FP1378 : Comparison of the Cosmetic and Functional Results of Subciliary Ext. DCR Vs Conventional Ext DCR

AIOS – Lacrimal Award

Dr. Gupta V P, G04208, Dr. Jolly Rohatgi

Authors: Dr. V. P. Gupta ¹; Dr. M. Memunisha ²; Dr. J. Rohatgi ³

Institutions:

1. Dr. Ved Prakash Gupta, MBBS; MD;DNBChief, Oculoplasty, Orbital & Lacrimal servicesDirector – Professor & Head, Department of Ophthalmology,Principal,University College of Medical Sciences & G. T. B. Hospital,Delhi – 110095, India
2. 2.Dr. M. Memunisha, MSPost graduate in ophthalmology
3. 3.Dr. Jolly Rohatgi, MSProfessor, Department of Ophthalmology,University College of Medical Sciences & G.T.B. Hospital, Delhi – 110095, India

The address for correspondence:

Dr. V. P. Gupta,

Director – Professor & Head, Department of Ophthalmology,

Principal,

University College of Medical Sciences & G. T. B. Hospital,

Delhi – 110095, India

Phone numbers: +91- 9818164208; +91- 9868399795; +91- 9212593418

Fax number: 91-011-22590495

e-mail: vpg275gv@yahoo.co.in

Abstract

Purpose:

There is no study in world literature comparing the subciliaryexternal dacryocystorhinotomy (DCR)with conventional Ext. DCR.This study compared the cosmetic and functional outcomes of subciliary incision Ext. DCR with conventional Ext. DCR.

Methods:This prospective randomized interventional study enrolled 40 consecutive patients undergoing conventional vertical incision 2 flap Ext.DCR[GrI=20] and subciliary incision, single flapExt.DCR[GrII=20].Final scarswere evaluated subjectively by the patient and objectively by the physician using high-resolution digital photographs.

Results:The mean age &duration of surgery were comparable. Anatomic and functional success was (100%) in both groups. At the final follow up, the invisible scar on objective and subjective scar grading was 10% &15%in Gr I VS 90% and 100% in GrII.Follow-up ranged from 3 months to1 year.

Conclusion:Subciliaryexternal DCR provided an excellent cosmetic scar while retaining the 100% functional success of external DCR.

 Introduction:

External dacryocystorhinostomy (Ex-DCR) has been accepted as the standard surgical procedure for the treatment of nasolacrimal duct obstruction (NLDO) with high success rate ^{1- 3}. The original external approach (Ex-DCR) was described by Toti in 1904¹ and modified by, Dupuy-Dutemp&Bouguet by adding the mucosal flap anastomosis² and since then, many new modifications have been made to improve the original procedure. ³ The basic surgical principle of external DCR is creation and edge-to-edge suturing of both anterior and posterior flaps of the sac and nasal mucosa.

Ex-DCR has been performed with two popular incisions i.e. a linear vertical incision in the nasal skin medial to the angular vein or a curvilinear/straight incision 3 – 4 mm medial to medial canthus. Scar hypertrophy, webbed scar and pigmentary changes are some of the commonly observed problems^4-8. Although the classical nasal incision may also provide excellent cosmetic results, visibility of the standard Ex-DCR scar has been reported to vary from 9% to 33% in various studies^4-8. There have been very few studies that have addressed the visibility of Ex-DCR scars, and recommendations to minimize it^{4 – 10}. Most recently the lower eyelid incision for DCR has been further modified and led to the development of Ex-DCR through a subciliary incision^8,10.A subciliary DCR provided an excellent functional cosmetic scar outcome while retaining the access and advantages of external DCR procedure^7-10. Only few studies are available on subciliary EX-DCR^7-10. However, there is no study in world literature comparing thesubciliaryExt. DCR with conventional Ext. DCR.This study compared the cosmetic and functional outcomes of subciliary incision Ext. DCR with conventional Ext. DCR.

MATERIALS AND METHODS

This prospective randomized interventional study was conducted at the Department of ophthalmology, University College of Medical Sciences and GTB Hospital, Delhi, after obtaining prior approval of the institutional ethics committee for the study.  Forty consecutive patients with acquired nasolacrimal duct obstruction/ chronic dacryocystitis/ communicating mucocele were enrolled during December, 2013 to February 2015. The patients were randomized into 2 equal groups of 20 each by computer generated randomization as follows:

Group 1: [n=20]: Conventional external dacryocystorhinostomy (CONV. EX-DCR)

Group 2: [n=20]:  External dacryocystorhinostomy using lower eyelid subciliary incision (Subciliary EX-DCR)

Inclusion criteria was as follows:Patients in the age group of 15 to 70 years of age, primary acquired nasolacrimal duct obstruction, chronic dacryocystitis andcommunicating mucocele.

Patients with following conditions were excluded from the study:Prior acute dacryocystitis,failed DCR, lacrimal fistula, co-existing canalicular pathology or previous eyelid or lacrimal surgery and any contraindication for DCR.

All patients were subjected to thoroughevaluation including history, clinical examination, routine tests including haemoglobin, urine for sugar and albumin, blood sugar fasting and post prandial, bleeding time, clotting timeand special investigations such as syringing, probing, Jones dye test, Schirmer’s test and detailed ENT examination to rule out any contraindication for DCR. Preoperatively moxifloxicin 0.5%eye drops were instilled 3 days prior to be surgery.

Operative techniques

All patients underwent external dacryocystorhinostomy (DCR) under local anesthesia. All patients were operated by single surgeon after written informed consent under loupe magnification.

All patients received local anesthetic infiltration (50:50 mixture of 2% Lignocaine admixed with 1:100,000 adrenaline and bupivacaine with hyaluronidase) infraorbital, infratrochlear block and infiltration at incision site and nasal packing. The nasal cavity was packed with 12-16 inch long 1 inch wide ribbon gauze soaked with local anesthetic mixture / xylocaine jelly. Group 1 patients underwent Conventional external dryocystorhinostomy (CONV. EX-DCR) through 12-15mm long straight skin incision 3-4 mm medial to medial canthus, starting at the level of medial canthal tendon, with osteotomy size of 15-17mm X12-15 mm, and creation and  suturing of both the anterior flap as well as posterior flaps of sac and nasal mucosa using 6-0 vicryl sutures.  The skin was closed using subcuticular stitching using 6-0 vicryl suture.

Group 2 Patients underwent External dacryocystorhinostomy(Subciliary EX-DCR) using lower eyelid subciliary incision, 1 to 2 mm below lash line, 12-15 mm long, placed along the medial half of lower eye lid, reaching up to medial canthus.  Subcutaneous dissection was then carried out inferomedially, to reach the anterior lacrimal crest. At the level of the anterior lacrimal crest, the orbicularis fibers were gently separated, to expose the periosteum over the anterior lacrimal crest. The periosteum along the anterior lacrimal crest was next incised from the level of the medial canthal tendon extending inferiorly, and the periosteum was widely elevated using lacrimal sac dissector wound edge were retracted with cat”spaw retractor. The periosteum and lacrimal sac was retracted laterally. The nasal pack was removed. The posterior part of lacrimal fossa i.e. lacrimal bone was broken with blunt lacrimal dissector. The bony osteotomy was now enlarged using small kerrison bone punch initially and then with large bone punch. This was followed by deroofing of upper end of nasolacrimal canal. Thus large osteotomy was made which included removal of anterior and posterior part of lacrimal fossa, 3-4 mm of anterior lacrimal crest, bone just opposite common cancalicular opening underneath MPL, & upper part of bony nasolacrimal canal. The size of osteotomy was 15-17mm X12-15 mm as measured by Castroviejo caliper in horizontal and vertical meridian. Suction was used if bleeding obscured the operative area. Nasal pack was reinserted so that nasal mucosa bulges. The lower punctum was dilated using Nettleship’spunctum dilator. 3-0/4-0 lacrimal probe was passed from lower punctum to reach the sac. The sac lumen was tented using this probe. Vertical incision was given at the tip of lacrimal bone with 15 No Bard-Park knife and then with Westcott scissors the incision was extended above and below. The sac material extruded confirming the perforation of sac. Posterior sac flap was excised meticulously. Two horizontal incisions one in upper part and another in lower part of sac using Westcott scissors to fashion the anterior sac flap Now U-shaped incision was given in nasal mucosa with 15-no.Bard-Parker knife to create only anterior flap. The nasal pack was pulled underneath the nasal flap. The Flaps were sutured using 6-0 (polyglactin), vicryl suture having saptulated needle. 3 interrupted sutures were given closing the flaps taut. Wound was closed in layers.The skin was closed using subcuticuticlar stitching using 6-0 vicryl suture.

Parameters evaluated were:Intraoperative parameters: ease / problem of wound exposure, creation of bony ostium and flaps, suturing of flaps, duration of surgery, complications like bleeding, flap related problems

Functional success, cosmetic outcome and postoperative complications

Criteria for functional success: Successful functional outcome was defined as relief from epiphora, and patent lacrimal syringing/irrigation at the end of three months.

Postoperative Care:Routine postoperative wound care and medications were prescribed. Nasal pack was removed after 24 hours. Postoperatively, the patients were examined on day 1, 1 week, 6 weeks, 3 months, and thereafter every 3 to 6 months.

All patients underwent standard digital face photography before and after surgery periodically. Photographs were taken using a digital camera equipped with a macrolens and built-in flash. Photographs were taken at the same periodic interval in all the cases [preoperatively, day 7, 6 weeks, 3 months, final visit]. The magnification, the area to be photographed and the camera resolution was kept constant.At each postoperative visit, functional and cosmetic outcomes were evaluated. Patients were interrogated about relief of epiphora and syringing was done.

Subjective assessment

Patient was asked to grade degree of epiphora relief on a 5 point scale as follows: Score 1-Free of symptom, score 2-Significantly improved, score 3 – Slightly improved, score 4 – no improvement, score 5 – worse.

Score of 1, 2& 3 was regarded as success

Objective assessment was done by lacrimal syringing.

Cosmetic outcome of the scar was evaluated objectively and subjectively. Postoperatively photographs taken at the final visit was evaluated by independent 3 observers for objective grading of the scar. Photographs of each patient was randomly numbered, and the evaluator was instructed to grade the appearance of the scar by grading the scar visibility using the following scar grading scale that was used earlier [Devoto et al⁴, 2004].

Objective scar grading scale [Devotoet al⁴, 2004]: 0-invisible scar; 1- minimally visible scar; 2- moderately visible scar; 3- very visible scar

Subjective grading of scar visibility was performed by the patient using the same grading scale. All patients were given a questionnaire to rate the incision at the final visit after surgery [minimum 3 months postoperative]  as follows:

Subjective grading of scar:Patient survey to rate incision[Devotoet al⁴, 2004]

 

1.Can you see your incision site?

• No [grade 0]
• Yes, it is minimally visibally [grade1]
• Yes it is moderately visible [grade2]
• Yes it is very visible [grade3]

2.Are you overall satisfied with the scar?

• Yes
• No

3.Regarding the scar, would you have this same operation done again?

• Yes
• No

 Postoperative treatment included: nasal pack removal after 24 hours,oral and topical Antibiotics, tab. vitamin C, B complex, nasal decongestants and NSAIDs for 5 days. Patients were followed-up on day 1, 7^th day, 6^th week, at end of 12^th week and then every 3 monthly till the end of the study. Minimum follow-up was 3 months. Statistical Analysis was performed using non-parametric Wilcoxon signed rank test for subjective criteria and paired student – t test for objective criteria.

Results:

There were 4 (20.0%) males and 16 (80.0%) females in group 1 and 2 (10.0%) males and 18 (90.0%) females in group 2.The difference between the groups was not statistically significant (p=0.676).Age of the patientsranged from 15 to 75years with a mean of   50.65±13.72 yearsin group I and 51.85±15.93 yearsin group II [NS].In group I, right eye was affected in 11 patientsand left eye in 9 patients, while in group 2 the right eye was involved in 9 patients and left eye in 11 patients [NS, P=0.446]. The mean duration of surgery was 41.75± 10.79minutes in group 1and 46.00± 9.81 in group 2[statistically not significant (p=0.336)].The mean intraoperative osteotomy size of group 1 was 153.0± 24.84mm²and in group II size was 138.9± 18.64mm².The difference of osteotomy size between the groups was statistically significant (p=0.013). No complications were noted in17(85.0%) in group 1and 15(75.0%) in group 2. Post operativeperi-orbital echymosis occurred in 1(5%) and edema in 2(10%0 cases in gr.1. Intraoperative herniation of periorbital fat was observed in 2(10%) eyes in gr. II in 2 senile cases. It was easily treated by excision of fat uneventfully. Postoperative grade II medial ectropionoccurred in 3 (15%) eyes in gr. 2. The ectropion disappeared in 4 weeks. Syringing was patent in all eyes in both the groups at all follow – ups. On subjective evaluation at the end of 12 weeks all 20(100%) were symptom free (i.e. score 1) in gr. I and18 (90%) symptom free (i.e. score 1) and 2(10%) significant improvement [score2] in group II. The functional success rate at the end of 12 weeks of surgery in group I and group 2 was 100%.

On objective scar gradingby the end of 12 weeks [table 1] only 2(10%) eyes in group 1 had invisible scar [0 scar score]compared to 18 (90%) in group II; while 16 (80.0%) patients had grade1-minimally visible scar&2 (10%) patient had grade 2 moderately visible scar in group 1 [table2] compared to 2 (10%) havinggrade1-minimally visible scar in group 2.  Subjective scar grading in group I was 0(invisible scar) in 3 (15.0%) patients, 1:minimally visible scarin  16[80%] and 2:moderately visible scar in 1[5%].The subjective scar grading in group II was 0 (invisible scar)in 20(100.0%)[table2]. Thus, group II (subcilliary) DCR had minimum scar following surgery.The mean follow up duration in group I was 9.7 monthsand 9.8 months in group II.

Table 1: Objective Scar grading

	0: invisible scar	1:minimally visible scar	2: moderately visible scar	3: very visible scar
Group I	2 (10%)	16 (80%)	2 (10%)	0
Group II	18 (90%)	2 (10%)	0	0

 Table 2: Subjective scar grading: patient survey

	Group I	Group II
Q1: Can you see your incision site?
No:0: invisible scar	3[15%]	20 [100%]
Yes:1:minimally visible scar	16[80%]	00
Yes:2:moderately visible scar	1[5%]	00
Yes:3:very visible scar	00	00
Q2: Are you overall satisfied with the scar?
Yes:	20 [100%]	20 [100%]
No:	00	00
Q3: Regarding the scar, would you have the same operation done again?
Yes:	20 [100%]	20 [100%]
No:	00	00

Discussion

Dacryocystorhinostomy(DCR) is a common lacrimal surgery performed for managing epiphora due to nasolacrimal duct obstruction by creating an anastomosis between the lacrimal sac and the nasal mucosa via a bony ostium to increase tear drainage for relief of epiphora. It may be performed through an external skin incision or intranasally with or without endoscopic visualization.  External dacryocystorhinostomy (Ex-DCR) still remains the gold the standard surgical procedure for the treatment of nasolacrimal duct obstruction (NLDO)^1-3.

The basic surgical principle of conventional external DCR is creation of both the sac and nasal mucosal anterior and posterior flaps and edge-to-edge anastomosis of mucosal margins to provide an intact mucosal pathway between the lacrimal sac and the nasal cavity. Advantages of the external approach include excellent success rates, reported to be up to 90-100% ^1-3.

Disadvantages of external DCR include a visible cutaneous scar including scar hypertrophy, webbed scar and pigmentary changes^4-8. There have been very few studies that have addressed the visibility of Ex-DCR scars, and recommendations to minimize it ^4-7. Harris in 1989 was the first to demonstrate that Ex-DCR can also be done with a horizontal incision placed on a lower lid crease⁶. Lower lid relaxed skin tension lines are horizontal and incisions placed on these lines are hardly noticeable shortly after surgery⁵. Putterman⁶ pointed out difficulties associated with tissue retraction during dacryocystorhinostomy with eyelid incision. Mjarkesh et al recently objectively analyzed the cutaneous scar after external dacryocystorhinostomy and compared the cosmetic result of a nasal incision and an inferior eyelid incision and concluded that the inferior eyelid incision seemed to give much better cosmetic results than the nasal incision ¹⁰.

The lower eyelid incision for DCR has been further modified and led to the development of Ex-DCR through a subciliary incision^7-11. Devoto et al⁴ has prospectively evaluated the cosmetic outcome of standard Ex-DCR scar by physician and patient grading.

Present study comparatively evaluated the functional and cosmetic outcomes of conventional Ex-DCR [Group I], and Ex-DCR with lower eyelid subciliary incision [Group II].

The functional success rate at the end of 12 weeks of surgery in both the groups I, & II was 100%. Thus the success rate were same with both anterior and posterior sac and nasal mucosal flaps [Group I] and only anterior sac and nasal mucosal flaps in Ex-DCR with lower eyelid subciliary incision [Group II]. However, fashioning and suturing of posterior sac and nasal flaps is difficult, challenging and time consuming compared to only anterior flap technique. Dave et al reported anatomic and functional success in all 17 [100%] eyes following subciliary incision Ext-DCR.¹¹

Using the subjective⁴ scar grading the evaluation of cosmetic outcomes of the 2 groups in the present study revealed that scars were grade 0 [invisible scar] in 15% in Group I, & 100% in Group II. However, all the patients were satisfied with their scars. Similarly, on objective scar grading⁴ also, invisible scars were present in only 10% in group 1 compared to 90% eyes in Group II. Thus, group II (subcilliary) DCR had best cosmetic outcome or minimum scar following surgery.

Visibility of the standard Ex-DCR scar has been reported to vary from 9% to 33% in various studies.^3-5 Two studies from Australia reported the scar visibility following Ex-DCR to be rare, and more likely to be a concern for young patients and females. Dave et al.¹¹ reported that objective scar grading was grade 0 (invisible scar) in 47% and grade 0 – 1 (invisible or minimally visible scar in 82.2 % at final follow-up after subciliary incision Ext – DCR. The subjective scar grading by the patient reported 88% scars to be grade 0 (invisible scar) and 100% scars to be grade 0 – 1(invisible or minimally visible)¹¹. The same study reported that moderately visible scar was noted in 11.2% case objectively.¹¹

Although the classical nasal incision may also provide excellent cosmetic results^5,6, it is believed  that the lower eyelid approach offers following  advantages over the classical nasal incision: 1. The dissection is in the lower eyelid minimizing the bleeding, 2. There is no concern about angular vessels, 3. The lacrimal sac is approached from below at the nasolacrimal duct entrance and the osteotomy site is thus quite low preventing any degree of stump syndrome, 4. Finally, as the nose is not manipulated the patients are able to wear glasses immediately after surgery. However, few complications encountered in subciliary DCR include intraoperative herniation of orbital fat & medial ectropion postoperatively.  Herniation of orbital fat was encountered in 10% of cases in gr.2 only. Herniation occurred in 2 senile cases, probably due to involutional dehiscence of orbital septum resulting in herniation of nasal pad of fat. It was easily treated by excision of fat uneventfully. Lower lid laxity particularly in elderly patients has been attributed as the cause of medial ectropion. It has been suggested that the wound closure should be done carefully in order to avoid medial ectropion. However, we noted postoperative medial ectropion in 15% cases despite meticulous layered wound closure. The ectropion was temporary and disappeared in 4 weeks time without causing any epiphora.

 Conclusions:

It thus concluded that both the techniques of external DCR viz. conventional external dacryocystorhinostomy with anterior and posterior sac and nasal mucosal flaps [Group I] and external dacryocystorhinostomy using lower eyelid subciliary incision [Group II] are equally effective techniques with excellent functional success rate of 100%. The best cosmetic outcome was achieved in subciliary external dacryocystorhinostomy with presence of invisible scar on objective scar grading in 10% and 90% of cases in Group I & Group II respectively as well as presence of invisible scar on subjective scar grading in 15% and 100% cases. Anterior sac flap and U – shaped nasal mucosal flap appears to be the best technique based on ease of flap creation and suturing. Further studies are suggested comparing these techniques in more number of cases and longer follow-up are suggested.

 References

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6. Dupuy-Dutemp L, Bouguet M. Note preliminairesur en procede de dacryocystorhinostomie. Ann Oculist 1921;158:241.
7. Olver JM. Tips on how to avoid the DCR scar. Orbit. 2005;24:63–6.
8. Devoto MH, Zaffaroni MC, Bernardini FP, et al. Postoperative evaluation of skin incision in external dacryocystorhinostomy. Ophthal Plast Reconstr Surg. 2004;20:358–61.
9. Sharma V, Martin PA, Benger R, et al. Evaluation of the cosmetic significance of external dacryocystorhinostomy scars. Am J Ophthalmol. 2005;140:359–62.
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11. Putterman AM. Eyelid incision approach to dacryocystorhinostomy facilitated with a mechanical retraction system. Am J Ophthalmol. 1994;118(5):672-4.
12. Kim JH, Woo KI, Chang HR. Eyelid incision for dacryocystorhinostomy in Asians. Korean J Ophthalmol. 2005;19(4):243-6.
13. Akaishi PM,Mano JB, Pereira IC, Cruz AA. Functional and cosmetic results of a lower eyelid crease approach for external dacryocystorhinostomy. Arq Bras Oftalmol. 2011 Jul-Aug;74(4):283-5.
14. Mjarkesh MM,Morel X, Renard G. Study of the cutaneous scar after external dacryocystorhinostomy. J Fr Ophtalmol. 2012 Feb;35(2):88-93.
15. Dave TV, Javed Ali M, Sravani P, Naik MN. Subciliary incision for external dacryocystorhinostomy. Ophthal Plast Reconstr Surg.2012 Sep-Oct;28(5):341-5.