Original Investigation
Primary Powered Endoscopic Dacryocystorhinostomy in the Setting of Acute Dacryocystitis and Lacrimal Abscess Saurabh Kamal, M.D., Mohammad Javed Ali, F.R.C.S., Aditi Pujari, M.S., and Milind N. Naik, M.D. Dacryology Service, L V Prasad Eye Institute, Hyderabad, India
Purpose: The purpose of the present study is to report authors’ experience of primary powered endoscopic dacryocystorhinostomy in the setting of acute dacryocystitis and lacrimal sac abscess. Methods: A prospective interventional case series of 20 primary powered endoscopic dacryocystorhinostomies were performed in 20 patients presenting with acute dacryocystitis and lacrimal sac abscess at a tertiary eye care center from April to December 2013. None of the patients received preoperative antibiotics. All cases were operated by single surgeon (M.J.A.) using a standard described technique. All patients were intubated for 6 weeks. A minimum follow up of 6 months after stent removal was considered for the final analysis. The main outcome measures were the resolution of infection and the anatomical and functional successes of the surgical procedure. Results: The mean age at presentation was 39.2 years. Sixty percent of patients (12/20) presented with acute dacryocystitis, 35% (7/20) with a lacrimal abscess, and 5% (1/20) with a dacryopyocele following a failed probing. None of the cases received preoperative antibiotics. Ten percent of patients (2/20) underwent additional septoplasty. All the cases showed resolution of pain and swelling at 1 week follow up. Two patients were noted to have small edge granulomas of the ostium, which were successfully managed by focal excision. At the final follow up, anatomical success was achieved in 95% (19/20) and functional success in 90% (18/20) of the patients. Conclusions: Primary powered endoscopic dacryocystorhinostomy is an effective modality in the management of acute dacryocystitis and lacrimal abscess, and result in rapid resolution of the disease. (Ophthal Plast Reconstr Surg 2015;31:293–295)
A
cute dacryocystitis is a suppurative inflammation of lacrimal sac secondary to a nasolacrimal duct obstruction. It is defined as “a medical urgency which is clinically characterized by rapid onset of pain, erythema and swelling, classically below the medial canthal tendon with or without pre-existing epiphora mainly resulting from the acute infection of the lacrimal sac and perisac tissues.”1 Uncontrolled progression can lead to development of lacrimal abscess as well as preseptal and orbital Accepted for publication July 24, 2014. This study has been reviewed by the ethics committee and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Informed consent was obtained from the patients. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Mohammad Javed Ali, f.r.c.s., Dacryology Service, L V Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad 500034, India. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000309
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
cellulitis.1,2 Traditionally, acute dacryocystitis is treated conservatively with a systemic antibiotic, systemic anti-inflammatory, and if required percutaneous drainage of lacrimal abscess1,3 followed by a dacryocystorhinostomy (DCR) after resolution of infection. Disadvantages of conservative approach include longer time to resolution (mean, 10 days; range, 7–28 days), occurrence of cutaneous fistula (6% cases), prolonged and recurrent infections, and risk of failure of subsequent surgery due to scarring, intrasac synechiae, or organized granulation tissue within the lacrimal sac.1,2,4 Endonasal endoscopic DCR probably has an edge over conservative approach because it can be performed in an acute phase, decreases the morbidity, and hastens the recovery.4,5 Few studies have obtained good results with early surgical management of acute dacryocystitis with reported success rates of up to 94.4%.4–8 The purpose of the present study is to report authors’ experience and efficacy in primary powered endoscopic DCR in cases of acute dacryocystitis and lacrimal sac abscess.
METHODS A prospective interventional case series of 20 primary powered endoscopic DCRs were performed in 20 patients presenting with acute dacryocystitis and lacrimal sac abscess at a tertiary eye care center from April to December 2013. Institutional review board approval was obtained, and the study adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all the patients. Demographic data, clinical features, previous lacrimal surgical intervention, final diagnosis, and complications were noted. None of the patients received preoperative antibiotics. All cases were operated by a single surgeon (M.J.A.) within a day of presentation. A minimum follow up of 6 months after stent removal was considered for the final analysis. Surgical Technique. Under general anesthetic, all the patients underwent powered endoscopic DCR as described by Wormald.9 The lateral wall and head of the middle turbinate (MT) were injected with 2% lidocaine with 1:80,000 adrenaline, and nasal mucosa was decongested with neuropatties soaked in the same solution. In brief, the technique described by Wormald can be summarized as follows. Using a 30° nasal endoscope, the procedure is begun by raising a posteriorly based mucosal flap centered over the lacrimal sac. The incision for this flap begins 8 mm above the axilla of the MT and is continued anteriorly approximately 8 mm to 10 mm. A vertical incision is continued inferiorly to the insertion of the inferior turbinate before a horizontal incision is directed posteriorly back to the insertion of uncinate process. Using a suction freer elevator, the mucosal flap is then raised off the lateral wall to expose the frontal process of maxilla and its junction with lacrimal bone. A small round knife is then used to remove the thin lacrimal bone from the sac before using a Hajek-Kopfler forward punch (Karl Storz, Tuttlingen, Germany) to remove the remaining bone covering nasolacrimal duct and frontal process of maxilla. Once the bone becomes thick and is not amenable to punch removal above the axilla of the middle turbinate, a curved high-speed diamond burr (Synthes, West Chester, PA, USA) is used to remove the rest of the bone to expose the sac completely. The agger nasi is exposed during this process
293
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
S. Kamal et al.
because the fundus of sac extends above the axilla of middle turbinate. Once the entire sac is fully exposed, a Bowman’s probe tents the medial sac wall, which is incised vertically along its entire length to create anterior and posterior flaps. Horizontal cuts superiorly and inferiorly in lacrimal sac flaps allow them to be reflected onto the lateral nasal wall like an open book. The initial nasal mucosal flap that was raised to expose the sac is now refashioned and reflected back to cover the superior and inferior exposed bone and achieve a good mucosa to mucosa apposition. Any intrasac synechiae noted were gently released with crescent knife. Mitomycin-C (0.02%) was applied for 3 minutes. Circumostial injection of mitomycin-C was performed as described earlier by the authors.10 All patients were intubated using a Crawford bicanalicular silicone stent, which was removed after 6 weeks. Postoperatively, all cases received oral antibiotics (co-amoxiclav) and anti-inflammatory (ibuprofen) for 1 week. Topical antibiotics (tobramycin) and tapering mild topical steroid eye drops (fluorometholone) were used for 2 weeks. Postoperative follow up and nasal endoscopic evaluations were performed in 1 week, 6 week, 3 months and 6 months. The main outcome measures were resolution of infection and anatomical and functional successes. Anatomical success was defined as patent ostium on irrigation and functional success as free flow of dye in ostium on functional endoscopic dye test and resolution of epiphora.
RESULTS Twenty powered endoscopic DCRs were performed in 20 patients. The mean age at presentation was 39.2 years (standard deviation = 20.2; range, 3–68 years). The male to female ratio was 1:3 (5:15). Fifty-five percent (11/20) of the cases involved the left lacrimal system. Of the 20 patients, 60% (12/20) presented with acute dacryocystitis, 35% (7/20) with a lacrimal abscess, and 5% (1/20) with a dacryopyocele following a failed probing. All the patients had a prior history of epiphora with 90% (18/20) having constant watering and the remaining 10% (2/20) experiencing it intermittently. Twenty-five percent (5/20) of the cases had history of at least 1 attack of acute dacryocystitis in the past 1 year. None of the cases received preoperative antibiotics before surgery. Ten percent (2/20) of the cases underwent additional septoplasty along with endoscopic DCR. An increase in the perioperative bleeding was noted in all the cases but none to the extent of interfering with the surgical procedure. All the cases showed the resolution of pain and swelling at 1 week follow up. Two patients were noted to have small granulomas at the edge of ostium, which were successfully managed by focal excision. At the final follow up, epiphora resolved in all patients except 2. One had a complete cicatricial closure of the ostium, and the other had epiphora despite a patent ostium. The anatomical success was achieved in 95% (19/20) and functional success in 90% (18/20) of the patients.
DISCUSSION External DCR is not preferred in the setting of an acute dacryocystitis because of the risk of spread of infection, subsequent development of fistula or nonhealing wound, and associated surgical difficulties.3,7 Percutaneous incision and drainage of abscess carries the risk of injury to the lacrimal sac and is painful for patients because local anesthesia does not achieve the desired effect. In fact the drainage of cutaneous abscess was regarded by patients as the second most painful procedure in the emergency department despite the use of local anesthesia.11,12 Endonasal DCR by virtue of its approach overcomes many of these disadvantages. Endonasal endoscopic DCR has been used for early surgical management of acute dacryocystitis.4–8 Studies using laserassisted endoscopic DCR in acute dacryocystitis5,6 have reported lower success rate of 67% to 83% as compared with 90% to 94% seen with standard mechanical endoscopic DCRs.4,7 The technique of primary powered endoscopic DCR allows creation of a large osteotomy sufficient to expose the entire lacrimal sac, and
294
facilitates complete sac marsupialization and a perfect mucosa to mucosa apposition allowing healing by primary intention. This technique has reported success rates comparable with an external DCR even at a long-term follow up.9,13,14 Madge et al.7 retrospectively analyzed 18 cases of acute dacryocystitis treated with endoscopic DCR in their multicentric study. All patients underwent intubation, and 27.8% of them were subjected to mitomycin-C application. Resolution of acute dacryocystitis was noted in all cases with no recurrences. The anatomical and functional successes were achieved in 94.44% of patients. Comparable success rates with good health economics were proposed as arguments for early surgical intervention. The current study also used circumostial injection of mitomycin-C technique of mitomycin C application in all their patients as per described protocol10 and was able to achieve final anatomical success rates of 95%. Duggal et al.8 exclusively studied the benefits of a nonpowered, mechanical endoscopic DCR in 11 patients with lacrimal abscess. All the patients had a past history of epiphora and acute dacryocystitis. They reported resolution of signs and symptoms in all patients following surgery and reported anatomical success in 81.8% and functional success in 72.7% of their patients. Preoperative antibiotics have been used in previous published reports of endoscopic DCR in acute dacryocystitis.4–8 Although patients in authors’ series did not receive any preoperative systemic antibiotics, they believe it may be necessary in cases of cellulitis, orbital involvement, and associated sinusitis. None of the patients in authors’ series presented with these complications. No additional complications have been reported with the use of silicone intubation in setting of acute dacryocystitis when compared with routine cases.4,5 However, 2 studies have raised concerns that silicone intubation can promote granulation tissue, and in acute dacryocystitis its placement can be difficult as a result of edema and cellulitis.8,15 However, neither did authors observe any technical difficulty in its placement nor did they observe any tube-related complications in their series. The strengths of the current study are single operating surgeon and a uniform surgical technique. The limitation of the current study is a small sample size, although it is comparable with an earlier multicentric study.7 In conclusion, powered endoscopic DCR is a safe and effective modality for primary treatment of acute dacryocystitis and lacrimal abscess with a good success rate.
REFERENCES 1. Ali MJ, Joshi SD, Naik MN, Honavar SG. Clinical profile and management outcome of acute dacryocystitis: two decades of experience in tertiary eye care centre. Semin Ophthalmol 2015;30:118–23. 2. Ali MJ, Motukupally SR, Joshi SD, et al. The microbiological profile of lacrimal abscess: two decades of experience from a tertiary eye care center. J Ophthalmic Inflamm Infect 2013;3:57–61. 3. Cahill KV, Burns JA. Management of acute dacryocystitis in adults. Ophthal Plast Reconstr Surg 1993;9:38–41; discussion 42. 4. Wu W, Yan W, MacCallum JK, et al. Primary treatment of acute dacryocystitis by endoscopic dacryocystorhinostomy with silicone intubation guided by a soft probe. Ophthalmology 2009;116:116–22. 5. Lee TS, Woog JJ. Endonasal dacryocystorhinostomy in the primary treatment of acute dacryocystitis with abscess formation. Ophthal Plast Reconstr Surg 2001;17:180–3. 6. Morgan S, Austin M, Whittet H. The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy. Br J Ophthalmol 2004;88:139–41. 7. Madge SN, Chan W, Malhotra R, et al. Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series. Orbit 2011;30:1–6. 8. Duggal P, Mahindroo NK, Chauhan A. Primary endoscopic dacryocystorhinostomy as treatment for acute dacryocystitis with abscess formation. Am J Otolaryngol 2008;29:177–9. 9. Wormald PJ. Powered endoscopic dacryocystorhinostomy. Laryngoscope 2002;112:69–72.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
10. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 11. Korownyk C, Allan GM. Evidence-based approach to abscess management. Can Fam Physician 2007;53:1680–4. 12. Singer AJ, Richman PB, Kowalska A, et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999;33:652–8.
Endoscopic DCR in Acute Dacryocystitis and Lacrimal Abscess
13. Ali MJ, Psaltis AJ, Murphy J, Wormald PJ. Powered endoscopic dacryocystorhinostomy: a decade of experience. Ophthal Plast Reconstr Surg 2015;31:219–21. 14. Ali MJ, Psaltis AJ, Bassiouni A, et al. Long-term outcomes in primary powered endoscopic dacryocystorhinostomy. Br J Ophthalmol 2014;98:1678–80. 15. Walland MJ, Rose GE. The effect of silicone intubation on failure and infection rates after dacryocystorhinostomy. Ophthalmic Surg 1994;25:597–600.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
295
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Primary Powered Endoscopic Dacryocystorhinostomy in the Setting of Acute Dacryocystitis and Lacrimal Abscess Saurabh Kamal, M.D., Mohammad Javed Ali, F.R.C.S., Aditi Pujari, M.S., and Milind N. Naik, M.D. Dacryology Service, L V Prasad Eye Institute, Hyderabad, India
Purpose: The purpose of the present study is to report authors’ experience of primary powered endoscopic dacryocystorhinostomy in the setting of acute dacryocystitis and lacrimal sac abscess. Methods: A prospective interventional case series of 20 primary powered endoscopic dacryocystorhinostomies were performed in 20 patients presenting with acute dacryocystitis and lacrimal sac abscess at a tertiary eye care center from April to December 2013. None of the patients received preoperative antibiotics. All cases were operated by single surgeon (M.J.A.) using a standard described technique. All patients were intubated for 6 weeks. A minimum follow up of 6 months after stent removal was considered for the final analysis. The main outcome measures were the resolution of infection and the anatomical and functional successes of the surgical procedure. Results: The mean age at presentation was 39.2 years. Sixty percent of patients (12/20) presented with acute dacryocystitis, 35% (7/20) with a lacrimal abscess, and 5% (1/20) with a dacryopyocele following a failed probing. None of the cases received preoperative antibiotics. Ten percent of patients (2/20) underwent additional septoplasty. All the cases showed resolution of pain and swelling at 1 week follow up. Two patients were noted to have small edge granulomas of the ostium, which were successfully managed by focal excision. At the final follow up, anatomical success was achieved in 95% (19/20) and functional success in 90% (18/20) of the patients. Conclusions: Primary powered endoscopic dacryocystorhinostomy is an effective modality in the management of acute dacryocystitis and lacrimal abscess, and result in rapid resolution of the disease. (Ophthal Plast Reconstr Surg 2015;31:293–295)
A
cute dacryocystitis is a suppurative inflammation of lacrimal sac secondary to a nasolacrimal duct obstruction. It is defined as “a medical urgency which is clinically characterized by rapid onset of pain, erythema and swelling, classically below the medial canthal tendon with or without pre-existing epiphora mainly resulting from the acute infection of the lacrimal sac and perisac tissues.”1 Uncontrolled progression can lead to development of lacrimal abscess as well as preseptal and orbital Accepted for publication July 24, 2014. This study has been reviewed by the ethics committee and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Informed consent was obtained from the patients. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Mohammad Javed Ali, f.r.c.s., Dacryology Service, L V Prasad Eye Institute, Road No 2, Banjara Hills, Hyderabad 500034, India. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000309
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
cellulitis.1,2 Traditionally, acute dacryocystitis is treated conservatively with a systemic antibiotic, systemic anti-inflammatory, and if required percutaneous drainage of lacrimal abscess1,3 followed by a dacryocystorhinostomy (DCR) after resolution of infection. Disadvantages of conservative approach include longer time to resolution (mean, 10 days; range, 7–28 days), occurrence of cutaneous fistula (6% cases), prolonged and recurrent infections, and risk of failure of subsequent surgery due to scarring, intrasac synechiae, or organized granulation tissue within the lacrimal sac.1,2,4 Endonasal endoscopic DCR probably has an edge over conservative approach because it can be performed in an acute phase, decreases the morbidity, and hastens the recovery.4,5 Few studies have obtained good results with early surgical management of acute dacryocystitis with reported success rates of up to 94.4%.4–8 The purpose of the present study is to report authors’ experience and efficacy in primary powered endoscopic DCR in cases of acute dacryocystitis and lacrimal sac abscess.
METHODS A prospective interventional case series of 20 primary powered endoscopic DCRs were performed in 20 patients presenting with acute dacryocystitis and lacrimal sac abscess at a tertiary eye care center from April to December 2013. Institutional review board approval was obtained, and the study adhered to the tenets of the Declaration of Helsinki. Informed consent was obtained from all the patients. Demographic data, clinical features, previous lacrimal surgical intervention, final diagnosis, and complications were noted. None of the patients received preoperative antibiotics. All cases were operated by a single surgeon (M.J.A.) within a day of presentation. A minimum follow up of 6 months after stent removal was considered for the final analysis. Surgical Technique. Under general anesthetic, all the patients underwent powered endoscopic DCR as described by Wormald.9 The lateral wall and head of the middle turbinate (MT) were injected with 2% lidocaine with 1:80,000 adrenaline, and nasal mucosa was decongested with neuropatties soaked in the same solution. In brief, the technique described by Wormald can be summarized as follows. Using a 30° nasal endoscope, the procedure is begun by raising a posteriorly based mucosal flap centered over the lacrimal sac. The incision for this flap begins 8 mm above the axilla of the MT and is continued anteriorly approximately 8 mm to 10 mm. A vertical incision is continued inferiorly to the insertion of the inferior turbinate before a horizontal incision is directed posteriorly back to the insertion of uncinate process. Using a suction freer elevator, the mucosal flap is then raised off the lateral wall to expose the frontal process of maxilla and its junction with lacrimal bone. A small round knife is then used to remove the thin lacrimal bone from the sac before using a Hajek-Kopfler forward punch (Karl Storz, Tuttlingen, Germany) to remove the remaining bone covering nasolacrimal duct and frontal process of maxilla. Once the bone becomes thick and is not amenable to punch removal above the axilla of the middle turbinate, a curved high-speed diamond burr (Synthes, West Chester, PA, USA) is used to remove the rest of the bone to expose the sac completely. The agger nasi is exposed during this process
293
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
S. Kamal et al.
because the fundus of sac extends above the axilla of middle turbinate. Once the entire sac is fully exposed, a Bowman’s probe tents the medial sac wall, which is incised vertically along its entire length to create anterior and posterior flaps. Horizontal cuts superiorly and inferiorly in lacrimal sac flaps allow them to be reflected onto the lateral nasal wall like an open book. The initial nasal mucosal flap that was raised to expose the sac is now refashioned and reflected back to cover the superior and inferior exposed bone and achieve a good mucosa to mucosa apposition. Any intrasac synechiae noted were gently released with crescent knife. Mitomycin-C (0.02%) was applied for 3 minutes. Circumostial injection of mitomycin-C was performed as described earlier by the authors.10 All patients were intubated using a Crawford bicanalicular silicone stent, which was removed after 6 weeks. Postoperatively, all cases received oral antibiotics (co-amoxiclav) and anti-inflammatory (ibuprofen) for 1 week. Topical antibiotics (tobramycin) and tapering mild topical steroid eye drops (fluorometholone) were used for 2 weeks. Postoperative follow up and nasal endoscopic evaluations were performed in 1 week, 6 week, 3 months and 6 months. The main outcome measures were resolution of infection and anatomical and functional successes. Anatomical success was defined as patent ostium on irrigation and functional success as free flow of dye in ostium on functional endoscopic dye test and resolution of epiphora.
RESULTS Twenty powered endoscopic DCRs were performed in 20 patients. The mean age at presentation was 39.2 years (standard deviation = 20.2; range, 3–68 years). The male to female ratio was 1:3 (5:15). Fifty-five percent (11/20) of the cases involved the left lacrimal system. Of the 20 patients, 60% (12/20) presented with acute dacryocystitis, 35% (7/20) with a lacrimal abscess, and 5% (1/20) with a dacryopyocele following a failed probing. All the patients had a prior history of epiphora with 90% (18/20) having constant watering and the remaining 10% (2/20) experiencing it intermittently. Twenty-five percent (5/20) of the cases had history of at least 1 attack of acute dacryocystitis in the past 1 year. None of the cases received preoperative antibiotics before surgery. Ten percent (2/20) of the cases underwent additional septoplasty along with endoscopic DCR. An increase in the perioperative bleeding was noted in all the cases but none to the extent of interfering with the surgical procedure. All the cases showed the resolution of pain and swelling at 1 week follow up. Two patients were noted to have small granulomas at the edge of ostium, which were successfully managed by focal excision. At the final follow up, epiphora resolved in all patients except 2. One had a complete cicatricial closure of the ostium, and the other had epiphora despite a patent ostium. The anatomical success was achieved in 95% (19/20) and functional success in 90% (18/20) of the patients.
DISCUSSION External DCR is not preferred in the setting of an acute dacryocystitis because of the risk of spread of infection, subsequent development of fistula or nonhealing wound, and associated surgical difficulties.3,7 Percutaneous incision and drainage of abscess carries the risk of injury to the lacrimal sac and is painful for patients because local anesthesia does not achieve the desired effect. In fact the drainage of cutaneous abscess was regarded by patients as the second most painful procedure in the emergency department despite the use of local anesthesia.11,12 Endonasal DCR by virtue of its approach overcomes many of these disadvantages. Endonasal endoscopic DCR has been used for early surgical management of acute dacryocystitis.4–8 Studies using laserassisted endoscopic DCR in acute dacryocystitis5,6 have reported lower success rate of 67% to 83% as compared with 90% to 94% seen with standard mechanical endoscopic DCRs.4,7 The technique of primary powered endoscopic DCR allows creation of a large osteotomy sufficient to expose the entire lacrimal sac, and
294
facilitates complete sac marsupialization and a perfect mucosa to mucosa apposition allowing healing by primary intention. This technique has reported success rates comparable with an external DCR even at a long-term follow up.9,13,14 Madge et al.7 retrospectively analyzed 18 cases of acute dacryocystitis treated with endoscopic DCR in their multicentric study. All patients underwent intubation, and 27.8% of them were subjected to mitomycin-C application. Resolution of acute dacryocystitis was noted in all cases with no recurrences. The anatomical and functional successes were achieved in 94.44% of patients. Comparable success rates with good health economics were proposed as arguments for early surgical intervention. The current study also used circumostial injection of mitomycin-C technique of mitomycin C application in all their patients as per described protocol10 and was able to achieve final anatomical success rates of 95%. Duggal et al.8 exclusively studied the benefits of a nonpowered, mechanical endoscopic DCR in 11 patients with lacrimal abscess. All the patients had a past history of epiphora and acute dacryocystitis. They reported resolution of signs and symptoms in all patients following surgery and reported anatomical success in 81.8% and functional success in 72.7% of their patients. Preoperative antibiotics have been used in previous published reports of endoscopic DCR in acute dacryocystitis.4–8 Although patients in authors’ series did not receive any preoperative systemic antibiotics, they believe it may be necessary in cases of cellulitis, orbital involvement, and associated sinusitis. None of the patients in authors’ series presented with these complications. No additional complications have been reported with the use of silicone intubation in setting of acute dacryocystitis when compared with routine cases.4,5 However, 2 studies have raised concerns that silicone intubation can promote granulation tissue, and in acute dacryocystitis its placement can be difficult as a result of edema and cellulitis.8,15 However, neither did authors observe any technical difficulty in its placement nor did they observe any tube-related complications in their series. The strengths of the current study are single operating surgeon and a uniform surgical technique. The limitation of the current study is a small sample size, although it is comparable with an earlier multicentric study.7 In conclusion, powered endoscopic DCR is a safe and effective modality for primary treatment of acute dacryocystitis and lacrimal abscess with a good success rate.
REFERENCES 1. Ali MJ, Joshi SD, Naik MN, Honavar SG. Clinical profile and management outcome of acute dacryocystitis: two decades of experience in tertiary eye care centre. Semin Ophthalmol 2015;30:118–23. 2. Ali MJ, Motukupally SR, Joshi SD, et al. The microbiological profile of lacrimal abscess: two decades of experience from a tertiary eye care center. J Ophthalmic Inflamm Infect 2013;3:57–61. 3. Cahill KV, Burns JA. Management of acute dacryocystitis in adults. Ophthal Plast Reconstr Surg 1993;9:38–41; discussion 42. 4. Wu W, Yan W, MacCallum JK, et al. Primary treatment of acute dacryocystitis by endoscopic dacryocystorhinostomy with silicone intubation guided by a soft probe. Ophthalmology 2009;116:116–22. 5. Lee TS, Woog JJ. Endonasal dacryocystorhinostomy in the primary treatment of acute dacryocystitis with abscess formation. Ophthal Plast Reconstr Surg 2001;17:180–3. 6. Morgan S, Austin M, Whittet H. The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomy. Br J Ophthalmol 2004;88:139–41. 7. Madge SN, Chan W, Malhotra R, et al. Endoscopic dacryocystorhinostomy in acute dacryocystitis: a multicenter case series. Orbit 2011;30:1–6. 8. Duggal P, Mahindroo NK, Chauhan A. Primary endoscopic dacryocystorhinostomy as treatment for acute dacryocystitis with abscess formation. Am J Otolaryngol 2008;29:177–9. 9. Wormald PJ. Powered endoscopic dacryocystorhinostomy. Laryngoscope 2002;112:69–72.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Ophthal Plast Reconstr Surg, Vol. 31, No. 4, 2015
10. Kamal S, Ali MJ, Naik MN. Circumostial injection of mitomycin C (COS-MMC) in external and endoscopic dacryocystorhinostomy: efficacy, safety profile, and outcomes. Ophthal Plast Reconstr Surg 2014;30:187–90. 11. Korownyk C, Allan GM. Evidence-based approach to abscess management. Can Fam Physician 2007;53:1680–4. 12. Singer AJ, Richman PB, Kowalska A, et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999;33:652–8.
Endoscopic DCR in Acute Dacryocystitis and Lacrimal Abscess
13. Ali MJ, Psaltis AJ, Murphy J, Wormald PJ. Powered endoscopic dacryocystorhinostomy: a decade of experience. Ophthal Plast Reconstr Surg 2015;31:219–21. 14. Ali MJ, Psaltis AJ, Bassiouni A, et al. Long-term outcomes in primary powered endoscopic dacryocystorhinostomy. Br J Ophthalmol 2014;98:1678–80. 15. Walland MJ, Rose GE. The effect of silicone intubation on failure and infection rates after dacryocystorhinostomy. Ophthalmic Surg 1994;25:597–600.
© 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
295
Copyright © 2014 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
