Sir,

We read with interest the article by Malhotra et al1 on ‘A consideration of the time taken to do dacryocystorhinostomy (DCR) surgery’. In the article, they reported and compared the surgical time and success rates of external, endoscopic endonasal surgical and endoscopic endonasal laser DCR. A few issues, however, that can directly affect the final results may need further discussion.

Like many other surgical procedures, endoscopic endonasal lacrimal surgery has a steep learning curve that can affect the surgical time and success rate of the procedure. Onerci et al2 have demonstrated a disparity in the results of endoscopic endonasal DCR surgery performed by experienced and less experienced surgeons, and the success rates were 94.4% and 58%, respectively. From the methodology of the present study, we understand that all surgeries were performed by ‘an oculoplastic trained ophthalmologist while learning endonasal lacrimal surgery’. We are not sure whether the unequal skill levels in different procedures may influence the surgical outcomes. Information on the actual experiences of the surgeon with regard to the three procedures involved in the study before starting the study may be relevant in interpreting the final results.

Anatomical variations inside the nasal cavity are likely to affect the endoscopic approach more than the external approach in DCR surgery. Narrow nasal cavity, as an example, is a challenging and demanding situation for endoscopic procedure, in which extra time or ancillary procedure might be required.3 We have observed a marked difference in the surgical time of the endoscopic surgical and endoscopic laser procedures. Basically, the steps in preparation and in passing the tube were quite similar between these two procedures. Was this due to a difference in case-mix? We would be grateful for information on the possible reasons of the time difference.

Lastly, duration of silicone tube intubation and granulation tissue formation are known to be important factors for surgical failure in endoscopic endonasal DCR. Prolonged intubation has been shown to associate with higher failure rate because of granulation reaction induced at ostium.4 Strategic postoperative endoscopic cares including tube repositioning,and debris and granulation tissue removal would improve the success rate of endoscopic surgery.5 These factors that may affect the outcomes, nevertheless, have not been fully addressed in the article.

We commend Malhotra and co-workers for their good work. We hope the discussion would broaden our understanding on the merits and shortcomings of the different DCR procedures.