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P. S. Hull, S. A. Lalchan, J. M. Olver; Optimising Success in Endoscopic Revision Surgery for Failed Dacryocystorhinostomy. Invest. Ophthalmol. Vis. Sci. 2009;50(13):4830.
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© ARVO (1962-2015); The Authors (2016-present)
To assess the main causes of failure of dacryocystorhinostomy (DCR) surgery and recommend techniques to increase success with revision endonasal DCR.
We report on our experience of fifteen endoscopic revision DCR surgeries in fourteen patients (eight female, six male) with previous failed endonasal, endolaser or external DCR presenting with recurrent nasolacrimal duct obstruction. Study duration was one year. Causative factors for failure were assessed in clinic, at surgery and post operatively from review of surgical videos. All cases were revised by one surgeon via an endonasal approach, irrespective of whether previous surgery was external or endonasal. All patients had temporary bicanalicular stenting with silicone tubes. Nasal mucosal flaps were intentionally removed.
Pre revision surgery, symptoms of epiphora occurred in all cases with two also experiencing mucous discharge. Of the fifteen cases, 67% had one previous failed DCR surgery, 27% two previous failed DCR surgeries and 7% three previous failed DCR surgeries. Regarding the previous surgery, 57% were external, 33% endonasal and 10% endolaser DCR.Most cases had multiple aetiologies for previous failure. The primary aetiology was a blocked ostium due to membranous scarring (73%). 27% had sump syndrome with mucosa obstructing the ostium. 27% of cases had an ostium that was too small and 20% an ostium that was too high. Two cases (13%) had a common canalicular block. At the time of revision DCR surgery, five cases (33%) needed additional partial middle turbinectomy, four (27%) required anterior ethmoidectomy and three (20%) had both. One patient needed further revision surgery with a septoplasty to achieve success.Minimum follow up was 4 months (range 4 months to 14 months). The short term results of this ongoing study indicate that 87% of cases have had a symptomatically successful outcome.
The main aim of DCR surgery is to open the lacrimal sac fully, to ensure unimpeded flow of tears from the common canaliculus in to the nose. Patients typically have multiple aetiologies for failure most frequently with obstruction of the ostium by scarring. We recommend using direct visualisation endonasally during revision surgery, to ensure the optimal position and size of the ostium without any remnants of bone or mucosa to cause obstruction. Flexibility of surgical technique using instruments such as the microdebrider and diamond burr along with additional procedures such as middle turbinectomy to widen the nasal space, greatly help to achieve precise, successful, revision surgery.
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