Tranexamic Acid in Dacryocystorhinostomy: A Systematic Review

Tranexamic acid (TXA) is an antifibrinolytic drug that inhibits the conversion of plasminogen to plasmin, thereby reducing the enzymatic degradation of fibrin and preserving hemostasis across various surgical fields. Dacryocystorhinostomy (DCR) is a frequently performed surgical procedure to manage nasolacrimal duct obstruction (NLDO), in which intraoperative bleeding remains a significant challenge that may impair visualization and prolong operative time. However, the overall impact of TXA in DCR remains uncertain. This systematic review aimed to examine the current research on the role of TXA in DCR, focusing on its impact on intraoperative bleeding, surgical duration, and surgical field clarity. The systematic review was conducted in compliance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. PubMed/MEDLINE, Cochrane, and Google Scholar databases were searched up to March 30, 2025, and randomized controlled trials (RCTs) assessing TXA use in DCR were identified. Studies were screened and selected based on predefined eligibility criteria. Four RCTs involving a total of 286 patients were included. Three studies compared intravenous or topical TXA with normal saline (placebo), and one compared TXA with hydralazine and remifentanil. Two studies, one evaluating intravenous administration and the other topical administration of TXA, demonstrated a statistically significant decrease in both intraoperative hemorrhage and surgical duration. However, one trial reported no significant difference in the assessed outcomes, and the study that compared TXA with alternative agents found greater efficacy with hydralazine and remifentanil. Surgical field clarity and surgeon satisfaction improved with TXA in some cases, but the results were not statistically significant. A low risk of bias was identified in one trial, whereas the remaining studies were judged to raise some concerns, largely attributed to subjective outcome measures. TXA may be effective in reducing intraoperative hemorrhage and surgical time during DCR, with both topical and intravenous routes demonstrating potential benefits. However, the available evidence remains limited due to small sample sizes, variable outcome measures, and subjective assessments. Further research is required to improve the robustness of the evidence and establish the most effective dosing regimens.