Since external dacryocystorhinostomy (Ext-DCR) was first described in 1904 by Toti [
For the DCR procedure, most surgeons prefer general anesthesia (GA) to local anesthesia (LA), because GA can completely eliminate pain during periosteal elevation and the creation of an osteotomy [
We evaluated the tolerability and efficacy of Endo-DCR performed with the patient in the sitting position under local anesthesia with sedation (LAS). The visual analogue scale (VAS) was used to determine patients’ perceptions of pain, a postoperative questionnaire was used to evaluate subjective success, and the nasolacrimal syringing test was employed to determine objective improvements.
From May 2012 to August 2014, a total of 92 patients (95 eyes) presented with epiphora to the Myoung Eye Plastic Surgery Clinic in Seoul, Korea, and were treated with Endo-DCR under LAS. The mean age of the patients was 58.32 years (range, 31–80), all of whom provided informed consent for data analysis. This study was approved by the institutional review board and was conducted in accordance with the Declaration of Helsinki.
Bosmin gauze (1 : 100,000 epinephrine) (Jeil Pharmaceutical, Seoul, Korea) was used to pack the middle turbinate for 10 minutes before the patients were assisted to the leaning position without the chin up to minimize the posterior nasal influx of blood, which irritates the airway (trachea or epiglottis), and to facilitate the intraoperative removal of posterior nasal influx material by oral suction (Figure
(a) Preparation of patient in sitting position. (b) Infraorbital nerve block. (c) Medial canthal nerve block. (d) Ethmoidal nerve block.
A 4 mm diameter, rigid nasal endoscope was inserted into the nose (at a 0-degree angle), and an additional 1.5 mL of local anesthetic was injected into the area of the nasal mucosal flap around the axilla of the middle turbinate (Figure
(a) Administering anesthetic to nasal mucosal flap. (b) Posterior nasal packing. (c) Incision site. (d) Adjustment of drill burr length (lower panels) and position of drill at operative site (upper panel).
A sickle knife was used to make a curvilinear incision in the mucosa starting at about 5 to 6 mm above the axilla of the middle turbinate (Figure
After removing enough maxillary bone around the axilla of the middle turbinate (at least 1 cm in diameter), the lacrimal sac was tented up with a number 1 Bowman probe and was cut superiorly and inferiorly with a sickle knife to identify the opening of the common canaliculus. The anterior flap of the lacrimal sac was folded over in apposition to the nasal mucosa, and the posterior flap remnant was partially cut. If an uncinate process that interfered with tear flow was present, it was partially removed. The lacrimal tubes were passed through the same internal opening of common canaliculus from the upper and lower canaliculi and were retrieved endoscopically (Figure
(a) Position of lacrimal tubes through the same internal opening of the common canaliculus. (b) Packing with Nasopore. (c) Horizontal probe passing through the lower canalicular plane. (d) At 6 months postoperatively, the internal opening is well formed.
Patients were instructed to restrain from excessive physical activity, sleep with their heads elevated, and avoid nose blowing for 3 days after surgery to minimize nasal bleeding complications. Levofloxacin eye drops (Cravit, Santen, Japan), a topical antibiotic, and fluorometholone 0.1% eye drops (Taejoon Pharm, Seoul, Korea), a topical steroid, were applied four times a day for 2 months until extubation, and postoperative pain was controlled with an oral analgesic for 5 days.
Intraoperative and postoperative pain scores were evaluated using a patient questionnaire on postoperative day 7 at the outpatient clinic. Patients were asked to use the six-level VAS to report their degree of pain based on a score of 0 to 10, with 0 indicating no pain and 10 indicating the greatest pain (Figure
(a) Visual analogue scale (VAS) used by patients for subjective assessment of pain. (b) Distribution of intraoperative (blue) and postoperative (red) pain scores.
A paired
From May 2013 to August 2014, there were 92 patients (95 eyes) with epiphora treated with Endo-DCR under LAS at the Myoung Eye Plastic Surgery Clinic. Of these 92 patients, 78 (80 eyes) were women (84.78%). The patients ranged in age from 31 to 80 years, with a mean (±SD) age of 58.32 ± 10.65 years. Fifty percent (46 of 92) of patients were older than 60 years of age; systemic diseases in this older group included high blood pressure (18), diabetes mellitus (6), hyperlipidemia (5), renal function disorder (3), and liver disorder (3), all of which can be risk factors when GA is used. In addition, 10 of the patients over age 60 took aspirin for anticoagulation.
Among the 95 eyes treated, the two main causes of epiphora were chronic dacryocystitis (45 eyes [47.37%]) and primary acquired nasolacrimal duct obstruction (34 eyes [35.80%]). Other causes included nasolacrimal duct stenosis (9 eyes [9.47%]), lower canalicular obstruction (3 eyes [3.16%]), functional nasolacrimal duct obstruction (35 eyes [3.16%]), and common canalicular obstruction (1 eye [1.05%]). The use of local anesthesia at three sites during the operation successfully controlled pain, and the administration of intravenous midazolam did not interfere with patients’ ability to expectorate posterior nasal blood.
Intraoperative and postoperative pain scores as assessed by patients using the VAS (Figure
Intraoperative versus postoperative pain scores, as reported by 92 patients (95 eyes) using the visual analogue scale (VAS).
VAS pain score | Intraoperative | Postoperative |
---|---|---|
Number of eyes | ||
0 (no pain) | 51 | 48 |
1 | 21 | 14 |
2 | 8 | 7 |
3 | 7 | 3 |
4 | 4 | 2 |
5 | 2 | 12 |
6 | 1 | 6 |
7 | 1 | 2 |
8 | 0 | 1 |
9 | 0 | 0 |
10 (greatest pain) | 0 | 0 |
Total eyes | 95 | 95 |
When offered the option of undergoing Endo-DCR under GA if their other eye needed to be treated, 76 of the 92 patients (82.61%) said they would prefer Endo-DCR under LAS again, even though 22.11% of the patients reported a postoperative pain score above 5 (Figure
The average duration of the Endo-DCR was 30 minutes. In cases involving patients who took anticoagulant therapy or had narrow nasal cavities, the operation took longer. Posterior nasal bleeding during surgery was effectively controlled by oral suction. For the 71 eyes followed up for more than 6 months, the rate of subjective surgical success was 90.14% (64/71) and the rate of objective surgical success was 95.77% (68/71). The three recurrent cases were caused by granuloma, with lower canalicular obstruction in two. In terms of postoperative complications, nasal bleeding was the most common (53/95 eyes [55.79%]), but it subsided within a week after the operation and did not require any specific coagulative treatment. Other minor complications, including nasal stuffiness and headache, also subsided within a week.
Significant intraoperative bleeding during Endo-DCR under GA is a well-known complication that can prolong surgery and frequently results in postoperative epistaxis, because GA promotes venous engorgement and vasodilation [
While the visual analogue pain score may suffice to quantify pain, the amnesic effect of midazolam can result in the mean intraoperative pain score being lower than the mean postoperative pain score; however, it is more important to have the patient consciously sedated to allow the operation to go more smoothly. Furthermore, the average score for patients’ recollection of intraoperative pain was 1.03 (hurts just a little bit), allowing patients to accept Endo-DCR under LAS again instead of the same procedure performed under the more complicated GA.
In our study, two patients (4 eyes) reported intraoperative pain scores on VAS of between 5 (hurts even more) and 7 (hurts a whole a lot), but they chose Endo-DCR under LAS again for their other eye. The other possible reasons why 82.61% of the patients said they would prefer Endo-DCR in the sitting position under LAS rather than under GA are the less complicated preoperative preparation and the psychological benefit of being stabilized and able to return home after only 30 minutes in the recovery room.
In conclusion, Endo-DCR in the leaning position under LAS can be used as a useful, rapid, and more feasible alternative to Endo-DCR in the supine position under either GA or LA, especially when GA would pose some risk or for patients who do not want GA.
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964, as revised in 2013.
Informed consent was obtained from all patients included in this study.
The authors declare that they have no competing interests.