In a new study, Samir Mohapatra, Suryasnata Rath and others from LVPEI examine if Mitomycin C, an antibiotic drug used to treat cancer, can also improve surgery outcomes in patients with blocked tear ducts justifying its use as an adjuvant.
When you blink, tears spread across the eye’s surface, keeping it moist and protected. They then drain through tiny openings called puncta at the corners of the eyelids near the nose. The tears flow down a duct—the nasolacrimal duct--into the nose, where they evaporate or are reabsorbed into the body. In some people, a blockage develops in the duct due to injury or inflammation and is called primary acquired nasolacrimal duct obstruction (PANDO). The standard treatment for this condition is dacryocystorhinostomy (DCR), a surgery that creates a new passage between the tear sac and the nasal cavity so tears can drain again. While the procedure has high success rates, a common cause of failure is the development of fibrosis at the opening. This has led to the use of adjuvants — substances applied during surgery to improve surgical outcomes.
One such adjuvant used in DCR is Mitomycin C (MMC). It is a chemotherapeutic antibiotic that works by inhibiting DNA synthesis and cell proliferation, reducing the activity of fibroblasts – the cells responsible for scar formation during wound healing. Because of this property, MMC has been used to reduce post-operative fibrosis in DCR to facilitate healing. However, its efficacy as an adjuvant that leads to better outcomes is ambiguous. While most studies support the use of MMC to improve DCR outcomes, a 2023 literature review found most of them were small or methodologically limited. Further, these studies used varied MMC concentrations and duration used making extrapolation difficult.
A new study published in American Journal of Ophthalmology by researchers from LVPEI picks up this gauntlet. The large, double-blind randomized clinical trial included 442 (314 women) patients undergoing non-endoscopic endonasal DCR for PANDO at two tertiary eye care centers. The patients were divided equally into two groups – one received MMC and the other did not (the control). All patients underwent standardized surgical techniques like mucosal flapping (the new drainage pathway is lined with a piece of mucosal tissue for healing) and silicone tube intubation (placing a soft silicone tube to keep the passage open while healing). Patients were followed up at regular intervals from 2 weeks to one year after surgery to assess its success through structural outcomes like lacrimal patency (whether the new pathway remained open) and functional outcomes like epiphora (whether symptoms like watery eyes improved).
At one-year and five-year intervals, the outcomes were excellent 93-95% for both groups, though there was no clinically significant difference between them: applying MMC to the surgical site led to no measurable benefit for patients. The authors note that surgical practices like mucosal flaps and silicone intubation already minimize scarring effectively producing a ceiling effect and therefore, MMC could offer little added benefit.
‘Mitomycin C is routinely used as adjuvant to improve outcomes in endonasal DCR surgery. However, current evidence is weak and drawn from studies rated as underpowered, biased and heterogenous,’ notes Dr Suryasnata Rath, ophthalmic plastic surgeon at LVPEI, and the corresponding author of this study. ‘Long term outcome at five years clearly shows that MMC did not enhance outcome in endonasal DCR. Our study will help clinicians to reconsider MMC as an adjuvant based on credible evidence.’
Citation
Mohapatra S, Rath S, Kapoor AG, Mohapatra A, Ali MH, Behera M, Jayakrishnan G. Mitomycin C in Non-endoscopic Endonasal Dacryocystorhinostomy: A Randomized Clinical Trial Involving 442 Cases. Am J Ophthalmol. 2026 Jan;281:601-609. doi: 10.1016/j.ajo.2025.10.005. Epub 2025 Oct 10. PMID: 41075858.
Photo credit: Fig 30 and 31, Pg. 29, “The American journal of anatomy" (1912), The Internet Archive.
