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 with and without use of laser.

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 the Final Interventional Procedures Document (FIPD) and submit it to the Institute.
• The FIPD may be used as the basis for the Institute's guidance on the use of the procedure in the NHS in England and Wales.

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

Closing date for comments: 25 November 2003

Target date for publication of guidance: March 2004

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

Endoscopic dacryocystorhinostomy (DCR) can be performed using either surgical instruments or a laser to create an opening between the nose and the lacrimal sac. Evidence on the safety and efficacy of these two techniques is different.

Current evidence on the safety and efficacy of endoscopic DCR without the use of laser appears adequate to support use of the procedure, provided that normal arrangements are in place for consent, audit and clinical governance.

Current evidence on the safety and efficacy of endoscopic DCR with the use of laser does not appear adequate to support the use of this procedure without special arrangements for consent and for audit or research. Clinicians wishing to undertake endoscopic DCR with the use of laser should inform the clinical governance leads in their Trusts. They should ensure that patients offered it understand the uncertainty about the procedure's safety and efficacy and should provide them with clear written information. Use of the Institute's Information for the Public is recommended. Clinicians should ensure that appropriate arrangements are in place for audit or research. Publication of safety and efficacy outcomes will be useful in reducing the current uncertainty. NICE is not undertaking further investigation at present.

The Interventional Procedures Advisory Committee particularly noted the need for proper training in the performance of endoscopic DCR with and without laser. NICE has approached the Royal College of Ophthamologists with regard to training standards for this procedure.

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 the nasolacrimal duct. If NLDO is left untreated, the symptoms persist and may be distressing for the patient.

Endoscopic DCR, with or without laser, is one of several techniques used to unblock the nasolacrimal duct. The standard approach to DCR is by open surgery.

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

Under local anaesthesia, an endoscope is inserted into the nose. Surgical instruments or a laser are used to create an opening between the nose and the lacrimal sac through the mucosa and intervening bone. Silicone tubes can be inserted with the aim of improving long-term patency.

The studies reviewed showed that endoscopic DCR without use of laser is efficacious: one RCT reported success rates of 75% (24/32). After 12 months, 59% (19/32) of patients were asymptomatic. However, there is little evidence relating to the use of laser in the procedure. For more details, refer to the Overview (see Appendix).

The Specialist Advisors stated that endoscopic DCR is now established practice. They also stated that endoscopic DCR with the use of laser is less efficacious than endoscopic DCR without laser.

The rates of reported complications were low: they included minor bleeding and granulation of tissue around the silicone tube. For more details, refer to the Overview (see Appendix).

Specialist Advisors listed infection as a potential adverse event.

The Advisory Committee noted that the impact of using a silicone tube to maintain patency was uncertain.

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

• Interventional Procedure Overview of Endoscopic dacryocystorhinostomy, October 2002

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