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Table 1.  
Cohort Characteristics
Cohort Characteristics
Table 2.  
Final Multivariate Logistic Regression Model Resultsa
Final Multivariate Logistic Regression Model Resultsa
1.
Fayers  T, Dolman  PJ.  Bicanalicular silicone stents in endonasal dacryocystorhinostomy: results of a randomized clinical trial.  Ophthalmology. 2016;123(10):2255-2259.PubMedGoogle ScholarCrossref
2.
Chong  KK, Lai  FH, Ho  M, Luk  A, Wong  BW, Young  A.  Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction.  Ophthalmology. 2013;120(10):2139-2145.PubMedGoogle ScholarCrossref
3.
Huang  J, Malek  J, Chin  D,  et al.  Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy.  Orbit. 2014;33(2):81-90.PubMedGoogle ScholarCrossref
4.
Longari  F, Dehgani Mobaraki  P, Ricci  AL, Lapenna  R, Cagini  C, Ricci  G.  Endoscopic dacryocystorhinostomy with and without silicone intubation: 4 years retrospective study.  Eur Arch Otorhinolaryngol. 2016;273(8):2079-2084.PubMedGoogle ScholarCrossref
5.
Sobel  RK, Carter  KD, Allen  RC.  Bilateral lacrimal drainage obstruction and its association with secondary causes.  Ophthal Plast Reconstr Surg. 2014;30(2):152-156.PubMedGoogle ScholarCrossref
6.
Kim  SE, Lee  SJ, Lee  SY, Yoon  JS.  Clinical significance of microbial growth on the surfaces of silicone tubes removed from dacryocystorhinostomy patients.  Am J Ophthalmol. 2012;153(2):253-257.e1, e251.PubMedGoogle ScholarCrossref
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Research Letter
January 2018

Revision Surgery After Dacryocystorhinostomy in a National Cohort

Author Affiliations
  • 1Department of Ophthalmology, University of North Carolina, Chapel Hill
  • 2Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
  • 3Scheie Eye Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia
JAMA Ophthalmol. 2018;136(1):94-95. doi:10.1001/jamaophthalmol.2017.4881

Dacryocystorhinostomy (DCR) is the standard treatment for nasolacrimal duct obstruction.1 Despite limited data from predominantly small single-surgeon studies showing clear benefit for patient outcomes, silicone stents are commonly placed, and we believe endonasal approaches are increasing in use.1-4 In this study, we examined the rate of revision after DCR and evaluated associated risk factors in a national patient cohort.

Methods

Data from all patients undergoing DCR from January 1, 2000, to December 31, 2012, were extracted from the Clinformatics Data Mart Database (Optum). This study was exempt from review by the University of Pennsylvania Institutional Review Board owing to the deidentified data. The primary outcome was the rate of revision DCR within 1 year. For inclusion, patients were required to have 12 or more consecutive months of plan enrollment prior to and after the date of initial DCR. Use of this inclusion period reduced the possibility of a second DCR being considered an initial surgery. Exclusion criteria included insufficient laterality documentation. However, if the initial DCR was bilateral, a second DCR was counted as a revision. Multivariate logistic regression was performed using Stata software (version 14; StataCorp LLC). All P values were 2 sided, and statistical significance was set at  < .05. All variables with P < .20 in univariate analysis were included in the final multivariate model.

Results

We found that 1215 patients who underwent DCR met inclusion criteria (903 [74.1%] were female and 312 [38.0%] were male; mean [SD] age, 67.3 [15.5] years), and 98 (8.1%) had a revision within 1 year (Table 1). The category of younger age (patients <30 years) was associated with revision (OR, 2.66; 95% CI, 1.15-6.15; P = .02). Other preexisting diagnoses known to predispose to nasolacrimal duct obstruction were not associated with revision surgery.5

There were 634 patients (52.2%) who received a lacrimal stent at initial surgery. Fifty-eight revisions (9.1%) were performed in the patients who initially received a stent. Stent placement was not associated with rate of revision in multivariate analysis (OR, 1.30; 95% CI, 0.85-1.98; P = .23) (Table 2).

A total of 1036 patients (89.1%) underwent external DCR and 127 (10.9%) endonasal. Ninety-five (8.2%) underwent revision, with 83 (8.0%) having had external and 12 (9.5%) endonasal DCR initially. The rate of revision was not associated with surgical approach in multivariate analysis (OR, 0.97; 95% CI, 0.69-1.35; P = .84) (Table 2).

Discussion

Our study from a large North American database supports findings of smaller single-surgeon studies.1,2,4 Stent placement was not associated with revision. Although stents can maintain patency during the postoperative period, at least 1 study has suggested stents may promote ostial granulation.4 Another study has shown an association between positive Pseudomonas aeruginosa culture on stents and surgical failure.6 Surgical approach, external or endonasal, was not associated with revision surgery. Patients younger than 30 years had higher odds of revision; however, the small sample size (38 [3.1%]) within this age category limits generalizability about this finding.

The current study has several limitations related to claims data research. First, prior studies have defined DCR success by resolution of epiphora or patency on irrigation.1-4 We defined failure through the surrogate outcome of revision surgery, which may underestimate the number of cases with residual mild epiphora or partial obstruction on irrigation that did not require further surgery. Second, we were unable to review medical records to verify billed procedure codes. Third, because physician choice determined stent placement or surgical approach, we cannot determine if severity of canalicular or nasolacrimal disease biased management.

Conclusions

We found that of 1215 patients, 98 (8.1%) had undergone revision DCR within a year after initial surgery. Numerous medical and surgical factors were evaluated, including the insertion of a lacrimal stent or surgical approach, and we found no association with revision surgery. Knowing the rate of revision in the typical clinical setting may assist prognostic counseling and set performance measures for quality reporting in registries.

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Article Information

Corresponding Author: Kian Eftekhari, MD, Department of Ophthalmology, University of North Carolina, Chapel Hill, 5142 Bioinformatics Bldg CB 7040, Chapel Hill, NC 27599 (kian_eftekhari@med.unc.edu).

Accepted for Publication: September 23, 2017.

Published Online: November 22, 2017. doi:10.1001/jamaophthalmol.2017.4881

Author Contributions: Drs Eftekhari and VanderBeek had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Obtained funding: VanderBeek.

Administrative, technical, or material support: VanderBeek.

Study supervision: Kozin, VanderBeek.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr VanderBeek is supported by K12 Award EY015398 and K23 Award EY025729-01 from the National Institutes of Health (NIH). Dr VanderBeek received additional funding from Research to Prevent Blindness and the Paul and Evanina Mackall Foundation. Funding from each of the sources was received in the form of block research grants to the Scheie Eye Institute.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

References
1.
Fayers  T, Dolman  PJ.  Bicanalicular silicone stents in endonasal dacryocystorhinostomy: results of a randomized clinical trial.  Ophthalmology. 2016;123(10):2255-2259.PubMedGoogle ScholarCrossref
2.
Chong  KK, Lai  FH, Ho  M, Luk  A, Wong  BW, Young  A.  Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction.  Ophthalmology. 2013;120(10):2139-2145.PubMedGoogle ScholarCrossref
3.
Huang  J, Malek  J, Chin  D,  et al.  Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy.  Orbit. 2014;33(2):81-90.PubMedGoogle ScholarCrossref
4.
Longari  F, Dehgani Mobaraki  P, Ricci  AL, Lapenna  R, Cagini  C, Ricci  G.  Endoscopic dacryocystorhinostomy with and without silicone intubation: 4 years retrospective study.  Eur Arch Otorhinolaryngol. 2016;273(8):2079-2084.PubMedGoogle ScholarCrossref
5.
Sobel  RK, Carter  KD, Allen  RC.  Bilateral lacrimal drainage obstruction and its association with secondary causes.  Ophthal Plast Reconstr Surg. 2014;30(2):152-156.PubMedGoogle ScholarCrossref
6.
Kim  SE, Lee  SJ, Lee  SY, Yoon  JS.  Clinical significance of microbial growth on the surfaces of silicone tubes removed from dacryocystorhinostomy patients.  Am J Ophthalmol. 2012;153(2):253-257.e1, e251.PubMedGoogle ScholarCrossref
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