External versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center

Purpose

To study the duration of surgery, outcomes, adverse events and success rates of external versus endonasal dacryocystorhinostomy (DCR) surgery in a specialized lacrimal surgery center.

Methods

Prospective, interventional case series. Standard external DCR technique was performed. Mechanical endonasal DCR was performed with enlargement of the ostium and full length opening of the lacrimal sac. Surgical time, duration of intubation, incidence of hemorrhage, infection, wound dehiscence; follow-up duration and functional success at the end of follow up were recorded.

Results

Functional success and symptomatic relief were equivalent in both procedures. Endonasal DCR surgery was found to be quicker to perform than external DCR surgery. The follow-up duration was comparable in both groups (mean 9 months). Patient satisfaction was significantly higher in the endonasal DCR group (9.3 versus 8.6).

Conclusion

Endonasal DCR surgery offers a very attractive alternative to the well established technique of external DCR surgery for the treatment of primary acquired nasolacrimal duct obstruction with equivalent success rates, shorter surgical time and higher patient satisfaction.     

Prognostic factors for outcome of endoscopic dacryocystorhinostomy in patients with primary acquired nasolacrimal duct obstruction

Purpose

To evaluate the prognostic factors for outcome of endoscopic dacryocystorhinostomy (DCR) in patients with primary acquired nasolacrimal duct obstruction.

Materials and Methods

Eighty-three consecutive cases of endoscopic DCR performed for primary acquired nasolacrimal duct obstruction by a single surgeon were included in a retrospective, noncomparative case series. The outcome was assessed at a minimum of 5 months after surgery, being at least 3 months after removal of stents. Surgical success was defined both subjectively and objectively. Subjective success was defined as absence of epiphora. Objective anatomical success was defined as patency on syringing, and presence of a functioning rhinostomy evaluated using the functional endoscopic dye test. Variables assessed included age at surgery, gender, side, duration of intraoperative mitomycin C application, and duration of stent left in-situ. The prognostic factors for outcome were analyzed by the logistic regression test.

Results

Of the 79 analyzed cases, 74 (93.7 %) had successful surgical outcomes. The mean age at time of surgery was 55.5?±?13.3 years, and the majority of patients were female (85 %). The mean follow-up period was 23.3?±?16.8 months. Age at surgery is a significant factor influencing the surgical outcome (P?<?0.05). Gender, side, duration of intraoperative mitomycin C application, and duration of stent left in-situ had no significant association with the outcome (P?>?0.05).

Conclusion

In endoscopic DCR for primary acquired nasolacrimal duct obstruction, younger patient age at time of surgery was associated with a higher rate of failure.     

Indikation und Prognose der Dakryozystorhinostomie im Kindesalter Eine klinische Studie 1970–2000

Background. Dacryocystitis in infants is a serious complication of congenital, but seldom of acquired nasolacrimal duct obstructions. If conservative treatment fails, dacryocystorhinostomy (DCR) appears to be effective. The indications, special clinical history and results will be reviewed. Patients and methods. From 1/1970 to 2/2000, a total of 72 children (56 male, 16 female) with persistent dacryocystitis (18 bilateral) were treated surgically by DCR and were continuously documented. The patients ranged in age from 10 months to 14 years old (mean age 4.9 years). Included in our study were 66 children (52 male, 14 female) with 84 surgically treated lacrimal ducts (46 right eyes, 38 left eyes) who underwent control examinations. Results. The cause of dacryocystitis was congenital obstruction in 63 children and trauma (maxillary fracture) in 3 children, respectively. Of these, 20 children (30.3%) had additional anomalies of the lacrimal system, 21 (31.8%) systemic malformations and 8 out of the 66 children (12.1%) had a family history of nasolacrimal duct obstruction. Since 1985 the surgical procedures have been performed under microsurgery conditions and since 1998 sometimes with a transcanalicular laser-assisted technique. We found a functional success rate (with complete resolution of symptoms) of 90.4% (76 out of 84 lacrimal ducts) over follow-up periods ranging from 1 month to 12 years (average 1.6 years). Conclusion. Patients with persistent dacryocystitis due to congenital nasolacrimal duct obstruction have a prevalence of further nasolacrimal abnormalities and a family history. The dacryocystorhinostomy of infants requires minimal invasive (sometimes laser-assisted) techniques. In the case of persistent dacryocystitis, DCR is indicated after the age of 1 year and has the same success rate in infants as in adults (90–95%).     

Endoscopy-Guided Transcaruncular Jones Tube Intubation without Dacryocystorhinostomy

Purpose

To evaluate the functional surgical success, complications, and degree of satisfaction after endoscopy-guided transcaruncular Jones tube intubation without dacryocystorhinostomy (DCR).

Methods

A pair of Westcott scissors was passed into the nose from the side of the caruncle, and the lacrimal bone was penetrated between the lacrimal sac and the nasal mucosa. After the proper length of Jones tube was decided, the tube was inserted into the nasal cavity and fixed at the caruncle with nonabsorbable suture material. This procedure was done without DCR. We retrospectively reviewed the 60 patients (70 eyes) with canalicular obstruction who underwent Jones tube intubation in this manner.

Results

The overall success rate was 91.4%. The length of Jones tube used ranged from 16 to 30?mm. Retrograde air blowing into the eye via the Jones tube was the most common complaint (25 of 70 eyes). Complications of this technique included tube problems (25.7%), in particular, downward displacement (22.9%), which was corrected easily in the outpatient clinic, and extrusion. Other complications were frequent inflammation and conjunctival growth over the tube opening.

Conclusions

Endoscopy-guided Jones tube intubation without DCR is a simple and useful procedure for correcting canalicular obstruction.?Jpn J Ophthalmol 2006;50:141–146 © Japanese Ophthalmological Society 2006     

Effects of Nasopore Packing on Dacryocystorhinostomy

Purpose

To investigate the effects of placement of the absorbable packing material Nasopore at the anastomosis site of newly formed mucosal flaps on postoperative re-bleeding, discomfort, and on the success rate of dacryocystorhinostomy (DCR).

Methods

A review of the medical records of patients with primary acquired nasolacrimal duct obstruction that underwent external or endonasal DCR by a single surgeon was performed. The degree of re-bleeding, discomfort, and postoperative results, including anatomical success, functional success and postoperative nasal findings such as granulation, synechiae, and membrane formation were compared in patients whose anastomosis site was packed with either Nasopore or Merocel, a non-absorbable packing material.

Results

A total of 77 patients (101 eyes) were included. Of the 101 eyes, 30 were packed with Nasopore, while 71 were packed with Merocel. The Nasopore group showed significantly better results than the Merocel group in the degree of re-bleeding and the level of patient discomfort (p = 0.000, 0.039, respectively; Pearson''s chi-square test), whereas there were no statistically significant differences between the two groups in postoperative anatomical and functional success (p > 0.05).

Conclusions

Nasopore significantly reduced postoperative nasal re-bleeding and patient discomfort during the early post-surgical period, but failed to show an effect on the postoperative anatomical and functional success of DCR.     

A novel technique to recanalize the nasolacrimal duct with endodiathermy bipolar probe

Aims:

To evaluate a new approach for recanalization (RC) of nasolacrimal duct obstruction in the treatment of the symptomatic nasolacrimal duct obstruction (NLDO).

Materials and Methods:

A prospective, interventional, comparative study in 302 eyes of 209 patients of symptomatic nontraumatic NLDO. Eyes with previous failed surgery were excluded. One hundred and fifty-one eyes underwent RC with 20 G endodiathermy bipolar probe connected to a 7 W diathermy followed by bicanalicular intubation under direct visualization. One hundred and fifty-one eyes underwent standard external dacryocystorhinostomy (DCR). Follow-up was for 24 months and evaluation was done on basis of change in symptoms and lacrimal syringing. Data was analyzed by Chi-square test and unpaired t-test. P value < 0.05 was considered statistically significant.

Results:

Success defined as an asymptomatic patient or freely patent syringing was 92.7% (140 eyes) in RC group and 83.44% (126 eyes) in DCR group. Success was significantly more (P ≤ 0.01) in RC than DCR group. Surgical time was significantly less in RC than DCR (P ≤ 0.001). In RC group, RC could not be performed in three eyes and had to be later taken up for DCR. Intubation after RC was not achieved in four eyes; however these eyes had a patent pathway till 24 months. Twenty-two eyes had a premature extrusion of the tube; but the success rate in these (20 eyes) was comparable to the others within the group (P > 0.05). Two eyes in RC and one in DCR group had complications.

Conclusions:

RC with 20 G endodiathermy bipolar probe is a quick, simple, and effective alternative to standard external DCR.     

Acquired Nasolacrimal Duct Obstruction in Children

Purpose

To study the clinical characteristics of acquired nasolacrimal duct (NLD) obstruction in Korean children.

Methods

The records of 38 patients under the age of 15 years who had undergone silicone intubation or dacryocystorhinostomy (DCR) for acquired NLD obstruction were evaluated. Patients who had congenital NLD obstruction or a history of NLD obstruction due to trauma were excluded.

Results

The mean age of the patients was 3 years (range, 1–8 years). The causes of the NLD obstruction were epidemic keratoconjunctivitis (EKC) in 32 patients, herpetic blepharitis in one, and idiopathic in five. In patients with a history of EKC, symptoms were observed at a mean age of 12.7 months (range, 3–51 months). These patients demonstrated multifocal features of obstruction, unlike those in the idiopathic group. Silicone intubation was performed in 32 patients, external DCR in three, and endonasal DCR in three. The lacrimal procedures were beneficial in 36 of the 38 patients. The mean follow-up period was 7.6 months.

Conclusions

Acquired NLD obstruction in children was mostly caused by EKC in our study. It is important to suspect NLD obstruction in children with persistent epiphora that develops after EKC.?Jpn J Ophthalmol 2007;51:437–441 © Japanese Ophthalmological Society 2007

     

Clinicopathologic findings after nasolacrimal polyurethane stent implantations

PURPOSE: To evaluate the results of nasolacrimal polyurethane stent implantations for the treatment of primary acquired nasolacrimal duct obstruction, and to determine the effects of various surgical procedures, including stent removal, in subsequent nasolacrimal duct obstruction. METHODS: This study included 15 patients who had nasolacrimal polyurethane implantations for the treatment of primary acquired nasolacrimal duct obstruction. Occluded stents were removed either by nasal endoscopy or during dacryocystorhinostomy (DCR). Cultures and biopsies were performed on the removed stents, and the results of the secondary DCR were analyzed for a 6-month follow-up period. RESULTS: During stent removal surgery, various degrees of chronic inflammatory reaction and fibrous tissue formation were detected in the lacrimal sac and nasolacrimal duct. Formations of granuloma and fibrous tissue were found in 15 eyes, and culture-positive reaction were found in nine of the 15 eyes. Conventional dacryocystorhinostomy surgery was performed in nine of the 15 eyes and a silicone tube was located at the canaliculi. Subjective and objective outcome were favorable in 13 of the 15 eyes. CONCLUSIONS: The success rate of nasolacrimal polyurethane stent implantation for the treatment of primary acquired nasolacrimal duct obstruction is low. This may result from a chronic inflammatory reaction. Despite the low success rate of nasolacrimal polyurethane stent implantation, the success rate of endonasal DCR as a subsequent surgery is favorable.     

Congenital lacrimal fistula associated with Down syndrome

Background

The aim of this work is to investigate the prevalence and clinical characteristics of congenital lacrimal fistula in Down syndrome patients.

Methods

The medical records of 198 Down syndrome patients who were referred to a tertiary ophthalmology clinic from 2000 to 2010 were retrospectively reviewed to identify patients with congenital lacrimal fistula. The demographic data, clinical features, clinical management, and clinical outcomes were recorded. The main outcome measures were the presence and laterality of fistula, accompanying adnexal and oculomotor abnormalities including congenital nasolacrimal duct obstruction (NLDO), the type of surgery performed, and surgical outcome. The prevalence of congenital lacrimal fistula in Down syndrome patients was calculated upon this data.

Results

Congenital lacrimal fistula was identified in 8/198 (4.04?%) patients, 4 (2.02?%) of whom presented with bilateral lacrimal fistula. All patients that had lacrimal fistula complained of tearing from their eyes. Congenital NLDO was observed in seven of eight patients with lacrimal fistula. Five patients underwent excision of the lacrimal fistula for the improvement of cosmesis, and three of these patients also underwent lacrimal silicone intubation for NLDO. Another patient received lacrimal silicone intubation for NLDO without excision of the lacrimal fistula. Excision of the lacrimal fistula was successful in all patients; however, tearing persisted after surgery in two patients with uncorrected NLDO.

Conclusions

Congenital lacrimal fistula occurs more frequently in Down syndrome patients and therefore these patients should be thoroughly examined for this abnormality. Down syndrome patients with congenital lacrimal fistula should be also examined for NLDO, because this condition is frequently observed in these patients.     

The efficacy of sleeve technique in primary nasolacrimal duct obstruction with a high lacrimal sac

Purpose:

To evaluate the efficacy of a sleeve technique during endoscopic dacryocystorhinostomy (DCR) in primary nasolacrimal duct obstruction (NLDO) patients with a high lacrimal sac.

Materials and Methods:

The medical records of 45 patients (49 cases) undergoing endoscopic DCR for primary NLDO with a high lacrimal sac were retrospectively reviewed. In 19 patients (21 cases), the thick maxilla covering the common canalicular opening was removed using a drill and a bicanalicular silicone tube was inserted (group 1). In 26 patients (28 cases), instead of removal of the thick maxilla, a sleeve was inserted into the bicanalicular silicone tube (group 2). At 6 months postoperatively, the success rate was evaluated and the size of the intranasal mucosal ostium was measured.

Results:

The success rates in group 1 and 2 was 90.5% and 96.4%, respectively (P =0.400). The intranasal mucosal ostium in group 1 and 2 measured 1.7 ± 0.7 mm and 3.1 ± 1.0 mm, respectively, and the difference was significant (P =0.042).

Conclusions:

In primary NLDO patients with a high lacrimal sac, DCR inserting a silicone tube and a sleeve together had a satisfactory success rate without using a drill. In comparison with traditional surgical methods, it helped enlarge the size of the intranasal mucosal ostium.     

Meta-analysis of randomized controlled trials in dacryocystorhinostomy with and without silicone intubation

Objective

To determine the effect of bicanalicular silicone intubation (SI) on dacryocystorhinostomy (DCR) success rate in adult primary acquired nasolacrimal duct obstruction.

Long-term results of probing guided with soft cannula in children with congenital nasolacrimal duct obstruction

Purpose

To report the results of soft probing in children with congenital nasolacrimal duct obstruction (CNLDO).

Materials and Methods

A prospective, non-randomised interventional study included 158 eyes of 122 children aged 2 months–5 years, with CNLDO. A plastic intravenous catheter sheath supported intraluminally with a guiding metal probe was introduced through the superior canaliculus. During intubation, the plastic cannula was gently introduced through the nasolacrimal system, while the metal probe inside was withdrawn concurrently. After the complete withdrawal of the metal probe, the duct was irrigated with a high pressure saline solution through the plastic cannula. Once the obstruction was totally dissolved and a patent passage was observed, the plastic cannula was withdrawn and the procedure was completed with a nasolacrimal lavage with a gentamycin and dexamethasone combination.

Results

Clinically successful results were achieved in 142 eyes (89.8 %). No significant complications occured intraoperatively or postoperatively.

Conclusions

In children under age 5, our technique has a high success rate with no significant complications. This method allows probing in a more controlled way. This method may be particularly suitable for surgeons during training, when the most false lumen formation is observed.     

Comparison of scanning electron microscopy findings regarding biofilm colonization with microbiological results in nasolacrimal stents for external, endoscopic and transcanalicular dacryocystorhinostomy

AIM:To compare bacterial biofilm colonization in lacrimal stents following external dacryocystorhinostomy (EX-DCR), endoscopic dacryocystorhinostomy (EN-DCR), and transcanalicular dacryocystorhinostomy (TC-DCR) with multidiode laser.METHODS: This prospective study included 30 consecutive patients with nasolacrimal duct obstruction who underwent EXT-, EN-, or TC-DCR. Thirty removed lacrimal stent fragments and conjunctival samples were cultured. The lacrimal stent biofilms were examined by scanning electron microscopy (SEM).RESULTS:Eleven (36.7%) of the 30 lacrimal stent cultures were positive for aerobic bacteria (most commonly Staphylococcus epidermidis and Pseudomonas aeruginosa). However anaerobic bacteria and fungi were not identified in the lacrimal stent cultures. Twenty-seven (90%) patients had biofilm-positive lacrimal stents. The conjunctival culture positivity after the DCR, biofilm positivity on stents, the grade of biofilm colonization, and the presence of mucus and coccoid and rod-shaped organisms did not significantly differ between any of the groups (P＞0.05). However, a significant difference was found when the SEM results were compared to the results of the lacrimal stent and conjunctival cultures (P＜0.001).CONCLUSION: Type of dacryocystorhinostomy (DCR) surgery did not affect the biofilm colonization of the lacrimal stents. SEM also appears to be more precise than microbiological culture for evaluating the presence of biofilms on lacrimal stents.     

Endoskopisch kontrollierte Chirurgie mit dem Mikrobohrer und Intubation der Tränenwege

Purpose. Operative procedures to manage lacrimal outflow obstruction were made traditionally without endoscopic assistance. For dacryoendoscopy we previously used a 0.5-mm endoscope with a special wash cannula. We now use the microendoscope Vitroptic T for dacryoendoscopy and for endoscopically controlled surgery with a microdrill. Methods. In an attempt to perform microinvasive lacrimal surgery we use a 1.1-mm endoscope (Vitroptik T) with a wash cannula, a channel for the microoptic and a channel for a microdrill. We report on our initial experiences and on the results of eight patients with stenosis of the lacrimal outflow system who were treated with an endoscopic microdrill and silicone tubing. One patient had lacrimal stenosis after external dacryocystorhinostomy (DCR), and seven patients showed punctual stenosis in the nasolacrimal duct. Results. Using the dacryoendoscope (Vitroptic T) we were able to visualize pathologic changes of the lacrimal outflow system. Intraoperative situations during dacryoendoscopy are demonstrated. The Vitroptic T allows dacryoendoscopy and endoscopically controlled surgery of the lacrimal drainage system. Three months after surgery in six patients (75%) the lacrimal outflow system was patent with the silicone tube in place, and these patients had no epiphora. The patient with re-stenosis after external DCR showed patency. Conclusions. Dacryoendoscopy and endoscopic controlled surgery of the lacrimal drainage system enables atraumatic and minimally invasive surgery. The Vitroptik T with the microdrill allows endoscopically controlled microsurgery. Possible indications for the microdrill are punctual stenosis and re-stenosis after external DCR.     

The prevalence of amblyogenic factors in children with persistent congenital nasolacrimal duct obstruction

Background

To evaluate the prevalence of amblyopia risk factors in children that underwent probing for persistent congenital nasolacrimal duct obstruction (CNLDO).

Methods

The medical records of children with CNLDO (after 1 year of age) that underwent probing were reviewed. Amblyopia risk factors, based on the American Association for Pediatric Ophthalmology and Strabismus referral criteria in 2013, were sought in the patients? records before probing. The proportion of the patients with anisometropia >1.5 diopters (D) was separately calculated. In unilateral cases of CNLDO, sphere, astigmatism, and spherical equivalent of the eyes with CNLDO were compared with contralateral eyes in order to assess the effect of CNLDO on refractive error. In the follow-up examinations, the success of the probing or the need for additional procedures (Crawford intubation, Monoka intubation, or dacryocystorhinostomy) was evaluated. The prevalence of anisometropia between ‘successful probing’ and ‘failed probing’ groups was compared.

Results

A total of 433 cases were included in the study. 41 cases (9.46 %) had amblyopia risk factors. Twenty-four cases (5.5 %) had anisometropia >1.5 D (spherical or cylindrical). In unilateral cases of CNLDO, the sphere and spherical equivalent of the eyes with CNLDO were significantly greater than those of the contralateral eyes (p?p?=?0.03).

Conclusions

The findings of greater prevalence of anisometropia >1.5 D (compared with the prevalence in the general population) and significantly greater sphere and spherical equivalents in the eye with CNLDO (compared with contralateral eye) in unilateral cases with CNLDO, suggested some relationships between anisometropia and long-term untreated CNLDO. The finding of more anisometropia in failed probing cases may support the theory of structural abnormality as an explanation for the possible relationship between congenital nasolacrimal duct obstruction and anisometropia.     

Changes in cytokines in tears after endoscopic endonasal dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction

Purpose

We attempted to compare the cytokine composition of tears between primary acquired nasolacrimal duct (NLD) obstruction and normal controls. We investigated the changes in cytokines in tears after endoscopic endonasal dacryocystorhinostomy (DCR).

Patients and methods

Eighteen patients underwent endonasal DCR, with seven patients undergoing bilateral DCR, resulting in twenty-five DCRs in total. Eleven contralateral un-operated eyes were used as normal controls. Silicone stents were removed 3 months after surgery. Tear samples were collected from all eyes before surgery, and at 1 month, 2 months, 3 months, and 4 months after surgery. The level of interleukin (IL)-1β, IL-2, IL-6, IL-10, transforming growth factor (TGF)-β2, fibroblast growth factor (FGF)-2, and vascular endothelial growth factor (VEGF) in the tears was measured.

Results

The concentrations of IL-2, IL-6, IL-10, VEGF, and FGF-2 were significantly higher in eyes with NLD obstruction than controls before surgery (P=0.006, 0.018, 0.002, 0.048, and 0.039, respectively). Most inflammatory cytokines (IL-1β, IL-2, IL-6, VEGF, and FGF-2) were higher in the tears of the DCR group compared with the controls during the postoperative follow-up, but then rapidly decreased to the level of the controls after removal of the silicone stent. The recurred eyes showed a higher level of TGF-β2 and FGF-2 in tears compared with the eyes that showed good surgical results (P<0.005 and <0.005, respectively).

Conclusion

The tear levels of inflammatory cytokines were higher in eyes with NLD obstruction than controls. The changes in cytokine level during the postoperative period showed the importance of cytokine analysis in understanding wound healing after DCR.     

Value of external dacryocystorhinostomy]

Present surgical techniques to distal obstruction of the nasolacrimal duct system are the external dacryocystorhinostomy (DCR) and alternatively the endonasal laser-assisted DCR and the transcanalicular laser-assisted DCR. Combining the own experiences and the overview of bibliography the different surgical techniques are compared. As criteria are used the success rate (long term patency rate), the perioperative conditions and the patient selection. The conclusion is that the success rates for conventional external lacrimal surgery are better than those for endonasal and transcanalicular laser-assisted DCR. Therefore at present the external DCR still remains the gold standard by which other methods are measured.     

Transconjunctival dacryocystorhinostomy: Long term results

Purpose

To evaluate the outcomes of transconjunctival dacryocystorhinostomy (TRC-DCR) surgery in patients with epiphora due to primary acquired nasolacrimal duct obstruction (PANDO) at second year follow-up.

Methods

In this retrospective, interventional study, 33 eyes of 29 patients, with epiphora due to PANDO, are included. Lower eyelid conjunctiva is incised at vestibulum inferomedially to access the lacrimal sac and nasal mucosa. Bone is perforated with burr and rongeurs and saccal and nasal flaps are anastomosed. Conjunctival wound edges are apposed and left unsutured. Intraoperative difficulties, surgical time and complications are noted. Average follow-up time was 2 years. Anatomical success was defined as patent lacrimal passages upon irrigation and functional success was defined as relief of epiphora.

Results

In nineteen (57.6%) eyes the surgeries were completed with the anterior and the posterior flaps sutured. In eight eyes (24.2%) only anterior flaps could be sutured. In 6 eyes (18.2%), the surgical procedure was converted to external dacryocystorhinostomy since the nasal mucosa could not be exposed adequately via transconjunctival route. The mean surgical time was 65.1 min. One patient had a millimeter long lower eyelid margin laceration in one eye (3.7%) intraoperatively due to traction for visualization of the operative site.Epiphora resolved in 25 of 27 eyes (92.5%) in whom TRC-DCR could be completed. Epiphora and failure to irrigation were noted in two eyes (7.4%) at the postoperative 4th and 8th months, respectively and required reoperation. No complications occurred, except granuloma formation at the conjunctival incision site in three eyes (11.1%).Epiphora resolved in all the six eyes of patients who underwent an external DCR (100%).

Conclusion

Transconjunctival dacryocystorhinostomy is a scarless dacryocystorhinostomy technique which is performed without endoscope and/or laser assistance, with 92.5% success rate comparable to external DCR at the second year follow-up without major complications.     

Endoscopic-assisted retrieval of retained lacrimal stent material in congenital nasolacrimal duct obstruction without dacryocystorhinostomy

We report a 3-year-old child with history of congenital nasolacrimal duct obstruction who failed lacrimal probing and underwent bicanalicular intubation. Removal of stent from the superior punctum was unsuccessful and it was trapped in the lacrimal sac. We performed endonasal endoscopic-assisted retrieval of retained stent material without necessitating dacryocystorhinostomy (DCR). There was no recurrence of infection and nasolacrimal duct obstruction symptoms during 6 months of follow-up.     

Dacryocystorhinostomy: History,evolution and future directions

Dacryocystorhinostomy (DCR) is a procedure of choice for nasolacrimal duct obstruction and chronic dacryostenosis in the setting of patent canaliculi and a functional lacrimal pump. Two major approaches are utilized: external, via a transcutaneous incision and endonasal endoscopically guided. The surgery has a high success rate via both approaches. We review the history, evolution, current techniques, complications and future directions of DCR.