To the Editor

We read with interest Mandal et al’s recent publication demonstrating the role of topical antihypertensives in the failure of dacryocystorhinostomy (DCR) surgery by inducing inflammation, fibrosis and cicatrization at the site of anastomosis [1].

Factors responsible for successful outcomes of DCR surgery are precise localization of lacrimal sac, adequately sized osteotomy sufficient to expose the complete extent of lacrimal sac including fundus, marsupialization of the entire length of sac and mucosa to mucosa anastomosis to ensure healing by primary intention. The reported causes of failure are cicatricial ostium closure, scarred common canaliculus, obstructed distal canaliculi, organizing granuloma and bone neogenesis [2].

In the current study 11 eyes of 10 patients were mentioned to be on topical antihypertensives, though the table 2 lists 11 patients. Amongst these 11 eyes, 8 underwent external and 3 were operated by endoscopic route, 1 being a revision surgery. Revision surgeries are associated with suboptimal outcomes, the yearly success rates from immediate to 5 years following the first revision by endoscopic approach being 93.3%, 75.5%, 71.1%, 68.9%, 68.9%, and 68.9% [3]. The authors related the influence of scarring in endonasal DCR surgery to smaller mucosal anastomosis, however they achieved successful outcome with endonasal approach in the revision surgery, with greater potential for scarring.

One patient in external DCR group had granulation tissue around the ostium which was revised twice by endonasal DCR. Silicone intubation is known to induce foreign body reaction and granuloma formation [4]. Other causes being, operative trauma, bare osteotomy bone without mucosal coverage and inherently aggressive healing. The recommended management is removal of stent, along with topical ocular and nasal steroids, none of which have been mentioned in the post-operative course [5].

Availability of change in osteotomy size during postoperative course, time of extubation and post-operative duration since onset of failure, would have given better insight to the causes of unsuccessful outcome in the present study. To conclude, a prospective study on primary acquired nasolacrimal duct obstruction, using a uniform surgical technique and excluding revision procedures is recommended to implicate the role of ocular hypertensives in outcome of DCR surgery.