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We have read the thought provoking article by Yung and Hardman-Lea on their experience with surgical endoscopic dacryocystorhinostomy (DCR).1 We appreciate the success rates achieved by them, which are among the highest in endonasal lacrimal surgery and comparable with those of external DCR in most centres of the world. We would like to discuss some relevant issues and seek clarifications about certain controversial areas.
The authors have adequately described their surgical technique for negotiating nasolacrimal duct (NLD) as well as common canalicular obstructions.1 However, they have not mentioned the technique they employed in tackling more proximal blocks—that is, those involving the upper, lower, or both canaliculi in their group of such patients (13 cases).
A detailed elucidation of how the authors approached the individual lacrimal canaliculi from the endonasal route to relieve the obstruction will be extremely valuable to the readers as a whole, and to dacryologists in particular.
Silicone stents have become an almost universally accepted adjunct in lacrimal surgery for enhancing success rates in cases with relatively poor prognosis. However, we would like to express serious reservations about keeping the stent in situ permanently, as described by the authors in proximal canalicular obstructions. Most of the previous studies have recommended placement of the stent for a period ranging from 3–9 months.2 Although silicone stents are absolutely inert and usually harmless, on prolonged placement they can act as a nidus for granuloma formation and infection, leading to failure of the lacrimal procedure in the long run.5,6 Moreover, inadvertent traction to the nasal end can result in slitting of the puncta and cheese wiring of the canalicular complex, whereas gradual ascent in the nasal cavity can lead to prolapse of the tube at the medial canthus.7 So, in our opinion, the time period of stent placement should be optimised and permanent placement could have long term deleterious effects.
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