Best treatments available for distal acquired lacrimal obstruction: A systematic review and meta-analysis

Background: Epiphora is a common clinical sign whose primary cause is post-canalicular lacrimal obstruction. Treatment is both surgical and non-surgical. In the literature, there is some evidence to suggest that some treatments are superior to others, but there are no direct comparative data in this regard. Objective of review: To analyse the success rates of all available treatments to resolve post-canalicular acquired lacrimal obstruction. Type of review:: Systematic review and meta-analysis. Search strategy:: A literature search was conducted in the US National Library of Medicine (PubMed), EMBASE, SCOPUS and Cochrane databases with a final search performed in January 2020. Evaluation method:: The search strategy identified articles published later than 2000 with at least 50 procedures performed both surgically (external dacryocystorhinostomy [EXT-DCR], endoscopic dacryocystorhinostomy [END-DCR] and transcanalicular laser dacryocystorhinostomy [TCL-DCR]) and non-surgically (balloon dacryoplasty [DCP], probing-stenting [SP] and polyurethane stent [PoS]). The primary outcome was functional success, defined as symptom resolution or less than MUNK 2 scale; in addition to this, the influence of adjunctive treatments, such as application of mitomycin C and post-procedural silicone stenting, was evaluated. Results: In total, 14 958 papers were selected, 440 of which were reviewed after screening; 55 were included after full-text review, which involved 9337 procedures. Mean success rate was 48.9% (35.7%-62.3%) for DCP, 54.4% (41.8%-66.5%) for SP, 73.6% (59.7%-84%) for PoS, 80% (75.1%-84%) for TCL-DCR, 89.8% (83.3%-93.9%) for EXT-DCR and 89.5% (87.2%-91.5%) for END-DCR. Among all procedures, a difference was noted between DCP and END-DCR (P <.001), DCP and EXT-DCR (P <.001), SP and END-DCR (P <.001), SP and EXT-DCR (P <.001), END-DCR and PoS (P =.016), and END-DCR and TCL-DCR (P =.001); no differences were noted between END-DCR and EXT-DCR (P = 1.00), EXT-DCR and PoS (P =.121) and EXT-DCR and TCL-DCR (P =.223). Considering surgical procedures, no differences were seen if a silicone stenting was applied, whereas, due to heterogeneity of the literature data, no statistical analysis was feasible for application of mitomycin C. Conclusions: Our analyses suggest that, among all procedures available, END-DCR and EXT-DCR should be considered as treatments of choice to resolve distal acquired lacrimal obstruction.