Indian Journal of Clinical and Experimental Ophthalmology

Print ISSN: 2395-1443

Online ISSN: 2395-1451

CODEN : IJCEKF

Indian Journal of Clinical and Experimental Ophthalmology (IJCEO) is open access, a peer-reviewed medical journal, published quarterly, online, and in print, by the Innovative Education and Scientific Research Foundation (IESRF) since 2015. To fulfil our aim of rapid dissemination of knowledge, we publish articles ‘Ahead of Print’ on acceptance. In addition, the journal allows free access (Open Access) to its content, which is likely to attract more readers and citations of articles published in IJCEO. Manuscripts must be prepared in more...

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Get Permission Pakdel: Very early endoscopic DCR in acute suppurative dacryocystitis perspective


Introduction

Typically acute dacryocystitis is associated with pain, tenderness, erythema, bulging in medial canthal area. Most patients have pre-existing epiphora.3, 4

Traditionally, acute dacryocystitis is managed by systemic antibiotics, trans-cutaneous drainage of abscess, if exists, and late dacryocystorhinostomy (DCR). Recent studies showed an increased success and safety of endoscopic DCR in the acute inflammatory stage.3, 5, 6, 7, 8 However, nomenclature, exact time frame and optimal surgical technique are still elusive in early endoscopic DCR. In this article, we will provide a comprehensive perspective and try to answer the challenges.

Why Shifting to Early Lacrimal Drainage Surgery?

Acute dacryocystitis with extension to peri-orbital and orbital region carries the risk of crucial complications including orbital cellulitis, orbital abscess, central retinal artery occlusion, blindness, extra-ocular dysmotility, superior ophthalmic vein thrombosis and intracranial extension of the infectious process.4, 9, 10, 11, 12, 13

Earlier resolution of infection in medial canthal and orbital region, may decrease the probability of major infection-related complications.3, 4, 14

Lacrimal drainage obstruction can be bypassed through nasal cavity without passing through inflamed and congested tissue of the medial canthal complex, thus potentially decreasing bleeding, fistula and scar formation.4, 14, 15, 16

Finally, earlier resolution of infection and restoration of lacrimal drainage in an earlier stage may accelerate resolution of inflammation,3, 4, 14 reducing the probability and duration of hospital admission, duration of antibiotic therapy and consequently adverse drug related events.17

Evidence Supporting the Shift to Early Endo-Nasal Endoscopic DCR

Surgical success

Endonasal endoscopic surgery was popularized in late 90s and early 2010th using laser assisted surgery resulted in success rate of 67%-83%.11, 12, 13, 14 Success rate after refining of the endonasal endoscopic systems, techniques using cold steel instruments instead of laser, was 82%-94%.3, 4, 7, 15

Pakdel et al. reported similar success rate for very early endoscopic DCR compared to late external DCR.4 Yu and colleagues, in a randomized clinical trial on patients with acute dacryocystitis that underwent endoscopic DCR, found a higher anatomical success rate in patients operated within 2 days compared to those that operated within 3-5 days with earlier resolution of infection and no added complication.18

Time Frame for Early Endoscopic Surgery

There is a wide time-lapse in studies on early endoscopic DCR in patients with acute dacryocystitis, from 2 to 21 days. It sounds rational that an earlier surgical intervention as soon as patients status and operation facilities allow, could result in faster recovery. Wu et al., Li et al., Naik et al. studied endoscopic DCR patients with acute dacryocystitis with a wide time frame of 5 to 21 days and named it as early intervention.3, 16, 19, 20, 21 Pakdel et al. showed significant reduction in inflammation in patients when operated within three days. Thus, named this treatment approach as very early endoscopic DCR (VE-EnDCR).4 Yu et al. in a randomized clinical trial compared urgent (operated within 2 days) to early (operated 3-5 days) endoscopic DCR in patients with acute dacryocystitis.18

Safety

Increased intra-operative bleeding has been argued as a complication of endoscopic DCR on inflamed lacrimal sac. Bleeding has not been regarded as an obstacle for successful endoscopic surgery in acute dacryocystitis. In my experience, I have noticed trivial difference in bleeding in the acutely inflamed compared to non-inflamed conditions, although this was not remarkable or necessitating unusual techniques. Pakdel and associates in a case control study, found that the average duration of inflammatory signs in patients that underwent very early endoscopic DCR (VE-EDCR) and those that underwent late external DCR (L-ExDCR) were 8.00 (SD = 4.63) and 16.11 (SD = 11.58) days, respectively (p = 0.027).4 This was in concert with results of other studies.3, 18 One study on patients with acute dacryocystitis and abscess, showed lower pain and faster resolution of pain in those that underwent early endoscopic DCR compared to those that underwent percutaneous abscess drainage.20

Patient Selection

Based on the current evidence, I may recommend very early endonasal endoscopic DCR to all patients with acute dacryocystitis and primary nasolacrimal duct obstruction (PANDO).

However evidence is scant on early endoscopic DCR in patients with acute suppurative dacryocystitis with secondary nasolacrimal duct obstruction such as traumatic, granulomatous, previously failed DCR, those with complicated infection including orbital cellulitis, orbital abscess and also those patient with immunodeficiency status.

Deductively, very early DCR is advantageous in patients with immunocompromised state such as those with diabetes mellitus, cancers or on treatment with immunosuppressive agents. It is plausible to consider very early endoscopic DCR in those patients with extended or complicated cellulitis including: facial cellulitis, orbital cellulitis, orbital abscess, superior ophthalmic vein thrombosis, cavernous sinus thrombosis and intracranial extension of infection. We found that patients with past complex naso-orbital fractures may have higher failure rate than those with PANDO.4

Conclusion

In conclusion, very early endoscopic DCR can be considered for patients with acute suppurative dacryocystitis secondary to primary nasolacrimal duct obstruction.

Conflict of Interest

None.

References

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EY Li ES Wong AC Wong HK Yuen Primary vs Secondary Endoscopic Dacryocystorhinostomy for Acute Dacryocystitis With Lacrimal Sac Abscess FormationJAMA Ophthalmol2017135121361

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F Pakdel M Soleimani A Kasaei K Ameli N Pirmarzdashti AS Tari Shifting to very early endoscopic DCR in acute suppurative dacryocystitisEye (Lond)2020349164853

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P Duggal NK Mahindroo A Chauhan Primary endoscopic dacryocystorhinostomy as treatment for acute dacryocystitis with abscess formationAm J Otolaryngol20082931779

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F Pakdel Silicone Intubation Does not Improve the Success of Dacryocystorhinostomy in Primary Acquired Nasolacrimal Duct ObstructionJ Ophthalmic Vis Res2012732712

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TS Lee JJ Woog Endonasal Dacryocystorhinostomy in the Primary Treatment of Acute Dacryocystitis with Abscess FormationOphthalmic Plast Reconstr Surg20011731803

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S Morgan The treatment of acute dacryocystitis using laser assisted endonasal dacryocystorhinostomyBr J Ophthalmol200488113941

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NJ Schmitt RL Beatty JS Kennerdell Superior Ophthalmic Vein Thrombosis in a Patient With Dacryocystitis-Induced Orbital CellulitisOphthalmic Plast Reconstr Surg20052153879

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ML Pfeiffer A Hacopian H Merritt ME Phillips K Richani Complete Vision Loss following Orbital Cellulitis Secondary to Acute DacryocystitisCase Rep Ophthalmol Med20162016963069810.1155/2016/9630698

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AK Alsalamah HM Alkatan YH Al-Faky Acute dacryocystitis complicated by orbital cellulitis and loss of vision: A case report and review of the literatureInt J Surg Case Rep2018501304

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SN Madge W Chan R Malhotra Endoscopic Dacryocystorhinostomy in Acute Dacryocystitis: A Multicenter Case SeriesOrbit201130116

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J Huang J Malek D Chin Systematic Review and Meta-Analysis on Outcomes for Endoscopic Versus External DacryocystorhinostomyOrbit20143328190

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S Kamal MJ Ali A Pujari MN Naik Primary Powered Endoscopic Dacryocystorhinostomy in the Setting of Acute Dacryocystitis and Lacrimal AbscessOphthalmic Plast Reconstr Surg20153142935

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BG Bell F Schellevis E Stobberingh H Goossens M Pringle A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistanceBMC Infect Dis201414113

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B Yu Y Tu G Zhou H Hong W Wu Immediate Endoscopic Dacryocystorhinostomy in Patients With New Onset Acute DacryocystitisLaryngoscope2022132227883

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B Yu JY Sun Q Ye YH Tu GM Zhou WC Wu Surgical outcomes in acute dacryocystitis patients undergoing endonasal endoscopic dacryocystorhinostomy with or without silicone tube intubationInt J Ophthalmol20211468448

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SM Naik MK Appaji S Ravishankara AS Mushannavar SS Naik Endonasal DCR with Silicon Tube Stents: A Better Management for Acute Lacrimal AbscessesIndian J Otolaryngol Head Neck Surg201365Suppl 23439

21 

JY Sung JM Kim JY Hwang KN Kim J Kim SB Lee Optimal Timing for Primary Early Endoscopic Dacryocystorhinostomy in Acute DacryocystitisJ Clin Med202110102161



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Article type

Editorial


Article page

317-319


Authors Details

Farzad Pakdel*


Article History

Received : 26-08-2022

Accepted : 06-09-2022


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