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Purpose: To investigate the effects of hydroxybutyl chitosan (HBCS) with and without 5-fluorouracil (5-FU) during endoscopic endonasal dacryocystorhinostomy (Endo-DCR). In addition, the present study observed the impact of HBCS and 5-FU on the functions of the nasal mucosal cell population in vivo. Methods: Patients were randomized into HBCS (group A), HBCS combined with 5-FU (group B), and gelatin sponge control group (group C). 16S rRNA high-throughput sequencing technology examined the conjunctival sac and nasal flora changes. In addition, CCK8, cell scratching, and flow cytometry were used to investigate the effects of HBCS and 5-FU on the nasal mucosal cell populations. Results: Subjects in groups A, B, and C had anastomotic areas of 21.83 ± 12.69 mm2, 21.57 ± 14.53 mm2, and 12.45 ± 8.16 mm2, respectively (P = 0.0359). Group A had less severe epiphora than the other two groups at 1-, 2-, and 12-week postoperative follow-up (P < 0.05). Complications around the anastomosis in group A were the least severe of the three groups (P = 0.0259). After surgery, the proportion of pathogenic bacteria in the conjunctival sac and nasal cavity was higher in groups A and B than in healthy adults. At the 2-week follow-up, the structure of nasal flora in group A was more similar to that of the healthy adults compared to group B. Conclusion: Intraoperative use of HBCS at the anastomose improves the postoperative outcome of En-DCR. 5-FU cannot give better postoperative results in En-DCR and is detrimental to the normalization of the postoperative flora in patients with chronic dacryocystitis. At the cellular level, both HBCS and 5-FU inhibit the migration of nasal mucosal cell populations, and 5-FU inhibits proliferation but does not promote apoptosis.

Purpose: In this study, we aimed to compare closure of the incision for external dacryocystorhinostomy (ext-DCR) by suturing with 6-0 Prolene versus closure with 2-octyl cyanoacrylate and assess the results in terms of the aesthetic and functional aspects of the scar, operating time, postoperative symptoms and complications, and the economic cost of the two techniques. Methods: Sixty-three patients with distal lacrimal obstruction and indication of ext-DCR were initially enrolled in a longitudinal prospective cohort study. Patients underwent ophthalmologic evaluations including lacrimal probing, external examination with photograph, measurement of the surgical wound, timing the cutaneous closure phase of the surgery, recording postoperative wound pain using visual analog scale (VAS), and recording the patient’s and clinician’s subjective satisfaction with the scar using Patient and Observer Scar Assessment Scale (POSAS) at 6 months postsurgery. The 63 eyes were divided into two groups: the wounds in group 1 were closed with 6-0 Prolene using continuous locking suture and the wounds in group 2 were closed with 2-octyl cyanoacrylate. Results: There was no difference in baseline characteristics (age, sex, and race), and no statistically significant differences were found in wound length, POSAS score, VAS score, or serious complications of the wound between the two groups. There were differences in surgery time and economic cost for group 2 compared to group 1 of -2.39 min and -€5.37/operation, respectively. Conclusion: This is the first study in the literature that compares 6-0 Prolene versus Dermabond®. The latter one presents advantages compared to Prolene, given that it reduces the length of surgery, reduces costs, and allows for greater flexibility in postoperative follow-up visits.

Background: The usual procedure for nasolacrimal duct obstruction is dacryocystorhinostomy (DCR). Flap-based DCR techniques lead to better surgical outcome provided flaps do not dislocate in the post-operative period. Objectives: This study was conducted to compare gelfoam with merocel tamponade for fixation of mucosal flaps in endoscopic DCR. Materials and Method: Merocel tamponade was used for fixation of flaps in 26 patients. Gelfoam was used in 26 patients, and surgical results were compared. Results: The surgical success rate was greater in merocel tamponade fixation with less complications. Conclusion: Merocel tamponade can be used successfully for mucosal flap fixation in endoscopic DCR for better surgical outcome.

Context: The prognosis of combined septoplasty and endoscopic dacryocystorhinostomy (En-DCR) for moderate nasal septum deviation (NSD) has not yet been fully investigated. Purpose: To evaluate whether septoplasty improves the prognosis of En-DCR for moderate NSD. Settings and Design: A retrospective cohort study in a real-world clinical setting. Methods: The postoperative FICI DCR ostium grading scores and functional and anatomical information at 1, 2, 3, and 6 months were determined for consecutive patients with chronic dacryocystitis (CD) and moderate NSD who underwent En-DCR. Statistical Analysis Used: Univariate and generalized estimating equation multivariate analyses were used to compare the outcomes of the septoplasty and non-septoplasty groups. Results: En-DCR and septoplasty were concurrently performed for 32 (20.1%, 32/158) cases. The total FICI DCR ostial scores for the septoplasty and non-septoplasty groups were highest at the first (4.97 ± 0.177 vs. 4.97 ± 0.176, P > 0.05) and lowest at the sixth (4.41 ± 1.341 vs. 4.50 ± 1.355, P > 0.05) postoperative months. At the end of follow-up, the two groups showed comparable proportions of patients requiring definitive intervention for the ostium (6.3% vs. 7.1%, P > 0.05), comparabe functional success rates (87.5% vs. 90.5%, P > 0.05) and anatomical success rates (93.8% vs. 92.9%, P > 0.05). Only the non-septoplasty group experienced nasal mucosal adhesions (3.2%, 4/126). Conclusions: In patients with CD and moderate NSD, nasal septoplasty did not impact En-DCR prognosis, but reduced the complications. Skilled surgeons should reconsider septoplasty in the absence of otolaryngological indications.

Introduction: The definitive management of complete nasolacrimal duct obstruction from chronic dacryocystitis is surgical. The surgery of choice is dacryocystorhinostomy (DCR), which can be done external or endonasal with or without stenting. We aim to compare the anatomical and functional outcomes of endoscopic endonasal DCR with and without stenting. Materials and Methods: This prospective study was carried out involving 30 patients of either sex randomly divided into two groups of 15 patients each. Group A underwent endoscopic DCR with stenting of the canaliculi, whereas Group B underwent endoscopic DCR without stenting. These patients were followed up at week 1, 6, and 12. The success of surgery in each group was determined by the absence of epiphora (Munk scale grades: 0 and 1), patent ostium on irrigation, positive Jones test, and decrease in the marginal tear film volume as seen on dye disappearance test (grade: 0 and 1) at week 12. Final data were analyzed using SPSS 21 version. Results: About 86.6% success rate was noted in the group where stenting was done (Group A) compared to 100% success in the group without stenting (Group B). This difference was, however, not statistically significant (P = 0.143). Failures in the study were attributed to the closure of rhinostomy ostium at week 12 follow-up. The most common complication noted was postoperative pain around the bridge of nose. Stent-related complications such as conjunctivitis and difficulty in removal of the stent were also noted. Conclusion: In our study, the surgical results of endoscopic endonasal DCR without stenting were better than endoscopic dacryocystorhinostomy with stenting both anatomically as well as functionally.

A systematic review and meta-analysis were conducted to evaluate the success and complications of endoscopic laser dacryocystorhinostomy (ELDCR) vs. external dacryocystorhinostomy (ExDCR) in primarily acquired nasal duct obstruction. The search of PubMed, Embase, and Cochrane Central Register of Controlled Trials databases revealed 109 studies on ELDCR and ExDCR. Eleven studies were found to be suitable for review. The primary objective was to compare the success rate between ELDCR and ExDCR. The secondary objectives were to analyze the surgical time, overall complications, bleeding, infection, intranasal synechia, and granulation tissue. Pooled analysis of all studies revealed that ELDCR had a significantly lesser success rate compared to ExDCR (80.3% vs. 91.6%; odds ratio [OR] 0.41; 95% confidence interval [CI] [0.27, 0.62]; P < 00001; I2 = 13%). However, there were no difference in the overall complication rate (12.0% vs. 13.0%; OR 1.04; 95% CI [0.17, 6.33]; P = 0.97, I2 = 80%) and intranasal synechiae (9.5% vs. 4.3%; OR 2.22 [1.04, 4.72]; P = 0.04; I2 = 10%). The ExDCR group had significantly increased risks of bleeding (1.9% vs. 13.0%; OR 0.20; 95% CI [0.09, 0.47]; P = 0.0002; I2 = 0%) and infection (0.3% vs. 4.6%; OR 0.09; 95%CI [0.02, 0.51]; P = 0.006; I2 = 0%). Nevertheless, ELDCR needed a shorter surgical time compared to ExDCR (mean difference [MD] −28.35, 95% CI [−35.45, −21.26], P < 0.00001, I2 = 78%). Although ELDCR is associated with lesser bleeding, lesser infection, and shorter surgical duration, the success rate of ExDCR is higher.

Surgery, by nature, involves blood loss. Thus, suction plays an important role in ensuring a clean operating view and ease of access. In ophthalmology, there is a void for an efficient and flexible suction apparatus that is yet to be filled. Our innovation, the Eyespirator, is made using recycled or inexpensive parts, is easy to assemble, and can serve as a cost-effective alternative to the current apparatus under use. It helps to overcome the difficulties caused by large instruments and non-pliable suction tips, unregulated generation of vacuum, and high pressures generated causing trauma to the delicate structures, and can prove to be of immense use in fields such as ophthalmology where the small surgical field is a big challenge. It creates a vacuum by using a simple water pump and is regulated by a foot pedal. This can be deployed even in rural settings, and small modifications can allow its usage in a wide variety of surgical fields.

A 36-year-old male patient presented with a firm swelling in the left lacrimal sac region with a history of recurrent episodes of acute dacryocystitis, which partly resolved with systemic antibiotics. Computed tomography showed diffuse soft tissue mass without bony erosion in the same area. Incisional biopsy confirmed diffuse large cell lymphoma of non-Hodgkin's type by histopathology and immunohistochemistry. Oncologists did not detect systemic involvement, and the patient received six cycles of cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone (CHOP). Epiphora was resolved, and no recurrence of the lesion was seen with subsequent dacryocystorhinostomy with intubation and was in good health for up to 3 years of follow-up. Although primary lacrimal sac lymphoma is a rare entity, high suspicion, and prompt action in atypical cases can save lives from aggressive diffuse large cell lymphoma.

A 62-year-old female presented with complaints of persistent phantosmia (foul smell) for the last 4 months. She has a past history of right-sided dacryocystorhinostomy (DCR) 18 months back and left-sided DCR 12 months back. In the initial follow-up period, the patient had frequent visits to her otolaryngologist and ophthalmologist. She experienced phantosmia often but was reassured. The patient presented to us and was examined in an operation theater. It was discovered that the foul-smelling foreign body was present in her right nasal cavity above the middle turbinate. It was removed. A retained gauze piece was revealed to be a cause of phantosmia. The purpose of reporting is to create awareness among ophthalmologists and otolaryngologists. Retained gauze piece following DCR surgery presenting as phantosmia is a new symptom after DCR surgery previously not reported in the literature. Repeated complaints of a postoperative patient, should be dealt with vigilantly and timely.

Purpose To provide an Arabic translated, cross-culturally adapted version of the Lacrimal System Questionnaire (Lac-Q) and to validate the translated version. Materials and methods Arabic translation of the Lac-Q passed four stages: forward translation of the original English version to Arabic, backward translation to English, comparison of the original and the backward translated versions, and then a final review of the created Arabic version by an expert committee. Revalidation involved asking each participant after signing an informed consent to complete the Arabic version of the Lac-Q preoperatively, 6 and 12 weeks postoperatively. The surgical success was assessed 12 weeks postoperatively by Jones test 1 and by asking the patients to complete a satisfaction form with the surgical outcome. The patient reported being ‘satisfied’ or ‘not satisfied’ according to the improvement of the symptoms and if he/she believed further treatment was required. Results The Arabic version of the questionnaire was completed by 39 patients, where 11 of them had bilateral surgery done in the same sitting. We found a statistically significant positive correlation between patients’ social and eye symptom scores (preoperatively and 6 and 12 weeks postoperatively). Good internal consistency and test–retest reliability were confirmed by calculated Cronbach’s alpha and intraclass correlation coefficient, respectively. In addition, good discriminative validity was confirmed by a statistically significant difference between the scores of the diseased eye before the surgery and the eyes treated surgically. The score difference between the patients with successful and failed surgeries was statistically significant confirming good responsiveness of the studied version. Conclusion The Arabic version of the Lac-Q is a valuable tool to assess the lacrimal symptoms.

Aim: To compare the surgical outcome between anterior-posterior flap (APF) and anterior suspended flap (ASF) in external dacryocystorhinostomy (DCR). Settings and Design: This was a prospective, non-randomized, comparative, interventional, clinical study, done in J. P. M Rotary Club of Cuttack Eye Hospital and Research Institute, Cuttack. Materials and Methods: This was a single-centre hospital-based study on patients with primary nasolacrimal duct obstruction who underwent external DCR conducted during a period of 18 months. The patients were selected into either of the two procedures, that is, anterior-posterior flap external dacryocystorhinostomy (APF-DCR) or anterior suspended flap external dacryocystorhinostomy (ASF-DCR) and were reviewed at day 1, day 7, 1 month, 3 months, and 6 months postoperatively. Absence of epiphora was considered as the subjective success rate, whereas patent sac was considered as an objective success rate. Statistical Analysis Used: Statistical analysis was done using the Statistical Package for the Social Sciences (SPSS) version 13 software. Results: In our study, 131 patients underwent APF-DCR, whereas 133 underwent ASF-DCR. At the final follow-up, the subjective success rate was 88.3% and 87.7%, respectively, while the objective success rate at 6 months was 85.8% and 87.7% in the APF-DCR group and ASF-DCR group, respectively. However, there was no statistically significant difference between the groups, both subjectively and objectively. Intraoperative haemorrhage and other postoperative complications were very few in both the groups. Conclusions: We recommend performing ASF-DCR, as the suspension of anterior flaps prevents the possibility of granulation tissue formation at the rhinostomy site. Again, simultaneous suturing of the anterior flaps along with excision of the posterior flaps speeds up the procedure.

Purpose: To evaluate the role of tranexamic acid in controlling intra-operative and immediate post-operative bleeding during external dacryocystorhinostomy. Methods: This was a double-blinded randomized placebo-controlled trial. All patients diagnosed with primary acquired nasolacrimal duct obstruction presenting between June 2018 to December 2019 were included in the study. All patients in the study group received a single dose of 1 gm tranexamic acid injection intravenously 30 minutes before the surgery, whereas the patients from group B (placebo) received normal saline. The effect of the injection was measured in terms of duration of the surgery, surgical field grading, amount of total blood loss during the surgery, and the need for postoperative nasal packing. Results: A total of 96 patients were included, of whom 45 were males and 51 were females. The study group (Group A) included 51 patients (27 males and 24 females) and the control group (Group B) included 45 patients (18 males and 27 females). There were no statistically significant differences between the two groups in terms of the duration of surgery (48.43 ± 20.01 minutes vs. 53.38 ± 19.8 minutes, P = 0.228), view of the surgical field (P = 0.084), the amount of intraoperative blood loss (88.63 ± 69.34 mL vs. 88.89 ± 51.93 mL, P = 0.984) and requirement of postoperative nasal packing (54.9% vs 62.2%, P = 0.471). Conclusion: There seems to be little to justify the role of preoperative intravenous tranexamic acid injection in controlling intra-operative and immediate postoperative bleeding during external dacryocystorhinostomy.

Extranodal natural-killer/T-cell lymphoma (ENKTL) is a rare type of non-Hodgkin lymphoma. However, it is common in Asia and South America. ENKTL, nasal type (ENKTL-NT), predominantly presents initial unspecific clinical manifestations involving the nasal cavity and its adjacent structures. We present two cases to increase the awareness of the ENKTL-NT cases masquerading inflammatory processes. Although the main clinical feature is a rapidly progressive facial destruction, none of these patients experienced the mentioned complaint. Its various manifestations frequently lead to misdiagnosis and delayed treatment, particularly in those with marked ocular, not nasal symptoms. Our patients were previously diagnosed with inflammatory conditions, namely sinusitis, idiopathic orbital inflammation, dacryocystitis, and orbital cellulitis. The combined approach of chemotherapy and radiotherapy has been proposed as the treatment of choice. Both cases showed young adults treated with combined therapy, yet showing poor outcomes. Clinicians should be aware of its existence and have to consider ENKTL-NT as one of the differential diagnoses in sinonasal or orbital inflammatory cases with unusually rapid progression or unresponsive to treatment.

Purpose: Fibrin glue was used for anastomosis of lacrimal sac and nasal mucosal flaps and was compared with the conventional suture technique in external dacryocystorhinostomy. Methods: A prospective interventional randomized control study in which 50 consecutive patients of primary acquired nasolacrimal duct obstruction (PANDO) were equally allocated into two groups. The case group underwent glued technique of external dacryocystorhinostomy (Ext DCR) in which fibrin glue was used for the apposition of the anterior lacrimal sac and nasal mucosal flaps. In the control group, conventional technique of Ext DCR was used to suture the flaps. Functional success was assessed by improvement in epiphora and fluorescein dye disappearance test (FDDT), whereas anatomical success was assessed by lacrimal irrigation and endoscopic view of the osteotomy site. Results: The anatomical success in both the groups was 92%, whereas the functional success was 92% in the case group and 88% in the control group. The difference in the success rates between the two groups was statistically non-significant. Conclusion: Glued technique of Ext DCR is a simple and easy alternative to suturing of the flaps. Though the final outcome was comparable in both the groups, glue can be especially useful in uncooperative cases, in cases of excessive bleeding, or in situations where the flaps are very thin or have become friable.

A 3-year-old female child presented to us with complaints of watering in the left eye since birth, along with swelling near the medial canthus of the left eye for 1 week. External examination revealed a burst lacrimal sac abscess. The child underwent left eye probing with intubation. Cultures of the lacrimal sac contents revealed Kocuria rhizophila, a Gram-positive bacterium, as the primary pathogen. K. rhizophila was identified based on phenotypic characteristics and the VITEK-2 system. On follow-up visit, she had a recurrence of nasolacrimal duct obstruction with discharge from the left eye and subsequently underwent dacryocystorhinostomy. This study reports the first case K. rhizophila dacryocystitis, its clinicomicrobiological correlation, and management.

Our purpose was assess the long-term efficacy of 4-mm coronary balloon catheter dacryoplasty in revision endoscopic dacryocystorhinostomy (RevEnDCR). This retrospective interventional case-series was performed for patients who underwent RevEnDCR aided by a 4-mm coronary balloon catheter (CBC) dacryoplasty. The indications for the surgery were previously failed DCRs by external or endoscopic approach where the ostium showed near total cicatrization with or without the presence of organized granuloma threatening the internal common opening (ICO). The coronary balloon (4 × 10 mm, SPALNO, Cardiomac, Haryana, India) with the guidewire was used and a minimum of >12 months of follow-up was considered for analysis. Ten lacrimal systems of eight patients with mean age of 48.8 years underwent CBC-assisted revision endoscopic DCR. Of the 10 failed DCRs, 6 had a previous external approach DCR and 4 were endoscopic DCRs. Grossly stenosed ostium with near total cicatricial closure were noted in half of the patients (50%, 5/10) while the remaining half, in addition, showed organized granulomas threatening the ICO. The surgical technique using CBC was found to be minimally invasive, easy to perform with multiple advantages like uniform clearance of the area in front of ICO and more predictable lacrimal sac flaps. At a mean follow-up of 20 months, anatomical and functional success were achieved in 90% (9/10) of the eyes. We conclude that coronary balloon catheter-assisted revision endoscopic DCR is a minimally invasive and viable alternative in select group of patients of failed DCR with near total cicatrisation or organized granulomas threatening ICO.

Background Dacryocystorhinostomy (DCR) is an operation that creates a lacrimal drainage pathway into the nasal cavity to facilitate drainage of the previously obstructed excreting system. Objective To compare effectiveness and complications of external and endoscopic DCR for treatment of primary acquired [nasolacrimal duct obstruction (NLDO)]. Patients and methods The present study included 60 patients (38 females and 22 males) aged between 18 and 50 years complaining of epiphora owing to NLDO. Patients were subdivided into two groups: group A included 30 (50%) eyes of 25 patients who were subjected to endoscopic DCR, and group B included 30 (50%) eyes of 27 patients who were subjected to external DCR. Results In this study, the right eye was more commonly affected than left eye. The percentage of right eye affection was 53.3% and left eye affection was 33.3%%. Massive intraoperative bleeding in group A was seen in five (16.5%) cases, whereas in group B, massive intraoperative bleeding was noted in nine (29.7%) cases. The difference was statistically nonsignificant (P=0.617). The successful surgical outcome after 6 months was achieved in 28 (92.4%) of 30 patients for the endoscopic DCR and 26 (85.4%) of 30 patients for external DCR surgery. The difference was not statistically significant (P=0.604). Conclusion DCR is the standard treatment for NLDO. It can be performed by external or endoscopic approach. Both these approaches have minimal complications and comparable surgical outcome. However, endoscopic DCR is a safe, minimally invasive effective day-care technique with good aesthetic results.

AIMS: Hyperlacrimation due to ocular surface or lid abnormality was ruled out and apposition of lower punctum to globe was checked. SUBJECTS AND METHODS: This was a pilot study at a tertiary eye care center where 40 patients of proximal canalicular block 0.05). Complications include tube extrusion, dislocation, conjunctival overgrowth, and sump syndrome. CONCLUSION: Laser and external CDCRs are both effective and safe procedures for the treatment of proximal canalicular blocks with comparable success rates and complications.

Purpose: To assess the patient reported outcome and quality of life in post external dacryocystorhinostomy operated patients. Methods: A prospective questionnaire based study was carried out on 112 patients diagnosed with chronic dacryocystitis who underwent external dacryocystorhinostomy in the department of Orbit and Oculoplasty at a tertiary eye hospital in South India. Results: We included 112 cases in our study. Mean (SD) of the age of patients was 48.03 (12.79) years and ranged from 7 to 72 years of age. 44 (39.3%) patients were males and 68 (60.7%) were females. All cases had subjective symptoms of tearing, pain and swelling at baseline which were relieved by post-operative 3 in all cases. The mean (SD) best corrected visual acuity was 0.28 (0.39) at baseline and 0.25 (0.37) at postoperative 3 (p < 0.001). All four parameters studied in the GBI questionnaire - total mean GBI (32.22 vs 48.86, P < 0.001), general subscale (31.21 vs 44.08, P < 0.001), social health (46.28 vs 61.01, P < 0.001), physical outcome (22.17 vs 55.80, P = 0.0001) scores showed significant improvement from 1 vs 3 months post DCR. Conclusion: The GBI questionnaire is an effective tool for assessing patients' quality of life following DCR. External DCR can not only produce a successful anatomical outcome but also bring about a measurable improvement in subjective symptoms and quality of life among patients with symptomatic NLDO.

Purpose The aim of this study was to detect the prevalence of adult encysted dacryocystocele among patients with lacrimal passage obstruction and to evaluate its management by canaliculo-dacryocystorhinostomy (canaliculo-DCR). Patients and methods This is a prospective nonrandomized study that evaluated 381 adult patients who had acquired lacrimal passage obstruction. Of 47 patients who had encysted nonexpressible dacryocystocele, 48 eyes were included in this study. Dacryocystoceles were thoroughly evaluated before performing canaliculo-DCR with bicanalicular silicone intubation to address the two sites of lacrimal passage obstruction. Results Of 47 patients with nonexpressible dacryocystocele, 43 completed the postoperative follow-up period. The mean age of patients was 53.23±14.89 years. Approximately 88.4% of the patients lived in rural areas. Dacryocystoceles were in the right side in 62.8% of the patients. Females represented 83.7% of all patients, and 83.3% of them regularly applied traditional eye cosmetic (kohl) for a period ranging from 5 to 35 years. Canaliculo-DCR yielded 79% (34 out of 43 patients) success rate in the management of adult encysted dacryocystocele. Conclusion Adult acquired encysted nonexpressible dacryocystocele represented 12.6% of cases with lacrimal passage obstruction. Overall, 79% of the patients responded well to canaliculo-DCR procedure.

Aim The aim of this study was to evaluate the efficacy of buccal mucous membrane graft-assisted-dacryocystorhinostomy (DCR) for the treatment of refractory acquired nasolacrimal duct (NLD) obstruction. Patients and methods This is a prospective, interventional case series study that included 10 patients with acquired NLD obstruction (12 eyes), associated with expected poor mucosal flaps (either due to previous failed DCR or atrophic rhinitis). In nine eyes failed previous DCR procedures were reported, while three eyes had associated atrophic rhinitis evidenced by nasal examination. Two patients had bilateral obstruction. All eyes had symptomatic epiphora. All eyes were treated with modified DCR using a buccal mucous membrane graft. The outcome was assessed in terms of relief of epiphora, patency of irrigation testing, and patency of the osteotomy site assessed by rhinoscopy at the third postoperative month, in addition to the duration of the procedure and the postoperative complications. Results After a minimum follow-up period of 6 months, in 11 (91.7%) out of the 12 eyes with epiphora, there was complete relief of tearing. Lacrimal passages were patent to irrigation testing postoperatively. One case with late advanced atrophic rhinitis showed recurrence of tearing after silicone tube removal. No complications to the donor graft site or surgical site were observed. Conclusion Buccal mucous membrane grafting-assisted DCR (at the level of the flaps) is a safe and effective technique for the treatment of cases of refractory acquired NLD obstruction.

PURPOSE: Isolated cases of nasolacrimal duct obstruction (NLDO) secondary to rhino-orbito-facial reconstructive surgeries have been reported previously. We report the clinical profiles and management outcomes of a series of patients with iatrogenic INDO. MATERIALS AND METHODS: Case records of all patients who presented with secondary NLDO over 5 years were retrospectively analyzed. The case series included seven patients with NLDO secondary to orbito-facial surgeries. RESULTS: The study included six males and one female patient with a mean age of 29 ± 12.58 years. All the patients had a history of road traffic accidents following which they underwent an open reduction and internal fixation by maxilla-facial surgeons. All of them presented to the Ophthalmology outpatient department with epiphora following the surgical intervention. Imaging revealed the implants were responsible for obstructing the nasolacrimal ducts in all seven cases. Five patients underwent external dacryocystorhinostomy while dacryocystectomy was performed in two. Implant removal was necessary for five patients without any compromise on the structural integrity of the orbital walls. CONCLUSION: Precise knowledge of the orbital anatomy, especially that of the lacrimal drainage system is imperative for surgeons performing surgeries in the midface area. A multidisciplinary approach and inclusion of surgeons trained in lacrimal surgeries can prevent such avoidable complications.

Background: The present study was performed to compare the effectiveness of propofol–remifentanil and propofol–hydralazine in inducing controlled hypotension in patients undergoing the dacryocystorhinostomy (DCR) surgery and reducing their bleeding volume during surgery. Materials and Methods: The present double-blind, randomized clinical trial was performed on 70 patients who were candidates for DCR surgery and divided into two groups. In both the groups, general anesthesia protocol was performed. Moreover, in the first group, a syringe containing 2 mg of remifentanil in 20 ml of distilled water (0.1 mg/ml) was infused at the rate of 0.15 μg/kg/min (P + R group). In the second group, a syringe containing 20 mg of hydralazine in 20 ml of distilled water (1 mg/ml) was infused at the rate of 0.5–10 mg/h (P + H group). Results: The hemodynamic parameters were not significantly different between the two groups in the studied times (P > 0.05). In contrast, the bleeding volume in the P + R group with the mean of 61.29 ± 50.06 ml was significantly lower than that of the P + H group with the mean of 152.31 ± 90.81 ml (P < 0.001). Moreover, the mean score of surgeon's satisfaction level in the P + R group was higher than that of the P + H group (5.91 ± 0.28 vs. 4.29 ± 0.65; P < 0.001). Conclusion: According to the results of this study, there was no significant difference between the P + H and P + R groups in terms of fluctuations in the hemodynamic parameters and the occurrence of complications. However, a reduction in the bleeding volume and a higher satisfaction level of the surgeon were observed in the P + R group compared with the P + H group.

PURPOSE: The purpose of this study is to describe the results of endonasal endoscopic nasolacrimal duct dissection (EE-NLDD); a surgical technique used for the treatment of primary nasolacrimal duct obstruction (NLDO). MATERIALS AND METHODS: Before the operation, the patency of the nasolacrimal duct (NLD) was evaluated through irrigation and probing. The EE-NLDD surgical procedure involved the removal of the bony structure covering the NLD. The NLD mucosa was dissected and marsupialized with nasal mucosa, creating a mucosa-covered ostium. The bone surrounding the lacrimal fossa and lacrimal sac mucosa was preserved throughout procedure. The postoperative anatomical and functional outcomes were evaluated through irrigation, endonasal endoscopic fluorescein dye test, and subjective descriptions of the patients. STUDY DESIGN: This is a retrospective chart review study which included all patients with primary NLDO treated with EE-NLDD surgical technique from February 2012 to July 2016 in Taipei Medical University Shuang Ho Hospital by a single surgeon (YD, Shen). RESULTS: The mean follow-up time for the 39 patients (43 eyes) was 14.7 months (range: 0.5–46 months). Anatomical patency was achieved in all patients. Under endonasal endoscopy, fluorescein dye was observed at the internal orifice after the dye was instilled into the conjunctival sac in all patients. The complete resolution of the epiphora was reported in 36 patients (39 eyes) and two patients (2 eyes) exhibited an improvement of the epiphora after surgery. However, one patient (2 eyes) reported persistent bilateral epiphora without improvement even under solid evidence of anatomical patency. No major complications were noted intraoperatively or postoperatively. CONCLUSIONS: The results suggested that the EE-NLDD is a safe and effective procedure and has a success rate comparable with that of conventional endonasal dacryocystorhinostomy.

Purpose The aim was to study the efficacy and safety of addition of dexmedetomidine to local anesthesia (LA) for patients undergoing external dacryocystorhinostomy (DCR). Patients and methods A total of 70 adult patients who presented for external DCR were included in this prospective double-blinded study. They were randomly distributed into two equal groups. All patients received LA with 8 ml mixture, composed of 3.5 ml of lidocaine 2% without epinephrine and 3.5 ml of plain bupivacaine 0.5%. Either 1 ml normal saline (0.9%) or that containing 20 µg dexmedetomidine was added to the mixture for each group. The onset and the duration of sensory blockade as well as perioperative sedation were verified. Visual analog score was evaluated in the postoperative period till 12 h postoperatively. Anesthesia-related perioperative complications and patient satisfaction were also reported. Results Dexmedetomidine added to a LA block in external DCR significantly decreased the onset of anesthesia to 2.23±2.11 min (P=0.015) and increased the duration of sensory block to 200.45±37.98 min (P=0.0001). In addition, it significantly decreased the postoperative pain score 6–8 h postoperatively (P

Nasolacrimal system serves as a conduit for tear flow from eye to the nasal cavity. Periodic blinking initiates a pump mechanism, helping in the even distribution of tears over the ocular surface, which then flows into the lacrimal sac and finally to the nasal cavity via the nasolacrimal duct (NLD). Obstruction in this system leads to inadequate tear drainage, which clinically presents as epiphora. Lacrimal outflow system disorders are very annoying to the patients, and sometimes vision threatening. Surgery is a definitive solution for most outflow obstructions, and patients should be counseled accordingly. Chronic use of topical medications for NLD problems is neither cost-effective nor efficacious, but only prolongs agony. This article aims to provide a comprehensive insight into the commonly performed lacrimal drainage surgeries. Literature search using PubMed, Cochrane, and Google Scholar with a combination of various words appropriate to this article was done and relevant articles were reviewed.

Medical myths develop when existing beliefs are not challenged. They remind us that we can be mistaken and need to question ourselves. Oculoplasty, a vital branch of ophthalmology, has been of interest to surgeons since olden days. This field has seen transformative changes in the last few years in light of new understanding and sophisticated techniques. In this write-up, we wish to address a dozen of these “unchallenged” myths which may not be wrong concepts but conventional approaches that need renewed thinking.

Oculoplastic surgeries encompass both emergency surgeries for traumatic conditions and infectious disorders as well as elective aesthetic procedures. The COVID-19 pandemic has brought about a drastic change in this practice. Given the highly infectious nature of the disease as well as the global scarcity of medical resources; it is only prudent to treat only emergent conditions during the pandemic as we incorporate evidence-based screening and protective measures into our practices. This manuscript is a compilation of evidence-based guidelines for surgical procedures that oculoplastic surgeons can employ during the COVID-19 pandemic. These guidelines also serve as the basic framework upon which further recommendations may be based on in the future, as elective surgeries start being performed on a regular basis.

Background: Dacryocystorhinostomy (DCR) refers to the surgical procedure that is used to relieve the chronic obstruction of the nasolacrimal duct obstruction (NLDO). In a maxillofacial setting, NLDO may arise subsequent to a facial trauma or orthognathic surgery. There is a dearth of literature from this part of the world. This article intends to provide a single maxillofacial center experience in DCR. Materials and Methods: This is a retrospective, noncomparative, noninterventional, record audit type of study of all consecutive patients fulfilling inclusion and exclusion criteria. All patients with epiphora and diagnosed with lacrimal apparatus damage between 1 January 2008 and 31 December 2017 requiring DCR were considered for the study. Details of demographics, phase of treatment (primary/retreatment), types of bones involved, age, complications, period suffering from epiphora, and follow-up were obtained. All data were entered and analyzed using the Statistical Package for the Social Service (version 16; IBM). Descriptive statistics of the frequency and mean ± standard deviation (SD) as appropriate were presented. Chi-square test and one-way analysis of variance were used appropriately. P ≤ 0.05 was taken to be statistically significant. Results: In all, 83 patients fulfilled the inclusion and exclusion criteria. It is more common in males (n = 56, 67.47%) with a mean ± SD of 32.24 ± 10.80 (18–59 years) with 27 (32.53%) of them presenting primarily after fractures. Fracture was the most common pathology seen in 81.93% (n = 68) of cases, while the rest were as a result of orthognathic cases. Le Fort II and III set of bones contributed to 59% of cases, while the orbitonasal complex contributed to only three cases. NLD obstruction was seen in 68 (81.9%) of cases. On an average, the patients suffered for 9.3 ± 6.74 months (range 0.5–22 months) before seeking treatment and the average follow-up was 31.07 ± 11.69 months (range 15–54 months). Discussion and Conclusion: Fractures and surgeries involving nasal bones carry an innate risk of damaging the NLD system. The pattern of need for DCR and occurrence of NLDO in this part of the world have been described. The extent of the anatomical variations and need for proper surgical planning are highlighted.

PURPOSE: The purpose of this study is to assess the outcomes of lacrimal gland injections of botulinum toxin A (BoNTA) for epiphora secondary to lacrimal drainage disorders and functional epiphora. METHODS: This was a retrospective interventional case series where cases were divided into functional and nonfunctional epiphora. RESULTS: A total of 37 eyes of 31 patients were identified: 13 males and 18 females. The mean age was 52 years (median = 53, range 29–86). The functional epiphora group had seven patients (8 eyes), subcategorized into hypersecretion (5), crocodile tears (1), and post seventh nerve palsy (1). Obstructive group (nonfunctional) had 24 patients (29 eyes), subcategorized into proximal canalicular block (12), common canalicular block (6), punctal stenosis (3), posttraumatic nasolacrimal duct obstruction (1), and partial nasolacrimal duct obstruction (1). Median preinjection Munk scores were similar in both groups (Grade 4). At 1 month, the median Munk score improved to 1 and 2 in functional and nonfunctional groups, respectively, after receiving a median dose of 4 units of BoNTA. Median reduction in Munk score was 75% in functional group versus 50% in nonfunctional group (P = 0.07). No difference in terms of complications was noted (transient ptosis). CONCLUSIONS: Reduction in epiphora after lacrimal gland injection of botulinum toxin is seen in cases with functional epiphora as well as those with a physical obstruction in the lacrimal drainage pathway. While the symptomatic improvement was more in functional epiphora, the difference between the two groups was not statistically significant.

Purpose: To describe the outcome of external dacryocystorhinostomy (DCR) as a suitable alternative to dacryocystectomy (DCT) in cases of isolated lacrimal sac rhinosporidiosis. Methods: This was a retrospective, interventional case series. Institutional review board approval was obtained for the study. The chart review of 13 patients who underwent external DCR surgery for isolated lacrimal sac rhinosporidiosis between July 2012 and May 2018 was performed. Demographic details, clinical presentation, preoperative and intraoperative findings, surgical technique used, postoperative management, surgical outcome and duration of follow up were reviewed for each patient. Results: Thirteen patients were included in the study. Nine (69.2%) were male and four (30.8%) were female. The mean age was 22.1 years (range: 8–46 years). Involvement was unilateral in all cases. The commonest presenting complaint was epiphora with discharge seen in 10 cases (76.9%). An intrasac granuloma was grossly identified intraoperatively in 12 out of the 13 patients. Mean follow up was 26.9 months (range: 1.5–68 months). Till the last follow up, all cases were symptom free and did not have any evidence of recurrence of infection. Conclusion: From this series of cases reported by the authors, external DCR with appropriate precautions to prevent recurrence appears to be a suitable alternative to conventional DCT with excellent long-term outcomes without disease recurrence.

Purpose: The objective of the study is to evaluate the effectiveness of the transcaruncular approach of dacryocystorhinostomy (DCR) in the management of the cases of chronic dacryocystitis. Materials and Methods: A prospective study was conducted on 30 patients presenting in the outpatient department with chronic dacryocystitis at a tertiary eye care center. Intraoperative parameters were observed and noted at the time of surgery. Patients were followed up for a minimum period of 6 weeks and interviewed for subjective improvement of symptoms. Outcome measures were anatomical patency, epiphora, esthetic outcome, and presence of any complications. Results: Thirty patients of chronic dacryocystitis with nasolacrimal duct obstruction comprising 22 females and 8 males with a mean age of 43.8 years were operated by transcaruncular modification of external DCR. The surgical success rate of 90% was achieved after a follow-up period of 6 weeks. Postoperative complications included periorbital edema, mild nasal bleeding, and section leak which resolved by day 7 postoperatively. The procedure was associated with minimal intraoperative complications. One patient (3%) had significant intraoperative bleeding, and two patients (7%) had canalicular injury and both the patients were managed with canalicular intubation. Conclusions: Transcaruncular DCR is a cost-effective and esthetic approach not requiring the use of any endoscope or lasers and provides the benefits of external approach without a skin incision. It is associated with minimal intraoperative and postoperative complications. The surgical success rate of the procedure is comparable to the other conventional methods of DCR.

Purpose: To compare the efficacy of a single perioperative bolus dose of intravenous antibiotic versus postoperative oral antibiotic prophylaxis for prevention of surgical site infection (SSI) in external dacryocystorhinostomy (DCR) for primary acquired nasolacrimal duct obstruction (PANDO). Methods: This was a prospective randomized controlled study with a noninferiority design. Patients undergoing external DCR surgery were randomized into two groups A and B. Patients in group A received a single bolus dose of intravenous cefazolin 1 g at surgery, whereas those in group B received oral cephalexin 500 mg postoperatively twice a day for 5 days. Allocation concealment was ensured by sequentially numbered opaque sealed envelopes (SNOSEs). Both groups were advised identical postoperative local wound care regimens. Any clinical evidence of SSI at 4 weeks of follow-up in either group was the main outcome measure. Results: In all, 338 patients randomized into two groups of 169 patients each participated in this study. At follow-up of 4 weeks, only one patient in group B developed postoperative SSI. None in group A developed postoperative SSI. Other potential risk factors for postoperative SSI were also analyzed by univariate and multivariate analyses but none achieved statistical significance in either group. Conclusion: Our results demonstrate that a single bolus dose of perioperative intravenous antibiotic offers adequate prophylaxis against postoperative SSI and compares favorably with the more commonly used oral antibiotic prophylaxis in external DCR for PANDO in our population and our practice scenario.

Purpose The purpose of this study was to evaluate the effectiveness of intraoperative mitomycin C (MMC) with canaliculodacryocystorhinostomy (DCR) and bicanalicular silicone intubation for the management of adult lacrimal sac mucocele. Patients and methods In a 3-year period, 30 eyes of 28 adult patients with acquired lacrimal sac mucocele were enrolled in the study after thorough evaluation and if required computed tomography imaging was taken. All patients had at least 8 mm of patent proximal canaliculi. Under general anesthesia, all patients underwent canaliculo-DCR with bicanalicular silicone intubation and intraoperative MMC 0.2 mg/ml solution applied for 5 min to the lacrimal passages. All patients were followed up for at least 12 months postoperatively. Results The mean age of the patients was 48.90±12.28 years and 78.6% of the cases were women. After a follow-up period of an average of 16 months, 93.3% of the patients reported successful results (disappearance of epiphora and lacrimal sac swelling and patent lacrimal passages) and only 6.7% presented with recurrent epiphora and obstructed lacrimal passages. No case of recurrent lacrimal sac mucocele was reported. Conclusions Canaliculo-DCR with bicanalicular silicone intubation and intraoperative MMC yielded satisfactory results in 93.3% of adult patients with acquired lacrimal sac mucocele.

PURPOSE: The purpose of this study is to compare the success rates of endoscopic endonasal dacryocystorhinostomy (EN-DCR) and external DCR (EX-DCR) for the treatment of primary acquired nasolacrimal duct obstruction (PANLDO). DESIGN: This was a retrospective, comparative, nonrandomized clinical study. METHODS: Reviewed medical records of PANLDO underwent DCR at Far-Eastern Memorial Hospital from May 2011 to June 2017. Data regarding the lacrimal passage system, comorbidities, surgical outcomes, and postoperative complications were analyzed. Anatomical success was defined as patency confirmed by intranasal endoscopic inspection of the ostium and successful lacrimal irrigation; functional success was defined as complete resolution of epiphora and positive fluorescein dye disappearance test, which were assessed at postoperative 6th months. RESULTS: One hundred and seventy patients (37 males, 133 females, mean age 57 years) underwent 178 DCR surgeries for PANLDO. The overall anatomical success rate was 94.4% (93.5% in EN-DCR vs. 95.8% in EX-DCR, P = 0.511) and functional success rate was 90.4% (90.7% in EN-DCR and 90.1% in EX-DCR, P = 0.909). Surgical outcomes were comparable between two groups. Complication rate was low in both groups, including 11 cases of early canalicular stent dislodge (7 in EN-DCR, 4 in EX-DCR), one case of postoperative nasal bleeding in EN-DCR, and two skin wound dehiscence and three cutaneous keloid formation in EX-DCR. None of these cases were concluded into surgical failure at the final visit. The time to symptoms relief was statistical significantly shorter in EN-DCR group (1.7 vs. 3.7 weeks in EX-DCR, P < 0.001). CONCLUSIONS: Success rate of DCR for PANLDO in our study was high, and complication rate was low for both endoscopic and external approaches. There was no statistically significant difference between them. EN-DCR provided higher satisfaction due to quicker recovery and lack of external incision. Endoscopic DCR should be considered as the primary treatment of choice for PANLDO.

Purpose: The purpose of the study was to evaluate the functional success rates using dacryoscintigraphy (DSG) after transcanalicular diode laser dacryocystorhinostomy (TDL-DCR). Methods: In this retrospective study, we investigated the records of 56 patients who underwent TDL-DCR for unilateral primary acquired nasolacrimal duct obstruction and anatomic patency was achieved. The lacrimal drainage systems of the other eyes of the patients were normal and were selected as control group. The functional success was evaluated with tear transit time (TT) on DSG and epiphora complaints' score (ECS) at postoperative 6 months. Results: Twenty-two (39%) of the patients were male and 34 (61%) were female, with a mean age of 46.6 (21–64). The dacryoscintigraphic findings of the operated and healthy eyes showed that there was statistically insignificant prolongation in the tear TT at the operated side at postoperative 6th month (P > 0.05). The mean ECS of operated eyes was 0.89. Functional success was achieved in 43 (76.8%) patients when the ECS of 0 and 1 was accepted as successful. A statistically significant delay in drainage was observed in DSG in all of the cases with epiphora score of 2 and 3 (P < 0.05). The tear TT was prolonged with the age increase (P < 0.05), but there was no significant difference concerning the gender. Conclusion: DSG is an effective tool to evaluate the functional success of TDL-DCR.

Purpose: To evaluate the results of conjunctival culture in fellow eyes of patients with unilateral nasolacrimal duct obstruction (NLDO) and its changes after successful dacryocystorhinostomy (DCR) surgery. Methods: In this prospective study, 71 adult patients with unilateral NLDO and 41 age and sex-matched controls without NLDO were evaluated. The patients were divided into 2 groups based on clinical examination; group A with purulent regurgitation and group B without purulent regurgitation. They all underwent DCR. Before DCR surgery, microbiologic specimens were taken bilaterally from the conjunctiva of both eyes. Postoperative conjunctival sampling was continued weekly until the culture became negative or the colony count reached to the range of the control group. Results: There were 38 and 33 patients in groups A and B, respectively. Silicone tube was inserted for 17 patients (23.9%). The culture was positive for bacterial growth in 56 fellow eyes (79%). The conjunctival culture in the control group was positive in 17 eyes (41.4%). The mean count of colonies in a sample unit was 624.73 ± 2412.31, 195.75 ± 407.56, and 9.5 ± 1.5 for group A, group B, and controls, respectively. The mean time of normalization of specimens was 1.43 ± 0.69 weeks (range 1–4). Higher colony count at baseline and presence of silicone tube in infected eye were significantly associated with longer normalization time for fellow eye (P

Purpose The aim of this study was to assess the effect of the designing of four types of mucosal flaps on the success rates of dacryocystorhinostomy. Patients and methods In this prospective randomized study, dacryocystorhinostomy was performed for 128 eyes with nasolacrimal duct obstruction in adults complaining of epiphora. Patients were subdivided into four groups: group 1included 32 eyes in which only anterior flaps were sutured; group 2 included 32 eyes in which anterior flaps were sutured together with excision of posterior flaps; group 3 included 32 eyes in which anterior and posterior flaps were sutured; and group 4 included 32 eyes in which no flaps were created. Patients of all groups were followed up for 6 months. Assessment of operative success depended on subjective patient satisfaction − that is, stoppage or reduction in epiphora. Objective patency of fistula was assessed by means of positive syringing and estimating the area of the fistula using ultrasound. All data of four groups were statistically compared to assess significance. Results The success rate in group 1 was 100% in the first week, 100% after 1 month, and 93.8% after 6 months. The success rate in groups 2 and 3 was 100% in the first week, 100% after 1 month, and 96.8% after 6 months. There was no statistical significance for this disparity. The success rate in group 4 was 87.5% in the first week owing to fibrosis, 81.2% after 1 month, and 65.6% after 6 months. Using B-mode ultrasonography, the mean osteotomy area was 400mm2 intraoperatively for all cases, 337.4 mm2 (84.3% of intraoperative size) for the successful cases on the second postoperative day, and 32.2 mm2 (8% of intraoperative size) 6 months after the operation. Osteotomy size in unsuccessful cases was 237 mm2 (59.2% of intraoperative size) on the second postoperative day and 3.3 mm2 (0.8% of intraoperative size) 6 months after the operation. Conclusion Suturing of anterior suspended flaps in daryocystorhinostomies increases the success rate as in groups 1, 2, and 3. The difference between suturing, removing, or leaving the posterior flaps was found statistically nonsignificant. Thus, it can be judged intraoperatively according to its redundancy, ease of access, and operation time. It is not recommended to remove anterior and posterior flaps as this decreases the success rate significantly. The use of B-mode ultrasonography for follow-up of the osteotomy size postoperatively is recommended as a safe, effective, and noninvasive procedure.

Context: Conjunctivodacryocystorhinostomy (CDCR) is the procedure of choice for proximal canalicular blocks. However, the complications of tube migration and extrusion limit its widespread practice. Aim: The aim of this study is to evaluate the efficacy and complications of the new “mirror tuck technique” for fixation of lacrimal bypass glass tube without holes in proximal canalicular blocks in laser CDCR. Materials and Methods: A prospective interventional study was conducted in forty consecutive eyes of adult patients, undergoing 980 nm diode laser CDCR for proximal canalicular blocks. After creating the tract under endoscopic guidance, the collar of the glass tube was fixed to the conjunctiva with 6-0 prolene suture by “mirror tuck technique.” Success was defined as the absence of extrusion of tube with patent tract and relief in epiphora at 1 year of follow-up. Results: Both anatomical and functional success was achieved in 39 (97.5%) cases. Tube displacement occurred in one patient suffering from allergic conjunctivitis in which the tube had to be removed. A temporary heaviness was reported by 5 (12.5%) patients till about 2 weeks. Conjunctival overgrowth over the tube occurred in 1 (2.5%) eye at 5 months which was excised and treated with application of 0.02% mitomycin C with no subsequent recurrence. There were no cases of suture abscess or suture intolerance warranting tube removal. Conclusion: “Mirror tuck technique” is an effective method for tube fixation (for tube without holes) in CDCR. However, it is important to position the conjunctival opening so as to leave sufficient space for passage of sutures for anchorage medially.

Purpose: The aim is to compare the outcome of nonendoscopic endonasal dacryocystorhinostomy (NEN DCR) with external DCR (EXT-DCR) in the treatment of nasolacrimal duct obstruction (NLDO) in children. Methods: A retrospective, comparative chart analysis of all consecutive children

Purpose: To study the clinical profile of children aged

Cervicofacial emphysema (CFE), mostly seen after trauma or dental procedures, is an unexpected, extremely rare condition after uncomplicated dacryocystorhinostomy (DCR). It may be misdiagnosed as angioedema or necrotizing fasciitis. In this article, we present the case of a 40-year-old female with CFE twice after uncomplicated unilateral DCR for left and right sides on different operative days. CFE was confirmed by computed tomography, demonstrating extensive air within subcutaneous tissues of the face, neck, and orbital cavity. Subcutaneous crepitation supported the diagnosis. This is the first case report, to the best of our knowledge, describing a patient with recurrent massive CFE after each unilateral DCR.

Background: Nasolacrimal duct (NLD) obstruction is a common clinical entity encountered both by ophthalmologists as well as otorhinolaryngologists. Endoscopic dacryocystorhinostomy (DCR) has emerged as a gold standard surgery for treatment of this disorder. Silicone stents are often promoted as agents to maintain patency of surgically created fistula during postoperative period in this surgery. Aim: The aim of this study is to evaluate and compare the outcomes of endoscopic DCR with and without silicone stenting. Materials and Methods: A prospective observational study was conducted. Totally 50 patients with acquired NLD obstruction were enrolled in the study and were randomly assigned to two groups: Group I underwent the surgery with silicone stent placement while the Group II underwent the surgery without stent placement. The patients were evaluated in terms of relief of symptoms and postoperative complications. Results: The overall success rate for endoscopic DCR in this study was 90% which is comparable with the reports in the literature. Success rate for patients with placement of stent was 92% and without stenting was 88%. However, there was no significant statistical difference between the two groups. Conclusion: Use of silicone stents does not influence results of Endoscopic DCR.

Background: Since the introduction of external dacryocystorhinostomy (DCR) as one among the treatment modalities for chronic dacryocystitis, various treatment modifications have been developed with the goal of attaining the best possible post-surgical outcomes. The use of silicone tube intubation is one of them. But it's an effect on patency of the lacrimal system during external DCR in cases of primary nasolacrimal duct obstruction (NLDO), canalicular obstruction or in revision surgeries is still controversial. Objective: To evaluate the outcomes of external dacryocystorhinostomy (DCR) with primary silicone stent intubation in patients with a history of chronic dacryocystitis. Methods: A prospective cross-sectional study involving data of 18 patients with chronic dacryocystitis who underwent external DCR with primary silicone stent intubation from May 2018 to May 2019. Postoperative follow-ups were at 1 week,1,3 and 6 months. The stents were removed at 3 months. Subjective and objective assessments on each visit were done by asking for symptoms of epiphora, checking for sac regurgitation and patency by syringing. Results: Complications like a recurrence of epiphora, infection, loss or extrusion of stents etc. were not reported. Three patients experienced mild discomfort post-intubation with no watering and the sac was patent on syringing. Two patients had minimal watering but the sac was patent on the syringing indicating absence of blockage of the nasolacrimal duct. Conclusion: External DCR with primary silicone stent intubation is a successful procedure for the treatment and prognosis of chronic dacryocystitis. Overall the surgical outcomes were successful.

Aim: The study aims to report a single trainee's experience of learning and performing endoscopic endonasal dacryocystorhinostomy (En-DCR). Settings and Design: This study was a retrospective, interventional case series. Subjects and Methods: Fifty-four eyes of fifty patients presenting at a tertiary eye care center over 1 year were included in the study. All cases underwent endoscopic DCR with mitomycin-C and silicone intubation. The parameters studied included demographics, clinical features, intraoperative details, and postoperative ostium evaluation. Stent removal and nasal endoscopy were performed at 6 weeks and a further ostium evaluation at 3 and 6 months following surgery. Anatomical success rate was defined as patent irrigation, and functional success rate was defined as positive functional endoscopic dye test and absence of epiphora. Results: Fifty-four eyes of fifty patients were operated, and three cases were lost to follow-up after surgery. The mean age at presentation was 34 (4–75) years. Clinical diagnosis included primary acquired nasolacrimal duct (NLD) obstruction in 72% (39/54), acute dacryocystitis in 15% (8/54), failed DCR in 7% (4/54), and persistent congenital NLD obstruction in 5% (3/54). The first five cases needed intervention by the mentor for superior osteotomy. Common variations in anatomical landmarks were posterior location of sac, large ethmoidal bulla, high internal common opening, and thick maxillary bone. Surgical time taken in the last 27 eyes was significantly lesser compared to the surgical duration taken in the initial 27 cases (P < 0.05). Anatomical and functional success rate was 94% (48/51) at 6 months follow-up period. Conclusions: Endoscopic En-DCR has a good success rate when performed by oculoplastic surgery trainees. Nasal anatomical variations, instrument handling, and adaptation to monocular view of endoscope are few of the challenges for beginners. Structured skill transfer can help trainees to learn and perform En-DCR with acceptable success rates.

Purpose: To study the cosmetic outcome of external dacryocystorhinostomy (Ex-DCR) and to detect the factors affecting it. Patients and Methods: Prospective randomized interventional study included forty patients who were treated by 40 Ex-DCRs. In twenty patients, medial canthal vertical incision was used and in the other twenty cases, subciliary incision was used. The skin was closed using vicryl 6-0 or prolene 6-0 interrupted sutures, and each one was randomly used in twenty patients (10 patients of each incision type). Cosmetic outcome was evaluated 6 months postoperative by the patients and by an oculoplastic surgeon on a four grades scale. Cosmetic results and its correlation to patients′ age, sex, skin complexion, type of incision, and type of skin sutures were studied. Results: The mean scar grading was 0.98 ± 1.0 and 1.3 ± 1.0 in patients′ and examiner′s assessment. About 27.5% described their scars as cosmetically significant. The cosmetic outcome was significantly affected by the type of incision with only 5% significant scars in subciliary incision group. Prolene 6-0 suture was associated with better cosmetic results with 15% significant scars. 50% of dark-skinned patients showed cosmetically significant scars. Although no correlation was found between patients′ age and cosmetic outcome, pediatric patients showed higher tendency to scar visibility with mean scar grade 1.2 ± 1.0 and 1.5 ± 0.9 in patients′ and examiner′s assessment. Conclusion: Dark skinned and pediatric patients are more prone to visible Ex-DCR scar. The use of subciliary approach and prolene 6-0 skin sutures is associated with more favorable cosmetic outcome.

Purpose: To report the anatomical and cosmetic outcome of transconjunctival dacryocystorhinostomy (TDCR) in an Asian Indian population. Methods: TDCR was initially performed in cadaver eyes followed by patients with primary acquired nasolacrimal duct obstruction (NLDO). This was a prospective noncomparative case series of all consecutive TDCRs performed between April 2013 and June 2015. Outcome measures were anatomical patency, epiphora, presence of diplopia, aesthetic outcome, and health status. Results: A total of 17 (18 eyes) patients with a mean age 43.9 ± 11.8 years (range, 32–75) were included in the study. Eight were males, and one patient underwent TDCR in both eyes. TDCR was successfully performed in 15/18 (82%) eyes under local anesthesia. Procedure converted to transcutaneous external DCR in two and dacryocystectomy in one patient each. Mean duration of surgery was 52.6 (range, 29–110) min. Anatomical patency and relief from epiphora was achieved in all (15/15) eyes after TDCR at a median follow-up of 15.5 months. At final follow-up, objective assessment of the cosmetic outcome graded the surgical scar at the lateral canthus as invisible in all except one and conjunctival fornix as visible only after eyelid eversion in all patients. Disturbance of the medial fat pad was not seen in any patient. A questionnaire-based health status evaluation showed marked improvement in anxiety/depression before and after TDCR with an overall well-being score of 88 on a scale of 0–100 (worst–best) after TDCR. Conclusions: TDCR offers a promising aesthetic approach in patients with primary acquired NLDO and gives excellent functional and cosmetic outcome.

Aims: To evaluate the outcome of nonendoscopic endonasal dacryocystorhinostomy (NEN-DCR) in patients with nasolacrimal duct obstruction (NLDO) in India. Methods: Retrospective case series of NEN-DCR between July 2012 and October 2014. All patients had follow-up >3 months. Success was defined anatomically as patency on irrigation and functionally as relief from epiphora. Statistical Analysis Used: Fischer's exact test and Chi-square test. Results: A total of 122 patients (134 eyes; 81 female; mean age 37 ± 18 years) were included. Indications were primary acquired NLDO in 92 (68%) eyes of adults (>18 years), NLDO in children (