What is the preferred treatment for dacryocystocele, DCR (dacryocystorhinostomy) or other interventions?

Management of Dacryocystocele: DCT vs DCR

Endoscopic dacryocystorhinostomy (DCR) is the preferred treatment for dacryocystocele in adults due to its high success rate of 90-95% and minimal invasiveness compared to traditional approaches.

Understanding Dacryocystocele

A dacryocystocele is a distention of the lacrimal sac due to obstruction of the nasolacrimal drainage system. It presents with:

• Epiphora (excessive tearing)
• Swelling in the medial canthal area
• Possible purulent discharge if infected (dacryocystitis)
• Potential nasal obstruction in congenital cases

Treatment Options

First-line Treatment: Endoscopic DCR

Endoscopic dacryocystorhinostomy (DCR) has emerged as the preferred surgical approach for managing dacryocystocele in adults for several reasons:

• High success rate: Studies show success rates of 90-95% 1, 2
• Minimally invasive: Avoids external skin incision and disruption of medial canthal structures 1
• Excellent patient satisfaction: 97% of patients rate the cosmetic outcome as "good" to "excellent" 2
• Cost-effective: Requires limited follow-up and can often be performed as an outpatient procedure 2

Alternative: External DCR

External DCR remains the historical gold standard with which other approaches are compared:

• Success rates consistently above 90% 2
• May be preferred in cases with complex anatomy or when endoscopic visualization is limited
• Drawbacks include visible external scar and greater tissue disruption

Probing/Dilation Techniques (DCT)

Simple probing or dacryocystotomy (DCT) procedures:

• More appropriate for congenital cases or as initial management in neonates 3
• Less effective for chronic adult dacryocystocele
• Higher recurrence rates compared to DCR

Special Considerations

Congenital Dacryocystocele

• Initial management may include conservative measures (massage, antibiotics)
• If conservative treatment fails, endoscopic marsupialization is recommended 3
• Interdisciplinary approach (ophthalmology and rhinology) is beneficial

Infected Dacryocystocele

• Presence of purulent secretions requires prompt intervention
• Pre-operative purulent secretions are significantly correlated with post-operative success 1
• May require antibiotic therapy before definitive surgical management

Diagnostic Workup

• When epiphora is the only symptom, imaging (dacryocystography) should be performed to locate the obstruction
• When purulent secretion accompanies epiphora, imaging may be redundant 1

Surgical Technique for Endoscopic DCR

1. Performed under local or general anesthesia
2. Microsurgical or endoscopic visualization
3. Creation of a rhinostomy (opening) between the lacrimal sac and nasal cavity
4. May include silicone tube intubation for 3-4 weeks post-procedure
5. Intraoperative nasal exploration to identify potential foreign bodies or other etiologies 4

Potential Complications

• Hemorrhage (3.9%)
• Scarring (2.6%)
• Recurrence of obstruction (5-8%)
• Infection

Follow-up Care

• Postoperative assessment for patency
• Topical corticosteroids may be needed to reduce inflammation
• Silicone tubes typically removed after approximately 3-4 weeks

In conclusion, while both DCT and DCR have roles in managing dacryocystocele, endoscopic DCR offers the best combination of high success rate, minimal invasiveness, and patient satisfaction for adult patients with dacryocystocele.