over follow-up(as in this study); this can be explained by the fact that the anterior flab was suspended by suturing it to the subcutaneous tissue. Other studies that utilized the antifibrotic effect of intraoperative MMC application showed results ranging from 100% success as in the study by You and Fang [26] to 90.5%success as in the study by Roozitalab et al. [6], with follow-up of 1year in both studies. Feng et al. [7] also reported higher success rate when MMC was used, but some patients in their study showed delayed skin wound healing. The complication rate was comparable with other studies, with epistaxis being the most common complication but fortunately, it was usually mild and resolved spontaneously [19],[20],[21],[22],[23],[24].


  Conclusion Top


The use of amniotic membrane with EX-DCR was effective in improving the results and increasing the survival of the ostium between the sac and the nasal cavity, with no added complications. However, larger multicenter studies with longer follow-up are needed before establishment of this treatment strategy.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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10.Lee S-H, Tseng SC. Amniotic membrane transplantation for persistent epithelial defects with ulceration. Am J Ophthalmol 1997; 123 :303-312.  Back to cited text no. 10
    
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13.Tsubota K, Satake Y, Ohyama M, et al. Surgical reconstruction of the ocular surface in advanced ocular cicatricialpemphigoid and Stevens-Johnson syndrome. Am J Ophthalmol 1996; 122 :38-52.  Back to cited text no. 13
    
14.Tseng SC, Prabhasawat P, Lee SH. Amniotic membrane transplantation for conjunctival surface reconstruction. Am J Ophthalmol 1997; 124 :765-774.  Back to cited text no. 14
    
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16.Barton K, Budenz DL, Khaw PT, Tseng SC. Glaucoma filtration surgery using amniotic membrane transplantation. Invest Ophthalmol Vis Sci 2001; 42 :1762-1768.  Back to cited text no. 16
    
17.Kuchar A, Stinkogler FJ. Antegrade balloon dilatation of nasolacrimal duct obstruction in adults. Br J Ophthalmol 2001; 85 :200-204.  Back to cited text no. 17
    
18.Eliezer RN, Kasahara N, Umbelino CC, Pinheiro Rk. Use of amniotic membrane in trabeculectomy for treatment of glaucoma. Arq Bras Oftalmol 2006; 69 :1590-1597.  Back to cited text no. 18
    
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[PUBMED]    
20.Tök Ö, Burakgazi AZ, Kocaoðlu FA. Results of external dacryocystorhinostomy and reasons of failure. T Klin J Ophthalmol 2007; 16 :159-162.  Back to cited text no. 20
    
21.Erdöl H, Akyo lN, Imamoðlu HI, Sozen E. Long-term follow-up of external dacryocystorhinostomy and the factors affecting its success. Orbit 2005; 24 :99-102.  Back to cited text no. 21
    
22.Ari ª, Cingü AK, ªahin A, Gün R, Kiniº V, Çaça Ý. Outcomes of revision of external dacryocystorhinostomy and nasal intubation by bicanalicular silicone tubing under endonasal endoscopic guidance. Int J Ophthalmol 2012; 5 :238-241.  Back to cited text no. 22
    
23.Choi YJ, Hwang SJ, Lee TS. Short-term clinical results of amniotic membrane application to endonasaldacryocystorhinostomy. J Korean Ophthalmol Soc 2008; 49 :384-389.  Back to cited text no. 23
    
24.DelaneyYM, Khooshabeh R. External dacryocystorhinostomy for the treatment of acquired partial nasolacrimal obstruction in adults. Br J Ophthalmol 2002; 86 :533-535.  Back to cited text no. 24
    
25.Deka A, Saikia SP, Bhuyan SK. Combined posterior flap and anterior suspended flap dacryocystorhinostomy: a modification of external dacryocystorhinostomy. Oman J Ophthalmol 2010; 3 :18-20.  Back to cited text no. 25
    
26.You YA, Fang CT. Intraoperative mitomycin C in dacryocystorhinostomy. Ophthal Plast Reconstr Surg 2001; 17 :115-119.  Back to cited text no. 26
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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