A simple and efficient technique for suturing and knotting during endoscopic dacryocystorhinostomy

Abstract

Purpose: This study evaluated the long-term outcomes of endoscopic suturing and knotting-dacryocystorhinostomy (eSK-DCR) without the use of a stent or mitomycin C.

Methods: A prospective interventional case series was performed on patients with nasolacrimal duct obstruction (NLDO) who underwent eSK-DCR at Zhongshan Ophthalmic Center from October 2019 to December 2019. The surgeon sutured the lacrimal sac mucosa with the nasal mucosa by tying knots under endoscopic DCR. Subject demographics, preoperative data and postoperative data were collected, including clinical presentation, Munk score for epiphora, surgical indications, operation time, duration of knotting, number of knots, endoscopic ostium size, complications, and anatomical and functional success. Anatomic success was defined as patent ostium on lacrimal irrigation, and functional success was defined as subjective improvement in symptoms. Statistical analysis was performed by IBM SPSS software (Version 20.0; SPSS Inc., Chicago, IL, USA).

Results: A total of 60 patients (71 eyes) underwent pure eSK-DCR. Of these, 95.0% (57/60) were females. The mean age of the patients was 54.7 years. The mean surgical time was 37.60 min, and the average time for each knotting was 2.86 min. Endoscopic evidence found that all patients showed patent ostium and normal healing of the flaps after 4 weeks. The Munk scores dropped significantly at 6 months postoperatively compared to preoperative scores (P < 0.0001). Although 4 patients (7 eyes) were lost to follow-up at the end of the 2-year period, the anatomical and functional success remained stable during the 2-year follow-up period (anatomical, 100%; functional, 87.5%). No serious complications were detected during the follow-up period.

Conclusion: Pure eSK-DCR is a simple and reliable therapeutic method for the management of NLDO. The surgical outcomes were good and remained stable beyond 6 months postoperatively.

Keywords: Dacryocystorhinostomy; Endoscopic; Nasolacrimal duct obstruction; Outcomes; Suturing and knotting.

Fig. 1

Typical clinical photograph of the endoscopic dacryocystorhinostomy procedure. a After opening the bony ostium, the lacrimal sac was exposed. b The lacrimal sac flap was lifted and then reflected onto the residual nasal mucosa. U = upper U-shape flap

Fig. 2

Suturing and knotting technique for endoscopic dacryocystorhinostomy. a Microneedle insertion through the lacrimal and nasal mucosa flaps under endoscopy. b The first knot was made outside of the nostril. c One end of the thread was grasped using the ophthalmic needle holder, and the first knot was slide through the anterior naris. d The first knot was placed close to the nasal mucosa, while tension was maintained on both threads. e After making a second knot outside the nostril, a second knot was made and placed to tighten the first knot using the ophthalmic needle holder while tension was maintained on both threads. f The excess suture filaments of the first suture were cut off. g A second suture was performed using the same technique as (a-f). h After suturing and knotting, the lacrimal flap was accurately anastomosed to the nasal mucosa flap. Triangle = first knot on the mucosa; arrow = second knot; asterisk = first suture; double asterisk = second suture

Fig. 3

Munk scores of epiphora. Subjects were able to achieve a reduction in eSK-DCR performed. Subjects averaged 3.21 scores (± 1.32 standard deviation) preoperatively. They averaged 0.29 scores (± 0.68 standard deviation) at postoperative month 6 and 0.59 scores (± 1.20 standard deviation) at postoperative year 2. The Kruskal–Wallis test comparing preoperative and postoperative month 6 or postoperative year 2 scores showed all P < 0.0001