Oct 292012

(Please see my original post on DCR alternatives if you haven’t already.)

Here is a list of some additional studies supporting alternative or at least precursors to DCR surgery. This is by no means a complete collection of relevant studies, but it’s a solid foundation for your further research. One of the most common lines you’ll hear from a doctor looking to write off something he or she is ignorant of is this: ‘You can’t base your practices on a single study.’ Yes, this is true. A single study doesn’t prove much. But we’re not looking at a single study. When this list was originally complied (2007), there were already dozens and dozens of studies. As of this writing, fives years later, there are even more. The research is solid. Doctors can’t keep on ignoring the facts.


Dacryocystorhinostomy for partial nasolacrimal obstruction

Br J Ophthalmol. 2002 September

‘Although we agree that most patients with PNLO may eventually require a DCR the importance of giving a thorough trial to less invasive treatments such as forced syringing, stents, balloon dacryoplasty, and silicone intubation before undertaking a DCR in such cases has not been adequately emphasised. It is true that variable results have been reported with these techniques but there are studies which show success rates as high as 73.3% with antegrade balloon dilatation combined with silicone intubation even in cases of complete nasolacrimal obstruction over a 1 year follow up.’

Resolution of Epiphora with Nasolacrimal Stents: Results of Long-term Follow-up in a Multicenter Prospective Study

J Vasc Interv Radiol, 2003

PURPOSE: To evaluate in a prospective, multicenter setting the long-term effectiveness of polyurethane stents in the percutaneous management of epiphora.

RESULTS: The initial technical success rate of stent placement was 95%. The average time of the procedure was 6 minutes (range, 3–70). Resolution of epiphora was complete in 452 eyes and partial in 18. On follow-up (mean, 24 months; range, 1 week to 67 months), 340 of 496 stents remained patent (68.5%).

Nasolacrimal Stents in the Management of Epiphora: Medium-term Results of a Multicenter Prospective Study

PURPOSE: To evaluate in a prospective multicenter setting the clinical utility of polyurethane stents in the percutaneous management of epiphora.

Initial technical success rate of stent placement was 97%. Resolution of epiphora was complete in 175 eyes  and partial in five. On follow-up (mean 5 450 d; range 5 8–730 d), 157 of 183 stents remained patent (85.8%). Of the 24 obstructed, 19 were easily withdrawn and 17 of these patients remained asymptomatic for a mean of 15 months (secondary patency rate 5 89.5%).

CONCLUSIONS: The procedure is simple and safe. It can be performed on an outpatient basis and the original technique could be improved with some technical modifications. It is well tolerated by patients and may be considered as a valid alternative technique for the resolution of epiphora.

Nasolacrimal intubation in adults

Br J Ophthalmology, 1998

Background/aims—Silicone intubation has been shown to be successful in the management of epiphora in children. The effectiveness of this procedure was assessed in adults.

Results—Complete resolution of symptoms was reported in 54.3%. A partial improvement was reported in 14.3%.

Conclusion—Silicone intubation of the nasolacrimal system is a successful procedure in the management of adult epiphora.

Silicone Intubation and Postoperative Mitomycin Application for Partial Nasolacrimal Duct Obstruction in Adults

J Korean Ophthalmol Soc. 2005 Jan

PURPOSE: This study nasolacrimal duct (NLD) stenosis in adult, evaluated the clinical results of treatment with topical 0.04% mitomycin C (MMC) eyedrops after silicone tube intubation.

RESULTS: The mean follow-up periods was 9.3 months. Twenty-two eyes (76%) showed no epiphora and complete passing into the cavity by lacrimal irrigation.

CONCLUSIONS: Silicone tube intubation with topical MMC eyedrops for treatment of patients with tearing due to NLD stenosis is effective, safe and easy. This technique can be tried before DCR if the surgeon has a thorough of nasal cavity anatomy and probing.

Nasolacrimal stenting: toward improving outcomes with a simple modification of the song stent

Cardiovasc Intervent Radiol, 2006 Jul-Aug

‘The initial technical success rate of stent placement was 97%. Resolution of epiphora was complete in 180 eyes and partial in 3. On follow-up (mean = 18 months; range: 2 days to 24 months), 165 of 195 stents (85%) remained patent. Primary patency rates at follow-up were 86%, 84%, 84%, and 79% in the first 6 months, second and third 6 months, and the present (24 months), respectively. Stents became obstructed in 30 patients, but all but 2 were easily withdrawn and 20 of these patients remained asymptomatic for a mean of 14 months (secondary patency of 67%).’

Long term follow up of nasolacrimal intubation in adults

Br J Ophthalmol. 2006 Apr

AIMS: The authors have previously reported a short term mean 15 month follow up of nasolacrimal intubation in adults. The effectiveness of this procedure for long term (mean 78 months) control of epiphoria is assessed here.

RESULTS: Complete long term resolution of symptoms was reported in 50.7%. A partial improvement was reported in 38.5%, and no improvement in 10.7%. A better outcome was associated with a canalicular than nasolacrimal duct obstruction. On long term follow up 16.9% required dacrocysto-rhinostomy (DCR). CONCLUSION: Nasolacrimal intubation, a minimally invasive procedure is successful in the long term control of epiphora. Selection of patients with canalicular duct obstruction gives higher success rates with fewer patients subsequently requiring the DCR procedure.

Transluminal Balloon Dilatation of the Lacrimal Drainage System for the Treatment of Epiphora

AJR, 1995

‘Technical success was achieved in all 19 eyes with incomplete obstruction and in 46 (75%) of 61 eyes with complete obstruction. Initial success was achieved in all 19 eyes with incomplete obstruction and in 36 (59%) of 61 eyes with complete obstruction. In a follow-up period of 6-i 8 months (mean, I 3 months ), reobstruction occurred in none of the eyes with incomplete and in two eyes with complete obstruction.

CONCLUSION. Our experience shows that transluminal balloon dilatation is an effective treatment for incomplete obstruction of the LDS.’

Dacryocystoplasty: Treatment of Epiphora by Means Of Balloon Dilation of the Obstructed Nasolacrimal Duct System

Radiology, 1994

‘In 18 of these cases (90%), results comparable with those of dacryocystorhinostomy were achieved. No side effects were observed.’

CONCLUSION: DCP is potentially the treatment of choice for epiphora due to acquired stenotic obstruction of the nasolacrimal duct system.’

Clinical Effectiveness of Balloon Dacryocystoplasty in Circumscribed Obstructions of the Nasolacrimal Duct

Ophthalmologica, 2007

‘The main argument to continue DCP as first or second line treatment in selected patients with duct obstructions is its lack of invasiveness. Even patients with increased risk of general anesthesia can be treated and approximately half of the operations may be avoided.’

Long-term results of balloon dacryocystoplasty: success rates according to the site and severity of the obstruction

Eye, 2007 Aug

‘The clinical success rate was 57.1% in common canalicular (complete: 33.3%, partial: 75%), 50% in proximal nasolacrimal duct (complete: 38.5%, partial: 64.5%), and 68.2% in distal nasolacrimal duct (complete: 57.1%, partial: 73.3%) obstructions. The overall success was 54.5% (54/99 eyes) for the entire series at the last clinical follow-up visit.’

Obstructed Nasolacrimal Duct System in Epiphora: Long-term Results of Dacryocystoplasty by Means of Balloon Dilation

Radiology, 1997

‘The long-term primary patency rate was 70%. Repeat dacryocystoplasty was successful in 10 of the 11 cases with initial failure or reobstruction during follow-up, which yielded a long-term secondary patency rate of 81%.’

Treatment of obstructive epiphora in adults by balloon dacryocystoplasty

Br J Ophthalmol, 1999

‘Balloon dilatation may prove suitable for the treatment of patients with partial obstruction below the level of the lacrimal sac, especially in those who are poor candidates for surgery, or who do not wish to undertake dacryocystorhinostomy.’

Efficacy of probing as treatment of epiphora in adults with blocked nasolacrimal ducts

Br J Ophthalmol, Apr 1998

AIMS—To determine the efficacy of probing in the initial treatment of epiphora and the symptom free period in adults with blocked nasolacrimal ducts.

RESULTS—35% of the eyes had an outcome of no watering after probing, 17% mild watering, 35% moderate watering, and 11% severe watering. The patients’ satisfaction (watering subjectively improved) after undergoing this procedure was 82%, which is higher than previously reported. The mean symptom free period in eyes with no watering was 11.25 months

CONCLUSIONS—Probing in adults with confirmed nasolacrimal duct obstruction can be recommended as an initial treatment procedure because of its relatively good efficacy and high patient satisfaction without compromising subsequent surgical treatment if unsuccessful.

 Posted by on October 29, 2012

  One Response to “Additional Studies Supporting Alternatives to DCR”

  1. Hello George,
    I just wanted to thank you for all the good info in your blog. Thanks lots!

    I don’t know if you recall my situation, I wanted your advice please. I’ve had problems over several years getting the left lower punctum to stay open. After the 1st doctor tried to perform a 2 snip that was a success for a few months it closed again. I was referred to octoplastic (sp?) surgeon in my area who was able to syringe and open both upper on lower ducts. After about a year to closed off and she inserted a Rietling tube running through both the upper & lower punctum. Once healed the tube allowed the tears to wick around the tubing and give me some relief. I wanted to leave in the tubing, but after about 9 months the surgeon wanted to remove the tubing. About 2-3 weeks after removing they closed off again. I persuaded her to please put the tubing back in before trying a Jones tube and she agreed. She wanted to take the tubing out in 3-6 months because of concerns of scar tissue. In the meantime, I went to see a surgeon at MUSC in Charleston, SC (an 1 1/2 hr drive) with the tubing in place who told me he had patients who had left the tubes in for months, even years without any problems, and he told me the risks involved in doing this. The tubes have a been in now almost six months and I would like to leave them in indefinitely as he suggested.

    I go back to see him the day after tomorrow for a check up, I would appreciate your opinion.

    Would you leave them in a while longer or remove them at some point?

    Marsha G.

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