In this prospective, longitudinal study, we included the patients who applied to the ophthalmology clinic with epiphora, were diagnosed as PANDO, and underwent ext-DCR with BCSI in one or both eyes between December 2019 and February 2021. All the patients had epiphora symptoms for at least six months when they enrolled in the study. PANDO was diagnosed performing lacrimal irrigation with a 27-gauge cannula through the dilated upper and lower punctum without flowing the isotonic saline to the throat or nose.
Patients were carefully examined with a biomicroscopy and nasal endoscopy to rule out pathologies of nasal, lacrimal, and adjacent tissues. Patients with congenital or secondary acquired nasolacrimal duct obstruction caused by nasal and paranasal pathologies (septal deviation, nasal cavity masses, sinüsitis, etc.), primary or metastatic lacrimal system tumors, naso-orbital fractures, mechanical reasons (e.g., dacryoliths), active anterior segment and lacrimal system infective-inflammatory pathologies (dacryocystitis, dacryoadenitis, conjunctivitis, keratitis, etc.), eyelid-eyelash pathologies (e.g., entropion, ectropion, distichiasis, trichiasis), history of ophthalmic surgery in the last three months and surgery at any level of the lacrimal drainage system, systemic autoimmune diseases (sarcoidosis, Sjogren disease, Wegener's granulomatosis, etc.), and had been using topical-systemic steroids, immunosuppressive-immunomodulatory or antiglaucoma drugs were excluded.
All the operations were undertaken by a single surgeon (MK) under general anesthesia. On the operated side, lignocaine and adrenaline-soaked gauze were applied through the nostril to the lateral nasal mucosa to minimize bleeding. Following a 12 mm vertical skin incision below the medial canthal ligament, the orbicular muscle was split with a monopolar cautery with the help of vein retractors until the periosteum was reached. The periosteum was incised and dissected to expose the lacrimal sac. After opening for about 10-15 mm bone hole, the nasal mucosa was exposed. The nasal gauze was taken out, and the ''H shaped'' incision was applied to the nasal mucosa and lacrimal sac to create flaps. Posterior flap suturing, bicanalicular silicon tube intubation, and anterior flap suturing were performed, respectively. All the tissues were closed by suturing in layers. The silicon tube was freely released to the nasal cavity after forming a square knot. For the incision side, tobramycin % 0.3 ointments (Tobrased opt. pomade, Bilim Pharmaceuticals. Inc., Istanbul, Turkey) three times a day for one week was prescribed. Patients also received a combination of loteprednol etabonate 0.5% and tobramycin 0.3% opt. susp. (Zylet, Bausch & Lomb Inc., Rochester, NY), and mometasone furoate %0.05 nasal spray (Nazoster, Santa Pharma Inc., Istanbul, Turkey) four times a day for two weeks. The skin sutures were removed during the first postoperative week. The silicon tubes stayed at least four months.
Tears samples were collected one day before surgery, in the first week, the first, and the third month after surgery. Tears samples were collected with a Schirmer strip that was placed lateral conjunctival cul-de-sac for about five minutes until at least 15 mm of the strip was filled with tears. The amount of tears was calculated in microliters with a regression graph corresponding to the Schirmer strips' tears level. The samples were stored in eppendorf tubes at -80°C within 10 minutes after sampling.
At the end of the study, the samples were taken out of the -80°C cabinet and brought to room temperature. The papers were cut into small pieces and incubated in 2 milliliters (mL) tubes with phosphate-buffered saline solution at room temperature in a shaker at 100 revolutions per minute (rpm) for about three hours. Then they were centrifuged at 1.000 rpm for five minutes. MCP-1 concentrations were measured in tears using human-specific enzyme-linked immunosorbent assays (ELISA) (BT-laboratory, Shanghai, China) according to the manufacturer's instructions. MCP-1 assay sensitivity was 2.43 ng/L with inter-assay and intra-assay coefficients of variation less than 10% and 8%, respectively. The statistical program recorded the data and represented the mean ± standard deviation for continuous variables and frequencies (percentages) for categorical variables. Friedman's analysis of variance and Wilcoxon tests were used for repeated measures analysis and pairwise comparisons. P < 0.05 was defined as statistically significant. Power analysis was performed using GPower 3.1 software.
Muğla Sitki Koçman University Clinical Research Ethics Committee approved this study with a 06/VI decision number. All patients provided informed consent. The Declaration of Helsinki's principle was consistently followed throughout the study.