The National Institute for Clinical Excellence is examining endoscopic dacryocystorhinostomy and will publish guidance on its safety and efficacy to the NHS in England and Wales. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about endoscopic dacryocystorhinostomy.

This document has been prepared for public consultation. It summarises the procedure and sets out the provisional recommendation made by the Advisory Committee.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows:

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales and Scotland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 23 November 2004

Target date for publication of guidance: February 2004

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of endoscopic dacryocystorhinostomy appears adequate to support use of the procedure, provided that the normal arrangements are in place for consent, audit and clinical governance.

Training is particularly important and the Royal College of Ophthamologists has been asked to produce standards for training.

Endoscopic dacryocystorhinostomy (DCR) is indicated for patients with lacrimal sac obstruction or nasolacrimal duct obstruction (NLDO). NLDO is common, and presenting symptoms include watering of the eye and dacryocystitis (infection). Endoscopic DCR is usually considered for patients who have been refractory to conventional treatment such as warm compresses, massage and probing of the nasolacrimal duct. If NLDO is left untreated, the symptoms persist and may be distressing for the patient.

Endoscopic DCR is one of several techniques used to unblock the nasolacrimal duct. The standard approach to DCR is open surgery.

Endoscopic DCR is a minimally invasive procedure used to bypass the nasolacrimal duct.

One randomised controlled trial reported success rates of 75% (24/32) for endoscopic DCR. After 12 months, 59% (19/32) of patients were asymptomatic. A large study, with 398 patients, that compared the use of lasers with electrocautery instruments for endoscopic DCR reported success rates of 92% (222/242) and 90% (28/31) using two different laser types, and a rate of 87% (39/45) for electrocautery instruments. At 1-year follow-up, 83% (65/78) of patients were symptom-free after a laser-assisted procedure in a case series of patients with dacryostenosis. For more details, refer to the Sources of evidence (see Appendix).

The Specialist Advisors stated that endoscopic DCR is now established practice, that failure rates are similar to conventional treatment, and that healing rates may be quicker.

The rates of reported complications were low and they commonly included minor bleeding. Adverse events were found to occur at similar rates with or without the use of lasers. One study of 78 consecutive patients undergoing laser-assisted DCR observed no incidents of bleeding or infection. For more details, refer to the Sources of evidence (see Appendix).

2.4.2 The Specialist Advisors listed infection as a potential adverse event, and scar tissue formation at the site of the laser beam causing lower success rates.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

Interventional procedure overview of endoscopic dacryocystorhinostomy, August 2004

Available from: www.nice.org.uk/IP022overview