الفهرس 
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Abstract
Background: Dacryocystorhinostomy (DCR) describes the creation of a functional pathway from the canaliculi into the nose through creating an osteotomy and opening the nasolacrimal sac into the nose. It can be performed via an external or endonasal approach.
External dacryocystorhinostomy (DCR) is the gold standard treatment of epiphora caused by acquired nasolacrimal duct obstruction due to patient acceptance, low cost, and high success rate. DCR aims to form a new, mucosa-lined pathway between the lacrimal sac and the nasal cavity where tears can bypass a lacrimal obstruction and drain directly in the nose. The original external approach was described in 1904.In the 1920s, mucosal flap anastomosis was added to the procedure as a modification, and since then, many new modifications have been made to improve the original procedure.
Objectives: To evaluate the outcomes of external DCR by using two different patterns of flap anastomosis; one only with anterior flap anastomosis and the other with both anterior and posterior flap anastomosis.
Materials and Methods: We followed the PRISMA statement guidelines 44during this systematic review and meta- analysis preparation. All steps were performed according to the Cochrane handbook of systematic reviews of intervention.
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We included studies that followed these criteria: Studies designs included randomized controlled trials, Adult patients with confirmed diagnoses of acquired nasolacrimal duct obstruction, Intervention as primary external DCR, Follow-up duration up to a minimum of four months, and demographic characteristics are accepted.
The risk of bias was evaluated by the Cochrane handbook of systematic reviews of interventions 5.1.0. The cohort and case controls of the included studies are prospective or retrospective cohort which was evaluated by Quality assessment of cohort and case controls studies by NIH tool data extraction.
We conducted this meta-analysis by using Open Meta Analyst (OMA) (Computer program) (Version 5.4. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). Regarding the study outcomes, risk ratio (RR) with 95% confidence interval (CI) was used for dichotomous variables, while the mean difference (MD) and 95% CI were presented for continuous variables.
Results: The initial search resulted in 468 articles from five databases including PubMed, Cochrane, Scopus, Web of Science (WOS), Embase, and Science Direct. A total of ten studies were finally included for the final qualitative synthesis and the quantitative analysis. We identified ten studies comparing double anterior and posterior mucosal flaps
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anastomosis versus single anterior mucosal in the surgical procedure of external dacryocystorhinostomy. The included studies focused on the outcomes of postoperative success rate, post-operative failure rate, perioperative complications including Intraoperative bleeding, Nasal mucosal tear, and Cheese wiring of punctum, we also focused on the postoperative bleeding score, Epiphora score, patency score, wound gaping, recurrence, mean surgical time, and the risk of watering eye.
Our results nearly showed no significant difference between anterior, posterior, and both flap in DCR regarding the postoperative success rate, the incidence of complications, bleeding score, Epiphora score, watering eye, Patency score, Wound gapping, Recurrence rate, and mean surgical time.
Conclusion: There was no difference in surgical success between single/double flap applications performed in external DCR operations. Also, Success rates were comparable between both techniques, and that the posterior mucosal flap has no role in the outcome of external DCR. Single flap anastomosis, external DCR can be implemented as a standard technique, without significantly compromising the final success rate. Anterior suspended flap external DCR is a simple, safe technique with a very high success rate and a satisfactory surgical time. No significant difference in terms of recurrence is seen in comparison to two flap anastomosis. Future
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randomized controlled trials (RCTs) with uniformity of the surgical components are warranted to validate these findings