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Powered endoscopic DCR allows the lacrimal sac to be fully exposed so that it stands proud of the lateral nasal wall after dissection. By fully preserving all the lacrimal mucosa during opening of the sac, the sac can be marsupialized into the lateral nasal wall, becoming part of the lateral nasal wall. This marsupialization is different from creating an ostium into the sac. Complete marsupialization decreases the l ikelihood of closure of the sac. In addition, preservation of the nasal mucosa allows this mucosal flap to be trimmed so that the nasal and lacrimal mucosa can be opposed to ensure primary intention healing rather than secondary intention healing and potentially lessens the risk of fibrosis and subsequent closure of the lacrimal ostium. Results of this procedure have proved to be reliable in primary, revision, and in pediatric DCRs.

With a careful, systematic approach to the patient with tearing after DCR, the appropriate management usually eliminates the epiphora. It is extremely important to identify all etiologic factors contributing to the DCR failure so that they can be properly addressed. Nasal endoscopy is essential because it may reveal a deviated septum, synechiae, or a middle turbinate blocking the DCR fistula. If the DCR fistula is stenotic or occluded, then the fistula can be reopened via an external, transcanalicular, or transnasal approach, either with or without the assistance of a laser. Often, simple balloon dilatation, with or without silicone intubation, is successful. Occasionally, repeat DCR is necessary, and mitomycin C may be used to enhance the likelihood of surgical success. If the canaliculi and DCR fistula appear patent to fluorescein dye and lacrimal irritation (syringing), then one may be dealing with reflex tearing caused by a dry ocular surface or lacrimal pump failure secondary to lower eyelid laxity. The former is treated with artificial tears, whereas the latter typically responds to horizontal tightening of the eyelid. Success can usually be assured once the etiology of the DCR failure is determined and appropriately treated.

This nasolacrimal catheter has been extremely successful and is now the standard technique in the author’s hands. It is simpler, faster, and more successful than other methods of maintaining nasal ostium patency in DCR surgery. It is well tolerated by the patient and is easily removed in the office setting. The Griffiths Nasolacrimal Catheter is available from BD Visitec (Franklin Lakes, NJ) in the Standard size (12-mm collar) and the Pediatric/Endonasal size (8-mm collar). The author has no financial interest in this device.

The Sisler trephine makes recanalization of a distally blocked lacrimal canaliculus an office procedure as opposed to major surgical microdissection in an operating room setting. The uniform, cylindrically shaped bolus of scar tissue removal makes for a sculptured passageway through the previous obstruction which, with its smooth and clean edges, is less likely to reocclude with time.