Dacryocystorhinostomy for Acquired

Nasolacrimal Duct Stenosis in the Elderly

(
80 Years of Age)
Andrea A. Tooley, MD,1 Kyle N. Klingler, MD,2 George B. Bartley, MD,1 James A. Garrity, MD,1
John J. Woog, MD,1 David Hodge, MS,3 Elizabeth A. Bradley, MD, MHS1

Purpose: The incidence of acquired nasolacrimal duct obstruction (NLDO) increases with age. Dacryocys-
torhinostomy, the denitive treatment for NLDO, has a high success rate (80%e100%) with a low complication
rate (1%e6%), but surgical outcomes have not been reported previously specically for an elderly population, in
which there may be increased risk for intraoperative and postoperative complications. The purpose of this study
was to examine surgical outcomes and complication rates of dacryocystorhinostomy in an elderly population.
Design: Retrospective cohort study.
Participants: Patients 80 years of age or older undergoing external dacryocystorhinostomy at the Mayo
Clinic between January 1, 1990, and December 31, 2010, were compared with a matched control group of
younger patients (40e79 years of age) undergoing external dacryocystorhinostomy by the same surgeons.
Methods: We reviewed the medical charts for patients as described above. Data abstracted from patient
medical records included symptomatic relief and complications such as tube protrusion, infection, persistent
bleeding, and return to operating room. Statistical analysis included a 2-sample t test to compare continuous
variables, chi-square testing for categorical comparisons, and the generalized estimating equation model to
control for nonindependence.
Main Outcome Measures: Primary end point was symptomatic improvement at last follow-up. Secondary
end points included anatomic patency, adverse event rate, and return to operating room within 1 month of
surgery.
Results: Forty-two dacryocystorhinostomies (32 patients) were performed in the elderly group. The control
group comprised 73 dacryocystorhinostomies in 63 patients. Resolution of symptom rate at last follow-up was
64% in the elderly group versus 86% in the younger cohort (P 0.02). Although there was no difference between
groups with respect to common postoperative complications, there was a higher rate of predened serious
complications in the elderly group (5 events vs. 1 event; P 0.01). There was no difference between groups
regarding need for additional eyelid surgery (P 0.30).
Conclusions: Although most elderly patients experience symptom resolution after dacryocystorhinostomy,
the rate of symptom resolution was lower than that of younger patients. The risk of routine complications was
similar between the groups. The risk of serious complications was higher in the elderly
group. Ophthalmology 2017;124:263-267 2016 by the American Academy of Ophthalmology

Acquired nasolacrimal duct obstruction (NLDO) is a com-
mon cause of epiphora in the elderly. Denitive treatment of
NLDO requires dacryocystorhinostomy, which has a suc-
cess rate of 80% to 100% whether performed externally or
endoscopically. Complication rates range from 1% to 6%,
with the most common complications being hemorrhage,
punctal erosion, silicone tubing prolapse, retrobulbar hem-
orrhage, and subcutaneous or orbital emphysema.1e3
Multiple factors confer an increased surgical risk on
elderly patients, including functional decline, reduced
reserve capacity, polypharmacy, and comorbid medical
conditions.4,5 Several studies have demonstrated increasing
age to be an independent risk factor for perioperative
complications and postoperative mortality.6e8 This
increased surgical risk in the elderly is present for both
highly complex operations and less complex procedures
such as cataract surgery.9
The World Health Organization denes elderly as the
chronological age of 65 years of age or older.10 Over the last
half century, the number of persons older than 65 years has
tripled worldwide. The population comprising those 85
years of age and older is projected to more than triple
from 5.9 million to 18.2 million by 2060, reaching 4.3%
of the total population.11 Because the elderly undergo the
highest number of surgical procedures, there is a need for
data to assess efcacy and safety of surgery in this age
group. With increasing life expectancies and increasing
overall ages of those undergoing surgical procedures, a
cutoff of 65 years of age to be considered elderly no
longer reects an extreme of age. In this article, we

2016 by the American Academy of Ophthalmology http://dx.doi.org/10.1016/j.ophtha.2016.10.018 263

Published by Elsevier Inc. ISSN 0161-6420/16

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 Ophthalmology Volume 124, Number 2, February 2017
describe the outcomes of dacryocystorhinostomy in patients
80 years of age or older compared with those of a younger
cohort.
Methods
After institutional review board or ethics committee approval was
obtained, we performed a retrospective cohort study of all patients
80 years of age or older who underwent dacryocystorhinostomy at
the Department of Ophthalmology, Mayo Clinic, between January
1, 1990, and December 31, 2010. Patients were excluded if they
previously had undergone any surgery for tearing, were younger
than 80 years at the time of surgery, or had not been examined in
the ophthalmology department. A matched control group consisted
of younger patients (40e79 years of age) who also underwent
dacryocystorhinostomy by the same surgeon within 12 months of
their paired elderly patient to control for potential changes in
surgical technique over time. To increase study power, up to
2 control participants were selected for each elderly participant.
The primary end point was symptom improvement. This was
dened as complete or substantial resolution of presenting symp-
toms at the time of last follow-up. Secondary end points included
anatomic patency as conrmed by lacrimal irrigation after
dacryocystorhinostomy, adverse event rate, and return to the
operating room within 30 days of the initial surgery. The rate of
predened serious complications also was evaluated; these
included death, vision loss, hemorrhage requiring intervention, and
adverse event requiring hospitalization for any reason within
1 month after surgery.
A 2-sample t test was used to compare continuous variables.
Chi-square testing was used for categorical comparisons. For
comparisons among patients who underwent multiple procedures,
the generalized estimating equation model was used to control for
nonindependence.
Results
A total of 32 patients 80 years of age or older met inclusion criteria
for the study group. The mean age at the time of surgery was
83.89.2 years. Ten patients underwent bilateral surgery, resulting
in a total of 42 dacryocystorhinostomy procedures in the study
group. All surgeries were external dacryocystorhinostomies. Sixty-
three control patients were identied (2 controls for all but 1 pa-
tient, for whom a second control could not be identied), with a
mean age at surgery of 63.211.6 years. Ten patients underwent
bilateral surgery, resulting in a total of 73 dacryocystorhinostomy
procedures in the control group. Both groups consisted of
approximately 75% women and 25% men. Patient characteristics
can be found in Table 1. The elderly group sought treatment with a
longer duration of symptoms (783 vs. 557 days in the control
group), although this was not statistically signicant (P 0.22).
Epiphora was the primary symptom in 74% of elderly patients
and 72% of younger patients. Dacryocystitis was a more frequent
primary symptom in elderly patients (21%) compared with
younger patients (13%), although this difference did not reach
statistical signicance (P 0.09). The remaining patients in each
group, 5% in the elderly group and 15% in the younger group,
had both epiphora and dacryocystitis as equal primary
symptoms. The elderly patients statistically were more likely to
seek treatment with comorbid lid conditions (48% vs. 21%;
P 0.01). These conditions included ectropion, eyelid laxity,
conjunctivochalasis, blepharitis, trichiasis, everted punctum,
punctal stenosis, kissing puncta, lagophthalmos, and meibomian
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gland dysfunction. The mean follow-up was longer in the control
group versus the elderly group (7.2 vs. 4.9 years; P 0.007).
Dacryocystorhinostomy resulted in symptom resolution at last
follow-up in 64% of elderly patients versus 86% in the younger
cohort (P 0.02; Table 1). Among those patients with comorbid
eyelid conditions at the time of presentation, 93% in the younger
cohort experienced resolution of symptoms at last follow-up
compared with 60% in the elderly population (P 0.05). There
was no difference between groups regarding the rate of perfor-
mance of additional eyelid surgery. Anatomic patency was docu-
mented in the medical record of only a minority of patients (20% of
patients in the younger group and 40% in the elderly group). This
information was missing from the medical record for the remaining
patients. Of the patients in whom anatomic patency was evaluated,
there was not a difference between groups (P 0.72).
There was no difference between groups with respect to com-
mon postoperative complications (P 0.73; Table 2). These
complications included silicone stent protrusion, infection such
as canaliculitis, prolonged monitoring in the postanesthesia care
unit, punctal erosion or cheese wiring, persistent bleeding, dry
eye, pyogenic granuloma formation, retained silicone stent,
sinusitis, antibiotic-related colitis, preseptal cellulitis, punctal
adherence or fusion, syncope, and urinary retention. Antibiotics
were prescribed before surgery only in patients with dacryocystitis.
All patients who experienced prolonged bleeding had been using
warfarin or aspirin. Data from the medical record regarding how
long patients withheld anticoagulation in the perioperative period
were not available for all patients. One patient taking warfarin
underwent bridge therapy with heparin. The rate of having any
complication was 32% in the elderly cohort and 33% in the
younger cohort (P 0.73).
Serious adverse events were predened as stroke, myocardial
infarction, hospitalization within 1 month, bleeding requiring
intervention, and death. There was a higher rate of serious adverse
events in the elderly group compared with the younger cohort
(15% vs. 2%; P 0.01; Table 3). Five serious adverse events in
the elderly population were documented and included 1 patient
each with stroke 25 days after surgery, myocardial infarction
2 days after surgery, hospitalization 3 days after surgery for
syncope and monitoring, bleeding after surgery requiring arterial
embolization by neuroradiology, and an emergency room visit
for hip arthroplasty dislocation requiring reduction. The patient
with bleeding requiring arterial embolization was prescribed
warfarin and used bridge therapy with heparin leading up to the
dacryocystorhinostomy, resuming warfarin the night of the
procedure. International normalized ratio (INR) at the time of
embolization was 1.6. The patient with syncope experienced a
loss of consciousness while putting in eye drops 3 days after
dacryocystorhinostomy. The single serious adverse event in the
younger cohort was a hospital admission in the week after
surgery for epistaxis requiring packing and balloon placement,
but no surgical intervention. The patient was taking aspirin. Only
1 patient in the younger cohort required a return to the operating
room within 30 days of the initial dacryocystorhinostomy. This
was for excision of a lesion that had been biopsied during the
dacryocystorhinostomy, and pathologic examination showed
lentigo maligna melanoma. No patients in either group required
surgical intervention for bleeding or wound infection within 30
days of initial dacryocystorhinostomy.
Discussion
In this study, we evaluated the safety and effectiveness of
dacryocystorhinostomy in a population of patients 80 years
 Tooley et al 
Dacryocystorhinostomy in the Elderly

Table 1. Patient Characteristics

P
Patient Characteristics <80 Years of Age 80 Years of Age Value
No. of patients 63 32
Age (yrs), median (range) 66.5 (40e78) 84.5 (81e97) <0.001
Gender, no. (%)
Female 47 (74.6) 24 (75) 0.97
Male 16 (25.4) 8 (25)
Symptom duration, days 557 783 0.22
Primary diagnosis, no. (%)
Epiphora 51 (72) 31 (74) 0.97
Dacryocystitis 9 (13) 9 (21) 0.09
Both 11 (15) 2 (5) 0.12
Laterality, no. (%)
Right 36 (49) 21 (50) 0.91
Left 37 (51) 21 (50)
Bilateral 10 (16) 10 (31) 0.08
No. of DCRs performed 73 42
Comorbid eyelid conditions, no. (%) 15 (21) 20 (48) 0.01
Eyelid procedure concomitant with DCR, no. (%) 5 (7) 5 (12) 0.33
Follow-up, median (range) 3.6 yrs (2.4 mose16.2 yrs) 6.6 yrs (1.2 mose20.4 yrs) 0.007

DCR dacryocystorhinostomy.

of age and older. Compared with a younger cohort, elderly comorbid eyelid conditions at the time of presentation, the
patients were less likely to experience symptomatic relief younger cohort experienced signicantly better resolution of
after dacryocystorhinostomy. The older population may be symptoms after surgery compared with their older counter-
more likely to have multiple conditions and not a simple parts, which may point to the complicated nature of symp-
NLDO, leading to other nonsurgical causes of persistent toms in the elderly. Another possible explanation for the
symptoms.12 In our study, elderly patients statistically were lower rate of surgical success in the elderly participants is
more likely to have comorbid eyelid conditions at that this group had more severe disease than did the younger
presentation, and therefore may have been more likely to control group. Elderly patients with more bothersome
have multifactorial mechanisms behind their symptoms. symptoms may be willing to undergo surgery, whereas those
This may include age-related changes such as eyelid laxity with mild symptoms may be more likely to decline surgical
and dry eye with reex lacrimation. Concomitant eyelid intervention compared with younger patients with mild
surgery was allowed in this study, and there was no dif- symptoms. The possibility of such selection bias cannot be
ference between groups regarding the frequency of com- evaluated further because information regarding the severity
bined surgery. Among the subset of patients who had of preoperative tearing in both cohorts was not available.
The rate of common postoperative complications was
Table 2. Nonserious Postoperative Complications similar between the 2 cohorts. The rates found in both
groups in our study were considerably higher than other
<80 Years of 80 Years of P postoperative complication rates reported in the literature.
Complications Age (n [ 73) Age (n [ 42) Value* One explanation for this is that we classied many common
All 22 (30) 11 (26) 0.61 postoperative events as complications that may not be
Tube protrusion 8 (11) 4 (9) documented routinely in the literature, including syncope,
Infection (canaliculitis) 4 (5) 1 (2) urinary retention, and antibiotic-related colitis. We also
Punctal erosion/cheese 1 (1) 1 (2) included several relatively common complications that other
wiring studies may have overlooked, including prolapsed stents,
Punctal adherence/fusion 1 (1) 0 (0)
Retained silicone tubing 0 (0) 1 (2)
punctal cheese wiring, and persistent postoperative
Preseptal cellulitis 1 (1) 0 (0) bleeding.13,14
Dry eye 4 (5) 2 (5) The rate of serious complications was higher in the
Pyogenic granuloma 1 (1) 4 (9) elderly group. Although all of the serious complications
Sinusitis 2 (3) 0 (0) occurred within 1 month of surgery, only the single incident
Persistent bleeding 3 (4) 2 (5) of bleeding in each cohort is directly attributable to the
Prolonged monitoring 0 (0) 2 (5)
dacryocystorhinostomy. It is impossible to know whether
Colitis (antibiotic related) 2 (3) 0 (0)
Urinary retention 0 (0) 2 (5) the serious events of stroke, myocardial infarction, and
syncope requiring hospitalization were precipitated by the
surgery, anesthesia, or both. All patients with serious com-
Data are no. (%), unless otherwise indicated.
*Generalized estimating equation.
plications underwent surgery with general anesthesia. The
hip dislocation was unlikely to have been precipitated by

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 Ophthalmology Volume 124, Number 2, February 2017
Table 3. Serious Adverse Events
Serious Adverse
Events within 1 <80 Years 80 Years
Month of Surgery of Age of Age
Any 1 (2%) 5 (15%)
Stroke 0 1
Myocardial infarction 0 1
Hospitalization 0 1
Bleeding requiring 1 1
intervention
Death 0 0
Vision loss 0 0
Miscellaneous* 0 1
*Emergency department visit for hip arthroplasty dislocation.
dacryocystorhinostomy or anesthesia because it occurred 29
days after surgery while the patient was bending over and
was the third dislocation for this patient. Previous studies
examining surgical outcomes have shown increased rates of
medical complications and mortality in elderly patients in
the postoperative period compared with elderly patients who
did not undergo surgical intervention.6e8 Increasing age has
been shown to be an independent predictor of postoperative
morbidity and mortality.8 This may be the result of elderly
patients having less functional reserve to offset the
physical stress of surgery. Aged patients also tend to be
assigned a higher American Society of Anesthesiologists
class, to have a lower baseline functional status, and to
have a higher comorbidity burden that could contribute to
postoperative complications.15
Elderly patients undergoing dacryocystorhinostomy had
a lower success rate both within our study and compared
with all patients examined in the literature. Other studies
have looked at success rates after dacryocystorhinostomy
without including age as a covariant. For example, in
a population-based study of patients treated from 1976
through 2000, average age at NLDO diagnosis was 59.522
years, with a dacryocystorhinostomy success rate of 94%.10
A recently published study examined patients undergoing
external dacryocystorhinostomy from 2009 through 2011
and found the average age at time of surgery to be
64.129.7 years, with 82.8% of patients noting full
resolution of symptoms.13 Our study of patients older than
80 years showed a signicantly lower success rate of
external dacryocystorhinostomy (64%) compared with
the 80% to 100% success rate historically documented.
With an aging patient population, the effect of age on
surgical outcomes is becoming more relevant. To our
knowledge, no existing studies examine outcomes of
dacryocystorhinostomy in a subset of elderly patients.
This study had several potential limitations. First, its
retrospective design relies on accuracy and completeness in
the medical record. We were not able to dene anatomic
patency in all postoperative patients because this was not
documented routinely, especially in patients who were
asymptomatic. This does not affect the study conclusions
because our main end point was symptomatic improvement,
266
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for which anatomic patency may have only partial rele-
vance.12 The study also is potentially limited by the data
being gathered from a tertiary referral center. However,
P
Value
the participants had routine NLDO, the treatment of which
should be similar to cases in nonacademic medical
0.01 centers. Our study does not evaluate the effectiveness of
endoscopic dacryocystorhinostomy procedures in elderly
patients. Finally, the denition we used for elderly could
be considered a potential limitation. To capture outcomes
for an older subset of patients, we selected 80 years of
age as our denition of elderly. We dichotomized age in
this study as opposed to evaluating age as a continuous
variable, which would have required a larger sample size
to nd the inexion point where risk increases. Although
many studies of operative outcomes in the elderly use 65
years as a cutoff, there is no set denition for elderly. In a
study examining practice guidelines for pharmacotherapy,
20 guidelines were reviewed and only 3 guidelines
dened elderly using chronological age; 2 guidelines
dened elderly by a chronological age of 65 years or
more and 1 guideline used the chronological age of 75
years or more.16 With the increasing age of the
population, an arbitrary age cutoff may not accurately
reect a specic patient population.
This study provides surgical outcomes and safety data
for aged patients undergoing dacryocystorhinostomy.
Compared with younger patients, those older than 80 years
undergoing external dacryocystorhinostomy had a signi-
cantly lower rate of symptomatic relief and more serious
complications. There was no difference in routine compli-
cations between the 2 groups. Most patients older than 80
years experienced improvement in symptoms after dacryo-
cystorhinostomy. Consideration of individual patient
symptoms in the context of medical comorbidities, com-
bined with discussion of the potential benets and risks of
surgical intervention, may allow more effective counseling
of elderly patients who are considering dacryocysto-
rhinostomy surgery.
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 Tooley et al 
Dacryocystorhinostomy in the Elderly
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Footnotes and Financial Disclosures
Originally received: August 14, 2016.
Final revision: October 19, 2016.
Accepted: October 19, 2016.
Available online: December 13, 2016. Manuscript no. 2016-56.
1
Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
2
Southern Idaho Ophthalmology, Twin Falls, Idaho.
3
Department of Health Sciences Research, Mayo Clinic, Jacksonville,
Florida.
Presented at: Women in Ophthalmology Summer Symposium, August
2016, Williamsburg, Virginia. Presented at the American Ophthalmological
Society meeting, May 2013, La Jolla California.
Financial Disclosure(s):
The author(s) have no proprietary or commercial interest in any materials
discussed in this article.
Supported by Research to Prevent Blindness, Inc., New York, New York.
The funding organization had no role in the design or conduct of this
research.
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13. Alnawaiseh M, Mihailovic N, Wieneke AC, et al. Long-term
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Author Contributions:
Conception and design: Tooley, Klingler, Bartley, Garrity, Woog, Bradley
Analysis and interpretation: Tooley, Klingler, Bartley, Hodge, Garrity,
Woog, Bradley
Data collection: Tooley, Klingler, Bartley, Garrity, Woog, Bradley
Obtained funding: none
Overall responsibility: Tooley, Klingler, Bartley, Garrity, Woog, Bradley
Abbreviations and Acronyms:
NLDO nasolacrimal duct obstruction.
Correspondence:
Elizabeth A. Bradley, MD, MHS, Department of Ophthalmology, Mayo
Clinic, 200 First Street SW, Rochester, MN 55901. E-mail: elizabeth@
mayo.edu.
267