Paediatric powered endonasal dacryocystorhinostomy

Dacryocystorhinostomy (DCR) is indicated in children with persistent nasolacrimal duct obstruction (NLDO). Endoscopic endonasal DCR has been successfully performed in both adults and children, with success rates similar to that of external DCR. This paper aims to evaluate the outcomes of paediatric patients undergoing endonasal endoscopic DCR at a district general hospital. A retrospective review of all patients attending a joint lacrimal clinic undergoing endonasal endoscopic DCR between October 2001 and December 2008 was performed. Sixteen children (17 eyes) aged between 2 and 14 were analysed. The main outcome measure was resolution of symptoms. Fourteen cases (82%) presented with epiphora with or without stickiness. Three cases had recurrent dacryocystitis. Three patients had Down syndrome. There were no operative complications. During a mean post-operative period of 12 months, all but one case showed an improvement of symptoms. While 60% of the patients had a complete resolution of symptoms, the remaining were minimally symptomatic. Of those with residual symptoms, two had Down syndrome. Endonasal DCR is a safe and effective intervention for children with persistent NLDO. Success is higher in children with no craniofacial abnormality. Joint care under a consultant Oculoplastic and ENT surgeon provides optimum care for these patients.     

Utilidad de las curas locales tras dacriocistorrinostomía láser

Introduction and objectivesEpiphora caused by nasolacrimal drainage system obstruction is the main indication for dacryocystorhinostomy (DCR). So are chronic conjunctivitis and dacryocystitis from the same origin. Nasal endoscopy and the introduction of laser assisted DCR have facilitated the performance of the technique. However, it requires complex and expensive equipment, so there are still supporters of the traditional external procedure.The aim of this work was to study the effectiveness and usefulness of local postoperative care in laser DCR final result.Material and methodsWe studied a group of 96 patients diagnosed with epiphora secondary to stenosis-occlusion of the nasolacrimal duct. Of these, 32 patients underwent surgery in both eyes, making a total of 128 cases. The surgery was performed in a private setting between January 1999 and December 2008. The 128 cases were divided into 2 groups: 59 cases in which between 4 and 6 postoperative cures were given in the 2 months following the surgery, and another group of 69 cases in which a single cure was given approximately 7 days after surgery. The final assessment of the outcome of the intervention was done in all cases between 24-30 months after surgery.ResultsIn 27 cases out of 128 (79% success), there was a restenosis of tear drainage. No statistically significant differences were found between the 2 groups.ConclusionsIn the sample of patients that were intervened using laser assisted DCR, implementation of postoperative cure was irrelevant in the success of the intervention.     

Use of endocanalicular dacryocystorhinostomy with multidiode laser in children

Objective

To evaluate the clinical outcome and efficacy of endocanalicular laser dacryocystorhinostomy using a multidiode laser in cases unresponsive to medical therapy, probing or intubation of pediatric nasolacrimal duct obstruction.

Methods

Eight children with nasolacrimal duct obstruction were treated with a multidiode laser. The study was prospective, non-randomized, and noncomparative. The patients, 2 (25%) males and 6 (75%) females, ranged in age from 8 to 13 years (mean 11.25 ± 2.43). Surgery was performed under general anesthesia. All procedures were performed using a multidiode laser. The nasal passage was visualized with a 30° nasal video endoscope. In all cases, silicone stents were inserted. The main outcome measure was resolution or improvement of the epiphora and no major laser damage intranasally. Patients were followed for at least 6 months.

Results

The endocanalicular laser dacryocystorhinostomy failed in one of the 8 (12.5%) cases, which had been secondary to trauma. The others were due to primary nasolacrimal duct obstruction. External dacryocystorhinostomy was performed on the failed case. None of the cases with primary nasolacrimal duct obstruction had obstruction after the endocanalicular laser dacryocystorhinostomy operation.

Conclusions

Endocanalicular laser dacryocystorhinostomy using a multidiode laser appears to be an effective technique in cases unresponsive to medical therapy, probing or intubation of primary nasolacrimal duct obstruction.     

Endoscopic dacryocystorhinostomy vs KTP 532 laser-assisted endoscopic dacryocystorhinostomy

Objectives  Advances in endoscopy and lasers have improved surgical management of chronic nasolacrimal duct obstruction. This is a preliminary comparison between standard and laser assisted endoscopic dacryocystorhinostomy (DCR). Study Design  Combined retrospective and prospective study. Setting  Tertiary referral hospital. Patients and Methods  Thirty-eight cases of chronic nasolacrimal duct obstruction underwent endoscopic DCR (26 standard and 12, laser-assisted) and were assessed at 3 and at 6 months postoperatively by nasal endoscopy. Results  Three months postoperatively (n=38), total relief of epiphora among the nonlaser group was 80.76 vs 75% in the laser group (P=0.982). At 6 months (n=19), the laser group had recorded 100% symptomatic relief compared to 85.71% in the nonlaser group (P=0.964). The laser group suffered fewer complications (33.33 vs 46.15% for nonlaser group). Conclusion  Lasers show promise in long-term management of duct obstruction and are associated with fewer complications. A larger study is required before and generalization is made.     

Pediatric Endoscopic Dacryocystorhinostomy Failures: Who and Why?

OBJECTIVE: The objectives of this study are to report outcomes of pediatric patients with nasolacrimal duct obstruction (NLDO) who underwent primary endoscopic dacryocystorhinostomy (DCR) and discuss causes of failure. STUDY DESIGN: The authors conducted a retrospective case series. METHODS: Charts of all patients less than 16 years of age who underwent primary endoscopic DCR from 1997 to 2004 were reviewed. Patients were grouped based on the presence or absence of facial anomalies or syndromes and whether the NLDO was congenital or acquired. Success was defined as complete resolution of symptoms, improvement included anatomic patency or partial symptoms, and failure as no improvement or demonstration of patency. RESULTS: Thirty-four patients (43 ducts) aged 11 months to 14 years were identified. There were 17 males and 17 females. Follow up ranged from 2 to 54 months (average, 21 months). Twenty-four patients (29 ducts) had congenital NLDO, seven patients (11 ducts) had congenital syndromes associated with craniofacial abnormalities, and three patients (three ducts) had acquired NLDO. In patients with congenital NLDO without craniofacial abnormalities or syndromes, 22 of 29 eyes (76%) were cured with another three (10%) showing improvement. Only one of 11 (9%) eyes of patients with congenital craniofacial abnormality or syndrome experienced complete resolution and only four of 11 (36%) eyes showed improvement. Of the patients with acquired NLDO, two of three (67%) of the eyes were cured and one (33%) improved. CONCLUSIONS: Endoscopic DCR is safe and effective for most children, although patients with craniofacial abnormalities or syndromes are extremely difficult to cure.     

Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is a well-established alternative to external approaches in the treatment of nasolacrimal canal obstruction. From July 2004 to December 2008, 92 endoscopic DCRs were performed on 88 patients at the Department of Otorhinolaryngology, San Raffaele Hospital, Milan. All patients were affected by chronic dacryocystitis with epiphora. Preoperative work-up included Jones tests, lacrimal pathways irrigation, nasal endoscopy, and imaging evaluation by computed tomography. The technique involved anastomosis of nasal mucosal, lacrimal sac flaps and a large bony ostium. A silicone tube was inserted in all patients that remained for a period of 3 months. The first endoscopic intervention was successful in 91.30% of patients. After a second revision endoscopic DCR, the overall success rate raised to 95.65%. Anastomosis of nasal mucosal between lacrimal sac flaps plays a key role in endoscopic DCR with a high success rate both in primary nasolacrimal obstructions and in revision cases.     

Outcomes after endoscopic dacryocystorhinostomy without mucosal flap preservation

BACKGROUND: The purpose of this study was to evaluate outcomes of powered endoscopic dacryocystorhinostomy (DCR) without the preservation of mucosal flaps for the management of acquired nasolacrimal duct obstruction. METHODS: A retrospective review was performed of patients undergoing endoscopic DCR without mucosal flap preservation from May 2003 to October 2006 at a tertiary referral medical center. Twenty-seven procedures were performed on 20 patients with epiphora secondary to acquired nasolacrimal duct obstruction. Main outcome measures were subjective improvement in epiphora and assessment of anatomic patency based on lacrimal irrigation. RESULTS: Mean follow-up was 16 months. Mild intermittent postoperative epiphora or complete resolution of epiphora was noted in 100% (27/27) of procedures; complete resolution was recorded in 93% (25/27) of procedures. Eighteen patients (25 procedures) were available for lacrimal irrigation at a mean of 16 months follow-up. Anatomic patency was confirmed in 100% (25/25) of procedures. CONCLUSION: Our results with endoscopic DCR are comparable with previously published outcomes. These data suggest that successfully powered DCR may be performed without the preservation of mucosal flaps.     

Clinical usefulness of endoscopic intranasal dacryocystorhinostomy

CONCLUSIONS: Endoscopic intranasal dacryocystorhinostomy (DCR) has the following advantages over external surgery: pain and hemorrhage are minimal; postoperative facial swelling and scarring are absent; and symptoms resolve rapidly after surgery. Furthermore, as no significant differences in postoperative results were apparent between external and endoscopic intranasal DCR, and because no facial skin incision is required, the clinical usefulness of endoscopic intranasal DCR is high. OBJECTIVES: In the treatment of nasolacrimal duct obstruction or chronic dacryocystitis in which epiphora or ocular discharge are chief complaints, endoscopic intranasal DCR is a safe, easy, minimally invasive, and reliable approach. In the present study, we describe the surgical procedures, techniques, and results of endoscopic intranasal DCR, and investigate its clinical usefulness. SUBJECTS AND METHODS: The subjects were 21 patients with nasolacrimal duct obstruction who underwent a total of 24 endoscopic intranasal DCR procedures. Etiologies of the obstruction were, respectively, cryptogenic (62.5%), secondary to partial maxillectomy (16.7%), complication of sinus surgery (12.5%), and due to underlying disease--Wegener's granulomatosis (4.2%) or nasal T-cell lymphoma (4.2%). To assess the clinical usefulness of this procedure, postoperative courses were assessed by reviewing medical records and conducting telephone interviews. In addition, to assess the therapeutic effects, postoperative results were statistically compared to those of external DCR. RESULTS: Closure of the surgical opening was seen in two cases (8.3%). In both cases, after the closed region was opened using an endoscopic procedure, symptoms resolved. Finally, lacrimal passage obstruction was not observed by lacrimal irrigation in any patient. None of the patients in the present study experienced major complications during or after surgery, and since their symptoms improved, the degree of satisfaction was high. When compared to external DCR, endoscopic intranasal DCR showed no statistically significant difference in postoperative results, thus confirming that similar therapeutic effects could be obtained for the two procedures.     

Endonasal flap suture-dacryocystorhinostomy (eFS-DCR): a new surgical technique for nasolacrimal duct obstruction (NLDO)

Conclusion: Endonasal flap suture-dacryocystorhinostomy (eFS- DCR) is a new and valuable technique for the treatment of nasolacrimal duct obstruction (NLDO). This technique could improve the success rate of endonasal DCR in comparison to external DCR. Objective: The standard procedure for NLDO is DCR. DCR can be performed via either an external or endonasal approach. External DCR is now regarded as the gold standard in the treatment of NLDO because of its higher success rate. However, we report a new endonasal surgical technique, eFS-DCR, and assess its efficacy by comparison with the standard endonasal DCR. Methods: We prospectively investigated a series of 62 consecutive patients with NLDO undergoing endonasal DCR. There were two surgical intervention groups: group 1 (24 patients, 28 sites) undergoing endonasal DCR without eFS; and group 2 (38 patients, 47 sites) undergoing eFS-DCR. Study end points were success rate, the ostium diameter (OD) of the lacrimal sac after DCR, and the duration of stent placement. We compared the two groups on these three points. Results: The success rate was 78.6% (22 of 28 sites) for group 1 (DCR without eFS) and 97.9% (46 of 47 sites) for group 2 (eFS-DCR). The ostium size in patients in group 2 was larger than that in group 1. The median time for the duration of stent placement was 42.5 days for group 1 and 31.5 days for group 2. There was a statistical difference (p < 0.01) in all these parameters between the two groups.     

Unexpected pathologies in patients referred for endoscopic DCR

The objective of this study is to describe a series of patients with different pathologies mimicking nasolacrimal duct obstruction (NLDO), diagnosed with the use of a computed tomography (CT) scan prior to a scheduled endoscopic dacryocystorhinostomy (DCR). This study is a retrospective report. We reviewed the medical records of 47 consecutive patients (57 sides) with long-standing epiphora between 2007 and 2012. All patients were referred to our tertiary Medical Center with a diagnosis of NLDO and were expected to undergo endoscopic dacryocystorhinostomy (DCR). They all underwent routine sinus CT scan prior to surgery. All scans, as well as the demographic and medical characteristics of these patients were reviewed. Of all 47 patients enrolled, in 4 patients (7 % of all sides), unexpected pathologies, other than nasolacrimal system distention, inflammation or infection were identified preoperatively. These included squamous cell carcinoma of the lacrimal sac and nasolacrimal duct, rhinoscleroma at Hasner’s valve region, a compressing ethmoidal mucocele and a case of dacryocystocele. These unusual pathologies mandated a different management and surgical approach. In all four cases, a preoperative CT scan helped in identifying the pathology and in localizing the lacrimal apparatus in relation to the paranasal sinuses. Different nasal, paranasal and lacrimal pathologies may mimic primary acquired NLDO. A high index of suspicion, a thorough clinical evaluation and utilizing preoperative imaging may lead to an alteration of patient management and to a completely different surgical approach.     

Outcomes of posterior lacrimal sac approach in endoscopic dacryocystorhinostomy: review of 35 cases

BACKGROUND: The purpose of this study was to describe the posterior lacrimal sac approach in endoscopic dacryocystorhinostomy (DCR) performed at our institute and report perioperative results achieved with this procedure. METHODS: A prospective clinical study was performed of 35 adult patients with nasolacrimal duct obstruction who underwent posterior lacrimal sac approach DCR from March 1998 to May 2005. Follow-up period ranged from 13 to 30 months (average, 17.5 months; SD, 6.8 months). "Surgical success" was defined as complete relief of epiphora and patent surgical ostium on endoscopic assessment. RESULTS: Surgical success was achieved in 30/35 (85.7%) patients after the primary surgery. Of 5 unsuccessful patients who complained of occasional epiphora, 4 patients had formed stenosis and 1 patient had granulation around the surgical opening, and all had revision surgery. Four of 5 (80.0%) patients achieved surgical success. Thus, including the result of revision surgery, 34/35 (97.1%) patients were successful. CONCLUSION: Posterior lacrimal sac approach in endoscopic DCR has several advantages: good sac accessibility, a low complication rate, and a relatively high success rate. Therefore, the posterior lacrimal sac approach appears to offer a useful alternative approach for the surgical treatment of nasolacrimal duct obstruction.     

Congenital dacryocystocele: is there a familial predisposition?

Congenital impatency of the nasolacrimal drainage system is relatively common. Dacryocystocele formation is an infrequent variant of such congenital nasolacrimal duct obstruction (NLDO). Congenital dacryocystocele typically manifests as a mass in the medial canthal region; alternatively the nasolacrimal expansion may present solely intranasally as a nasolacrimal duct cyst. Despite the relative frequency of congenital NLDO, there have been few reported familial cases. We report here two female siblings with congenital dacryocystocele, and review the etiology and potential inherited predisposition to this comparatively rare entity.     

Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy

Objectives and Study Design: The advent of the rigid endonasal endoscope and the development of functional endoscopic sinus surgery (FESS) technique have awakened interest in an endonasal endoscopic dacryocystorhinostomy (EESC-DCR) in treating nasolacrimal obstruction. This prospective, randomized study compares EESC-DCR with traditional external dacryocystorhinostomy (EXT-DCR) for their success rates, surgical duration, and postoperative symptoms. Patients and Methods: Sixty-four cases in 60 patients with primary acquired nasolacrimal sac or duct obstruction were divided into two subgroups by symptoms (simple epiphora/ chronic dacryocystitis). These patients were randomized within both subgroups into two operation groups. Altogether 32 EESC-DCRs and 32 EXT-DCRs were performed. The final follow-up visit was at 1 year. The patency of the lacrimal passage was investigated by irrigation and patients were questioned about their symptoms. Results: The success rate at 1 year after surgery was 75% for EESC-DCR and 91% for EXT-DCR after primary surgery. The difference was not statistically significant (P = .18). The success rate after secondary surgery with a follow-up time of 1 year was 97% in both study groups. The average duration for EESC-DCR was 38 minutes, and 78 minutes for EXT-DCR, (P < .001). Conclusions: EXT-DCR, when compared with EESC-DCR, appears to give a higher, although not statistically significant, primary success rate, but the secondary success rates are equal, indicating that these two different DCR techniques are acceptable alternatives.     

Comparison of two endoscopically assisted procedures in primary surgical treatment of congenital nasolacrimal duct obstruction in children older than 3 years: balloon dilatation and bicanalicular silicone tube intubation

OBJECTIVES: To determine the success of two transnasally endoscopic assisted procedures as balloon dilatation and bicanalicular silicone tube intubation for the primary surgical treatment of congenital nasolacrimal duct obstruction in children older than 3 years. STUDY DESIGN: Prospective randomized clinical trial. METHODS: An interventional case series of consecutive primary endoscopic assisted balloon dilatation (BD) and bicanalicular silicone tube intubation (STI) for congenital nasolacrimal duct obstruction in children older than 3 years was reviewed. BD was performed in 20 eyes of 17 patients and STI was performed 24 eyes of 20 patients. Clinical success was defined as a complete remission of epiphora at the end of follow-up period of 12 months and a continuation of the remission at least for 4 months. RESULTS: Eighteen out of 20 eyes (90%) nasolacrimal ducts responded to BD whereas the rate was 15 out of 24 eyes (62.5%) in STI group. No significant complications occured in BD group while the complication rate in STI group was 8 out of 24 eyes (33.3%). chi(2)-Statistical analysis showed significantly better results for BD in clinical success and complication rates than those of STI. CONCLUSIONS: BD should be the first choice therapy instead of invasive approaches with high rate of complications and lower success rates such as silicone intubation, in patients who are older than 3 years.     

Surgical success rate comparison in functional nasolacrimal duct obstruction: simple lacrimal stent versus endoscopic versus external dacryocystorhinostomy

Silicone tube intubation (STI) has been known as a standard treatment modality with functional nasolacrimal duct obstruction (FNDO). Recently, dacryocystorhinostomy (DCR) is suggested for FNDO treatment. However, there are no data for comparison according to the surgical types in FNDO patients. This study aimed to compare success rates of three different lacrimal drainage surgeries in FNDO patients. Consecutive patients (153 eyes) who were treated with surgical intervention due to FNDO were analyzed. Patients were divided into three groups according to the type of surgery undertaken: STI, endoscopic DCR (Endo-DCR), and external DCR (Ext-DCR). Symptomatic improvements in epiphora were evaluated using the following scoring system: 1, complete resolution (indicative of success); 2, partial resolution; and 3, no resolution or worsening of the condition. At months 3 and 6, the Endo-DCR group had the highest success rate (84.4 and 81.3 %), but there were no statistically significant differences in epiphora scoring among the patients. Epiphora was significantly improved after surgery by week 2 in the Endo-DCR group (p = 0.0339) and by week 3 in the STI group (p = 0.0161). There were no patients in the Endo- or Ext-DCR group with a score of 3 at month 6, but 4 of 6 (3.7 %) in the STI group had score of 3 at month 6 and underwent additional DCR for epiphora. Our results suggest that Endo-DCR offers the highest success rates in FNDO treatments in terms of the rapid and complete resolution of epiphora.     

Otologic T-tube in endonasal dacryocystorhinostomy: a new approach

CONCLUSION: Otologic T-tubes had a success rate of 73% if implanted during endoscopic dacryocystorhinostomy (DCR). We suggest that they can be used successfully in endoscopic DCR, and are promising as an alternative to silicone stent intubations. OBJECTIVE: To evaluate the efficacy of endoscopic DCR using otologic T-tube. MATERIALS AND METHODS: Twenty patients (22 eyes) with nasolacrimal duct obstruction underwent endoscopic DCR. After creating an aperture in the medial wall of the lacrimal sac, the otologic T-tube (1.15 mm diameter, Invotec, Jacksonville, FL, USA) was inserted into the sac transnasally. The T-tube was left in the lacrimal sac for between 3 and 6 months. The patients were followed up for between 6 and 24 months (mean 12.4 months). The improvement in patients' epiphora complaint was grouped as very good, good, or no change. RESULTS: Eleven eyes (50%) proved to be 'very good', whereas five eyes (23%) were good, and six eyes (27%) had no change. Of six eyes that were reported to have no change after the operation, three experienced spontaneous tube loss in the early period, one eye was a recurrent case, and the other two were primary cases.     

Translacrimal Transnasal Laser-Assisted Dacryocystorhinostomy

Chronic dacryocystitis is due to an obstruction in the nasolacrimal duct, with subsequent infection of the lacrimal sac. The goal of surgery is to reestablish intranasal drainage of the lacrimal sac. Classic dacry-ocystorhinostomy (DCR) requires an external incision and drilling through the lacrimal bone into the middle meatus. In our study a 600-micron neodymium:YAG (Nd:YAG) fiber with a blunt hemispherical tip is inserted via the lacrimal puncta. An intranasal ostium is created with the laser under intranasal endoscopic control. Silicon tubes are then left in place for 6 months. We have performed 49 procedures over the past 2 1/2 years, with a success rate of 85% after one surgical procedure, which is commensurate with standard DCR. This procedure provides a simple, bloodless, incisionless alternative to standard DCR.     

Otologic T-tube in endonasal dacryocystorhinostomy: a new approach

Conclusion. Otologic T-tubes had a success rate of 73% if implanted during endoscopic dacryocystorhinostomy (DCR). We suggest that they can be used successfully in endoscopic DCR, and are promising as an alternative to silicone stent intubations. Objective. To evaluate the efficacy of endoscopic DCR using otologic T-tube. Materials and methods. Twenty patients (22 eyes) with nasolacrimal duct obstruction underwent endoscopic DCR. After creating an aperture in the medial wall of the lacrimal sac, the otologic T-tube (1.15 mm diameter, Invotec, Jacksonville, FL, USA) was inserted into the sac transnasally. The T-tube was left in the lacrimal sac for between 3 and 6 months. The patients were followed up for between 6 and 24 months (mean 12.4 months). The improvement in patients’ epiphora complaint was grouped as very good, good, or no change. Results. Eleven eyes (50%) proved to be ‘very good’, whereas five eyes (23%) were good, and six eyes (27%) had no change. Of six eyes that were reported to have no change after the operation, three experienced spontaneous tube loss in the early period, one eye was a recurrent case, and the other two were primary cases.     

Endoscopic laser dacryocystorhinostomy. An unusual post-operative finding: re-opening of the nasolacrimal duct.

Endoscopic laser dacryocystorhinostomy (DCR) is a recognized technique for the surgical treatment of epiphora. Nasolacrimal duct obstruction is surgically bypassed by creating a passage from the lacrimal sac to the nasal cavity (rhinostomy). Some patients have undergone endonasal laser-assisted DCR, and were found to have an obstructed rhinostomy at follow-up. However, they reported a subjective improvement in their symptoms. Five such patients, at six months follow-up, were found to have a non-functioning rhinostomy with fluorescein dye emerging from under the inferior turbinate. These five patients along with four controls had post-operative macrodacryocystograms (MDCG) to delineate the anatomical passage by which tears were entering the nasal cavity. In the control group, clear passage of contrast into the middle meatus was demonstrated in three of the four subjects. In the study group, passage of dye to the inferior meatus, via the nasolacrimal duct was demonstrated in four of the five subjects. It is well recognized that a proportion of patients suffering from epiphora will have a natural resolution of their symptoms. Our results demonstrate that the resolution of epiphora in some operated patients was due to a re-opening of the nasolacrimal duct, and not because of a patent rhinostomy.     

A retrospective comparison of endonasal KTP laser dacryocystorhinostomy versus external dacryocystorhinostomy

We retrospectively reviewed all primary external dacryocystorhinostomies (DCRs) and endonasal KTP laser DCRs performed for epiphora as a result of nasolacrimal duct obstruction in our unit between 1993 and 2000. Forty-nine patients underwent an external approach and 76 endonasal laser procedures were performed. The success rate of the external group was 94% with a mean follow-up of 9 months. In contrast, the endonasal group's success rate was 64% with a mean follow-up of 12 months. This difference reached statistical significance (P = 0.0002). However, when including revision procedures, the success rate in the endonasal group increased from 64% to 82%. The success rate in the endonasal group improved from 50% in the first 38 cases to 79% in the last 38 cases (P = 0.0084), thereby demonstrating a learning curve. Our study confirms external DCR as the 'gold standard' for a successful outcome. However, the endonasal technique has significant advantages, including being a quicker procedure with less morbidity, no cutaneous scar, and being more amenable to a bilateral procedure, daycase surgery and local anaesthetic. We are persisting with the endonasal technique because of its advantages but have moved towards more 'cold steel' techniques in an effort to improve results and emulate other series. In conclusion, for nasolacrimal duct obstruction, the endonasal technique is our approach of choice, with revision surgery if necessary, and the external technique is held in reserve.