FP1032 : Evaluation of transcanalicular laser dacryocystorhinostomy for treatment of Acute dacryocystitis

Dr.Ruchi Goel,Dr.Sushil Kumar,Dr.Smriti Nagpal Gupta,Dr.Charu Sagar

Abstract

Context: Endoscopic diode laser dacryocystorhinostomy offers faster rehabilitation in acute dacryocystitis. The discomfort and failure when performed in a single sitting can be overcome by an initial small laser osteotomy followed by secondary surgical enlargement endoscopically or externally.

Aim: To compare the anatomical and functional success for the management of acute dacryocystitis by endoscopic laser dacryocystorhinostomy (DCR) using three approaches.

Subjects and methods: A pilot study was conducted on 45 eyes with acute dacryocystitis presenting between September 2016 to February 2017 that were randomly divided into 3 equal groups. Group1 underwent Transcanalicular laser assisted DCR single stage procedure. In group 2 and group 3, a 4X4 mm laser osteotomy was created and later enlarged surgically to 8X8mm by endoscopic and external approach respectively after 10 days. Success was defined as anatomical patency and relief in symptoms at one year follow up.

Results: The average number of acute episodes on presentation was 2.96. Success was achieved in 100%, 86.6% and 86.6% cases in group 3,2 and 1 respectively. Group 1 had more lid edema on post op-day 1(P=.028), with no difference in pain scores(p=.237) amongst the three groups. There was significant reduction in pain score from day 1to day4 in all the three groups(p=.000). The number of complications were more in group 1(p=0.000)

Conclusion

All the three modalities are effective in management of acute dacryocystitis however single stage procedure results in more lid edema initially.

Key words: Acute dacryocystitis, laser DCR, watering, endoscopic DCR

Introduction

The acute dacryocystitis has been described as `a medical urgency ` that presents with rapid onset of pain, erythema and swelling, classically below the medial canthal tendon, with or without pre-existing epiphora following acute infection of lacrimal sac and perisac tissues. ^[1]

The conventional treatment of this condition is prolonged systemic antibiotics, warm compresses and percutaneous drainage of lacrimal sac empyema.^[2]External dacryocystorhinostomy(Ex-DCR) is performed only after the acute infection resolves to prevent spread of infection in tissue planes,^[3] septicaemia, excessive bleeding ^[4]and wound gape. This delay in definitive surgery can be overcome by endoscopic dacryocystorhinostomythat can be safely performed in an acute setting thereby decreasing the duration of antibiotic therapy and hospitalization time.^[5]

The success rates of endoscopic DCR in acute setting however have not been consistent in the published literature. Also, different techniques namely endonasal surgical DCR, laser DCR and primary powered endoscopic DCR have success rates varying from 67% to 94% in acute dacryocystitis. ^[5-8]

It is believed that the defense mechanisms that prevent attacks from the organisms, are compromised by distal obstruction of the nasolacrimal duct leading to infection of lacrimal sac.^[9]Merely performing incision and drainage, does not lead to complete resolution. Creation of even a small osteotomy with diode laser on the other hand mayresult in rapid relief in signs and symptoms. The osteotomy may be subsequently enlarged in the second sitting in non inflammed tissues giving better results.

This study was thereby undertaken to establish the best protocol in management of acute dacryocystitis namely,transcanalicular laser assisted DCR (TL-DCR) with endonasal augmentation in a single stage or two stage. Furthermore, in the two-stage procedure, comparison of surgical augmentation by external and endonasal approach was done.

Subjects and methods

A prospective study was conducted in 45 eyes of 45adult patients suffering from Acute dacryocystitis who presented in Oculoplasty clinic at Gurunanak Eye centre, New Delhi from September 2016 to February 2017. The study was carried out in accordance with ethical guidelines of the Declaration of Helsinki and Institutional Review Board approval was taken. Exclusion criteria included previous history of DCR surgery, patients with nasal pathologies like allergic rhinitis, nasal polyp, neoplasia, mucosal necrotizing vasculitis, severe turbinate hypertrophy, severe high deviated nasal septum, lid abnormalities, punctal stenosis, canalicular abnormalities and uncontrolled systemic illness. Informed consent was taken from all the patients and they were randomly allocated into three groups using computer software (Research Randomizer).

• Group 1: Patients underwent TLA-DCR in a single stage.
• Group 2: Patients underwent TLA-DCR as a two stage procedure, 2nd stage was done after 10 days.
• Group 3: Patient underwent TL-DCR followed by External DCR after 10 days.

The preoperative assessment included detailed history of onset, duration and progression of discharge, swelling, pain and fever. Also, history of any previous episodes and intervention was taken.  A complete general physical examination, nasal examination along with ocular examinationwas performed. Medial Canthal Swelling, fistulous opening, scar marks at medial canthus were looked for. Slit lamp examination was done to rule out any obvious cause of reflex hyperlacrimation and status of puncta.Hemoglobin, bleeding time, clotting time and random blood sugar were tested.

Surgical technique:

All surgeries were performed as day-care procedures by the same surgeon (RG). Appasamy LASER DCR 980 nm Super Diode 15W in continuous mode was used. Preoperatively,

nasal decongestant drops (oxymetazoline 0.05%) four times a day and ofloxacin 0.3% eye drops four times a day were started. Injectable analgesic and anti-anxiety drugs were given immediately prior to surgery (injection diclofenac 75mg i.m. and injection promethazine 25mg i.m.) Ipsilateral nasal cavity was packed with ribbon gauze soaked in 15ml of 4% lignocaine with 1ml of 1:10,000 adrenaline.

Procedure: The affected eye was cleaned and draped. Topical anaesthetic drops put in the affected eye; upper and lower puncta were dilated with Nettleship punctum dilator. This was followed by local infiltration of operative site (i.e. in the skin around the medial canthus and at the nasal mucosa overlying the base of the lacrimal sac), with 2% lignocaine with 1:80,000 adrenaline, bupivacaine 0.75% and hyaluronidase 25IU/ml. In cases with abscess, a syringe with 22-G needle was used to aspirate the mucopurulent material which was sent for pus culture and sensitivity. Nasal pack was removed and nasal cavity was visualized with a zero degree  nasal endoscope. The fiber-optic cable of 980nm Diode Laser was then inserted via the lower canaliculus, to reach the sac. The aiming beam of the laser fiber pinpointed the lower most part of the sac, as seen through the nasal endoscope. Laser energy was delivered at 8W to vaporize the mucosa and some of the bone overlying the lacrimal sac and an opening of approximately 4mm in diameter was created.

In Group 1, ostium was enlarged in the same sitting to approximately 8mm diameter using 45°Weil-Blakesley nasal forceps, while in Group 2 ostium was enlarged to 8mm using Weil-Blakesley after 10 days. In group 3 external dacryocystorhinostomy was done after 10 days. Postoperatively nasal packing was done using a solution of 2% lignocaine with adrenaline 1:80,000.

Post op treatment: All patients received systemic antibiotic (tab amoxicillin-clavulanic acid 625mg tds) for 5 days and anti-inflammatory drugs (tab serratiopeptidase 10mg bd) for 1 week., topical antibiotics (ofloxacin 0.3% qid) for 6 weeks and nasal decongestant drops (oxymetazoline 0.05% qid) for 10 days. Group B & C patients received additional course of systemic antibiotics (tab amoxicillin-clavulanic acid 625mg tds) for 5 days, anti-inflammatory drugs (tab serratiopeptidase 10mg bd) for 1week after second stage. Tab Ibuprofen 400mg was given as per pain scoring. Antibiotic was changed if resistance was reported on culture sensitivity.

Post op evaluation: Each patient was followed-up on: Day 1, Day 4, Day 10, every 2 weeks till 2 months, then monthly till 12 months. Complications like bleeding, infection, pain, lid edema or any other complaint were noted. Regular syringing was performed to check the patency of the passage. Pain scoring was done using Visual Analogue Scale on day 1, 4 and 10 post operatively.

Outcome assessment

A successful outcome was defined as both, anatomical patency, as tested by syringing and functional success in terms of relief of symptoms (pain, swelling, epiphora and discharge).

STATISTICAL ANALYSIS

Results were analysed at the end of 12 months on MS Excel. Data analysis was done using Statistical Package for Social Sciences (SPSS). Qualitative data was expressed as percentage and frequency.

Quantitative data was expressed as mean and standard deviation.Paired t-test and Chi-Square were applied to compare the three groups and P value of <0.05 was considered significant.

Observations and Results

The study comprised of 45 eyes of 45 patients, diagnosed with acute dacryocystitis, who attended the oculoplasty clinic of GuruNanak Eye Centre, Maulana Azad Medical College. The mean age of the study group was 45.33±15.06 and male:femaleratio was 1:2. Right eye was affected in 30 and left in 25 patients. The presenting complaints were painful swelling 45 (100%), epiphora or discharge 40(88.8%), fistula 15(33%) and fever in 3(6%) cases. The average number of acute episodes on presentation was 2.96. Preoperative large sac swelling was observed in 18 (40%) eyes.There was no difference in pain scores on day 1 between the three groups, however there was a statistically significant decrease from day 1 to day 4.(p=0.000 paired t test)

Table 1:Intraoperative Complications

Complications	Group 1	Group 2(stage 1)	Group 3(Stage 1)	Total
Excessive bleeding	2	0	0	4
Laser burn	2	0	0	4
None	11	0	0	29
Total	15	15	15	45

Excessive bleeding and laser burn was more in group 1but was not statistically significant. (p=.123 Pearson Chi-Squaretest)(Table 1)

Table 2: Early post operative complications <7days

Complications	Group 1	Group 2	Group 3	Total
Periorbital edema	9	5	2	16
None	6	10	13	29
Total	15	15	15	45

Periorbital edema was more in group 1.(p=0.028 Pearson Chi-Square) (table 2)

Table 3: Late postoperative complications ≥ 7 days

Late Complications	Group 1	Group 2	Group 3	Total
Swelling	3	0	0	3
Watering	1	2	0	3
Discharge	1	2	0	3
None	10	11	15	36
Total	15	15	15	45

No statistically significant difference was observed in the late complications. (Table 3) However the total number of complications including intra and post- operative were more in group 1(p=0.000 Pearson Chi-Square test)

Table 4: Anatomical success at 12 months

Anatomical Patency	Group A	Group B	Group C	Total
Patent	15	15	15	45
Non Patent	0	0	0	0

Table 5: Functional success at 12 months

Functional Success	Group A	Group B	Group C	Total
Present	13(86%)	13 (86%)	15(100%)	41
Absent	2 (13.33%)	2 (13.33%)	0	4
Total	15(100%)	15(100%)	15(100%)	45(100%)

The anatomical success was achieved in 100% cases. (Table 4) Overallfunctional success was seen 91.1%. Group 3, group 2 and group 1 had 100%, 86.6% and 86.6% functional success respectively. (p=0.334 Pearson Chi-Square test).(Table 5)

Table 6: Antibiotic sensitivity of pus

S. No	Organism	Patients	Sensitive	Resistance
1	Klebsiella spp	2	Gentamicin, Piperacillin+Tazobactam, Amikacin, Ceftriaxone, Ciprofloxacin,  Imipenem	Amoxyclav
2	MRSA	2	Teicoplanin, Vancomycin, Erythromycin, Clindamycin, Linezolid	Penicillin
3	MSSA	1	Erthromycin, Clindamycin, Gentamicin, Linezolid, Vancomycin	Penicillin
4	Staph aureus	3	Amikacin, Gentamicin, Tobramycin, Ofloxacin, Chloramphenicol	Amoxycillin
5	E. coli	1	Colistin, Imipenem Intermediate sensitivity to Gentamicin, Meropenem	Amoxycillin
6	Acinatobacterspp	1	Ciprofloxacin, Piperacillin+Tazobactam	Amoxyclav, Amikacin, Imipenem
7	CoNS	3

MRSA  –Methicillin-resistant Staphylococcus aureus

MSSA  – Methicillin‐susceptible Staphylococcus aureus

E.coli – Escherichia coli

CoNS – Coagulase negative staphylococci

Table 7: Details of failed Cases

S. No.	Group	Time of failing (weeks post-surgery)	Cause	Management
1	A	10 weeks	Sump syndrome	Revision surgery using endoscopic instrumentation
2	A	12 weeks	Sump syndrome	Revision surgery using endoscopic instrumentation
3	B	12 weeks	Sump syndrome	Revision surgery using endoscopic instrumentation
4	B	14 weeks	Sump syndrome	Revision surgery using endoscopic instrumentation

Discussion

Traditional conservative treatment of acute dacryocystitis consists of warm compresses, oral broadspectrum antibiotics and analgesics. Topical antibiotics are of limited value as they donot reach the site of infection because of stasis with in the lacrimal drainage system. Although conservative treatment may alleviate the acute symptoms but its disadvantages arerecurrent infections that may culminate into orbital cellulitis; adverse effects of antibiotics; skin scar; fistula formation and failure of subsequent surgery due to scarring and granulation in the sac.^[12,13]

In case of abscess with pus point, percutaneous incision and drainage (I & D) is done to open sac and drain pus. This procedure may need to be repeated if patient develops recurrent abscess before planned External DCR surgery. Sometimes inflammation may persist chronically inspite of treatment, due to virulent organisms, presence of lacrimal sac abscess, non- penetration of antibiotics in inflammed tissues, antibiotic resistance and fistula formation.To shorten the morbidity associated with acute dacryocytitis, endoscopic DCR has been used safely in an acute setting. ^{[1,5,6,14,15]}

In our series of 45 cases, the mean age at presentation was 45.33±15.06 years similar to Jain et al ^[16] in contrast to third decade by others. ^[10,17,18]Female preponderance was noted as in other studies. ^[1,10,16,18]

The presenting complaints were painful swelling 45 (100%), epiphora or discharge 40(88.8%), fistula 15(33%) and fever in 3(6%) cases. Ali et al reported that their patients presented with swelling (84.4%), discharge(40.3%), epiphora(1.1%) and fever(5.8%).^[1] The average number of acute episodes at presentation was 2.96. Although the duration of symptoms varied among patients, these three groups were comparable.

There was no significant difficulty in the surgical procedure in either of the groups as the operating surgeon was well versed with the surgical approach. Two cases in Group 1had excessive bleeding and pain during surgery. The bleeding was controlled by nasal packing and injection ethamsylate 250mg i.m. stat. No patient complained of bleeding on subsequent follow up visits. The diode laser is documented to achieve effective tissue dissection with minimum collateral tissue damage ^[19], resulting in minimal haemorrhage and improved intraoperative view. Bleeding probably occurred due to nasal mucosal damage caused by the instrumental manipulation. Use of nasal decongestants and preoperative nasal packing with epinephrine soaked gauze further helps to decrease the chances of bleeding during the surgery.

Difficulty in inserting the fibre optic was observed in 14 cases because of local inflammation and skin excoriation.

Two patients, each in group 1 had charring of the medial canthal skin by the laser. The wound was managed by daily dressing with 5%povidione iodine and healed within a week.

Postoperative period

Post- operative pain, calculated using visual analogue scale showed significant reduction by 4^th post op day.The early resolution could be attributed to establishment of patency, combating the stagnation and thereby augmenting the effect of antibiotics.

Postoperative complications including periorbital oedema, ecchymoses, hematoma formation, canalicular erosion, nasal synechiae, granulation tissue formation as well as thermal injury to the canaliculus have been reported previously in various studies.^[20,21]Overall, 16 patients had periorbital edema in early postoperative period, that was significantly more in group 1. Prolonged surgery in inflamed tissues may have led to more edema in group 1.

Pus culture and sensitivity(Table 6)

Lacrimal sac aspiration was attempted in all the cases peroperatively and the aspirate was sent for microbiological analysis. Nine (20%) patients had positive findings, with multiple organisms in some cases. Out of the 13 organisms isolated, commonest was Staph aureus and all the growths showed resistance to penicillin. Lee observed that 27.3% cases were resistant to penicillin group of drugs and were taking antibiotics for long periods. High rates of microbial resistance to bacteria isolated from sac was found in macrolides (42.3%) and amoxicillin (37.7%), as reported by Kumar DA.²⁰ In a report by Mills et al,^[22]  the frequency of MRSA in the acute group was greater than that in chronic. According to Kumar DA,^[23]India has highest rate of antibiotic use, inappropriate use of antibiotics can cause risk of developing bacterial resistance among bacterial flora in lacrimal apparatus.

Anatomical success was achieved in all the patients at one year follow up but the functional success was 86.6% in group 1 and 2 as compared to group 3 that had 100 % success. In both Groups A and B, sump syndrome occurred between 10 to 14 weeks. (Table 7) Revision with endoscopic surgical enlargement helped in resolution of symptoms in all the cases. This indicates that second stage endoscopic enlargement of ostium after 14 weeks could have given better functional outcomes. The occurrence of sump syndrome could have been due to the distended lacrimal sac. It is believed that in order to achieve a higher success rate, it is very important to visualise the sac from the fundus to the duct and to remove the entire medial wall, or atleast the lowermost part of the sac, with or without laser. Wide openings to the nose allow better results and prevent mucosal closure as well as retention pouches caudal to rhinostomy.^[24]

The larger size of sac has however been used as an advantage in endoscopic surgical DCR by Lombardi et al. ^[15] They achieved 96.2% success in their series of 26 patients suffering from acute dacryocystitis with lacrimal sac empyema. They attributed the higher success to wide exposure of lacrimal sac medial wall and use of mucosal flaps to cover the drilled bone. They suggested that larger lacrimal sac flaps allowed sufficient mucosal tissue to cover the bone and reduce the risk of ostium shrinkage and obstruction.

We performed regular postoperative syringing in our patients, which helped to flush out the debris and maintain patency of the newly created passage. Laser DCR patients need relatively frequent follow-ups and regular syringing.^[4] As opposed to this, the postoperative care among patients of external DCR is much simpler, needing fewer number of postoperative visits.

Amadi AJ^[14]  emphasized the need for saline irrigation with budesonide along with endoscopic sinonasal debridement in post-operative period in the setting of high inflammatory state of acute dacryocystitis. Addition of above protocol could have helped in improving the functional success in Group 1 and 2.

The transcanalicular laser approach usually creates smaller rhinostomies than external DCR, a factor which may be correlated with its lower success rates. Along with this, performing TCLADCR in acute dacryocystitis further increases the chance of failure because of local inflammation in the lacrimal sac area leading to increased postoperative fibrosis.

To conclude, TCLA DCR is advantageous over conventional treatment of conservative therapy, providing immediate relief in symptoms of acute dacryocystitis. It can be the treatment of choice for patients suffering from non-resolving inflammation, fistula formation, multiple episodes of painful swelling, antibiotic resistance, skin excoriation, whereexternal DCR is delayed for long periods, causing discomfort to the patient, frequent hospital visits, increased morbidity.  All the three approaches have satisfactory success rates, however, due to prolonged surgery in inflamed tissues the likelihood of bleeding, laser thermal burn and postoperative edema is more in single stage procedure. TCLADCR group requires a more meticulous followup and intervention when ever required. A blanket treatment with penicillin group of drugs is not justifiable due to emergence of antibiotic resistance and appropriate antibiotic needs to be given after culture sensitivity.

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