Trends and Outcomes of Endoscopic Versus External Dacryocystorhinostomy: A 20-year Retrospective Multi-Institutional Analysis

Purpose: To evaluate 20-year multi-institutional trends in endoscopic dacryocystorhinostomy (EN-DCR) versus external dacryocystorhinostomy (EX-DCR) for acquired nasolacrimal duct obstruction, including comparative long-term revision rates. Methods: A retrospective cohort study was performed using the TriNetX federated research network. Annual surgical volumes and revision rates at 1, 10, and 20 years were analyzed for patients undergoing EN-DCR or EX-DCR. Propensity-score matching controlled for demographic and clinical characteristics. Joinpoint regression identified trends and significant shifts in procedural rates over time, expressed as annual percent change (APC) for specific intervals and average APC overall. Results: A total of 14,135 DCR procedures (9,948 EX-DCR, 4,187 EN-DCR) were performed on 12,623 patients. Over the study period, EX-DCR decreased from 87.1% to 60.0% (average APC, –1.9%; p < 0.05), with a greater decline noted after 2018 (APC, –3.9%; p < 0.01). Conversely, EN-DCR increased from 12.9% to 40.1% (overall average APC, +4.9%; p = 0.08), showing significant growth after 2012 (APC, +4.4%; p < 0.01). Surgical revision rates were similar at 1 (EX-DCR 9.0% vs. EN-DCR 8.6%, risk ratios = 1.04, p = 0.61), 10 (EX-DCR 14.5% vs. EN-DCR 13.6%, risk ratios = 1.06, p = 0.31), and 20 years (EX-DCR 14.7% vs. EN-DCR 13.7%, risk ratios = 1.07, p = 0.25). Overall success rates, defined as no surgical revision, were between 85.3% and 91.4% for both approaches. Conclusion: Over the past 20 years, endoscopic DCR has gained popularity, with steadily increasing use and comparable revision rates to external DCR.