Comparison of external dacryocystorhinostomy with nonlaser endonasal dacryocystorhinostomy

We compared outcomes after dacryocystorhinostomies (DCRs) performed by the traditional external approach (EX-DCR) or by a nonlaser, nonendoscopic endonasal approach (EN-DCR).

Retrospective, nonrandomized, comparative interventional case series.

A total of 354 consecutive cases of DCR were reviewed in 349 patients performed by one surgeon over a 4-year period with a minimum 1 year of follow-up using either EX-DCR or EN-DCR. Only patients with primary nasolacrimal duct obstruction and no eyelid, lacrimal sac, or canalicular pathology were included.

A total of 153 EX-DCR and 201 EN-DCR patients were identified. EX-DCR was performed under sterile conditions, and EN-DCR was performed with a clean setup. Silicone stents were placed for 3 months.

Patency of the lacrimal system as assessed by history and irrigation. Outcomes were graded as full success, partial success, or failure. Operative durations and postoperative complications were recorded from hospital charts.

There was no significant difference in age or gender distribution between the two groups. The mean operative duration was 34.3 minutes for EX-DCR and 18.5 minutes for EN-DCR (P < 0.0001, t test). Full success was achieved in 90.2% of EX-DCRs and 89.1% of EN-DCRs. Partial success was recorded in 2.0% of EX-DCRs and 4.0% of EN-DCRs. The failure rate was 7.8% for EX-DCR and 7.0% for EN-DCR. There was no statistical significance between these outcomes with a two-sample test for equality of proportions with continuity correction (P = 0.914, power = 80% for alpha = 0.05 to detect a decreased success rate of 12%). Eleven of the failed cases in each group underwent revision EN-DCR surgery, with 90.9% success in each group. Epistaxis requiring perioperative nasal packing occurred in 7 (4.6%) EX-DCR patients and 11 (5.5%) EN-DCR patients. Wound complications in EX-DCR included bruising in four patients, localized infections in two patients, and punctal eversion in six patients. In EN-DCR, inadvertent incision of the periorbita occurred in five patients. One patient reported transient diplopia after the medial rectus was inadvertently pulled during an EN-DCR. Five patients had an EX-DCR on one side and an EN-DCR on the other side. All five reported retrospectively that they preferred the endonasal approach.

The EN-DCR approach is more rapid than the traditional external approach, has an equivalent surgical success rate, and was preferred by patients who had alternative techniques performed on opposite sides.