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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Endonasal versus external DCR, Outcome 1 Anatomic success.
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Analysis 1.1

Comparison 1 Endonasal versus external DCR, Outcome 1 Anatomic success.

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Comparison 1 Endonasal versus external DCR, Outcome 2 Subjective success.
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Analysis 1.2

Comparison 1 Endonasal versus external DCR, Outcome 2 Subjective success.

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Comparison 1 Endonasal versus external DCR, Outcome 3 Intraoperative bleeding.
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Analysis 1.3

Comparison 1 Endonasal versus external DCR, Outcome 3 Intraoperative bleeding.

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Comparison 1 Endonasal versus external DCR, Outcome 4 Postoperative bleeding.
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Analysis 1.4

Comparison 1 Endonasal versus external DCR, Outcome 4 Postoperative bleeding.

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Comparison 1 Endonasal versus external DCR, Outcome 5 Wound infection/gaping.
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Analysis 1.5

Comparison 1 Endonasal versus external DCR, Outcome 5 Wound infection/gaping.

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Endonasal dacryocystorhinostomy (DCR) compared with external DCR for nasolacrimal duct obstruction

Patient or population: People with nasolacrimal duct obstruction

Settings: Hospital

Intervention: Endonasal DCR

Comparison: External DCR

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of Participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk1

Corresponding risk

External DCR

Endonasal DCR

Anatomic success

(i.e. patent lacrimal passage after a period of at least six months after operation)

900 per 1000

Laser‐assisted endonasal DCR

⊕⊝⊝⊝
VERY LOW2,3,4

621 per 1000 (468 to 828)

RR 0.69 (0.52 to 0.92)

64

(1)

Mechanical endonasal DCR

900 per 1000 (729 to 1000)

RR 1.00 (0.81 to 1.23)

40
(1)

Subjective success

(i.e. resolution of symptoms of watering following surgery)

840 per 1000

Laser‐assisted endonasal DCR5

⊕⊕⊝⊝
LOW2,3

588 per 1000 (428 to 815)

RR 0.70 (0.51 to 0.97)

64

(1)

Intraoperative bleeding

170 per 1000

Laser‐assisted endonasal DCR

⊕⊝⊝⊝
VERY LOW2,3,6

No cases of intraoperative bleeding reported in trial of laser‐assisted endonasal DCR

Not estimable

Not estimable

64

(1)

Mechanical endonasal DCR

170 per 1000 (85 to 337)

RR 1.00 (0.50 to 1.98)

40

(1)

Postoperative bleeding

40 per 1000

13 per 1000 (2 to 124)

RR 0.33 (0.04 to 3.10)

104

(2)

⊕⊝⊝⊝
VERY LOW2,7

Wound infection/gaping

40 per 1000

Laser‐assisted endonasal DCR

⊕⊝⊝⊝
VERY LOW2,7

No cases of wound infection/gaping reported in trial of laser‐assisted endonasal DCR

Not estimable

Not estimable

64

(1)

Mechanical endonasal DCR

8 per 1000 (0 to 157)

RR 0.20 (0.01 to 3.92)

40

(1)

CI: confidence interval; DCR: dacryocystorhinostomy; RR: risk ratio

GRADE Working Group grades of evidence
High‐certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate‐certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low‐certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low‐certainty: We are very uncertain about the estimate.

1The assumed control risk was estimated from the control group in the included studies.
2We downgraded one level for study limitations because the methods used for random sequence generation, allocation concealment and masking were not clearly described.
3We downgraded one level for imprecision because the number of participants enrolled in these trials was low and the estimate of effect was imprecise.
4We downgraded one level for inconsistency as there was clinical and statistical heterogeneity in the two trials (test for interaction P = 0.04).
5Subjective success was not reported in the trial of mechanical endonasal DCR (Moras 2011).
6We downgraded one level for inconsistency as there was clinical heterogeneity in the two trials. There were no cases of intraoperative haemorrhage in the trial of laser‐assisted endonasal DCR.
7We downgraded two levels for imprecision as there were only two events recorded, both in the external DCR group.

Figuras y tablas -
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Comparison 1. Endonasal versus external DCR

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Anatomic success Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 Laser‐assisted

1

64

Risk Ratio (M‐H, Fixed, 95% CI)

0.69 [0.52, 0.92]

1.2 Mechanical

1

40

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.81, 1.23]

2 Subjective success Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3 Intraoperative bleeding Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.1 Laser‐assisted

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 Mechanical

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4 Postoperative bleeding Show forest plot

2

104

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.04, 3.10]

4.1 Laser‐assisted

1

64

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 7.89]

4.2 Mechanical

1

40

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.01, 7.72]

5 Wound infection/gaping Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

5.1 Laser‐assisted

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

5.2 Mechanical

1

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]
Figuras y tablas -
Comparison 1. Endonasal versus external DCR
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