Primary vs Secondary Endoscopic Dacryocystorhinostomy for Acute Dacryocystitis With Lacrimal Sac Abscess Formation: A Randomized Clinical Trial

Abstract

Importance: Endoscopic dacryocystorhinostomy (EN-DCR) is emerging as the preferred procedure in the management of nasolacrimal duct obstructions. However, its safety and long-term efficacy in the setting of acute dacryocystitis with lacrimal sac abscess have not been well studied.

Objective: To compare outcomes of EN-DCR as primary treatment with EN-DCR as a secondary treatment after percutaneous drainage of lacrimal sac abscess in acute dacryocystitis.

Design, setting, and participants: This randomized clinical trial was conducted from October 1, 2012, to October 31, 2015, at a tertiary ophthalmic center. The assessors of success at postoperative year 1 were masked to the procedures received by the participants. All surgical procedures were performed by 2 oculoplastic surgeons with different levels of EN-DCR experience. Eligible participants had acute dacryocystitis and lacrimal sac abscess presenting within 2 weeks of onset, who were 18 to 90 years of age. Analysis was of the intention-to-treat population.

Interventions: Patients were allocated by block randomization to receive either percutaneous drainage of lacrimal sac abscess followed by EN-DCR after the acute episode subsided (control group) or primary EN-DCR within 2 weeks of presentation (intervention group). Both groups received a course of empirical systemic antibiotics (amoxicillin and clavulanic acid, 375 mg, to be taken 3 times a day for 1 week).

Main outcomes and measures: Primary outcomes were time from presentation to documentation of symptom resolution and recurrence within 3 months.

Results: Thirty-two patients were randomized equally into 2 treatment arms (control and intervention). The mean (SD) age of patients was 61 (13) years, and there was a predominance of women (27 [84%]). The mean (SD) time to symptom resolution was 13.8 (5.8) days in the intervention group compared with 31.7 (27.1) days in the control group (mean difference, 17.9; 95% CI, 3.71-32.01; P = .02). The mean (SD) time to surgery in the intervention group was shorter at 11.9 (6.3) days compared with 45.6 (30.1) days in the control group (mean difference, 33.6; 95% CI, 17.92-49.33; P < .001). Recurrences occurred once in the control group and did not occur in the intervention group. No differences in operation time and complications between the 2 groups were identified. The anatomical and functional success was 87.5% (14 of 16 cases) in both groups at postoperative year 1.

Conclusions and relevance: Primary EN-DCR in acute dacryocystitis with lacrimal sac abscess results in faster resolution compared with secondary treatment. No differences in recurrence, safety, or outcomes at postoperative year 1 were noted between the 2 treatment groups.

Figure 1.. Flow Diagram

Figure 2.. Time to Symptom Resolution for the Intervention and Control Groups

The intervention group had a significantly shorter time to symptom resolution compared with the time for the control group. Case 15 is marked as an outlier (filled circle), with time to resolution at 120 days. This patient had an episode of recurrent dacryocystitis requiring percutaneous drainage while on the list for definitive endoscopic dacryocystorhinostomy. The horizontal line in the middle of each box indicates the median, while the top and bottom borders of each box mark the 75th and 25th percentiles, respectively. The whiskers above and below each box mark the 90th and 10th percentiles, respectively.

Figure 3.. Correlation Between Time to Symptom Resolution and Type of Intervention

The correlation coefficient between time to operation and time to symptom resolution is R² = 0.56 (calculated by y = 0.96 + 0.67x) in the control group (A) and R² = 0.83 (calculated by y = 3.91 + 0.83x) in the intervention group (B).