Endonasal procedures in endocanalicular dacryocystorhinostomy

Abstract

Dear Editor, First of all, thank you for your critiques and valuable comments. Diode laser, as being one of the most portable and least expensive of the lasers available for endocanalicular dacryocystorhinostomy (ECL DCR), is the most commonly used laser for ECL DCR [1–3]. It can ablate bone and the soft tissues without causing excessive collateral damage [3]. We have been also performing diode laser ECL DCR, since the beginning of 2006 [4, 5]. Initially, our surgical procedure was simply the application of the laser energy until the probe was visualized by nasal endoscopy, and then the enlargement of the neo-ostium by additional laser applications [4]. During the follow-up of those initial cases, we recognized that synechia between the lateral surface of the middle turbinate (MT) and the medial surface of the lateral wall of the nose was a common finding in the failures [4]. We conducted a retrospective study comparing those two groups of patients who underwent diode laser ECL DCR with and without endonasal procedures [4]. There were three differences between the surgical procedures of two groups: (1) initial partial anterior inferior third middle turbinate resection (MTR) before laser application, (2) endonasal enlargement of the neo-ostium, after obtaining the initial fistula by laser application, and (3) antibioticsoaked cotton pledget packed in the sac at the end. The anatomical success rates increased from 71% to 93% by adding the endonasal procedures. The synechia between the MT and the lateral nasal wall was the most common finding in the failures encountered in cases without endonasal procedures. Routine MTR is a controversial procedure. Some favor MT preservation, while some practice MTR routinely [6]. However, none of the surgeons provided any scientific rationale for their approaches [6, 7]. Partial MTR was reported to be a safe procedure without any adverse effect on nasal physiology [6]. There has been considerable debate as to whether the ostium size made during dacryocystorhinostomy plays a role on the outcomes. Linberg et al. [8] reported that there is no statistically valid correlation between the size of the neo-ostium and the final size of the healed intranasal ostium. On the other hand, Rosen et al. [1] showed that the endocanalicular approach usually creates smaller neo-ostia than the external and endonasal approach, and this is correlated with lower success rates of ECL DCR. In our study, we concluded that endonasal interventions enabled us to obtain larger neo-ostium without excessive laser energy based on our outcomes, but the neo-ostium size was not documented, and this was one of our drawbacks [4]. After gaining more experience with ECL DCR, and recognizing the high synechia incidence in cases in which no endonasal procedures were applied, we abandoned the performance of ECL DCR without endonasal procedures after the middle of 2008. We conducted a prospective randomized comparative study on 91 patients with primary All the authors have full control of all primary data, and agree to allow Graefe's Archive for Clinical and Experimental Ophthalmology to review their data upon request. H. Basmak (*) :H. Gursoy Department of Ophthalmology, Eskisehir Osmangazi University Medical Faculty, Eskisehir, Turkey e-mail: hbasmak@ogu.edu.tr