Prospective Randomized Comparison of

External Dacryocystorhinostomy and

Endonasal Laser Dacryocystorhinostomy
Jouko Hurtikainen, MD,’ Reich Grenman, MD, PhD,’ Pauli Puukka, MSc,’ Heikki Seppgii, MD, PhD’

Objective and Design: The introduction of endonasal laser dactyocystorhinostomy (ENL-DCR) in the early
1990s showed great promise of changing dacryocystorhinostomy into an elegant, minimally invasive procedure from
the traditional external dactyocystorhinostomy (EXT-DCR). This prospective, randomized study compares these two
operations, their success rates, surgical durations, and postoperative symptoms.
Participants: A total of 64 cases in 61 patients with primary acquired nasolacrimal sac or duct obstruction were
divided into 2 subgroups by symptoms (simple epiphora and chronic dacryocystitis). These patients were randomized
within both subgroups into 2 operation groups with 32 cases in each group.
Intervention: Altogether, 32 EXT-DCRs and 32 ENL-DCRs were performed. The silicone tube was removed
at 6 months after surgery. The final follow-up visit was at 1 year after surgery. The patency of the lacrimal passage
was investigated by irrigation, and patients were questioned about their symptoms.
Main Outcome Measures: The patency of the lacrimal passage to irrigation and the duration of surgery were
measured.
Results: The success rate at 1 year after surgery was 91% for EXT-DCR and 63% for ENL-DCR after primary
surgery. The difference was statistically significant (P = 0.016). The surgical duration for ENL-DCR was three times
shorter than for EXT-DCR, the average duration being 23 minutes and 78 minutes, respectively (P < 0.0001).
Conclusions: The EXT-DCR, when compared with ENL-DCR, seems to provide superior operation results in
primary acquired nasolacrimal duct obstruction. Ophthalmology 7998; 705:7 706- 7 7 73

The traditional treatment of nasolacrimal obstruction is the difficulty in visualization of the endonasal anatomy
an external dacryocystorhinostomy (EXT-DCR), often during surgery. Massaro, Gonnering, and Harris” in 1990
performed by an ophthalmologist. The technique of EXT- were the first to describe an endonasal dacryocystorhinos-
DCR was described originally in 1904 by Toti’ and later tomy technique using laser (ENL-DCR) for creating the
modified by Dupuy-Dutemps and Bourguet* with the ad- opening between the nasal cavity and the lacrimal sac.
dition of suturing of the mucosal flaps, thus forming an The intranasal operative site was visualized with an op-
epithelium-lined fistula. Success rates of 85% to 95% for erating microscope, and the desired site of entry was iden-
EXT-DCR have been reported.“-* Disadvantages of EXT- tified by introducing a fiberoptic light needle into the
DCR include scarring of the facial skin, risk of copious lacrimal sac through the canaliculus. They used a high-
hemorrhage, and disruption of medial canthal anatomy. power argon blue-green laser. Potassium titanyl phos-
The endonasal approach was introduced in 1893 by phate (KTP),“,‘* carbon dioxide (CO,),” holmium:YAG
Caldwell’ but has been in limited use mainly because of (Ho:YAG),13-15 neodymium:YAG (Nd:YAG),” and com-
bined C02-Nd:YAG16 lasers have been used with a video
endoscope or operating microscope. Success rates of 68%
Originally received: May 1, 1997. to 85% have been reported.‘2-‘7
Revision accepted: November 18, 1997. In this study, we report the results of a randomized
’ Department of Ophthalmology, University of Turku, Turku, Finland. prospective comparison between the traditional external
2 Department of Otorhinolaryngology, University of Turku, Turku, Fin- DCR and endonasal laser DCR using combined C02-
land. Nd:YAG laser.
3 Social Insurance Institution, Research and Development Center, Turku,
Finland.
Presented in part at the IVth International Congress of the Internatlonal
Society of Dacryology, Stockholm, Sweden, June 12, 1996. Patients and Methods
Supported in part by a grant from the Turku University Foundation,
Turku, Finland. Patients referred to our clinic because of nasolacrimal obstruc-
The authors have no proprietary interest in any of the equipment men- tion were investigated using lacrimal irrigation and probing of
tioned in this article. the canaliculi with a blunt-tipped Bangerter lacrimal cannula
Reprint requests to Jouko Hartikainen, MD, Department of Ophthalmol- up to bony contact of the lacrimal sac fossa. The lids were
ogy, Turku University Central Hospital, FIN-20520 Turku, Finland. inspected, focusing on the positions of the lacrimal puncta and

1106
 Hartikainen
Characteristic
No. of patients/operations
Age (yrs)
Mean ? SD
Sex I’
Male/female
Duration of symptoms (yrs)
Mean
Range
Laterality of surgery (right/left)
No. of patients with a history of
acute dacryocysnns
No. of patients with previous silicone
intubation performed
SD = standard deviation.
the function of the orbicularis muscle. Anterior rhinoscopy and
Schirmer’s test were performed. Dacryocystography was per-
formed on all patients at the department of radiology. Only
patients with primary acquired nasolacrimal sac or duct obstruc-
tion and with a duration of symptoms for more than 1 year
were included in this study. Exclusion criteria were canalicular
or common canalicular obstruction ascertained with probing,
noticeable lower lid laxity, previous lacrimal surgery with the
exception of silicone intubation of nasolacrimal duct, age
younger than 15 years, suspicion of malignancy, radiation ther-
apy, posttraumatic bony deformity, and bone diseases.
The included patients were divided into two
symptoms: those who had simple epiphora with no discharge
and those who had chronic dacryocystitis with purulent dis-
charge. Altogether, 64 cases in 61 patients were randomized
within both subgroups for either EXT-DCR or ENL-DCR. One
patient with bilateral nasolacrimal obstruction was randomized
for bilateral ENL-DCR, and two patients with bilateral nasolac-
rimal obstruction were randomized for both EXT-DCR and
ENL-DCR. Thus, both groups included 32 cases. Of these cases,
11 were males and 53 were females. The mean age was 65
years (Tables 1,2). No preoperative selection based on the result
of anterior rhinoscopy or dacryocystography was performed.
All operations were performed between January and Decem-
ber 1994. The EXT-DCR and ENL-DCR operations were per-
formed with the patient under general anesthesia. Cotton pled-
gets soaked with 200-mg cocaine (total dose) and epinephrine
1:10,000 in saline were applied intranasally between the poste-
rior part of the middle and lower turbinate, as well as the roof
of the nasal cavity, to achieve a good hemostasis. Intravenous
antibiotics (cephuroxim, Zinacef, 750 mg; Glaxo Wellcome,
Research Triangle Park, NJ) were given at the beginning of the
anesthesia preceding surgical interventions. In both operations,
a silicone tube (S 1.1000; Bika, F.C.I., Issy-Les-Moulineaux,
France) was inserted and tied with several knots without fixating
it to the nasal wall. Special care was taken not to tie the tube
too tightly. On completion of the operations, antibiotic-cortico-
steroid (neomycin, polymyxin B and dexamethasone, Maxitrol;
Alcon, Ft. Worth, TX) ointment was applied. After surgery, the
patients used dexamethasone-chloramphenicol (Oftan Dexa-
Chlora, Santen, Tampere, Finland) drops three times daily for
2 weeks, and oral cephalexin (Kefexin, Orion, Espoo, Finland)
500 mg three times daily for 1 week.
The EXT-DCR operations were performed by one ophthal-
et al * Dacryocystorhinostomy
Table 1. Patient Data
External EndonasalLaser
Total Dacryocystorhinostomy Dacryocystorhinostomy
61164 32132 31132
65.0 ? 14.2 64.8 5 14.0 65.3 t 14.6
23-89 25-86 23-89
11/53 4128 7125
9 9 8
l->50 l->50 l->50
28136 11/21 17/15
7 2 5
1 1 0
mologist (JH) using the technique of Dupuy-Dutemps and
Bourguet. A straight incision of approximately 2 cm in length
was made medial to the angular vein, starting at the level of
the medial canthal ligament. The orbicularis muscle fibers were
separated with blunt dissection, and 4-O silk traction sutures
were used to open the wound. The periosteum overlying and
medial to the anterior lacrimal crest was exposed. The perios-
teum incision was made just medial and inferior to the bony
insertion of the medial canthal tendon. The osteotomy, approxi-
mately 12 mm in diameter, was created with Kerrison rongeurs.
The lacrimal sac and nasal mucosa were opened in a longitudi-
subgroups by nal fashion to form anterior and posterior flaps. The lacrimal
sac mucosa was inspected and biopsied for pathologic study.
Occasional lacrimal sac and nasolacrimal duct dacryoliths were
removed. The site of nasolacrimal obstruction was localized by
probing, and the internal pun&urn was inspected as well. The
posterior flaps were sutured with two or three 5-O Dexon su-
tures (Davis-Geck, Wayne, NJ), and the silicone tube was in-
serted and tied with several knots. The anterior flaps were su-
tured with running 5-O Dexon. The periosteum and orbicularis
muscle were closed in separate layers with 5-O Dexon sutures.
The skin incision was closed with three 6-O Novafil (Davis-
Geck) sutures. Nasal packing was not performed.
In the ENL-DCR operations, the lacrimal passages were
probed and a 20-gauge fiberoptic light pipe of the type used in
pars plana vitrectomies (Storz, Inc, St. Louis, MO) was lubri-
cated with antibiotic ointment and inserted into the lacrimal sac
through either of the lacrimal canaliculi into contact with the
medial wall of the lacrimal sac. The light was visualized endo-
nasally using an otorhinologic operating microscope (Zeiss
OPMI- 1, Oberkochen, Germany), and 1% lidocaine-epineph-
rine (1 ml) was injected locally into the lateral wall of the nasal
cavity, guided by the light pipe in the lacrimal sac. The eyes
of the patient were protected from laser burn by covering them
with several moistened cotton patch layers. The nasal mucosa
was evaporated and a bony ostium was created, guided by the
light pipe, using a continuous wave COZ-Nd:YAG combined
laser (Lasermatic-Dual Laser, Helsinki, Finland), applying the
laser beam endonasally in visual control using the microscope.
A bony opening of approximately 10 X 5 to 7 mm was pro-
duced, beginning from the thin lacrimal bone at the inferomedial
wall of the lacrimal sac fossa, where the light was visualized
most easily, and then the opening was enlarged to the thick
frontal process of the maxillary bone at the medial wall of the
1107
 Ophthalmology Volume 105, Number 6, June 1998

Table 2. Data of Patients Divided into Two Subgroups

External Endonasal Laser

Dacryocystorhinostomy Dacryocystorhinostomy
Stmpk Chrome Simple Chronic
Characteristic Eeiphora Dacryocystitis Epiphora Dacryocystitis
No. of patwnts/operations 16116 16116 15116 16116
Age (yrs) a
Mean 64.6 65.1 64.8 65.8
*SD k11.3 kl6.6 213.7 t15.9
Range 37-79 25-86 23-86 34-89
Sex
Male/female 2114 2/14 3113 4112
Duration of symptoms (yrs)
Mean 8 10 8 9
Range l-40 l->50 l-40 l->50
Laterahty of surgery (right/left) 6110 5/11 1016 719
No. of panents wth a history
of acute dacryocystltls 0 0 5

SD = standard deviation.

lacrimal sacfossaup to the anteriorlacrimalcrest.The carbon-
ized bone wasremovedwith the suctiontip. In mostcases,the
wall of the lacrimal sac was openedseparatelywith the laser
andbiopsiedfor pathologicstudy with endoscopicforceps.The
assistingophthalmologistfacilitated the laser ablation of the
lacrimal sac wall by tenting the medial sacwall nasally with
either the light pipe or the Bangerterlacrimal cannulainserted
into the lacrimal sac. The power settings of the laser varied
from 5 to 10 W for the CO1andwas5 W for Nd:YAG. Before
the siliconeintubation, the lacrimal sacand the operatingfield
were rinsedwith saline.No nasalpackingwas used.The ENL-
DCR operationswereperformedin cooperationby an otorhino-
laryngologist (RG) and an ophthalmologist(JH). The ophthal-
mologistinsertedthe light pipe into the sacandassistedduring
the laserablationwhile the otorhinolaryngologistperformedthe
actual lasersurgery.
The duration of surgery was measuredfrom the dilatation
of lacrimal puncta and irrigation of the lacrimal systemto the
end of the applicationof the pressurebandagefor the EXT-
DCR or to the applicationof antibiotic-corticosteroidointment
for ENL-DCR.
The first follow-up visit of the ENL-DCR group, 1 week
after surgery,wasperformedby the otorhinolaryngologist.The
intranasalrhinostomysitewascleanedfrom mucousanddebris.
The first follow-up visit performedby the ophthalmologistin
both groupswas 1 month after surgery.The operatedlacrimal
passagewas irrigated with salinesolution,and the tightnessof
the silicone tube was checked.At 6 monthsafter surgery,the
siliconetube was removed and the lacrimal passagewas irri-
gated. The tube was removedby cutting the siliconetube be-
tweenthe punctaandby eitherblowing the noseor by extracting
the tube from the nosewith forcepsin anteriorrhinoscopy.The
final follow-up visit was at 1 year after surgery. Patientswere
asked,usinga questionnaire,about the presenceor absenceof
dischargeand about watering of the eye outdoorsor indoors.
The patientswho underwentEXT-DCR were questionedabout
their satisfactionwith the cosmeticsof the cutaneousscar,and
the site wasinspected.The patency of the lacrimalpassage was
investigatedby irrigation and dacryoscintography.
The statisticalanalyseswere performedusingSAS 6.04 sta-
tistical software (SAS Institute, Inc., Cary, NC). The group
meanswere comparedwith Student’st test. Successratesand
other categoric variableswere testedwith Fisher’sexact test.
Statistical significancesare given as exact probability values.
The P valuesgreaterthan 0.05 are regardedas nonsignificant.
Results
Thirty-two EXT-DCR operationsand 32 ENL-DCR operations
were performedbetweenJanuaryandDeCember1994in a pro-
spectively randomizedfashionon 61 unselectedpatientswith
primary acquirednasolacrimalsacor duct obstruction.Compli-
cationsduring surgeryseldomoccurred; there wasno copious
intraoperative hemorrhage.After surgery, one patient in the
EXT-DCR grouprequiredan anteriornasaltamponadeandhos-
pitalization for 3 days. In the ENL-DCR group, there were
no intraoperativeor postoperativehemorrhages.No decisionto
convert the ENL-DCR operationto the EXT-DCR wasneces-
sary nor wasmiddleturbinectomyrequiredin either group.The
averagedurationof surgerywas78 minutes(standarddeviation
? 12.8; range,60- 115minutes)for EXT-DCR and 23 minutes
(standarddeviation 5 5.7; range, 14-38 minutes)for ENL-
DCR. The difference wasstatisticallysignificant(P < 0.0001).
Ethmoid sinuseswere incorporatedwithin the osteotomyin 7
(22%) of 32 in the EXT-DCR group and in 21 (66%) of 32 in
the ENL-DCR group. A tissuesamplefrom the lacrimal sac
was obtainedin 32 (100%) of 32 in the EXT-DCR group and
in 24 (75%) of 32 in the ENL-DCR group. Of the 24 samples
in the ENL-DCR group, 6 were too small or affected by the
laser,making histologicanalysisimpossible,whereasall sam-
plesin the EXT-DCR group could be processedfor histologic
analyses.
The operationwasclassifiedas successfulby the objective
demonstrationof a patent nasolacrimalsystemthrough irriga-
tion. The successrate at 1 year after surgery, on the basisof
the primary surgery,was29 (91%) of 32 for the EXT-DCR and
20 (63%) of 32 for the ENL-DCR group. The difference was
statistically significant (P = 0.016). The patency rates at 1
month were 32 (100%) of 32 for the EXT-DCR and 31 (97%)
of 32 for the ENL-DCR group. At 6 months,the patency rates
were 32 (100%) of 32 and 25 (78%) of 32, respectively, as

1108
 Hurtikainen et al * Dacryocystorhinostomy
Table 3. Patency Rates in Subgroups at Scheduled Postoperative Follow-up Vlslts
External
Dacryocystorhinostomy
Postoperative SDllple
Follow-up Visit Eprphora
1 mo
NO. 16/16
W) (100)
6 mos
NO. 16116
(%I (100)
12 mos (final visx)
NO. 14116
(%) (88)
No. = number of patients.
tested by irrigation immediately after removal of the silicone
tube.
Before randomization, the patients with primary acquired
nasolacrimal sac or duct obstruction were divided into two sub-
groups by symptoms. In the EXT-DCR group, two of the three
failures were in the group of simple epiphora and one was in
the group of chronic dacryocystitis. In the ENL-DCR group,
there were six failures in both subgroups (Table 3). When we
compared the success rates between the two operations in sub-
groups, we did not find a statistically significant difference in
the simple epiphora group (P = 0.220) nor in the chronic dacry-
ocystitis group (P = 0.0829).
Dacryoscintography was performed in 28 cases (88%) in the
EXT-DCR group and in 17 cases (53%) in the ENL-DCR group.
Of the cases that were classified as success by irrigation, dacry-
oscintigraphy was performed in 25 (86%) of 29 in the EXT-
DCR group and in 17 (85%) of 20 in the ENL-DCR group. Of
the DCRs that were patent to irrigation and were studied with
dacryoscintigraphy, 19 (76%) of 25 in the EXT-DCR group and
14 (82%) of 17 in the ENL-DCR group were found to be patent
to dacryoscintigraphy.
At the final postoperative follow-up visit, one patient (3%)
in the EXT-DCR and seven patients (22%) in the ENL-DCR
group reported having discharge, and this was stated on the
questionnaire. All these patients were postoperative failures to
irrigation. Watering indoors was reported by 2 patients (6%) in
the EXT-DCR group and by 11 patients (34%) in the ENL-
DCR group. In the EXT-DCR group, 1 of the 2 patients, and
in the ENL-DCR group, 1 of the 11 patients were found to
have a patent rhinostomy to irrigation. Watering outdoors was
reported by 5 cases (16%) in the EXT-DCR group and by 13
cases (41%) in the ENL-DCR group (Table 4). Four of the 5
patients in the EXT-DCR group and 1 of the 13 patients in the
ENL-DCR group were patent to irrigation. Interestingly, two
of the three patients in the EXT-DCR group who were classified
as failures to irrigation were asymptomatic. Both of these pa-
tients had postoperative obstruction at the common canaliculus,
ascertained by probing through the inferior canaliculus. How-
ever, the obstruction of one was only partial, obstructing the
inferior canaliculus, whereas the superior canaliculus was pa-
tent. Dacryoscintigraphy, performed before the final follow-up
visit, also showed patency in this patient. In the ENL-DCR
group, all the patients who were failures to irrigation had symp-
toms.
At the final postoperative follow-up visit, 31 of the 32 pa-
tients in the EXT-DCR group did not have any complaints about
EndonasalLaser
Dacryocystorhinostomy
Chronic Simple Chronic
Dacryocystitis Eprphora Dacryocystitu
16116 16116 15/16
(100) (100) (94)
16116 1406 11/16
(100) (88) (69)
15116 lo/16 lo/16
(94) (63) (63)
the cosmetics of the cutaneous scar. One patient, a 25-year-old
woman, reported color difference between the scar and the skin
around the scar. No cheloid formation occurred.
The removal of the silicone tube was scheduled at 6 months
after surgery in both groups. In one patient (3%) in the EXT-
DCR group, the tube dislocated superiorly 3 months after sur-
gery and was removed. In the ENL-DCR group, one patient
(3%) had superior dislocation of the tube at 6 weeks after sur-
gery. In this patient, the tube was repositioned by retracting it
intranasally in anterior rhinoscopy. It was removed 6 months
after surgery. In five patients, the tube was removed earlier than
scheduled (range, 2-5 months) because of irritation or infection.
The removal of the silicone tube was easy in 28 cases in the
EXT-DCR group and in 26 cases in the ENL-DCR group. In
four patients in the EXT-DCR group and in six patients in the
ENL-DCR group, there were difficulties in removing the tube
because of tightness at the rhinostomy site. In one patient in
the EXT-DCR group and in four patients in the ENL-DCR
group, the ophthalmologist was not able to remove the tube.
These patients were sent to the otorhinolaryngologist, who was
able to remove the tube from the EXT-DCR patient and from
two of the ENL-DCR patients after endonasal enlargement of
the rhinostomy. In two ENL-DCR patients, the knots were dis-
lodged into the sac and the tube was removed at a secondary
operation. Two of the four patients in the EXT-DCR group and
five of the six patients in the ENL-DCR group with difficulties
in removing the tube were postoperative failures.
Laceration of the puncta was observed after surgery in four
patients (13%) in the EXT-DCR group and in seven patients
(22%) in the ENL-DCR group. All four patients in the EXT-
DCR group were successes, whereas only two of the seven
patients in the ENL-DCR group were successes.
In this study, three postoperative follow-up visits in the EXT-
DCR group and four follow-up visits in the ENL-DCR group
were scheduled. However, additional visits before the scheduled
visits became necessary in 5 patients (16%) in the EXT-DCR
group and in 14 patients (44%) in the ENL-DCR group. The
characteristics of patients with failure of primary surgery are
summarized in Table 5.
Discussion
The introduction of ENL-DCR in the early 1990s showed
great promise of changing dacryocystorhinostomy into an
1109
 Ophthalmology Volume 105, Number 6, June 1998

Table 4. Symptoms at 12 Months Postoperatively by Questionnaire with Reference to Patency to

Irrigation

External Endonasal Laser

Dacryocystorhinostomy Dacryocystorhinostomy

Patent to Patent to
NO. f%) Irngaml NO. f%) legation

Asymptomatic 27132 (84) 25127 19132 (59) 19/19

Watering indoors 2132 (6) 112 11/32 (34) l/11
Watermg outdoors 5132 (16) 415 13132 (41) l/13
Discharge l/32 (3) O/l 7132 (22) O/7

No. = number of patients.

elegant, minimally invasive procedure from “the opera-
tion of bone cracking, cursing and postoperative fail-
ure.” ‘* The advantages of ENL-DCR mentioned in the
literature include limitation of tissue injury to the discrete
rhinostomy site, avoidance of a skin incision, excellent
hemostasis, the ability to perform a lacrimal bypass opera-
tion on an outpatient basis with quicker rehabilitation and
decreased overall healthcare expense, and patient prefer-
ence.” The success rates for ENL-DCR12-” seem to have
been lower than those reported previously for the tradi-
tional EXT-DCR,3-8 but no randomized studies to com-
part these operations have, to our knowledge, so far been
published. In the current study, we have made a prospec-
tive, randomized comparison of the traditional EXT-DCR
and ENL-DCR.
The EXT-DCR, with various modifications, consis-
tently has yielded success rates of approximately 9O%,3-8
whereas the success rates of ENL-DCR using different
wavelengths have been 68% to 85%.12-17 Tarbet and Cus-
tcr,6 in their recent retrospective study of 153 EXT-DCRs
with various etiologies performed for more than 9 years
and with a follow-up time from 2 weeks to 9 years, re-
ported a success rate of 96% after primary operation con-
firmed by irrigation. Their success rate with primary
EXT-DCR performed in patients with idiopathic nasolac-
rimal obstruction was 98%. The success rate with primary
and revised EXT-DCRs with various etiologies was 95%,
showing a slight decline with increased duration of fol-
low-up, the success rate being 89% at 1 year after surgery.
The ENL-DCR has been performed using different

Table 5. Characterlstlcs of Primary Failures

Interval Time of
until Tube Difficulties with Laceration
Failure Age Primary Postoperative Problems Removal Tube Removal of Punctum Type of
NoJGender (yrs) Operation Problems (mos) bos) (Yes/No) (Yes/No) Obstruction

l/F EXT-DCR Watering Yes No Postsaccal

2/F EXT-DCR Asymptomatrc Yes No Presaccal
3/F 73 EXT-DCR AsymptomatIc No No Presaccal
4/F 60 ENL-DCR Watermg, discharge Yes/ORL* Yes Postsaccal
5/M 57 ENL-LICK Watermg, lrrltatlon No No Postsaccal
Copious discharge,
6/F 55 ENL-DCR irritation, pam 3 No No Postsaccal
Discharge, irritation,
7/M 37 ENL-DCR punctal laceration 4 No Yes Postsaccal
E/F 53 ENL-DCR Discharge 5 NO Yes Postsaccal
Watermg, tube drawn
9/F ENL-DCR mslde the sac Yes/EESC-DCRt No Postsaccal
10/F ENL-DCR Watermg Yes No Postsaccal
11/M ENL-DCR Discharge, lrrltanon No Yes Presaccal
12/F ENL-DCR Watermg NO No Postsaccal
13/F ENL-DCR Watering, discharge Yes No Presaccal
14/F ENL-DCR Discharge, nwtatlon Yea/EXT-DCRt: NO Postsaccal
15/M ENL-DCR Watering No Yes Postsaccal

F = female; M = male; EXT-DCR = external dacryocystorhmostomy; ENL-DCR = en d onasal laser dacryocystorhinostomy; EESC-DCR = cndonasal
endoscoplc dacryocystorhinostomy; ORL = otorhmolaryngologlst; No. = number:
* Removed by otorhinolaryngologlst.
t Removed at endonasal endoscoplc dacryocystorhmostomy.
$ Removed at external dacryocystorhinostomy.

1110
 Hartikainen et al * Dacryocystorhinostomy
wavelength lasers, beginning with the argon blue-green
laser” with wavelengths of 488 and 514 nm, and later
the CO2 laser” and the KTP laser11S’2with wavelengths of
10,600 and 532.0 nm, respectively. The Ho:YAG laser13”4
with a wavelength of 2100 nm, and later, in combination
with the contact Nd:YAG laser15 with a wavelength of
1064 nm, has been used. In our pilot study of ENL-DCR,
we used a combined CO,-Nd:YAG laser.16 The success
rates have varied from 68% to 85% with follow-up times
ranging from 6 weeks to 23 months.‘*-” Metson and
associates14 have achieved the highest success rate, 85%,
with a follow-up time from 7 to 23 months (mean, 13.2
months) using the Ho:YAG laser.
Histologic findings in early primary acquired nasolac-
rimal sac or duct obstruction suggest that the obstruction
may be a reversible process.lg Therefore, the inclusion
criterion was the duration of lacrimal symptoms for at
least 1 year. The patients with symptoms for less than 1
year were treated primarily with silicone intubation.
In our study, the success rate was defined by an ana-
tomically patent nasolacrimal system ascertained by irri-
gation at 1 year after surgery in all patients. Our success
rates showed a similar tendency to previously reported
success rates.3-8”2-‘7 The EXT-DCR had a primary suc-
cess rate of 9 1% evaluated at 1 year after surgery, whereas
the primary success rate of ENL-DCR was 63%. The
success rate of ENL-DCR was slightly lower than re-
ported previously.“-” It compares well with the success
rate in our pilot study of endonasal CO,-Nd:YAG laser
DCR, in which the success rate of 12 patients at 1 year
after surgery was 67% after a single attempt and 83%
after reoperation.‘” In our pilot study, we had problems
with the breaking and extrusion of the tube in 4 of the
12 cases. This problem was alleviated by the use of dull-
edged forceps when tying the intranasal knot. The other
problem in our pilot study was the laceration of the punc-
turn in 3 of the 12 cases caused by excessive tightening
of the tube after spontaneous nasal displacement of the
piece of silicon catheter surrounding the tube at the site
of rhinostomy. In the current study, we did not use a
double stent. Rather, we plaited the silicone tube with
several knots to create a thicker stent at the rhinostomy
site. This led to a new problem, because some of the
knots dislodged into the lacrimal sac, making the removal
of the tube by pulling either difficult or impossible. Forced
pulling and endonasal surgical enlargement of the rhinos-
tomy site were mechanical traumas that later led to the
development of a scar membrane and postoperative fail-
ure in one of the four patients with difficulties in tube
removal in the EXT-DCR group and in four of the six
patients in the ENL-DCR group.
Technically, these two operations represent quite dif-
ferent types of surgery. The EXT-DCR is a traditional
operation with knife, scissors, forceps, and rongeurs,
whereas ENL-DCR is a recent operation, the most sig-
nificant instrument being the laser beam. We performed
EXT-DCR with the technique of Dupuy-Dutemps and
Bourguet, in which the anterior and the posterior flaps
are sutured to achieve a controlled epithelium-lined anas-
tomosis. The advantage of EXT-DCR was good intraoper-
ative visibility inside the lacrimal sac, allowing inspection
of the internal punctum and lacrimal sac mucosa and
permitting biopsies to be performed easily. Dacryoliths
could be detected and removed also. The difficulties in
this operation included intraoperative diffuse bleeding ob-
scuring visibility, usually at the beginning of the opera-
tion, and a narrow space in which to suture the posterior
flaps, although we created quite a large bony ostium.
Advantages of ENL-DCR included the avoidance of a
cutaneous wound, excellent hemostasis, both intraopera-
tively and postoperatively, and easy access to the rhinos-
tomy site leading to short operative time. Disadvantages
were the inability to detect possible lacrimal sac pathol-
ogy, especially the site of the internal punctum, when
performing the surgery without an endoscope, and the
difficulty of performing a reliable biopsy in nearly half
of the operations.
Nuss and associates” have investigated the optimum
wavelength for bony ablation. They noted that the contin-
uous-wave CO2 laser provided effective bone removal,
but both the continuous wave Nd:YAG and CO* lasers
were much less precise than pulsed lasers, causing more
peripheral thermal injury to nontarget tissues. In clinical
use, we have found that the combined CO,-Nd:YAG
laser provides an effective vaporization of tissue, includ-
ing bone, and excellent hemostasis. We tried to avoid
possible thermal damage to the lateral wall of the lacrimal
sac by tenting the lasered medial sac wall nasally with
either the light pipe or Bangerter lacrimal cannula inserted
into the lacrimal sac. The postoperative harmful influence
of peripheral thermal damage around the lasered rhinos-
tomy site was minimized by careful removal of carbon-
ized tissue with the suction tip and rinsing of the operating
field with saline at the end of the operation. Woog and
associates’3 pointed out four technical modifications re-
sulting in an improved success rate for ENL-DCR: (1)
creation of a larger DCR ostium (diameter, 6-8 mm), (2)
removal of larger amounts of mucosa from the medial
wall of the lacrimal sac and the superior portion of the
nasal lacrimal duct in an attempt to visualize the common
internal punctum, (3) use of a small drill for removal of
char and bone in addition to laser ablation of nasal and
lacrimal mucosa, and (4) use of a double stent. We agree
with modifications (1) and (2), but the other modifications
require comment. The combined C02-Nd:YAG laser
provides an effective bone ablation, even in the area of
the thick frontal process of maxillary bone at the nasal
wall of the lacrimal sac fossa that, combined with the
mechanical removal of carbonized tissue with the suction
tip and tenting the lacrimal sac wall nasally during laser
ablation, makes the use of a drill unnecessary. The use
of a double stent in our pilot study led to laceration of
the puncta from inadvertent tightening of the tube, re-
sulting from nasal displacement of the outer stent. There-
fore, we did not use it in the current study. After the
secondary operations, as well as after additional ENL-
DCRs, we reached the conclusion that the most important
modification resulting in an improved success rate for
ENL-DCR is frequent postoperative intranasal cleaning
of debris and mucus at the rhinostomy site performed by
1111
 Ophthalmology Volume
an otorhinolaryngologist. The postoperative care of the
patient who underwent EXT-DCR is simpler, generally
requiring either one or two follow-up visits, the last visit
including silicone tube removal.
There is a difference of opinion as to whether a silicone
tube should be inserted in the EXT-DCR operation. A
silicone tube, although inert material, may cause peripun-
ctal granulation and chronic infection, canalicular lacera-
tion, dislocate superiorly, and may be cut by the uniniti-
ated.” Allen and Berlin22 reported a statistically signifi-
cant increase in the failure rate of primary EXT-DCR with
silicone tubes inserted. However, Walland and Rose2’ did
not find a significant difference in the rate of failure or
postoperative infection in EXT-DCR cases with or with-
out silicone intubation. Comparisons between silicone
tubes from different manufacturers have not been per-
formed. The differences may be caused by granuloma
inducing impurities in some of the products. Silicone intu-
bation has been recommended in cases involving common
canalicular scarring, a large valve of Rosenmueller requir-
ing surgical excision, or a small contracted or scarred
lacrimal sac.22 Silicone tubing may be considered neces-
sary in EXT-DCR cases in which none or only one of
the flaps is sutured or to compensate for insufficient surgi-
cal skills. Our opinion is that the best epithelialized anas-
tomosis is achieved by suturing the posterior and anterior
flaps.
The necessity of silicone intubation in ENL-DCR oper-
ations has not been questioned. The retention time of the
silicone tube has varied from 6 days to 7 months.‘0-‘7
Boush and associates” have pointed out the importance
of adequate silicone tube retention. In their study of 46
ENL-DCR cases, the success rate with silicone tube reten-
tion of 4 months, as planned, was 81%, whereas the suc-
cess rate with premature silicone extubation was 22%. In
the current study, we performed silicone intubation in
both the EXT-DCR group and the ENL-DCR group to
make the groups similar in this respect. Silicone extuba-
tion was planned to be performed 6 months after surgery.
In five cases in the ENL-DCR group, the tube was re-
moved prematurely because of infection or irritation,
probably because of tightness of the tube. Although these
cases were failures to irrigation after primary operation,
the reason for the failure probably was not the premature
extubation but rather the infection or irritation itself.
Before surgery, we divided all the patients referred to
our clinic because of nasolacrimal sac or duct obstruction
into two subgroups by symptoms: those who had simple
epiphora with no discharge and those who had chronic
dacryocystitis with purulent discharge. Walland and
Rose23 reported a soft tissue infection occurring in approx-
imately 8% of patients after open lacrimal surgery. They
found that a five-fold reduction in this rate can be
achieved with routine administration of antibiotics after
surgery. In the current study, all patients received prophy-
lactic intravenous cephuroxim peroperatively and cepha-
lexin 500 mg three times daily orally for a week after
surgery. This antibiotic regimen satisfactorily covers the
bacteriology of lacrimal duct obstruction in adults, which
mostly consists of gram-positive organisms, Staphylococ-
1112
105, Number 6, June 1998
cus epidermidis being the most frequently isolated spe-
cies. In patients with chronic dacryocystitis, gram-nega-
tive organisms were isolated in 26% of samples from the
lacrimal sac, whereas they were isolated in only one sam-
ple (3%) of cases of nasolacrimal obstruction with simple
epiphora.24 In the current study, there were no wound
infections in the EXT-DCR group. The success rates did
not appear to correlate with the presence or absence of
discharge.
The duration of EXT-DCR was 78 minutes on average,
which is twice the duration Bartley25 reports in his article.
Tarbet and Custer6 reported a significant decline in surgi-
cal time occurring with increasing physician-surgical
team experience: the duration of simple EXT-DCR was,
on average, 100 minutes in 1988, declining to 52 minutes
in 1992. We have experienced the same tendency with
further EXT-DCRs. The duration of ENL-DCR was three
times shorter than the duration of EXT-DCR, being 23
minutes on average. However, it was even four to five
times shorter than the durations of ENL-DCRs reported
recently by others.‘2*‘4 The average surgical durations re-
ported in previous articles using Ho:YAG and KTP lasers
have varied from 89 to 116 minutes.‘2.‘4 In five articles
on studies using Ho:YAG, contact Nd:YAG, CO*, KTP,
and argon lasers, no operative time has been re-
ported. 10.11.13,1s,17
In the current study, we have compared EXT-DCR and
ENL-DCR in cases of primary acquired nasolacrimal sac
or duct obstruction, The most important result in the com-
parison of the two different lacrimal operations is the
success rate; the duration of surgery becomes important
only when the two operations achieve comparable success
rates. Currently, EXT-DCR is a superior operation, need-
ing only few postoperative follow-up visits and with a
very small risk of a disturbing cutaneous scar. Although
ENL-DCR achieved a significantly lower success rate, it
is preferred by many patients mostly because of the lack
of a cutaneous wound. With developing techniques and
experience, the success rate of ENL-DCR will increase,
but more frequent postoperative follow-up visits for
cleaning mucus and debris intranasally at the site of the
rhinostomy are needed.
References
1. Toti A. Nuovo metodo conservatore di cura radicale delle
suppurazioni croniche de1 sacco lacrimale (Dacriocistori-
nostomia). Clin Mod Firenze 1904; 10:385-7.
2. Dupuy-Dutemps, Bourguet. Pro&de plastique de dacryo-
cysto-rhinostomie et ses resultats. Ann Ocul 1921; 158:
241-61.
3. Rosen N, Mordechai S, Moverman DC, Rosner M. Dacryo-
cystorhinostomy with silicone tubes: evaluation of 253
cases. Ophthalmic Surg 1989;20:115-9.
4. Vanhoucke K, Colla B, Missotten L. Dacryocystorhinos-
tomy: indications, operations, results and some variants.
Bull Sot Belge Ophthalmol 1990;238:103- 10.
5. Dresner SC, Klussman KG, Meyer DR, Linberg JV. Outpa-
tient dacryocystorhinostomy. Ophthalmic Surg 1991; 22:
222-4.
 Hartikainen et al * Dacryocystorhinostomy
6. Tarbet KJ, Custer PL. External dacryocystorhinostomy:
surgical success, patient satisfaction, and economic cost.
Ophthalmology 1995; 102:1065-70.
7. Becker BB. Dacryocystorhinostomy without flaps. Ophthal-
mic Surg 1988; 19:419-27.
8. Emmerich KH, Busse H, Meyer-Rusenberg HW. Dacryo-
cystorhinostomia externa. Ophthalmologe 1994; 9 1:395 -8.
9. Caldwell GW. Two new operations for obstruction of the
nasal duct. N Y Med J 1893;57:581-2.
10. Massaro BM, Gonnering RS, Harris GJ. Endonasal laser
dacryocystorhinostomy: a new approach to nasolacrimal
duct obstruction. Arch Ophthalmol 1990; 108:1172-6.
1I. Gonnering RS, Lyon DB, Fisher JC. Endoscopic laser-as-
sisted lacrimal surgery. Am J Ophthalmol 1991; 1I 1:152-
7.
12. Reifler DM. Results of endoscopic KTP laser-assisted da-
cryocystorhinostomy. Ophthal Plast Reconstr Surg 1993;
9:23 l-6.
13. Woog JJ, Metson R, Puliafito CA. Holmium: YAG endona-
sal laser dacryocystorhinostomy. Am J Ophthalmol
1993;116:1-10.
14. Metson R, Woog JJ, Puliafito CA. Endoscopic laser dacryo-
cystorhinostomy. Laryngoscope 1994; 104:269-74.
15. Kong YT, Kim TI, Kong BW. A report of 131 cases of
endoscopic laser lacrimal surgery. Ophthalmology 1994;
101:1793-800.
16. Seppti H, Grenman R, Hartikainen J. Endonasal C02-
Nd:YAG laser dacryocystorhinostomy. Acta Ophthalmol
(Copenh) 1994;72:703-6.
17. Boush GA, Lemke BN, Dortzbach RK. Results of endona-
sal laser-assisted dacryocystorhinostomy. Ophthalmology
1994; 101:955-g.
18. Dryden RM, Wulc AE. Surgery of the lacrimal system. In:
Waltman SR, Keates RH, Hoyt GS, Frueh BR, Herschler J,
Carroll DM, eds. Surgery of the Eye. New York: Churchill
Livingstone, 1988; v. 2, chap. 50.
19. Linberg JV, McCormick SA. Primary acquired nasolacri-
ma1 duct obstruction: a clinicopathologic report and biopsy
technique. Ophthalmology 1986;93: 1055-63.
20. Nuss RC, Fabian RL, Sakar R, Puliafito CA. Infrared laser
bone ablation. Lasers Surg Med 1988;8:381-91.
21. Walland MJ, Rose GE. The effect of silicone intubation
on failure and infection rates after dacryocystorhinostomy.
Ophthalmic Surg 1994;25:597-600.
22. Allen K, Berlin AJ. Dacryocystorhinostomy failure: associ-
ation with nasolacrimal silicone intubation. Ophthalmic
Surg 1989;20:486-9.
23. Walland MJ, Rose GE. Soft tissue infections after open
lacrimal surgery. Ophthalmology 1994; 10 1:608- 11.
24. Hartikainen J, Lehtonen O-P, Saari KM. Bacteriology of
lacrimal duct obstruction in adults. Br J Ophthalmol
1997;81:37-40.
25. Bartley GB. The pros and cons of laser dacryocystorhinos-
tomy. Am J Ophthalmol 1994; 117:103-6.