Original Article Acta Medica Anatolia

Volume 3 Issue 1 2015

The Effect of Silicone Tube Intubation in External

Dacryocystorhinostomy
Adem Gül, Mustafa Duran, Ertugrul Can, Hilal Eser Öztürk, Nursen Aritürk
Department of Ophthalmology, Ondokuz Mayis University, Samsun, Turkey

Abstract
Objectives: We searched the effect of silicone tube implantation to the success rate of dacryocystorhinostomy surgery.
Methods: A total 79 patients with primary nasolacrimal duct obstruction had surgery between 2012 and 2014 were
retrospectively reviewed in a tertiary referral hospital. The patency of lacrimal drainage system was evaluated with lacrimal
syringing. Silicone tube intubation was added to surgery in 37 consecutive patients between 2012-2013 and was not used in
42 consecutive patients between 2013-2014. Age, gender, laterality, and lacrimal irrigation in the third month visit were
recorded. Surgical success was accepted as the patency of the formed ostium with lacrimal syringing/irrigation.
Results: Success rate was 89.2% (33/37) in patients with silicone intubation, and 88.1% (37/42) in without intubation. The
difference between the groups was not found as statistically significant (p>0.05).
Conclusions: This study shows that the silicone tube implantation is not necessary in the surgery. Omitting the use of silicone
rod reduces both the cost and the time of the surgery. Regarding with the possible complications including pyogenic
granuloma formation, punctal erosion, and corneal erosion, it is not essential to use silicone rod routinely in external
dacryocystorhinostomy.
Keywords: Dacryocystorhinostomy, silicone tube, external.
Received: 19.01.2015 Accepted: 19.02.5015 doi: 10.15824/actamedica.31629
Acta Medica Anatolia
Introduction
Nasolacrimal duct obstructions (NLDO) have been An inert and easily tolerable silicone material in DCR
treated with various methods such as silicone tube surgery was first described by Older (4). While some
intubation, balloon catheter dacryoplasty, and surgeons routinely use silicone tubes, the others
dacryocystorhinostomy (DCR). The most effective prefer it for only complicated cases. It is believed that
treatment method is dacryocystorhinostomy which is silicone tubes prevent the blockage of ostium (5,6).
done with different surgical modalities. External, Although, it was reported as using silicone tube
endonasal and trans-canalicular ways have been intubation was one of the most effective way to
used. Mitomycin-C may be added to the surgery to increase the surgical success rate (7), it has been a
increase the success rate. controversial issue.

External DCR is the gold standard surgical method in
the treatment of NLDO. It is cheap, the learning
period is short, the success rate is high and doesn’t
require high technology instruments (1).
Endonasal DCR has been most commonly done by
otorhinolaryngologists for a long time. In recent
years, ophthalmologists also perform endonasal DCR.
The advantages of endonasal method include no skin
incision and scarring, no touch to orbicularis oculi
muscle by this way preserving the lacrimal pump
mechanism, and enabling correction of accompanying
intranasal pathologies in same session (2,3). In trans-
canalicular laser method, nasal endoscope also is
used. Short surgical time, less time for learning period
and acceptable success rates are the advantages of
trans-canalicular laser method.
In the literature, while the success rates of DCR with
silicone tube intubation are seen, there is a paucity of
data regarding comparative studies. Therefore, we
studied the DCR surgeries with and without silicone
tube intubation to search the effect of silicone rod to
the success rate of surgery.
Materials and Methods
A total 79 patients who had DCR surgery between
2012 and 2014 were retrospectively reviewed in a
tertiary referral hospital. All patients had primary
nasolacrimal duct obstruction and no previous
surgery for nasolacrimal duct obstruction. A complete
ophthalmologic examination was performed. The
patency of lacrimal drainage system was evaluated
with lacrimal syringing. All patients were examined by
otorhinolaryngology department and when needed

Correspondence: Adem Gül MD, Department of Ophthalmology, Ondokuz Mayis University, Samsun, Turkey. 1
drademgul@gmail.com
Original Article
assessed with computed tomography. Informed
consent was taken from all patients.
Silicone tube intubation was added to surgery in 37
consecutive patients between 2012-2013 and was not
used in 42 consecutive patients between 2013-2014.
Age, gender, laterality, and lacrimal irrigation in the
third month visit were recorded. Surgical success was
accepted as the patency of the formed ostium with
lacrimal syringing/irrigation. All cases were done by a
single surgeon (AG). Exclusion criteria were
canalicular stenosis, epiphora due to adnexal,
corneal, conjunctival diseases, and age less than 20
years of age.
Descriptive methods and independent t-test were
used for statistical analyses and a p value <0.05 was
accepted as significant.
Surgical Method
All patients were operated under general anesthesia.
Two pads soaked with mixture of epinephrine and
lidocaine were placed on the level of middle
turbinate. The surgical incision was marked with a
skin marker, and the surgical site was infiltrated with
epinephrine and lidocaine mixture. The skin was
incised starting from 8-10 mm medial to medial
canthal ligament and extending in vertical direction
as being 10-12 mm. Periosteum was found with blunt
dissection and was incised with a scalpel. At this
stage, anterior portion of medial canthal ligament
was dissected for better dissection of lacrimal sac.
The thinnest part of medial wall of the orbit was
perforated and a 12x12 mm bony window was
opened with a bone punch. A metallic probe was
inserted from lower canaliculus after the puncta were
dilated. A small incision with the scalpel at the tip of
the probe, then H-type incision was made with the
scissors on the lacrimal sac. The same H-type incision
was also made on the nasal mucosa, then the
mucosal flaps were sutured to the flaps of lacrimal
sac. In the cases which silicone rods were used,
silicone tube intubation was made after the posterior
flaps anastomoses. The two ends of the silicone rod
were retrieved from the nose and tied then pushed
into the nose. Flaps and subcutaneous tissues were
sutured with 6/0 absorbable suture and the skin with
5/0 prolene suture. After the skin closure, lacrimal
irrigation was made to clean the newly formed
passage.
Patients were discharged after recovery from
anesthesia and called for third day and first week visit
to make lacrimal syringing. Silicone tubes were
removed in the third month visit.
Acta Med Anatol 2015;3(1):1-4
Gül A et al.
Results
The mean age were 58.5 years (range, 29-80) in
patients in whom silicone tube was used, and 58.2
years (range, 20-83) in patients that was not used.
Female to male ratio were 21/16 and in silicone tube
group, and 33/9 in silicone free group. Eighteen out of
37 patients in silicone group was operated from right
side, and also 18 out of 42 patients in silicone free
group was operated from the right side.
Success rate were 89.2% (33/37) in silicone group, and
88.1% (37/42) in silicone free group. The difference
between the groups was not found as statistically
significant (p>0.05).
The mean age was 53.2 in four patients (2 men, 2
women) in silicone group. In silicone free group, the
mean age was 52.2 in four unsuccessful cases who
were 4 women and 1 man.
There were no case with distal or common canalicular
obstruction.
In silicone group, no punctal erosion, corneal erosion,
and granuloma formation were seen for following 6
months in postoperative period. In only one patient,
silicone road extrusion was seen and the patient was
managed with the aiding of an intranasal endoscope,
and the silicone road was retrieved to previous
position.
Discussion
Silicone tube is an inert material and encapsulation
around the material is formed. There has been no
consensus for using silicone tube in external DCR.
Some surgeons have used it as routine (8,9). They
have thought that silicone tube protects the passage
by preventing granulation tissue formation in the site
of osteotomy and anastomoses in the postoperative
period. They have also thought that, it prevents
common canalicular obstruction. The other surgeons
have preferred it for only complicated cases like
unsuccessful cases, canalicular stenosis, and in cases
of insufficient flap formations (10-12). They claimed
that, silicone tube may lead to several complications
including punctal erosion, corneal erosion, and
pyogenic granuloma formation, beyond the cost of the
material.
Silicone tubes have been especially used in cases with
canalicular problems. Buttanri et al., used silicone tube
in 69 patients with distal/common canalicular
obstructions in external DCR surgery and reported the
success rate as 76%. They implicated that silicone tube
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Original Article
should be used in patients with distal or common
canalicular obstructions. In their study, although most
of the patients relieved after the removal of the tubes,
epiphora was started again in 21% of the patients (13).
In another study, Bayhan et al., reported that they
used silicone tube only in cases of distal/common
canalicular stenoses, and small-fibrotic sacs (14).
Choung et al. claimed that, the silicone tube should
not be used nearly half of the cases. They operated
166 cases and implanted silicone tube in 74 patients
whoose both lacrimal sacs and nasal spaces were large
for tear drainage. They reported that, although all
pasaages were anatomically patent, epiphora was
seen in 6.7% (15). Madge and Selva, also reported the
same conclusion that silicone tube was not required in
uncomplicated cases (16). Ozay et al., reported that
indications for silicone tube implantation in their study
were small-fibrotic sac in 19 cases, unsuccessful
previous DCR in 9, common canalicular stenosis in 9,
intraoperative technical problems in 7, and mucocele
in 3 patients. They reported the success rate as 84%
(12).
Comparative studies in this era are rare. Saiju et al.
studied in 100 patients and used silicone tube in 44
patients and not used in 56 patients. After six month
follow up, the success rates were 90% in silicone
group, and 87% in silicone free group, and the
difference between the groups was insignificant. They
also reported that silicone rod increased the cost of
the surgery as 20% (17). Ozkaya et al., used silicone
tube in nearly half of the patients and reported that
the success rates were 87.5 % in silicone used group,
and 86.3% in silicone free group (18).
An interesting example to search the essentiality of
silicone tube in external DCR surgery may be seen in
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Conclusion
External dacryocystorhinostomy is still gold standard
surgical treatment in primary nasolacrimal duct
obstruction. This study shows that the silicone tube
implantation is not necessary in the surgery. Omitting
the use of silicone rod reduces both the cost and the
time of the surgery. Regarding with the possible
complications including pyogenic granuloma
formation, punctal erosion, and corneal erosion, it is
not essential to use silicone rod routinely in external
dacryocystorhinostomy.
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