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The etiologies of nasolacrimal outflow obstruction are multifactorial. They can be the result of external forces causing clefts in the outflow pathway or of pressure causing occlusion of the system, as seen with nasal cysts or masses. Genetic factors may have a role in the embryogenesis of syndromic entities that are associated with epiphora. Obstruction to outflow must be distinguished from other causes of tearing such as lid malpositions, abnormal or misdirected lashes, or a poor lacrimal pump mechanism. An understanding of the various etiologies can help in better appreciating the anatomic sites of dysfunction and in the selection of the most appropriate medical and surgical solutions. [ABSTRACT FROM AUTHOR]

In summary, some differences between the lacrimal systems of males and females and those of different races have been well documented, such as the smaller nasolacrimal canal diameter of women as compared with men. However, further comparative studies are needed to fully address the anatomic differences, which would provide better surgical guidelines. Variations exist even within each gender and race. The key to being a successful lacrimal surgeon lies in the awareness of such nuances and the ability to adjust surgical technique when an anatomic variation is encountered in any patient. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Transcanalicular dacryoendoscopy combined with simultaneous minimally invasive therapy is a great step forward in diagnostic and operative choices. It has considerably reduced the rate of DCRs that would otherwise have been necessary to perform. Transcanalicular endoscopy enables new insights into the pathology of the diseases of the lacrimal system. Today, one can directly visualize lesions and decide immediately on appropriate interventions, whereas in the past, only indirect imaging was available. [ABSTRACT FROM AUTHOR]