A high-powered argon blue-green laser coupled to a 300-microns quartz fiberoptic catheter was used to create intranasal dacryocystorhinostomy fistulas in fresh-frozen cadaver heads. The procedure, which we term endonasal laser dacryocystorhinostomy, is described. Cadaver specimens were examined postoperatively. Laser rhinostomies were found to involve the posteroinferior portion of the lacrimal sac fossa. Tissues surrounding the fistula site showed no signs of damage. We report on the first patient to undergo endonasal laser dacryocystorhinostomy for the treatment of nasolacrimal duct obstruction, with 10 months of follow-up. We believe endonasal laser dacryocystorhinostomy offers the following advantages over standard external dacryocystorhinostomy:(1) Tissue injury is limited to the discrete fistula site.(2) The cutaneous scar and cosmetic blemish of an external dissection are eliminated.(3) Excellent hemostasis is maintained.(4) Minimal operative and postoperative morbidity permits outpatient surgery, with faster resumption of normal daily activities and increased cost-effectiveness.(5) Patients prefer endonasal laser dacryocystorhinostomy to external dacryocystorhinostomy.

The rigid Hopkins endoscope has been applied to simplify the operation of dacryocystorhinostomy, preventing unnecessary trauma to the medial orbital tissues. The success of the surgical technique is absolutely dependent on a thorough knowledge of the relevant surgical anatomy.

Since Sept. 1, 1989, we have successfully performed 20 video-endoscopic, transnasal, laser-assisted lacrimal procedures on 18 patients ranging in age from 3 to 88 years. This technique avoided a cutaneous scar and caused less surgical trauma and bleeding than that seen in conventional lacrimal surgery, which shortened postoperative recovery time and lessened postoperative pain. With minor modifications in surgical technique, both dacryocystorhinostomy and conjunctivodacryocystorhinostomy were performed with either the potassium titanyl phosphate or carbon dioxide lasers. The use of the video endoscope allowed laser surgery to be performed across a broad range of intranasal structural variations and provided an excellent medium for teaching this new technique.

Endoscopic dacryocystorhinostomy represent a new and promising approach to obstruction of lacrimal pathways. The surgical technique is described in detail. The results of 152 procedures were good or very good in 96% of cases, and no major complications occurred.

PURPOSE To describe a new endonasal dacryocystorhinostomy (DCR) technique and assess its efficacy. DESIGN Prospective nonrandomized interventional case series. METHODS A prospective series of 44 consecutive endonasal DCRs performed from January 1999 to December 2000 was entered into the study. The new technique involved creation of a large bony ostium and mucosal flaps to create an anastamosis between the lacrimal sac mucosa and nasal mucosa. Patients presenting with naso-lacrimal duct obstruction based on symptomatic, clinical, and radiologic grounds were included in the study. Patients who had undergone previous lacrimal surgery were excluded. Surgery was performed by two surgeons (A.T., P.J.W.) using a standardized operative technique. Patient demographics, presentation, examination findings, surgical and anesthetic data, postoperative success, complications, and follow-up were evaluated. Success was defined as anatomic patency as well as relief of symptoms as assessed by fluorescein flow on nasendoscopy, lacrimal syringing, and patient examination. Intubation of the lacrimal apparatus was performed in all operations and the tubes usually removed at 4 to 6 weeks postoperatively. After removal of the tubes follow-up was 13 months (mean, 12.9 months; range, 9-28 months; standard deviation [SD], 6.1 months). RESULTS There were 36 patients (12 male/24 female) who underwent 44 endonasal DCRs. The average age of the patients was 62.9 years old (range, 15-86 years old; SD, 19.1 years) and the main presentation was with epiphora (93%) and/or mucocoele (33%). In 13 operations (30%) a septoplasty was required at the time of surgery, and in 10 operations (23%) further endoscopic sinus surgery was performed in conjunction with the DCR. Anatomic success with a patent nasolacrimal system was achieved in 40 of 44 operations (91%). Symptomatic and anatomic success was seen in 39 of 44 operations (89%). Five of the DCRs were classified as failures. In one DCR the patient was symptomatic despite a patent nasolacrimal system and well-healed ostium. In two DCRs preoperative medial canalicular problems were noted. In two DCRs scarring and fibrosis of ostium were noted. CONCLUSIONS This new technique of endonasal DCR involves creation of a large ostium and construction of nasal and lacrimal sac mucosal flaps. Its anatomic success rate (91% or 40 of 44 DCRs) compares favorably with the success rate of other techniques for endonasal DCR and is also similar to the success of external DCR. Experience in endoscopic nasal surgery is important in endonasal DCR surgery, as other ancillary procedures may be required within the nose at the time of surgery.

Previously described techniques of endonasal laser-assisted dacryocystorhinostomy appear to offer several advantages over conventional external dacryocystorhinostomy, including the following:(1) decreased disruption of medial canthal anatomy,(2) enhanced hemostasis, and (3) avoidance of a cutaneous scar. Although good results were achieved, several limitations of early laser-assisted techniques have been noted, including difficulty in removal of the thick bone of the anterior lacrimal crest and inability to obtain specimens of lacrimal sac mucosa for biopsy purposes. In a series of 40 consecutive, primary endonasal dacryocystorhinostomy procedures, we used the holmium:YAG (Ho:YAG) laser for bone removal and endoscopic sinus surgical instrumentation to obtain lacrimal sac biopsy specimens. Intraoperative hemostasis was excellent and medial canthal scarring was avoided in all patients. The overall long-term ostium patency rate in our series was 82%. Several technical modifications adopted in the latter part of our series, including use of a small drill for supplemental bone removal, extensive removal of lacrimal sac mucosa, and use of a double stent, appeared to enhance this success rate.

BACKGROUND Despite the many advantages of endoscopic laser dacryocystorhinostomy, clinical data have been sparse, and the effectiveness of this procedure has not been fully evaluated. METHODS Among 127 patients (131 procedures) who underwent endoscopic laser lacrimal surgery, 92 procedures with longer than 3 months of follow-up were evaluated. The authors used endoscopic sinus surgery equipment, radiosurgical instruments, otodrill, microrongeur, holmium:YAG and contact neodymium:YAG lasers. RESULTS After the primary operation, 71 (77.2%) of 92 cases were symptom-free and had positive results on primary Jones dye test. With simple revision of failed cases, 88 (95.7%) of 92 cases were treated successfully. CONCLUSION Improvement of surgical technique and use of adequate surgical instruments were essential in increasing the rate of success. Endoscopic laser surgery is useful in treating patients with lacrimal passage obstruction, but a longer period of observation is necessary to confirm its effectiveness.

OBJECTIVE AND DESIGN: The introduction of endonasal laser dacryocystorhinostomy (ENL-DCR) in the early 1990s showed great promise of changing dacryocystorhinostomy into an elegant, minimally invasive procedure from the traditional external dacryocystorhinostomy (EXT-DCR). This prospective, randomized study compares these two operations, their success rates, surgical durations, and postoperative symptoms. PARTICIPANTS: A total of 64 cases in 61 patients with primary acquired nasolacrimal sac or duct obstruction were divided into 2 subgroups by symptoms (simple epiphora and chronic dacryocystitis). These patients were randomized within both subgroups into 2 operation groups with 32 cases in each group. INTERVENTION: Altogether, 32 EXT-DCRs and 32 ENL-DCRs were performed. The silicone tube was removed at 6 months after surgery. The final follow-up visit was at 1 year after surgery. The patency of the lacrimal passage was investigated by irrigation, and patients were questioned about their symptoms. MAIN OUTCOME MEASURES: The patency of the lacrimal passage to irrigation and the duration of surgery were measured. RESULTS: The success rate at 1 year after surgery was 91% for EXT-DCR and 63% for ENL-DCR after primary surgery. The difference was statistically significant (P = 0.016). The surgical duration for ENL-DCR was three times shorter than for EXT-DCR, the average duration being 23 minutes and 78 minutes, respectively (P < 0.0001). CONCLUSIONS: The EXT-DCR, when compared with ENL-DCR, seems to provide superior operation results in primary acquired nasolacrimal duct obstruction.

OBJECTIVE We compared outcomes after dacryocystorhinostomies (DCRs) performed by the traditional external approach (EX-DCR) or by a nonlaser, nonendoscopic endonasal approach (EN-DCR). DESIGN Retrospective, nonrandomized, comparative interventional case series. PARTICIPANTS A total of 354 consecutive cases of DCR were reviewed in 349 patients performed by one surgeon over a 4-year period with a minimum 1 year of follow-up using either EX-DCR or EN-DCR. Only patients with primary nasolacrimal duct obstruction and no eyelid, lacrimal sac, or canalicular pathology were included. INTERVENTION A total of 153 EX-DCR and 201 EN-DCR patients were identified. EX-DCR was performed under sterile conditions, and EN-DCR was performed with a clean setup. Silicone stents were placed for 3 months. MAIN OUTCOME MEASURES Patency of the lacrimal system as assessed by history and irrigation. Outcomes were graded as full success, partial success, or failure. Operative durations and postoperative complications were recorded from hospital charts. RESULTS There was no significant difference in age or gender distribution between the two groups. The mean operative duration was 34.3 minutes for EX-DCR and 18.5 minutes for EN-DCR (P < 0.0001, t test). Full success was achieved in 90.2% of EX-DCRs and 89.1% of EN-DCRs. Partial success was recorded in 2.0% of EX-DCRs and 4.0% of EN-DCRs. The failure rate was 7.8% for EX-DCR and 7.0% for EN-DCR. There was no statistical significance between these outcomes with a two-sample test for equality of proportions with continuity correction (P = 0.914, power = 80% for alpha = 0.05 to detect a decreased success rate of 12%). Eleven of the failed cases in each group underwent revision EN-DCR surgery, with 90.9% success in each group. Epistaxis requiring perioperative nasal packing occurred in 7 (4.6%) EX-DCR patients and 11 (5.5%) EN-DCR patients. Wound complications in EX-DCR included bruising in four patients, localized infections in two patients, and punctal eversion in six patients. In EN-DCR, inadvertent incision of the periorbita occurred in five patients. One patient reported transient diplopia after the medial rectus was inadvertently pulled during an EN-DCR. Five patients had an EX-DCR on one side and an EN-DCR on the other side. All five reported retrospectively that they preferred the endonasal approach. CONCLUSIONS The EN-DCR approach is more rapid than the traditional external approach, has an equivalent surgical success rate, and was preferred by patients who had alternative techniques performed on opposite sides.

OBJECTIVE This document describes endonasal dacryocystorhinostomy (DCR) and examines the evidence to answer key questions about the effectiveness of the procedure compared with external DCR; the relative indications, contraindications, advantages, and limitations of the procedure; and patient selection, surgical technique, postoperative care, and complications. METHODS A literature search conducted for the years 1968 to 2000 retrieved 93 citations. The panel members reviewed 71 of these articles and selected 64 for the panel methodologist to review and rate according to the strength of evidence. A level I rating is assigned to properly conducted, well-designed, randomized clinical trials; a level II rating is assigned to well-designed cohort and case-control studies; and a level III rating is assigned to case series and poorly designed prospective and retrospective studies, including case-control studies. RESULTS The published literature includes two reports that describe clinical trials comparing endonasal with external DCR with a 1-year follow-up. The success rate was 91% for the external DCR group in both reports and 63% and 75% for the endonasal DCR groups, defined by patency to irrigation. A longitudinal cohort study included a control group of age-matched external DCR patients who were compared with a study group of endonasal DCR patients. The reported success rate at 9 months following surgery for the endonasal cohort was 90% and was not statistically significantly different from the 94% success rate noted in the external DCR control group. Remaining data on reported success rates of primary and revision endonasal DCR were obtained from a collection of uncontrolled observational case studies with varying periods of follow-up and success rates ranging from 59% to 100%. CONCLUSIONS It is difficult to make definite evidence-based determinations about the relative efficacy of endonasal and external DCR because of the deficiencies in the reported literature. Based on level III evidence, the available data suggest that endonasal DCR may be a viable option for the correction of acquired nasolacrimal duct obstruction and complex forms of congenital dacryostenosis in selected patients. This procedure may be indicated on a primary basis or as revisional surgery following failed external or endonasal DCR. Some studies comparing endonasal DCR with external DCR suggested lower success rates in the endonasal group; other studies yielded success rates comparable with or exceeding those of external surgery. Reported complications of endonasal DCR do not generally appear to be greater in frequency or magnitude than those associated with external DCR. Disadvantages of endonasal DCR include the preferred use of general anesthesia by many surgeons, the high cost of expensive equipment and instrumentation, and the relatively steep learning curve for this procedure. Depending on the preference of the surgeon, more postoperative care may be required for patients undergoing endonasal DCR than external DCR. Both the advantages and the limitations of endonasal DCR relative to external DCR should be carefully discussed with patients who are contemplating endonasal surgery.