Revision DCR should address causes of primary surgical failure

Researchers evaluated the possible causative factors of unsuccessful dacryocystorhinostomy (DCR) surgery in 79 patients who underwent external DCR revision to manage recurrent epiphora.

The most common preoperative endoscopic finding was nasal mucosal fibrosis and synechiae. The most common causes of unsuccessful primary DCR surgery were inappropriate size and location of the bony ostium, fibrosis at rhinostomy site and canalicular obstruction, respectively.

Revision surgeries were performed using standard external DCR techniques with additional use of methylene blue irrigation to identify sac remnant. A large bony osteotomy from the level of common canaliculus to the superomedial part of the nasolacrimal duct was created. Cases with distal canalicular obstruction were either bluntly opened or bypassed with a trephine while those with proximal obstruction received Jones tubes. Success was achieved in 78 sites (93.9 percent) with the first revision surgery and in 81 sites (97.6 percent) with the second revision.

Interestingly, there were 10 cases of prior endonasal DCR in which the sac was found to be intact and no bony ostium was detected during reoperation probably due to inferiorly located anastomosis. The presence of bony regrowth or lacrimal sac reformation with overlying nasal mucosal fibrosis could only be speculated as details of prior surgeries were not available. On the other hand, the authors speculated that small bony ostium tend to have limited soft tissue anastomosis which may have a higher chance of healing over by fibrosis.

The authors conclude that although revision DCR shares standard concepts with primary DCR surgery, the success rate of primary DCR is higher. They recommend that revision DCR surgical planning include preoperative nasal endoscopy and address the possible causes of primary DCR failure.