Nazia Qidwai, et al
medial to the inner canthus. Although this incision
provides adequate exposure, there still remains the risk
of damaging angular vein, inadvertently, resulting in
massive intraoperative bleed. A newer incision is the
subciliary incision or the lower eyelid crease incision
placed horizontally in the lower eyelid relaxed skin
tension lines2. It not only spares the angular vein by
anatomical site but because it is placed horizontally in
the lower lid relaxed skin tension lines, it also provides
excellent cosmetic results3. This masks the scar as is
desired by most of the patients especially women.
Dacryocystitis is more commonly found in women and
cosmetic appearance is a major concern to most of
them especially the younger one4. The Subciliary
incision also retains the access and advantages of
external DCR procedure.5 lacrimal sac is entered from
the site of nasolacrimal duct. The osteotomy site is
very low. This prevents sump syndrome. Patients are
able to wear spectacles from 1st post-operative day3.
This study was undertaken to assess the functional as
well as cosmetic results of DCR using Subciliary
incision.
anesthesia, nasal packing was done. A 10 – 15mm
subciliary incision extending from the punctum
medially to mid pupillary line laterally, was given 1-2
mm inferior to the gray line of the lower eyelid,
parallel to and along the length of the lower eyelid
margin. Muscle and periosteum were retracted.
Lacrimal sac was exposed. Standard DCR was
performed. At the end of the surgery muscle was
closed with 6/0 Vicryl and skin with Prolene 6/0
sutures. Whilst closing skin, care was taken to avoid
punctal ectropion. Patients were followed up for 6
months. Post-operatively oral and topical antibiotic
and anti-inflammatory medicines were advised.
Patients were examined on 1stpost-op week, and then
1st, 3rd and 6th post-op months. They were assessed
for cosmetic as well as functional outcome. Functional
success was assessed for patency via syringing with
normal saline and cosmetic improvement by
photographing the inner canthus with a Nikon D70S
digital camera with a macro lens and resolution of
3008 × 2000 pixels at 1, 3 and 6 months post
operatively. The ophthalmologist and the patient
himself graded the Subciliary incision scar. The
resulting scar was judged according to a four level scar
grading scale (1 = unapparent, 2 = minimally visible,
3 = moderately visible, 4 = very visible)4. Statistical
analysis was done using SPSS version 23.0.
Qualitative variables were presented as frequency and
percentages. Pie and Bar charts were made for
categorical variables.
MATERIAL AND METHODS
This quasi experimental study with non-probability
convenience sampling was carried out at the
Oculoplasty clinic, Isra Post-Graduate Institute of
Ophthalmology, Al-Ibrahim Eye Hospital, Malir
Karachi. The institutional ethical committee approval
was taken. Patients in the age group of 20 to 70 years
having epiphora were recruited from July 2016 to
March 2017. They were subjected to ocular and
adnexal examination including syringing and probing.
Investigations like Dacryocystogram, skull x-ray, MRI
were advised when indicated to rule out local and
systemic pathologies. Patients with diagnosis of NLD
obstruction, chronic Dacryocystitis or Mucocele were
included. Patients with scar in lower eyelid,
Epicanthus, Acute-on-chronic Dacryocystitis, punctal
and canalicular disorders, ectropion or entropion of
inferior punctum, common or individual canalicular
obstruction, neoplasm of the lacrimal sac, tuberculosis
of the lacrimal sac, osteomyelitis of the lacrimal bone,
severe atrophic rhinitis, nasal polyp, granulomas,
neoplasms of nasal cavity, and patients who did not
give consent for follow-up, were excluded from the
study. Surgery was done by a single surgeon under
Local (2% Xylocaine admixed with 1:100,000
adrenaline) or General Anesthesia as per patient
requirement and desire. After administering
RESULTS
Out of 100 patients, 40 were male and 60, female. 10
patients were lost to follow-up out of whom 6 were
females and 4 males. Cosmetic and functional success
was noted in 90 (90%) eyes. Pre-operative irrigation
with normal saline revealed complete blockage of
nasolacrimal duct in all the patients. At the final
follow up, objective grading of the scar by the
ophthalmologists reported 85 scars to be invisible
(grade 1), 3 to be minimally visible (grade 2), 2 to be
moderately visible (grade 3)and 0 to be very visible
(grade 4). Subjective scar grading by the patient
reported 85 scars to be invisible (grade 1), 2 scars to
be minimally visible (grade 2) and 3 as moderately
visible. No post-operative complications were
observed in any of the cases.
Functionally 83 patients attained successful
surgical outcome which was confirmed by syringing
done at 1st week, 1st, 3rd and 6th months. This
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Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 142-146