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Original Research

Epiphora Drainage by DCR – Long‑Term Results

Abstract S. M. Balaji,
Background: Dacryocystorhinostomy (DCR) refers to the surgical procedure that is used to relieve the Preetha Balaji
chronic obstruction of the nasolacrimal duct obstruction (NLDO). In a maxillofacial setting, NLDO may Department of Oral and
arise subsequent to a facial trauma or orthognathic surgery. There is a dearth of literature from this part of Maxillofacial Surgery, Balaji
the world. This article intends to provide a single maxillofacial center experience in DCR. Materials and Dental and Craniofacial
Methods: This is a retrospective, noncomparative, noninterventional, record audit type of study of all Hospital, Chennai, Tamil Nadu,
consecutive patients fulfilling inclusion and exclusion criteria. All patients with epiphora and diagnosed India
with lacrimal apparatus damage between 1 January 2008 and 31 December 2017 requiring DCR were
considered for the study. Details of demographics, phase of treatment  (primary/retreatment), types of
bones involved, age, complications, period suffering from epiphora, and follow‑up were obtained.
All data were entered and analyzed using the Statistical Package for the Social Service  (version  16;
IBM). Descriptive statistics of the frequency and mean  ±  standard deviation  (SD) as appropriate were
presented. Chi‑square test and one‑way analysis of variance were used appropriately. P ≤ 0.05 was taken
to be statistically significant. Results: In all, 83  patients fulfilled the inclusion and exclusion criteria. It
is more common in males (n  =  56, 67.47%) with a mean  ±  SD of 32.24  ±  10.80  (18–59  years) with
27  (32.53%) of them presenting primarily after fractures. Fracture was the most common pathology
seen in 81.93%  (n  =  68) of cases, while the rest were as a result of orthognathic cases. Le Fort II
and III set of bones contributed to 59% of cases, while the orbitonasal complex contributed to only
three cases. NLD obstruction was seen in 68  (81.9%) of cases. On an average, the patients suffered
for 9.3  ±  6.74  months (range 0.5–22  months) before seeking treatment and the average follow‑up was
31.07  ±  11.69  months  (range 15–54  months). Discussion and Conclusion: Fractures and surgeries
involving nasal bones carry an innate risk of damaging the NLD system. The pattern of need for DCR
and occurrence of NLDO in this part of the world have been described. The extent of the anatomical
variations and need for proper surgical planning are highlighted.

Keywords: Dacryocystorhinostomy, epiphora, nasal trauma, nasolacrimal duct obstruction, tearing

of the eyes

Background later half of 1960s to involve silicone tubes

pushed through an external incision, bony
Congenital and acquired lacrimal drainage
window causing anastomosis.[3] Later, the
disorders cause excessive, unprovoked
newly created path was epithelialized and
watering of the eye, referred as epiphora.
tubes were removed. The use of such tube
Dacryocystorhinostomy  (DCR) is a type of
has been demonstrated to be nonirritating,
mid‑facial surgical procedure that is used to
extremely flexible, and with favorable
recreate and establish a gravity‑dependent,
results.[4‑7]
low‑resistance drainage pathway between
the lacrimal sac and the nasal cavity. The silicone tube intubation is generally Address for correspondence:
This is achieved by creating a patency performed with a Guibor or Crawford Dr. S. M. Balaji,
between lacrimal sac and the lateral nasal bicanalicular tube or Nunchaku‑style Balaji Dental and Craniofacial
Hospital, 30, KB Dasan
wall mucosa.[1] The earliest successful silicone tube or O’Donohue silicone tubes
Road, Teynampet, Chennai,
procedure was reported by Dupuy‑Dutemps [Figure 1].[8,9] Also, the procedure has been Tamil Nadu - 600 018, India.
and Bourguet in 1921 with a success rate performed with or without endoscopes.[8,9] E‑mail: [email protected]
of 94.8% in more than 1000 consecutive There are several reports describing the
cases of lacrimal gland pathology, often outcomes of performance of these types
Access this article online
causing serious epiphora.[2] The procedure of DCRs. However, there are very few
advocated was later modified by Gibbs in research on DCR in maxillofacial setting Website: www.ijdr.in
from this part of the world and that DOI: 10.4103/ijdr.IJDR_437_19
compares between primary DCR and Quick Response Code:
This is an open access journal, and articles are
distributed under the terms of the Creative Commons revision DCR. Hence, this work was carried
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows to address these lacunae.
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are
licensed under the identical terms. How to cite this article: Balaji SM, Balaji P. Epiphora
drainage by DCR – Long-term results. Indian J Dent
For reprints contact: [email protected] Res 2019;30:337-41.

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Balaji and Balaji: Epiphora drainage by DCR

Materials and Methods If no stoppage was observed, the stent was pushed through
the inferior meatus, and then visualized and grasped. The
This was a retrospective, noncomparative, noninterventional,
other end of the stent was similarly passed through the
record audit type of study of all consecutive patients
inferior punctum to pass through the nasolacrimal canal to
fulfilling inclusion and exclusion criteria. As this is a
reach the inferior meatus [Figure 2a and b].
retrospective audit study from clinical records of patients,
it was exempted from further ethical review. All patients If a hard stop was felt, the incision for the nasal‑mucosal
with epiphora and diagnosed with lacrimal apparatus flap was done at about 8  mm above the middle turbinate,
damage between 1 January 2008 and 31 December 2017 extending vertically or in a curvilinear fashion down to the
requiring DCR were considered for the study. All data were bone, as anatomy indicates. A  periosteal elevator  (Freer)
retrieved from records anonymously. Patients complaining was used to elevate the nasal mucosa, exposing the frontal
of epiphora after a trauma or surgery were investigated for process of the maxilla. If required, the flap was excised with
the cause. A  failed DCR, chronic dacryocystitis  (acquired a forceps (Weil‑Blakesley). If required, Rongeurs were used
nasolacrimal duct stenosis leading to outflow obstruction to trim the exposed maxillary frontal process. Osteotomy was
and subsequent infection and inflammation of retained gradually enlarged till the end of the stent was visualized. If
stagnant contents within the lacrimal sac), fistula formation, there was a fistula, pathological   canalization  along the path
and nasolacrimal duct  (NLD) obstruction were diagnosed of least resistance has to be removed [Figure 3a].[11]
by regurgitation of mucopurulent material on pressure over
The length of the bicanalicular stent was then adjusted
the lacrimal sac.[10,11] Prior to surgery, conventional history
between the superior and inferior punctum to prevent
of nasal blockage, type of trauma  (road traffic accidents,
tension before tying the two ends securely [Figure 3b]. This
fall, interpersonal violence), or orthognathic surgery
bicanalicular silicone stent acts as a temporary surgical
records were pursued [Table 1]. A  basic nasal examination
stent during the healing process of the damaged NLD.
was done to rule out gross pathology involving the nasal
Intraoperatively, irrigation through the lower canaliculus
and lacrimal apparatus. All surgeries were performed by
would confirm the patency of the lacrimal drainage system.
the authors with due training in the technique.
The patient was managed with corticosteroid and antibiotic
Inclusion criteria included any case of epiphora or that eye drops for a week following surgery to prevent ocular
requiring DCR, above the age of 18 years, of either gender, infection.[11,12]
providing consent for the treatment, and not suffering
Statistics
from any systemic condition that could influence lacrimal
apparatus patency and function, with adequate follow‑up and All data were entered and analyzed using the Statistical
all relevant case records. Those patients without sufficient Package for the Social Service  (version  16; IBM, Chicago,
follow‑up of at least 12  months or incomplete records IL, USA). Descriptive statistics of the frequency and
were excluded. Also, cases that had dacryocystitis (acute or mean  ±  standard deviation  (SD) as appropriate were
chronic) were excluded from the study. presented. Gender, type of pathology, bones involved,
cause, age, period suffering with epiphora, and follow up
From the case records, age, gender, phase  (primary DCR
formed the predictors, while the primary and retreatment
or retreatment DCR), primary pathology or cause of
formed the outcome variable. Pearson’s Chi‑square test
epiphora  (fracture/orthognathic), bones involved  (Le Fort
I/II/III/zygomatic complex/naso‑oribtal ethmoid complex/ was used to identify the association of predictors with the
orbitonasal), cause as either chronic dacryocystitis or a primary or retreatment groups. Similarly, one‑way analysis
failed DCR, or a long‑standing fistula or NLD obstruction of variance  (ANOVA) was used to identify the difference
were obtained. Also, the duration of time suffering from between the primary and retreatment procedures. Similarly,
epiphora was noted down. The complications, if any, were the period of epiphora and age were compared for the type
noted down. of bones involved using one‑way ANOVA. P ≤  0.05 was
taken to be statistically significant.
Surgical procedure
Results
Under general anesthesia, standard surgical preparations
were carried out. Lignocaine 2% with adrenaline was During the study period, 83  patients fulfilled the inclusion
infiltrated as required along the incision for the purpose of and exclusion criteria. It is more common in males (n = 56,
hemostasis as and when required. Initial punctal dilation 67.47%) with a mean ± SD of 32.24 ± 10.80 (18–59 years),
was carried out using a Nettleship dilator. A  O’Donohue with 27  (32.53%) of them presenting primarily after
type of bicanalicular stent, about 40 cm in length, made up fractures. Fractures was the most common pathology seen
of biological grade silicone with stainless steel probes at in 81.93%  (n  =  68) of cases, while the rest were as a
both the ends was used. An end of the stent was passed result of orthognathic cases. Le Fort II and III set of bones
through the superior dilated punctum under direct vision. contributed to 59% of cases, while the orbitonasal complex
It was then slowly passed through the avulsed end of the contributed to only three cases. NLD obstruction was
NLD and further into the canal, until a hard stop was felt. seen in 68  (81.9%) of cases. On an average, the patients
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Balaji and Balaji: Epiphora drainage by DCR

suffered for 9.3  ±  6.74  months (range 0.5–22  months) Table 1: Demographic parameters of the study group
before seeking treatment and the average follow‑up was (n=83) who underwent DCR
31.07 ± 11.69 months (range 15–54 months). Postoperatively, Parameter Groups n Percentage
the mild epiphora was observed in the two fistula cases that Gender Female 27 32.53
healed by 3 weeks time frame; slight bleeding was observed Male 56 67.47
in four cases and minor ocular infection in two cases. All Phase Primary 27 32.53
such complications were managed effectively. Retreatment 56 67.47
Table  2 shows the comparison of demographic predictor Pathology Fracture 68 81.93
Orthognathic 15 18.07
variables with the phase of treatment using Pearson’s
Bones Lefort 1 5 6
Chi‑square test. Gender  (P  =  0.263) was not significant,
Lefort 2 26 31.3
while basic pathology  (P  =  0.001), bones involved
Lefort 3 23 27.7
(P  =  0.001), and cause  (P  =  0.012) were statistically
Zygomatic complex 13 15.66
significant. Time period with complaint  (in months) was
Naso‑orbital ethmoid 13 15.66
statistically significant between primary and retreatment. complex
There were no differences in age or follow‑up [Table  3]. Orbito‑nasal complex 3 3.61
Table  4 shows the difference in age and time period with Cause Failed DCR 13 15.66
complaint and follow‑up compared by various set of bones Fistula 2 2.41
involved with statistical significance of P =  0.005 with the NLD obstruction 68 81.9
former and P = 0.001 for the latter. Mean Age (in years) 32.24±10.80 18-59
Mean lapse in treatment (in months) 9.3±6.74 0.5-22
Discussion Mean follow‑up (in months) 31.07±11.69 15-54
There are few studies on the incidence of lacrimal system
damage due to maxillofacial trauma. Such studies report Table 2: Comparison of demographic predictor variables
of the involvement of NLD system in 7%–15% of all with the phase of treatment
instances of trauma. There are reports that the incidence Primary Retreatment P
of nasolacrimal duct obstruction  (NLDO) following a n (%) n (%)
nasoorbitoethmoidal (NOE)  fracture ranges between Gender
29% and 68%. With the surgical correction, most of Female 7 (25.9) 20 (35.7) 0.263
the damages, notably of the NLDO, are corrected and Male 20 (74.1) 36 (64.3)
symptomatic epiphora rarely persists beyond 4–6  weeks Pathology
with appropriate management.[13] In a small subset of Fracture 27 (100) 41 (73.2) 0.001
population, the damages still persists. Based on the level Orthognathic 0 15 (26.8)
of trauma and bony displacement as well as the type Bones
of surgical intervention, there could be an NLDO or Lefort 1 type of fractures 0 5 (8.9) 0.001
fistula formed. Irrespective of the same, there would be Lefort 2 type of fractures 4 (14.8) 25 (39.3)
an epiphora associated. When the accumulated tears get Lefort 3 type of fractures 6 (22.2) 19 (30.4)
stagnated, infection may follow leading to acute or chronic Zygomatic complex bones 5 (18.5) 8 (14.3)
Naso‑orbital Ethmoid fractures 9 (33.3) 4 (7.1)
dacryocystitis, leading to more radical surgery involving
Orbito‑nasal bones 3 (11.1) 0
lacrimal sac.[11] The clinical features of NLDO and
Cause
subsequent infections in different types of facial trauma are
Failed DCR 0 13 (23.2) 0.012
routinely described in standard textbooks.[14]
Fistula 0 2 (3.6)
The involvement of the NLDO in the maxillary NLD obstruction 27 (100) 41 (73.2)
orthognathic surgeries of any Le Fort type is a possibility. DCR: Dacryocystorhinostomy; NLD: Nasolacrimal duct
The surgery involves extensive manipulation of the
complex nasomaxillary osseous apparatus. In case of the In the present research work, there were minor
anatomical deviation or poor surgical planning or control complications that were medically managed. Proper
of fracture lines, the NOE may be damaged or broken preoperative follow‑up is needed to avoid future issues
segments of bone could impinge the NLD causing NLDO. and persistence or failure of the DCR. Similar successful
The mechanism of such a damage in Le Fort I has been reports were also reported earlier.[9,11] Persistent
extensively reviewed.[15] The chance of the NLDO in Le infection, possibly as chronic dacryocystitis in the
Fort II and III types of orthognathic surgeries has been lacrimal apparatus, could also lead to the formation of
primarily due to abnormal anatomy or poor surgical a fistula. Management of such fistula is complex and
planning.[12,16] Literature is sparse on the incidence of would need elimination of the new path of drainage, the
NLDO post orthognathic surgeries.[12,15] epithelization.

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Balaji and Balaji: Epiphora drainage by DCR

Table 3: Difference in Age, Time period with Complaint

and follow up compared by primary and re-treatment cases
Mean±SD 95% CI for mean P
Lower Upper
Age in years
Primary 31.56±10.57 27.37 35.74 0.67
Re-treatment 32.57±9.91 29.92 35.23
Time period with
Complaint (in months)
Primary 1.03±0.38 0.88 1.18 0.000
Re-treatment 13.34±4.17 12.22 14.45
Follow up in months
Primary 32.59±12.57 27.62 37.56 0.414
Re-treatment 30.34±11.29 27.32 33.36
SD: Standard deviation; CI: Confidence interval
Figure  1: Skin incision placed, lacrimal sac exposed, and osteotomy of nasal
bone done. Silicone tube placed through the lacrimal sac and new ostium
experience and training in surgical procedure. Hospital
admission bias is a possibility and results thus need to be
carefully considered. The high number of retreatment cases,
often referred from external centers  (n  =  56), is the reason
for the same. Of the 68 cases that had maxillofacial trauma,
only 27  (39.7%) sought primary treatment with epiphora,
while the rest 41  (60.3%) were retreatment cases. In
orthognathic cases, all (n = 15) cases were retreatment cases.
The difference was statistically significant (P = 0.002).

Figure 2: (a) Lacrimal probe inserted through the lacrimal canaliculus parallel

The fractures of bones involving the nasal apparatus
to the medial canthal tendon. (b) Lacrimal intubation set with silicone tube required DCR. The highest risk was the Le Fort II pattern
followed by Le Fort III type of fractures. NOE alone
was less when compared with Le Fort. The least was Le
Fort I mostly due to orthognathic surgeries. Anatomical
abnormalities have been suggested as the cause.[12,15]
Patients suffering from epiphora owing to primary cause
reported a mean period of 1.03  months, while the
retreatment sought was for a mean of 13.34  months.
The difference was statistically significant  (P  =  0.000).
The set of bones have a different time frame of seeking
treatment. Those who had only orbitonasal bone fractures
Figure 3: (a) Skin incision placed, lacrimal sac exposed, and osteotomy of
nasal bone done. Formation of anterior and posterior flaps between the sought treatment earlier at 1.08  months, while those with
lacrimal sac and nasal mucosa followed by lacrimal silicone tube insertion. Le Fort I type of fractures/orthognathic surgeries waited
(b) Naso‑ethmoid complex fracture fixed using y plate. Silicone tube inserted
for 14.8  months before seeking treatment. The difference
into the ostium to facilitate the drainage of lacrimal secretions into the nose
was statistically significant  (P  =  0.005). This has clinical
significance. Depending the types or sets of bones
The intent of this article is to compare the characteristics
involved, the clinical severity of the epiphora may vary,
between the primary repair and retreatment of DCR in
necessitating the patients to seek immediate relief. Those
a maxillofacial clinical setting. DCR is often required for
with the orbitonasal fractures sought treatment earlier,
a case of NLDO, after a trauma  (spontaneously or after
while those with Le Fort I pattern of bone involvement
fracture reduction) or in orthognathic cases. In either
sought treatment later. This could be a reflection of the
scenario, abnormal anatomy and improper studying of the
severity of the compliant. Future studies would need to
radiographs, especially of the NOE region, could be one
consider the severity of epiphora and/or identify a grading
of the major causes of NLDO and subsequent epiphora.
system for the same. There are no previous studies in the
NLDO due to swelling, inflammation, or major infection
direction of comparing clinical features between primary
often recedes with proper medical attention. However, bony
and retreatment of DCR. Hence, the results of the studies
impingements or improper alignment of the bones causing
cannot be discussed in light of existing literature.
obstruction  (full/partial) on the NLD system could lead
to epiphora. The study used retrospective analysis from a Anatomical complexities of the NOE region and deviation
single center, operated by the primary author with adequate from normal are often noted. The operating surgeon while

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Balaji and Balaji: Epiphora drainage by DCR

Table 4: Difference in Age and Time period with Complaint and follow up compared by various set of bones involved
Parameter n Mean±SD 95% CI for Mean P
Lower Upper
Time period with Complaint (in months)
Lefort 1 type of fractures 5 14.8±2.59 11.59 18.01 0.005
Lefort 2 type of fractures 26 11.4±6 8.98 13.83
Lefort 3 type of fractures 23 9.17±6.36 6.43 11.92
Zygomatic complex bones 13 9.65±7.54 5.1 14.21
Naso‑orbital Ethmoid fractures 13 4.96±6.5 1.03 8.88
Orbito‑nasal bones 3 1.08±0.14 0.72 1.44
Age (in years)
Lefort 1 type of fractures 5 27.6±5.41 20.88 34.32 0.001
Lefort 2 type of fractures 26 29.65±8.2 26.10 33.20
Lefort 3 type of fractures 23 29.64±7.89 26.38 32.9
Zygomatic complex bones 13 41.23±11.38 34.35 48.11
Naso‑orbital Ethmoid fractures 13 30.62±8.7 25.36 35.88
Orbito‑nasal bones 3 44.67±11.85 15.24 74.09
SD: Standard deviation; CI: Confidence interval

planning for fracture reduction or orthognathic surgeries 3. Gibbs DC. New probe for the intubation of the lacrimal canaliculi
has to carefully consider the locoregional radiological with silicone rubber tubing. Br J Ophthalmol 1967;51:198.
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Can J Ophthalmol 1977;12:289.
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The difference in clinical characteristics of features 8. Mimura M, Ueki M, Oku H, Sato B, Ikeda T. Indications for and
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identity, but anonymity cannot be guaranteed. nasolacrimal duct. In: Schmidt‑Erfurth  U., Kohnen  T, editors.
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Conflicts of interest Ltd; 2018. p. 1061‑81.
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