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Decreasing medication use in patients with ocular hypertension
Title page: Decreasing medication use in patients with ocular hypertension
Dan C?lug?ru, PhD 1 and Mihai C?lug?ru, PhD 2
1Department of Ophthalmology, University of Medicine Cluj- Napoca/Romania
Phone number: 0745 827 552
Fax number: 0040 264 591468
2Department of Ophthalmology, University of Medicine Cluj- Napoca/Romania
Phone number: 0741 165 094
Fax number: 00 40 264 591468
E-mail: email@example.com Address of the Corresponding Author:
Strada Br?ncoveanu 11
E-mail: firstname.lastname@example.org The manuscript has been seen and approved by all authors; None of the authors has conflict of interest with the submission; The authors have never received financial support for this article;
Decreasing medication use in patients with ocular hypertension Re: Protocol-driven adjustment of ocular hypertensive medication in patients at low risk of conversion to glaucoma. Chan et al. Br J Ophthalmol 2015;99:1245-1250
In their article, Chan et al 1 evaluated the safety and potential savings of decreasing medication use in low-risk patients with ocular hypertension (OH). The authors concluded that 43.9% of low-risk OH eyes could safely reduce medications over 1 year, realizing substantial savings.
However, the study has several shortcomings, that prevent the validation of their results:
1. The authors pretended that the patients of their series had a low risk of conversion with a 5-year risk ? 15%. In fact, most patients included were at moderate risk with a 5-year risk of conversion between 5 and 15%.; 2
2. There was an increase in the intraocular pressure (IOP) from baseline (18.6 mmHg) to month 1 (20.5 mmHg) of the follow-up period; the difference (1.9 mmHg), though modest, is however, statistically significant. Of note, IOP is a major predictive factor for the development of primary open-angle glaucoma (POAG) and the risk of conversion to POAG from OH is around 10% for every 1-mmHg increase in IOP.3;
3. There were no data referring to the baseline values on medication of the mean visual field (VF) pattern standard deviation (PSD), VF mean defect, estimated 5-year risk of glaucoma conversion, and average retinal nerve fiber layer thickness;
4. Statistically significant increases occurred during the 1-year follow-up in the VF PSD and in the estimated 5-year risk of glaucoma conversion; also, one eye developed a repeatable VF defect and 13 eyes had 5-year risk > 15% at 1 year. These facts reflect a real worsening of the disease and are signs of OH progression, that bring up the issue of the opportunity to reduce medication use in these treated OH patients.
In conclusion, decreasing medication use is an act of great responsibility, requiring comprehensive and close monitoring of the OH patients. It should be made with extreme caution and only if there are no signs (even mild) of active and progressive OH.
References 1. Chan PPM, Leung CKS, Chiu V, et al. Protocol-driven adjustment of ocular hypertensive medication in patients at low risk of conversion to glaucoma. Br J Ophthalmol 2025;99:1245-50. 2. Weinberg RN, Friedman DS, Fechtner RD, et al. Risk assessment in the management of patients with ocular hypertension. Am J Ophthalmol 2004;138:458-67. 3. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study. Baseline factors that predict the onset of primary open- angle glaucoma. Arch Ophthalmol 2002;120:714-20.
Conflict of Interest:
Topical non-steroidal anti-inflammatory drugs to prevent cystoid macular oedema after cataract extraction: Are they effective?
We have read with interest the paper by Tzelikis et al. entitled: "Comparison of ketorolac 0.4% and nepafenac 0.1% for the prevention of cystoid macular oedema after phacoemulsification: prospective placebo- controlled randomised study" [Br J Ophthalmol 2015;99(5):654-658].
In order to consider as statistically similar the effects of ketorolac 0.4%, 0.1% nepafenac and placebo, the authors really needed to have established a margin of equivalence for the clinical effectiveness of the two active treatments versus placebo, which would have allowed determining the number of patients needed in each group and the associated statistical power, in order to test a hypothesis of equivalence, as previously suggested in a BMJ publication (1) citing Piaggio et al (2).
Although no working hypothesis is mentioned, the aim of the study suggests that the authors actually designed the study with the intention of demonstrating the superiority of active treatment over placebo. The results shown in Figure 1 are of paramount importance, given the objective of the work. The authors state that "operative check-up revealed a change in central subfields retinal thickness of <10 microns, between 10 and 25 microns, and >25 microns compared with preoperative values in all groups. The highest percentages of >10 microns were observed in the group 1". We agree with this statement. On applying the Jonckheere- Terpstra test to the data, we observed overall differences between the three categories of retinal thickness between at least two of the groups (p<0.001). A posteriori comparisons show that both the ketorolac group (p=0.02 and p=0.04) and the nepafenac group (p=0.03 and p=0.04) differed from the placebo group, for the category of <10 microns compared with >10 microns as well as for the category of 10-25 microns, respectively.
We would respectfully propose different wording from "statistically similar" macular foveal thicknesses between the active treatment and placebo groups.
1. Piaggio G, Elbourne DR, Altman DG, Pocock SJ, Evans SJ. Reporting of noninferiority and equivalence randomized trials: an extension of the CONSORT statement. JAMA 2006;295:1152-1160.
2. Research Methods & Reporting. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. http://www.bmj.com/content/340/bmj.c332 (accessed in July 2015)
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Time to embrace technical advances in the assessment of patients with corneal neovascularisation
We read with interest the article by Faraj et al1 proposing the clinical characterization of corneal neovascularization (CoNV) based entirely on slit lamp biomicroscopy and color photography. The authors provide a useful reminder of many issues previously discussed addressed in the 1970s.2 Their aim was to provide a nomenclature and a standardized system for grading and characterising CoNV. We have concerns about the "take-home" messages, which are not representative of the current standard of care for patients with CoNV. Biomicroscopy, whilst essential, is greatly complemented by ancillary techniques such as angiography and in vivo confocal microscopy (IVCM). The analogy is assessing the macula and guiding the treatment of retinal diseases such as AMD using only biomicroscopy and colour photography, with using angiography or OCT!
* Colour photography. Although the advent of digital image documentation allows a much improved image analysis than that achieved, for example, with hand drawings;3,4 photography is limited by inconsistent vessel delineation and standardization.4 Indeed, this was already recognized by Bron and Easty, who, in the 1970s, used angiography to study CoNV in more than 250 patients. 2
* Functional staging of CoNV. Angiography using fluorescein (FA) and indocyanine green (ICGA) allows the characterization of CoNV based on assessment of both morphologic (diameter, length tortuosity, area etc) and functional parameters such as flow and time to leakage, which are indicators of vessel maturity and disease activity.3,4,5 Angiography elucidates the anatomy of the marginal corneal and limbal vascular arcades which are important in the development of CoNV and peripheral corneal and limbal disorders.3 Relying only on clinical features to estimate vessel leakage, although helpful, is as acknowledged by the authors, unreliable.
* Multidimensional characterization of CoNV. Angiography and IVCM has been used to demonstrate acellular perfusion of ghost vessels, intravascular cellular traffic and with digital substraction analysis, has allowed the characterisation of lymphatic vessels, which are of great importance but evade mere clinical observation.6
* Guiding treatment. To undertake treatment such as selective fine needle diathermy (FND) only relying only on biomicroscopy is very challenging even aided by the patients pulse. Spiteri et al reported that angiography, even in the presence of exudate and scarring, allows precise detection of the afferent stems to guide FND. 4, 5
* Terminology. The suggested abbreviation "CVas" adds to the existing terminologic confusion rather than helping consolidate the more widely accepted term "CoNV". CVA is a well accepted term for cerebrovascular accident and clearly CVa is not a suitable abbrevation.
While the present study provides a useful reminder for the biomicroscopic characterisation of CoNV, it is time to embrace new technological advances similar to our retinal colleagues.
1 Faraj LA, Said DG, Al-Aqaba M, Otri AM, Dua HS. Clinical evaluation and characterisation of corneal vascularisation. Br J Ophthalmol 2015
2 Easty DL, Bron AJ. Fluorescein angiography of the anterior segment. Its value in corneal disease. Br J Ophthalmol 1971; 55: 671-682
3 Anijeet DR, Zheng Y, Tey A, Hodson M, Sueke H, Kaye SB. Imaging and evaluation of corneal vascularization using fluorescein and indocyanine green angiography. Investigative ophthalmology & visual science 2012; 53: 650-658
4 Romano V, Spiteri N, Kaye SB. Angiographic-guided treatment of corneal neovascularization. JAMA ophthalmology 2015; 133: e143544
5 Spiteri N, Romano V, Zheng Y, Yadav S, Dwivedi R, Chen J, Ahmad S, Willoughby CE, Kaye SB. Corneal angiography for guiding and evaluating fine-needle diathermy treatment of corneal neovascularization. Ophthalmology 2015; 122: 1079-1084
6 Romano V, Steger B, Zheng Y, Ahmad S, Willoughby CE, Kaye SB: Angiographic and in vivo confocal microscopic characterization of human corneal blood and presumed lymphatic neovascularization: a pilot study. Cornea 2015
Conflict of Interest:
Ketorolac does prevent retinal thickening and CME in routine cataract surgery
Your study actually confirms the data that we reported in the lead article of the AJO in October 2008 showing the benefit of ketorolac in preventing CME and retinal thickening after routine cataract surgery. To demonstrate statistical significance for CME, it requires a sample size of close to 400 patients per group. Your data clearly shows a trend to decreased retinal thickening when a NSAID is used in conjunction with steroids. You failed to reach statistical significance because you failed to have a large enough sample size. It requires approximately 80 to 100 patients to demonstrate definite statistical advantage with an approximately 95% chance of showing the correct result. Looking at your graphs there is a definite trend especially for ketorolac. In fact, your percentages for ketorolac are very similar to the percentages we reported. Similarly, your placebo group also is not far off the percentages we reported. However, our were statistically significant because there were over 260 patients in each group.
Conflict of Interest:
LETTER TO EDITOR
We Read with great interest the article Topical bromfenac reduces the frequency of intravitreal bevacizumab in patients with branch retinal vein occlusion by Masahiko Shimura et al.(1) We congratulate the authors for the concept and well conducted pilot study . Repeated intravitreal injections are known to have various complications(2) and it would be safer if noninvasive intervention like topical bromfenac can help to reduce the number of intravitreal injections .However, we would like to make an observation in the study design. Fundus Flourescein Angiography (FFA) of the enrolled patients was not performed at any time during the study. It is known that patients with branch retinal vein occlusion can develop CNP areas(Capillary Nonperfusion Areas) and the size of CNP areas is positively correlated with the amount of (Vascular Endothelial Growth Factor)VEGF(3,4). VEGF release is one of the important factors responsible for macular edema. Non availability of FFA can lead to the bias between the two groups because there is a chance of patients with larger CNP areas and thereby more VEGF at the baseline to be present in one group. We would like to suggest that CNP areas need to be considered while randomising patients to remove this bias.
1.Shimura M, Yasuda K. Topical bromfenac reduces the frequency of intravitreal bevacizumab in patients with branch retinal vein occlusion. Br J Ophthalmol. 2015 Feb;99(2):215-9.
2. Gunther JB, Altaweel MM. Bevacizumab (Avastin) for the treatment of ocular disease. Surv Ophthalmol 2009;54:372-400. 3.Fujikawa, Masato et al. Correlation between Vascular Endothelial Growth Factor and Nonperfused Areas in Macular Edema Secondary to Branch Retinal Vein Occlusion. Clinical Ophthalmology (Auckland, N.Z.) 7 (2013): 1497- 1501. 4.Noma H, Funatsu H, Yamasaki M, et al. Pathogenesis of macular edema with branch retinal vein occlusion and intraocular levels of vascular endothelial growth factor and interleukin-6. Am J Ophthalmol. 2005;140:256 -261.
Conflict of Interest:
Is larger endothelial graft size appropriate for Fuchs endothelial dystrophy?
We read with interest the results reported by Romano et al. The authors speculated the reason for lower endothelial failure in larger grafts (9.5mm) compared to smaller ones is due to the additional endothelial cells being transplanted.
It has been reported that the host peripheral endothelium in Fuchs endothelial dystrophy (FED) has some capacity towards restoring corneal deturgescence in denuded posterior stroma where the Descemet membrance endothalial keratoplasty (DMEK) did not attached.(1,2) This observation was seen in all 7 eyes with FED that had partial graft detachment but not in any of the 5 eyes with aphakic or pseudophakic bullous keratopathy (PBK).(1) In an eccentrically positioned DMEK, the area between the edge of the descemetorhexis and the edge of the graft often showed faster clearance in a fashion that starts from the recipient endothelium edge towards the graft.(2) In fact, this gap clears faster than the area over the attached DMEK.(2)
The above findings suggest the peripheral endothelium in FED may have migrated to cover the bare posterior stroma. Interestingly, the peripheral endothelium may have regenerative capacity as the endothelium cell density (ECD) appeared similar in the repopulated area and in eyes with completed attached graft.(2)
To accommodate a larger endothelial graft, the surgeon is likely to perform a larger descemetorhexis, hence removing more of the host's peripheral endothelium. Should some of latter remains, a large graft is likely to overlap hence damage the cells. Whether one should always aim to insert a larger graft in eyes with FED requires more thoughts.
In their study, Romano et al mentioned that graft failure is associated with ECD and graft size. One wonders whether there is an association between failure with combined graft size and diagnosis (PBK/FED).
1) Dirisamer M, Yeh RY, van Dijk K, Ham L, Dapena I, Melles GRJ. Recipient endothelium may relate to corneal clearance in Descemet membrane endothelial transfer. Am J Ophthalmol 2012; 154: 290-296. 2) Dirisamer M, Dapena I, Ham L, van Dijk K, Oganes O et al. Patterns of endothelialization and corneal clearance after Descemet membrane endothelial keratoplasty for Fuchs endothelial dystrophy. Am J Ophthalmol 2011; 152: 543-555.
Conflict of Interest:
Clinical features and treatment outcome of canaliculitis associated with the use of Smartplug
Dear Editor; We read with great interest the article entitled "Prevalence of canaliculitis after smartplug insertion during long-term follow-up" by Klein-Theyer et al.(1) I would like to contribute to the article with our clinical expeience.
Among 11 cases of canaliculitis after lacrimal plug insertion between 2007 and 2013 in a tertiary medical center, seven cases (64%) were noted to be associated with the use of Smartplug. All these patients were women with a mean age of 53-year-old. This propensity could be related to hormonal influence during menopause,(2) use of makeup,(3) or female predominance of dry eye requiring lacrimal plug insertion. The average time interval from plug insertion to the onset of symptoms was 4.7 years, which is in consistent with most published studies.(1) This means that the prevalence of lacrimal-plug canaliculitis may be underestimated if follow- up is not really long enough. The most common isolated microorganism in our study was Pseudomonas aeruginosa(29%), followed by Actinomyces(14%) and Staphylococcus aureus(14%). All canaliculitis resolved after canaliculotomy with removal of plug, and there was no recurrence was noted during a mean post-operative follow-up period of 11 months. In the study by Klein-Theyer and colleagues, the canaliculitis was resolved by topical antibiotics and "repeated" lacrimal irrigations, and one of them with persistent canaliculitis finally required canaliculotomy. Although they did not find any plug in the lacrimal drainage system by high-resolutional ultrasound, physicians should always keep in mind that lacrimal irrigation may cause dislodgement of an inflamed plug into the deep lacrimal drainage system, inciting infection or permanent blockage of the lacrimal drainage passages.(4) Canaliculotomy with removal of plug may be an effect and safe treatment option for these patients.
1. Klein-Theyer A, Boldin I, Rabensteiner DF, Aminfar H, Horwath- Winter J. Prevalence of canaliculitis after smartplug insertion during long-term follow-up. Br J Ophthalmol. 2015 Feb 26. pii: bjophthalmol-2014- 306290. doi: 10.1136/bjophthalmol-2014-306290.
2. Struck HG, H?hne C, Tost M. Diagnosis and therapy of chronic canaliculitis. Ophthalmologe. 1992; 89: 233-236.
3. Brazier JS. Hall V. Propionibacterium propionicum and infections of the lacrimal apparatus. Clin Infect Dis. 1993; 17: 892-893.
4. SmartPlug Study Group. Management of complications after insertion of the SmartPlug punctal plug: a study of 28 patients. Ophthalmology. 2006 Oct;113(10):1859.e1-6.
Conflict of Interest:
Video glass based vision testing for Home / School vision testing may make testing complete
Vision testing is a very tedious process. If a complete testing including contrast testing,colour testing,amsler test,glare test,speed of reading and other tests are undertaken it may take a lot of time.It is a reality that even today visual acuity testing alone is the deciding factor for undertaking cataract surgery. It has been noted by some authors that lack of government-funded routine eye examinations is associated with a reduced incidence of self-reported glaucoma and cataracts, probably due to reduced detection rates (1) this only means that some method of home testing may be essential.It is also possible that many kids would not go blind due to amblyopia if vision was to be tested .So it may be useful to test vision at home or school, which can be reported to the eye surgeon. Some authors have envisaged a lay person administered vision test which may be valid for identifying amblyopia in a controlled environment thus making a cost-effective and easily accessible vision screening performed by lay people a reality (2). A school vision screening program involving only school teachers was found to have resulted in more efficient screening than a program including professionals with the costs being a third of what would have been spend and it was found to also improve compliance with regards to hospital referral (3). Many authors have tried mobile app based methods for vision and concluded that while the results are not interchangeable with paper-based charts, mobile app tablet-based tests of reading speed are reliable and rapid to perform, with the potential to capture functional visual ability in research studies and clinical practice(4). Such apps can be easily incorporated into video glasses routinely used by children in video games.
We used a video glass available for playing video games and projected vision charts at an appropriate distance into the glass and tested vision at home. The fact that the glass had covers on the side, nullified the effect of ambient light. Also some homes in India may be actually cubicles and so may not have the requisite distance for testing and so in such cases a mobile app based visual testing with charts projected into the video glass helps in such situations. Following the ease of testing and the improved ability of patients or care takers who are now being able to test vision at home; different aspects of vision are now being tested by patients or care takers. When this becomes more common even eye surgeons will begin to do more tests.
1) Chan CH, Trope GE, Badley EM, Buys YM, Jin YP. The impact of lack of government-insured routine eye examinations on the incidence of self- reported glaucoma, cataracts, and vision loss. Invest Ophthalmol Vis Sci. 2014 Dec 9;55(12):8544-9. doi: 10.1167/iovs.14-15361. 2) Longmuir SQ, Pfeifer W, Shah SS, Olson R. Validity of a layperson- administered Web-based vision screening test. J AAPOS. 2015 Feb;19(1):29- 32. doi:10.1016/j.jaapos.2014.10.021 3) Priya A, Veena K, Thulasiraj R, Fredrick M, Venkatesh R, Sengupta S, BassettK. Vision screening by teachers in southern Indian schools: testing a new "all class teacher" model. Ophthalmic Epidemiol. 2015 Feb;22(1):60- 5. doi:10.3109/09286586.2014.988877. 4) Kingsnorth A, Wolffsohn JS. Mobile app reading speed test. Br J Ophthalmol.2014 Oct 29. pii: bjophthalmol-2014-305818. doi:10.1136/bjophthalmol-2014-305818.
Conflict of Interest:
Indirect ophthalmoscope , will it get replaced by smart phones in some settings?- Serial video recording of retinal conditions in ICCU setting with indirect ophthalmoscopy with inexpensive smart phones
Indirect ophthalmoscopy has advanced since its inception. We now recognize the importance of video imaging of the retina. Authors deviced various slit lamp adaptors to capture retinal image(1) Many authors have used smartphones coupled with indirect ophthalmoscopy and some even identified an iPhone application that can control the flash and reduce the intensity to levels that do not damage the retina.(2,3,4,5)
Some authors described a lightweight, compact, user-friendly, 3D printed attachment which enabled high quality fundus photos achieved by coupling smartphones to indirect ophthalmoscopy lens. (6)
In January 2013, the FDA approved the iExaminer (Welch Allyn), the first smartphone-based imaging adaptor system that attaches an iPhone 4 (Apple Inc, Cupertino, CA) to Welch Allyn's Panoptic Ophthalmoscope to capture images of the retina in combination with the iExaminer App.(7)
But all of the methods with adapters and iPhones are expensive or bulky and impossible to use in ICCU setting.
We used a blackberry Z 3 mobile phone to capture serial video recordings of cases in ICCU setting in patients on ventilator support and recorded various cases like Terson's syndrome and papillodema and other retinal conditions that need serial follow up. The smartphone allowed us to use 1080 p HD recording and the autofocus and ambient light sensors in recent cameras as well as the other features allow better evaluation of the retina.
The audio video combine recording allows for simultaneous commentary too which is important for Medical records and to save time in ICCU setting. The audio and video format supported are 3GP, 3GP2, M4A, M4V, MOV, MP4, MKV, MPEG-4, AVI, ASF, WMV, WMA, MP3, MKA, AAC, AMR, F4V, WAV, AWB, OGG, FLAC and these allow viewing in any setting,transfer over any media and storage and editing with ease so as to create a time compressed view of the condition for patient education and counselling.
The blackberry at a cost of Indian currency of 13,000 rupees is a very cheap piton for such video recording of the retina. It was very easy to train ICU residents and the ability to transfer data through encrypted messengers like Telegram allows for excellent management of such patients in the follow up period especially in ICCU setting in rural areas where Superspeciality may not be available round the clock in a country like India. The ease with which even residents and non ophthalmologists can acquire images and transfer the images ,makes smart phones replace indirect ophthalmoscopes in these settings. Besides the use of these methods by those screening for diabetic retinopathy in rural outreach settings makes it all the more exciting.The ability to see the video in slow motion allows for better screening as well as in better assessment in telepath alkaloid from rural areas as has been our experience.
Considering all these developments the traditional indirect ophthalmoscope may need to be modified and made less expensive and less bulkier and easier to use and learn even in emergency rooms and ICCU settings to withstand the competition from smart phones.
References:- 1) Chakrabarti D. Application of mobile technology in ophthalmology to meet the demands of low-resource settings. Journal of Mobile Technology in Medicine 2012;1(4S):1-3. 2) Lord RK, Shah VA, San Filippo AN, Krishna R. Novel uses of smartphones in ophthalmology. Ophthalmology 2010;117(6):1274. e3 3) Chakrabarti D. Application of mobile technology in ophthalmology to meet the demands of low-resource settings. Journal of Mobile Technology in Medicine 2012;1(4S):1-3. 4) Haddock LJ, Kim DY, Mukai S. Simple, Inexpensive Technique for High- Quality Smartphone Fundus Photography in Human and Animal Eyes. Journal of Ophthalmology 2013;2013. http://dx.doi.org/10.1155/2013/518479 5) Chhablani J, Kaja S, Shah VA. Smartphones in ophthalmology. Indian J Ophthalmol 2012;60(2):127 6) David Myung, Alexandre Jais, Lingmin He.Mark S. Blumenkranz, Robert T. Chang, 3D Printed Smartphone Indirect Lens Adapter for Rapid, High Quality Retinal Imaging. Journal MTM 3:1:9-15, 2014 7) Teichman JC, Sher JH, Ahmed IIK. From iPhone to eyePhone: A technique for photodocumentation. Canadian Journal of Ophthalmology/Journal Canadien d'Ophtalmologie 2011;46(3):284-6.
Conflict of Interest:
Endoscopic suturing of flaps in endonasal DCR with stenting further improves results
Endoscopic suturing of lacrimal sac flap to the nasal mucosa flap in Dacryocystorhinostomy ( DCR) was described by us as early as 2004 and a video of the procedure was published in textbook of oculoplasty (1) The audits done showed that the short term results were excellent and the only concern was the time taken to do the surgery. Three years later another paper described excellent results with suturing of the flaps and it was reported to have a primary success rate of 96 percent and ultimate success rate of 100 percent and the authors contemplated replacement of external DCR with endonasal DCR (2) Traumatic Dacryocystitis has been treated often by external DCR and some authors have suggested external DCR with stenting in such cases (3) We have noted in our audits that doing an endonasal DCR with suturing of the flaps and stenting both leads to 100 percent results even in cases with trauma where in there is Dacryocystitis with coexisting orbital fracture too. The endoscopy procedure does not disturb the lacrimal pump and the suturing of the flap causes healing by primary intention and makes the procedure 100 percent successful especially when combined with stents.
1) Sunil Moreker, Sneha K, Kirtane MV, Mankekar G. Endoscopic Dacrocystorhinostomy :Recent advances. Oculoplasty and reconstructive surgery , Jaypee publications 2010, page 286 2) Kirtane MV, Lall A, Chavan K, Satwalekar D. Endoscopic dacryocystorhinostomy with flap suturing. Indian J Otolaryngol Head Neck Surg. 2013 Aug;65(Suppl):236-41. doi: 10.1007/s12070-011-0354-z. 3) Rizvi SA, Sharma SC, Tripathy S, Sharma S. Management of traumatic Dacryocystitis and failed dacryocystorhinostomy using silicone lacrimal intubation set. Indian J Otolaryngol Head Neck Surg. 2011 Jul;63(3):264-8. doi:10.1007/s12070-011-0230-x.
Conflict of Interest:
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