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. 2024 Mar 15;103(11):e37312. doi: 10.1097/MD.0000000000037312

The efficacy of endoscopic dacryocystorhinostomy in the treatment of dacryocystitis: A systematic review and meta-analysis

Shui Liu a,b, Huang Zhang b, Yue-Rui Zhang b, Li-Jun Chen b, Xiao-Yi Yu a,*
PMCID: PMC10939585  PMID: 38489695

Abstract

Background:

This article aimed to discuss the efficacy and safety of endoscopic dacryocystorhinostomy (EDCR) versus external dacryocystorhinostomy (EX-DCR) for the treatment of dacryocystitis by meta-analysis.

Methods:

All randomized controlled trials that met the inclusion and exclusion criteria were collected by searching the following databases: PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang, from the establishment of the database to June 2023. Meta-analysis was performed using Stata 17.0 software and review manager 5.4 software. In the collected trials, the observation group was treated with EDCR, whereas the control group was treated with EX-DCR.

Results:

A total of 10 studies involving 969 patients were included in this analysis. There was a similar surgical success rate in the treatment of dacryocystitis between the 2 groups (RR = 1.021, 95% CI [0. 803, 1.297], P = 0. 865). However, compared with the control group, patients in the observation group had a higher total effective rate of treatment (RR = 1. 195, 95% CI [1. 063, 1.343], P = .003), and shorter operative time (WMD = −23.640, 95% CI [−35.533, −11.747], P < .001), and less intraoperative blood loss (WMD = −50.797, 95% CI [−80.339, −21.255], P = .001), shorter length of hospital stays (WMD = −4.570, 95% CI [−5.992, −3.148], P < .001), and lower incidence of adverse events (RR = 0.295, 95% CI [0.173, 0.504], P < .001).

Conclusion:

EDCR is an effective and safe surgical procedure for the treatment of dacryocystitis and can be used as an alternative to EX-DCR.

Keywords: dacryocystitis, endoscopic dacryocystorhinostomy (EDCR), external dacryocystorhinostomy (EX-DCR), meta-analysis

1. Introduction

Dacryocystitis is a common ocular disease mainly characterized by tearing, swelling of the lacrimal sac and increased secretion, which seriously affects the quality of life and visual function of patients.[1] It is commonly caused by an obstruction within the nasolacrimal duct and subsequent stagnation of tears and lacrimal sac contents in the lacrimal sac. Dacryocystitis is mostly caused by microbial infections such as Streptococcus pneumoniae infection and Haemophilus influenzae infection.[2] The common treatments for dacryocystitis include medication, lacrimal irrigation, lacrimal dilation, and surgery.[3] Nowadays, in the treatment of chronic dacryocystitis, conservative medication and lacrimal irrigation cannot achieve satisfactory outcomes. In this case, surgery is now the main treatment for dacryocystitis.[4]

Dacryocystorhinostomy (DCR) is a surgical method to anastomose the nasal cavity with the lacrimal sac to treat patients with obstructive lacrimal sac and nasolacrimal duct.[5] Although new techniques such as endoscopic dacryocystorhinostomy (EDCR), laser-assisted DCR, balloon dacryocystoplasty, and DCR combined with silicone intubation have appeared in recent years, external dacryocystorhinostomy (EX-DCR) has long been considered the standard surgical method with anatomical and functional success rates ranging from 95.3% to 100.0%.[6] However, EX-DCR causes complications, including prolonged and recurrent infections, adverse effects brought on by long-term use of systemic antibiotics, and cutaneous fistula formation.[7] In addition, EX-DCR can lead to the risk of surgical failure due to cutaneous scar formation, and intrasac synechiae and granulation tissue.[8] Nasal endoscopy can be used for the diagnosis and treatment of chronic dacryocystitis, and EDCR is a minimally invasive method for reconstructing the lacrimal canal. Compared with the traditional EX-DCR, EDCR has the advantages of less bleeding, less damage to the surrounding tissues, no residual scarring on the face, no effect on the function of the orbicularis oculi muscle, and a relatively quicker recovery. But it also has the disadvantages of high operating difficulty, unstable success rate, and high equipment costs.[9,10] Currently, the comparison of the efficacy and safety of EX-DCR and EDCR for the treatment of dacryocystitis is still controversial, and the results of different clinical trials are inconsistent. In order to solve this issue, this paper conducted a meta-analysis of the efficacy of EDCR versus EX-DCR for the treatment of dacryocystitis. By systematically evaluating the relevant studies, the success rate, incidence of complications, and patient satisfaction of the 2 surgical methods were compared and analyzed. This analysis is intended to serve as a foundation and manual for the clinical selection of surgical approaches for the management of dacryocystitis.

2. Research objects and methods

2.1. Search strategy

From PubMed, Web of Science, China National Knowledge Infrastructure, and Wanfang databases, the relevant clinical trials on EDCR and EX-DCR for the treatment of dacryocystitis published from the establishment of each database to June 2023 were collected. The adopted search terms and strategies were as follows: (dacryocystitis OR nasolacrimal duct obstruction OR epiphora) AND (endoscopic dacryocystorhinostomy OR endonasal) (endoscopic dacryocystorhinostomy OR endonasal dacryocystorhinostomy OR EDCR) AND (external dacryocystorhinostomy OR EX-DCR). Chinese databases were also searched using the Chinese expressions corresponding to the above search terms. In order to avoid missing studies, the relevant journals and references were also manually searched.

2.2. Inclusion and exclusion criteria

The eligible articles were screened according to the following criteria:

(1) Inclusion criteria: The type of trial was randomized controlled trial (RCT); The study subjects were patients who were clinically diagnosed with chronic dacryocystitis, acute exacerbation of chronic dacryocystitis, or nasolacrimal duct obstruction, etc, which met the surgical indications of EDCR; The observation group was treated with EDCR, while the control group was treated with EX-DCR; The results of the study included the success rate of the surgery, the complication rate, and the patient’s satisfaction, etc; The article was published in English or Chinese.

(2) Exclusion criteria: The type of study was review, case report, expert opinion, etc; The study subjects were patients with dacryocystitis caused by congenital nasolacrimal duct obstruction or others; The interventions were other surgical or nonsurgical methods; The results of the study were incomplete or unavailable; The article was a repetition of the published article or a low-quality document; The article was published in languages other than English or Chinese.

2.3. Data extraction and quality evaluation

The title, abstract and full text of the included studies were read independently by 2 researchers for the study screening. Disagreements about the included studies were resolved through discussion or by a third researcher. The following information was extracted from the included articles: basic information, including title of the article, name of the first author, year, and country of publication, as well as subgroups, sample size, age, gender, and disease course; and outcome indicators, including: surgical success rate (defined as asymptomatic patient or patency of the lacrimal drainage system at last follow-up)[7]; total effective rate = (Cured + Improved)/total cases * 100% (Cured, symptoms completely disappeared and the tear ducts flushed freely; Improved, symptoms have largely disappeared and there is some impediment to tear duct flushing; Ineffective: failure to meet the above criteria)[11]; perioperative indicators (operative time [min], intraoperative blood loss [mL], hospital stays [days]); incidence of adverse events (incisional infections and bleeding, recurrent tear duct obstruction, and abscesses, etc).

2.4. Statistical analysis

Stata 17.0 software was used for data analysis. Effect sizes were calculated for dichotomous data using relative risk (RR) and 95% confidence intervals (CI), and for continuous data using weighted mean difference (WMD) and 95% CI. P < .05 was considered statistically significant. The χ2 test and I2 test were performed to test for heterogeneity of the included studies. If I2 < 50% and P > .10, heterogeneity was considered insignificant and data was pooled using a fixed-effects model; otherwise, a random-effects model was used. The results were subjected to sensitivity analysis, subgroup analysis, and publication bias analysis to assess their stability and credibility. The Cochrane risk-of-bias tool in review manager 5.4 software was used to assess the quality of the included RCTs.

3. Results

3.1. Search results

A total of 1806 documents were retrieved from the database, and 1666 ones were left after deleting duplicate records. After a secondary screening, 359 studies were excluded from the remaining 398. A more detailed full-text screening was performed on the remaining 39 studies, of which 29 were excluded because they did not meet the established criteria. Thus, a total of 10 studies were finally included in the meta-analysis.[7,11–19] Figure 1 illustrates the PRISMA flow diagram for the included studies.

Figure 1.

Figure 1.

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The flow diagram of the included studies.

The basic information of the included studies is shown in Table 1. All the included studies were published from 1998 to 2023. Eight of the studies were from China, and the other 2 were from Finland and India. A total of 969 patients were involved in these studies, with 490 in the observation group and 479 in the control group.

Table 1.

The basic information of the included literature.

Study (yr) Nation Patients Intervention (Obs/Con) Female/male (Obs/Con) Age (Obs/Con) Disease course (Obs/Con) Study type Outcomes
Hartikainen 1998[12] Finland Nasolacrimal duct obstruction EES-DCR; ext-DCR 23/9; 28/4 61.0 ± 16.1; 64.8 ± 14.0 – RCT ①②
Li 2003[11] China Chronic dacryocystitis EES-DCR; ext-DCR 64; 62 – – RCT ⑥
Wu 2009[7] China Acute suppurative dacryocystitis EES-DCR; ext-DCR 32/8; 27/5 55.1 ± 11.9; 54.8 ± 12.4 4.7 ± 1.6; 4.3 ± 1.5 RCT ①③
Agrawal 2013[13] India Nasolacrimal duct obstruction EES-DCR; ext-DCR 151; 151 46 (29–61) – RCT ①②③
Li 2020[14] China Chronic dacryocystitis EES-DCR; ext-DCR 21/22; 23/20 41.30 ± 2.50; 40.80 ± 2.40 4.20 ± 1.60; 4.10 ± 1.50 RCT ②④⑥
Liu 2020[15] China Chronic dacryocystitis EES-DCR; ext-DCR 35; 35 50.1 ± 6.4 4.2 ± 1.2 RCT ②④⑤⑥
Peng 2021[16] China Chronic dacryocystitis EES-DCR; ext-DCR 13/22; 14/21 62.45 ± 5.23; 62.38 ± 5.19 3.48 ± 0.44; 3.59 ± 0.47 RCT ③⑥
Cheng 2022[17] China Chronic dacryocystitis EES-DCR; ext-DCR 15/2; 15/1 45.62 ± 3.22; 45.62 ± 3.22 5.62 ± 2.55; 5.62 ± 2.55 RCT ②③④⑤⑥
Yan 2022[18] China Chronic dacryocystitis EES-DCR; ext-DCR 14/9; 16/7 42.7 ± 9.5; 42.9 ± 9.3 4.7 ± 0.3; 4.8 ± 0.5 RCT ②③④⑤⑥
Sun 2023[19] China Acute dacryocystitis EES-DCR; ext-DCR 38/12; 36/14 74.61 ± 2.31; 74.35 ± 2.14 5.89 ± 1.37; 6.06 ± 1.41 RCT ②③⑤⑥
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① = surgical success rate; ② = operative time; ③ = adverse events; ④ = peroperative bleeding; ⑤ = hospital stays; ⑥ = total effective rate, Con = control, EES-DCR = endoscopic endonasal dacryocystorhinostomy, EXT-DCR = external dacryocystorhinostomy, MINORS = methodological index for nonrandomized studies, Obs = observation, RCT = randomized controlled trial.

3.2. Assessment of risk of bias

The risk-of-bias map and risk-of-bias summary of the included articles are shown in Figure 2A and B.

Figure 2.

Figure 2.

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Risk-of-bias plots for the included randomized controlled trial studies. (A) Risk-of-bias graph. Seven entries were scored for risk-of-bias. (B) Risk-of-bias summary. Each entry was rated as low risk (+), uncertain (?), or high risk (-).

3.3. Meta-analysis results

3.3.1. Surgical success rate

Three studies reported surgical success rates for both surgical modalities for the treatment of dacryocystitis. According to the results of this meta-analysis, no statistically significant difference was found in surgical success rates between the 2 surgical modalities (RR = 1.021, 95% CI [0.803, 1.297], P = .865; Fig. 3). There was significant heterogeneity among the included studies (I2 = 67.3%; P = 0. 047) (Fig. 3), and therefore, sensitivity analyses were performed using a case-by-case exclusion method. The results showed no significant change in the meta-analysis results regardless of the exclusion of any of the studies, indicating that the meta-analysis results were stable and reliable (Fig. S1, Supplemental Digital Content, http://links.lww.com/MD/xxx).

Figure 3.

Figure 3.

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Forest plot of the surgical success rate of endoscopic dacryocystorhinostomy versus external dacryocystorhinostomy for the treatment of dacryocystitis.

3.3.2. Total effective rate

There were 7 studies comparing the total effective rates of the 2 surgical modalities for the treatment of dacryocystitis. The included studies showed significant heterogeneity (I2 = 65.0%; P = .009) (Fig. 4), and the pooled effect sizes were estimated by a random-effects model. Meta-analysis results showed that the total effective rate of the observation group was significantly higher than that of the control group (RR = 1.195, 95% CI [1.063, 1.343], P = .003) (Fig. 4).

Figure 4.

Figure 4.

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Forest plot of the total effective rate of endoscopic dacryocystorhinostomy versus external dacryocystorhinostomy for the treatment of dacryocystitis.

Sensitivity analyses were performed using a case-by-case exclusion method. The results revealed no significant change in the meta-analysis results regardless of which study was excluded, indicating that the meta-analysis results were stable and reliable (Fig. S2, Supplemental Digital Content, http://links.lww.com/MD/xxx).

3.3.3. Perioperative indicators

The operative time for both surgical modalities for the treatment of dacryocystitis was reported in 7 studies, intraoperative blood loss in 4 studies, and the length of hospital stays for both groups in 4 studies. There was significant heterogeneity among the included studies (I2 > 50%; P < .001) (Fig. 5A–C), so a random-effects model was used to assess the pooled effect sizes. The meta-analysis results (Fig. 5A–C) showed that patients in the observation group had shorter operative time (WMD = −23.640, 95% CI [−35.533, −11.747], P < .001), less intraoperative blood loss (WMD = −50.797, 95% CI [−80.339, −21.255], P = .001) and shorter hospitalization time (WMD = −4.570, 95% CI [−5.992, −3.148], P < .001) than those in the control group.

Figure 5.

Figure 5.

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Meta-analysis of perioperative indicators for endoscopic dacryocystorhinostomy versus external dacryocystorhinostomy for the treatment of dacryocystitis. (A) Forest plot of operative time. (B) Forest plot of blood loss. (C) Forest plot of hospital stays.

In regard to the results of sensitivity analysis (Fig. S3A–C, Supplemental Digital Content, http://links.lww.com/MD/xxx), the results of meta-analysis were not significantly changed regardless of which study was excluded. This suggested the stability and reliability of the results of the meta-analysis.

3.3.4. Adverse events

Six studies compared the incidence of adverse events, i.e., common postoperative symptoms including infection and bleeding, recurrent tear duct obstruction, and abscesses, between the 2 surgical modalities for the treatment of dacryocystitis. Our meta-analysis (Fig. 6) disclosed that the incidence of adverse events was much lower in the observation group than in the control group (RR = 0.295, 95% CI [0.173, 0.504], P < .001). No heterogeneity was observed in the included studies (I2 = 0.0%; P = .697) (Fig. 6). With respect to the results of sensitivity analysis (Fig. S4, Supplemental Digital Content, http://links.lww.com/MD/xxx), the results of meta-analysis did not change significantly regardless of which study was excluded, which indicated that the results of meta-analysis were stable and reliable.

Figure 6.

Figure 6.

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Forest plot of the incidence of adverse events after endoscopic dacryocystorhinostomy versus external dacryocystorhinostomy for the treatment of dacryocystitis.

4. Discussion

In this study, a systematic comparison of the surgical outcomes of EDCR versus EX-DCR for the treatment of dacryocystitis was performed through a meta-analysis. After a comprehensive study search and analysis, a total of 10 papers were finally included in this meta-analysis. Totally 969 patients were included, with 490 cases in the observation group and 479 cases in the control group. We compared the 2 surgical modalities for the treatment of dacryocystitis in terms of the surgical success rate, total effective rate, perioperative indicators, and incidence of postoperative adverse events.

Surgical success rate refers to the degree of anastomosis between the lacrimal sac and nasal cavity after surgery, which is usually evaluated by lacrimal irrigation or imaging.[20] In this study, we discovered no discernible difference between the 2 surgical approaches in terms of surgical success rate. This is in line with some of the existing studies. One randomized prospective study found that the success rate of EX-DCR was much higher than that of endonasal laser-assisted DCR (82.10% vs 89.70%; P = .654), with patency of the lacrimal drainage system as a comparison criterion.[21] Another article compared EDCR with EX-DCR based on controlled septoplasty, and the results showed no significant difference between the 2 groups (P = .39).[22] A longitudinal cohort receiving EDCR was analyzed and compared with an age-matched control group receiving EX-DCR in a research. And no significant difference was found in outcomes between the 2 procedures (P > .05).[23] Surgical success rate was associated with the cause and degree of nasolacrimal duct obstruction, surgical technique and experience, the quality and functionality of surgical equipment and instruments, preoperative preparation, and postoperative care.[24]

EDCR is a well-established surgical technique for the treatment of dacryocystitis. This procedure has the advantages of short surgical time, less trauma, less bleeding, quicker recovery, no scarring, no impact on facial aesthetics, simultaneous management of comorbid intranasal lesions, and repeatability.[25] In this study, we found that EDCR was significantly superior to EX-DCR in terms of total effective rate, operative time, blood loss, hospital stays, and incidence of adverse events. Despite the fact that surgical outcomes are unaffected by the operative time, the mean time to symptom relief, length of hospital stays, and duration of antibiotic therapy were significantly reduced after EDCR. Clearly, reducing the amount of time spent in the hospital begins with shortening the interval between diagnosis and surgery. Total effective rate, which is typically measured by subjective patient satisfaction or questionnaire scores, reveals the level of symptomatic improvement in patients following surgery.[26] In this study, there was a difference in the overall total effective rate between the 2 surgical procedures, which may be related to several factors including individual differences, tear secretion, status of nasal mucosa, as well as anastomosis size and location.[27] Increased intraoperative bleeding has been observed in some trials, but the surgery can usually go smoothly. However, excessive bleeding can complicate the procedure and affect the formation of mucosal flaps,[28] which in turn can increase the difficulty and duration of the procedure.[29] Collectively, EDCR has obvious advantages over EX-DCR for the treatment of dacryocystitis.

Possible postoperative complications of EDCR include excessive bleeding, orbital fat prolapse, orbital injury and even blindness. While punctal erosion and slitting of the canaliculi are 2 complications associated with stent implantation (EX-DCR).[30] In this study, the incidence of adverse events was much lower in the observation group than in the control group. This may be attributed to the higher risk of subsequent surgical failure brought on by longer recession time for EX-DCR, prolonged and recurrent infections, fistula formation, skin scar formation, and scar formation, adhesions, and granulation tissue within the lacrimal sac.[31]

There are still some limitations to this study. First, despite an extensive literature search, only 10 studies were included in the meta-analysis, failing the assessment of publication bias. Second, only studies in English and Chinese were reviewed, which may have led to the exclusion of some relevant studies. Third, 8 of the 10 included studies were conducted in China, so whether the current results can be extrapolated to other countries requires a more comprehensive meta-analysis. Fourth, other surgical modalities for the treatment of dacryocystitis, such as laser-assisted DCR and balloon dilatation, were not compared and analyzed in this study. Fifth, we were unable to assess the impact of EDCR on the long-term outcome of patients with dacryocystitis because the meta-analysis was mainly based on data from published articles. Therefore, we need well-designed clinical randomized trials with larger sample sizes to further validate our results.

5. Conclusion

Compared with EX-DCR, EDCR has better clinical outcomes in the treatment of patients with dacryocystitis, with the advantages of shorter operative time, less intraoperative blood loss, and shorter hospitalization time, as well as a lower incidence of adverse events. Therefore, EDCR is recommended to be widely used in the clinical treatment of dacryocystitis.

Author contributions

Shui Liu and Xiao-Yi Yu designed and performed research. Huang Zhang analyzed data. Yue-Rui Zhang contributed to data interpretation. Li-Jun Chen wrote the paper. All authors read and approved the final manuscript.

Conceptualization: Shui Liu, Xiao-Yi Yu.

Data curation: Yue-Rui Zhang.

Formal analysis: Huang Zhang.

Investigation: Shui Liu, Li-Jun Chen.

Project administration: Yue-Rui Zhang.

Resources: Shui Liu.

Supervision: Huang Zhang.

Writing – original draft: Li-Jun Chen.

Writing – review & editing: Xiao-Yi Yu.

Abbreviations:

CI
confidence intervals
DCR
dacryocystorhinostomy
EDCR
endoscopic dacryocystorhinostomy
EX-DCR
external dacryocystorhinostomy
RR
relative risk.

SL and HZ contributed equally to this work.

The type of study is meta-analysis. This article does not contain any studies with human participants or animals performed by any of the authors.

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplemental Digital Content is available for this article.

How to cite this article: Liu S, Zhang H, Zhang Y-R, Chen L-J, Yu X-Y. The efficacy of endoscopic dacryocystorhinostomy in the treatment of dacryocystitis: A systematic review and meta-analysis. Medicine 2024;103:11(e37312).

Contributor Information

Shui Liu, Email: liushui0374@sina.com.

Huang Zhang, Email: csrleo1086@sina.com.

Yue-Rui Zhang, Email: csrleo1086@sina.com.

Li-Jun Chen, Email: anxiang@163.com.

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