ORIGINAL ARTICLE  
External Dacryocystorhinostomy with  
Intubation in Shrunken Fibrotic Sac in  
Chronic Dacryocystitis  
Erum Shahid1, Asad Raza Jafri2, Uzma Fasih3, Arshad Shaikh4  
1-3Abbasi Shaheed Hospital & KMDC. 4Spencer Eye Hospital & KMDC, Karachi  
ABSTRACT  
Purpose: To assess anatomical success rate of external dacryocystorhinostomy (DCR) with intubation in long  
standing chronic dacryocystitis with shrunken fibrotic sac. Secondary objective was to document frequency of  
intraoperative and postoperative complications of external DCR in such cases.  
Study Design: Quasi experimental study.  
Place and Duration of Study: Ophthalmology department, Abbasi Shaheed Hospital, Karachi from January 2015  
to December 2017.  
Material and Methods: Patients with chronic dacryocystitis for 2 years or more, 18 to 60 years old, repeated  
acute attacks twice or more in past 1 year and fibrotic sacs were included. Canaliculitis, canalicular blocks,  
punctal agenesis and enlarged sacs were excluded. Surgeries were carried out under general anaesthesia.  
Fibrotic lacrimal sac was identified and excised, ostium was created in nasal bone and bi-canalicular intubation  
was done. Surgery was labeled successful if patency of the pathway was achieved by syringing at 6 months  
postoperatively.  
Results: There were 82 patients, with 59 (72%) females. Mean ages were 32 ± 10.3 years. Left eye was seen in  
44 (53.7%) patients. Surgery was successful in 61 (74.3%) patients. Intraoperative bleeding occurred 8 (9.8%)  
and lacrimal crest was difficult to locate in 6 (7.3%) cases. Postoperatively wound infection and ecchymosis was  
seen in 8 (9.8%) patients, cheese wiring in 5 (6.1%) and fistula was seen in 2 (2.4%) patients. Cross tabulation  
was done between gender and successful dacryocystorhinostomy which was statistically not significant (p value  
0.71).  
Conclusion: Dacryocystorhinostomy with intubation has good surgical outcome in long standing chronic  
dacryocystitis with fibrosed sacs. It has few Intraoperative and postoperative complications but they are  
manageable.  
Key Words: Dacryocystorhinostomy, Canalicular Intubation, Dacryocystitis, Chronic dacryocystitis, Lacrimal Sac,  
Nasolacrimal duct blockage.  
How to Cite this Article: Shahid S, Jafri AR, Fasih U, Shaikh A. External Dacryocystorhinostomy with Intubation  
in Shrunken Fibrotic SAC in Chronic Dacryocystitis. Pak J Ophthalmol. 2020, 36 (2): 157-162.  
Doi: 10.36351/pjo.v36i2.1027  
INTRODUCTION  
One of the significant causes of ocular morbidity in  
Correspondence to: Erum Shahid  
Assistant Professor  
Department of Ophthalmology  
Abbasi Shaheed Hospital, Karachi  
Email: drerum007@yahoo.com  
children and adults is dacryocystitis1. An acute  
inflammation of the lacrimal sac with tenderness and  
erythema of overlying tissues is termed as acute  
dacryocystitis2. However, chronic dacryocystitis is  
157  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 157-162  
External Dacryocystorhinostomy with Intubation in Shrunken Fibrotic SAC in Chronic Dacryocystitis  
more common than acute condition. Initially it may  
MATERIAL AND METHODS  
present with only epiphora but later there can be  
mucoid discharge, conjunctival hyperemia and chronic  
conjunctivitis2. Lacrimal abscess has also been  
reported in 23% of eyes2,3.  
This study was conducted in the department of  
Ophthalmology, Abbasi Shaheed Hospital, Karachi, a  
tertiary care hospital, Karachi from January 2015 to  
December 2017. It was a Quasi experimental study  
with non-probability convenient sampling technique.  
The study was conducted in adherence to tenets of the  
Declaration of Helsinki. Written inform consent was  
taken from all the patients informing about the details  
of the procedure along with its complications.  
Dacryocystectomy was first described by Wool  
house in 1724 as treatment of choice for recurrent  
dacryocystitis secondary to nasolacrimal duct  
obstruction4. In recent years dacryocystectomy i.e.  
complete excision of lacrimal sac is limited to lacrimal  
sac tumors. Less commonly, if recurrent dacryocystitis  
is due to inflammatory causes such as Wegener’s  
granulomatosis, risk of subsequent nasal cutaneous  
fistula formation following DCR surgery5 or recurrent  
dacryocystitis without epiphora as well as in cases of  
dry eyes6.  
We included patients between 18 to 60 years of  
age with chronic dacryocystitis of 2 year or more in  
duration, repeated acute attacks twice or more in past 1  
year and presence of shrunken fibrosed sacs on  
dissection at the surgical table. Patients who had  
canaliculitis, canalicular blocks, punctal agenesis,  
mucoceles and enlarge sacs peroperatively were  
excluded. Detailed history of patients was recorded  
including demographics and duration of symptoms.  
Lacrimal passages were checked by probing and  
syringing in every patient. Nasal examination was  
carried out with the help of an ENT surgeon to exclude  
nasal pathologies. Significant nasal pathologies like  
polyps and severe deviated nasal septum were treated  
first by an ENT surgeon and then considered for an  
eye surgery. All the surgeries were carried out under  
general anaesthesia by a single surgeon.  
Currently Dacryocystorhinostomy (DCR) is the  
treatment of choice for patients with acquired  
nasolacrimal duct obstruction (NLDO)7. Various  
techniques have been employed like anterior and  
posterior lacrimal flap suturing with nasal flaps, with  
or without rubber catheter or silicone tube. Intubation  
with silicone tube was first introduced by Gibbs in  
1967, which is now widely practiced in lacrimal  
surgeries8. The cause of primary failure in patients  
with DCR is frequently due to closure of the  
rhinostomy site9. This closure is most commonly due  
to scarring, adhesion and granulation tissue  
formation10.  
Skin was cleaned with 10% povidone. Nasal  
packing was done with gauze piece soaked in  
xylocaine with 2% adrenaline. Upper and lower puncta  
were dilated with nettleship punctum dilator and  
probes were passed to check the patency. Vertically  
curved skin incision was given 8 to 10 mm away from  
the medial canthus and 12 to 15 mm long with surgical  
blade no 15. Hemostasis was achieved with suctioning  
and cotton swabs soaked in xylocaine with 2%  
adrenaline. Blunt dissection was done to separate skin  
and fascia, to expose medial palpebral ligament. This  
ligament was excised with blade. Underlying sac was  
identified and separated from periosteum. Fibrosed  
sacs were identified and defined as shrunken and  
contracted on surgical microscope. It was not possible  
to incise them and make a flap. They were completely  
excised. Periosteum was elevated to expose lacrimal  
fossa with periosteal elevator. Lacrimal osteotomy was  
created with Kerrison’s Rongeurs bone punch, about  
15 mm to 20 mm in diameter. Nasal pack was  
removed and curved artery forceps was introduced to  
check the opening of fistula. Nasal mucosa was cut  
open with blade. Silicone tube was then passed from  
Most of the patients reporting to a government  
sector hospital belong to a poor socioeconomic  
background. They present to us late and are unwilling  
for surgical treatment as first option. In fact, surgery is  
the last option for them either due to financial  
problems or illiteracy. In such patients, lacrimal sacs  
are fibrosed and shrunken such that the sac has to be  
sacrificed by removing it. If these sacs are to be left in  
place they are source of recurrent infections and failed  
procedure due to insufficient marsupialization11. Lee  
et al has reported small sacs to have a high risk of  
failure12. Endolaser equipment for DCR is expensive,  
needs more expertise and is not available in our setup.  
Objective of this study was to assess anatomic  
success rate of external DCR with intubation of  
fibrosed and shrunken sacs in chronic dacryocystitis.  
Further we studied the frequency of intraoperative and  
postoperative complications of external DCR in such  
cases.  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (2): 157-162  
158  
Erum Shahid, et al  
upper and lower puncta tied near lacrimal fossa. Now  
the tube was passed through the created fistula and  
retrieved in nasal cavity with an artery forcep. Another  
knot was tied in the tube and secured with silk 4/0.  
Dissected area was irrigated with an antibiotic solution  
(gentamycin 80 mg/2 ml). The wound was closed in  
two layers. Inner layer of medial palpebral ligament  
and subcutaneous tissue was closed with an interrupted  
Vicryl 6/0 and skin layer with an interrupted Proline  
4/0. Nasal cavity was packed with gauze piece rubbed  
in Polyfax ointment. Antibiotic ointment was applied  
to the wound and it was bandaged for 24 hours for  
hemostasis. Patients were discharged on the same day.  
Nasal pack and bandage was removed next day.  
Variables  
Frequency (%)  
Right eye  
Left eye  
Nasal Pathologies  
Mean duration of symptoms  
Successful procedure  
38 (46.3%)  
44 (53.7%)  
3 (3.7%)  
3.5 years ± 2.0 SD  
61 (74.3%)  
Intra-operative bleeding was seen in 8 (9.8%) and  
lacrimal crest was difficult to locate in 6 (7.3%)  
patients. Post-operatively wound infection and  
ecchymosis was seen in 8 (9.8%) patients. Fistula was  
least common and seen in 2 (2.4%) patients. Main  
outcome was successful surgery, which was seen in 61  
(74.3%)  
patients.  
Other  
intraoperative  
and  
postoperative  
summarized in table 2.  
complications  
of surgery are  
Patients were given oral antibiotic ciprofloxacin  
500 mg BD, an anti-inflammatory agent (Danzen DS)  
and an analgesic (Diclofenic sodium) and  
antihistamine for 5 days. Topical steroid and antibiotic  
eye drops (Moxifloxacin & dexamethasone) were  
given QID for 2 weeks with steroid and antibiotic  
ointment (tobramycin dexamethasone) at bed time.  
Skin sutures were removed on 10th postoperative day  
and silicone tube was removed at 6 months. Surgery  
was labeled successful if patient was symptom-free  
and patency was achieved on syringing at 6 months.  
Table 2: Intraoperative and postoperative complications of  
CDCR.  
Variables  
Frequency  
%
Intraoperative complications  
Angular vein cut  
Nasal mucosal bleed  
Difficult lacrimal crest  
4
4
6
4.9  
4.9  
7.3  
Postoperative complications  
Infection  
8
8
5
4
3
2
48  
9.8  
9.8  
6.1  
4.9  
3.7  
2.4  
58.7  
Intra-operative complications like an angular vein  
tear, nasal mucosal bleeding, and difficulty in passing  
tube or identifying lacrimal crest were recorded.  
Postoperative complications like infection, bleeding,  
ecchymosis, cheese wiring of puncta, lacrimal fistula  
and wound related complications were noted and  
entered in SPSS version 22. Frequencies and  
percentages were calculated for categorical data.  
Means with standard deviation, minimum and  
maximum were calculated for numerical data.  
Ecchymosis  
Cheese wiring  
Tube displacement  
Wound contracture  
Fistula  
Total  
Cross tabulation was done between gender and  
successful dacryocystorhinostomy which was  
statistically not significant (p value 0.71) given in table  
3.  
RESULTS  
Table 3: Cross tabulation showing association of success  
There were 82 patients in this study, males were 23  
(28%) and females were 59 (72%) with ratio of 1:3.  
Their mean ages were 32 ± 10.3 SD years. Left eye  
was involved in 44 (53.7%) patients. Other  
demographic features are given in table 1.  
of procedure with gender.  
DCR  
Gender  
Total  
Successful  
18 (21.9%)  
43 (52.4%)  
61(74.3%)  
Failed  
Male  
Female  
Total  
5 (6.1%)  
16 (19.5%)  
21 (25.6%)  
23 (28%)  
59 (72%)  
82 (100%)  
P value: 0.71  
Table 1: Demographic features of patients in this study.  
Variables  
Frequency (%)  
Mean age in years  
Minimum age  
Maximum age  
Females  
32 ± 10.3 SD  
18  
60  
59 (72%)  
DISCUSSION  
External dacryocystorhinostomy with silicone tube  
intubation gives 80 to 90% results depending upon  
159  
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External Dacryocystorhinostomy with Intubation in Shrunken Fibrotic SAC in Chronic Dacryocystitis  
surgical techniques, surgeon’s skills, correlated  
occurs in middle-aged or older people18. Female  
patients in our study were 59 (72%) with male to  
female ratio of 1:3. Most of other studies have similar  
male to female ratio with female preponderance6-8.  
Females are more frequently affected by this disease  
due to narrow lacrimal canals, hormonal factors, using  
colliriums (kajal/surma) and working in the dusty  
environment19. In our country women work in hot  
humid kitchen for long hours, they wear makeup and  
use of talcum powder could be another possible  
contributory factor. However, success rate of  
dacryocystorhinostomy does not depend on gender  
specified by insignificant p value (0.71).  
systemic or nasal disease and patient’s response to  
surgery13. Anatomic success rates vary from 90% to  
100% reported by various studies14. Whereas success  
rate in our study was 74.3% (61 out of 82 patients),  
checked by syringing the lacrimal passages at 6th  
month post operatively. Success rate of our patients  
was relatively less as compared to other studies13,14  
.
Repeated infections make theses sacs fibrosed. It is  
documented that chronic inflammation and fibrosis are  
most common histopathological changes of lacrimal  
sac in patients suffering from nasolacrimal duct  
obstruction15. It is very difficult to make complete  
marsupialization of fibrosed flaps so the sac has to be  
removed. We have specifically selected fibrosed and  
shrunken sacs with chronic dacryocystitis of minimum  
2-year duration. The above mentioned studies did not  
discuss mean duration of symptoms. Patients in  
developed countries present early and they have easy  
access to health care facilities. We can infer that  
longer the duration of symptoms, more are the  
episodes of acute infection more the sac will be  
fibrosed. More delayed the surgery more is the chance  
of failure. Early surgery will certainly improve  
outcome.  
Intraoperative bleeding including angular vein cut  
and nasal mucosal bleeding were seen in 8 (9.8%) of  
patients in our study. It depends on surgeon’s skill and  
experience. Other studies have reported 0 and 45%  
intraoperative bleeding and almost negligible bleeding  
post operatively (1.9%)13,14. It can be avoided by  
careful and blunt dissection. Accidental angular vein  
cut in our patients was ligated with Vicryl 6/0. Nasal  
mucosal bleeding was controlled with nasal packing  
for 24 hours and fortunately there was no bleeding in  
any patient on removing nasal pack on first  
postoperative day. It was difficult to find lacrimal crest  
for making ostium in 6 (7.3%) patients as it was deep  
seated. These patients had wide depressed nasal bridge  
and probably brachycephalic skull. This complication  
should be anticipated when selecting patients as flat  
nose and narrow face are at higher risk of developing  
dacryocystitis. Brachycephalic heads have high  
incidence of developing dacryocystitis because of  
narrow lacrimal fossa, longer nasolacrimal duct and  
small diameter of inlet of nasolacrimal duct20.  
Failed cases in our study were 21 (25.7%).  
Syringing was done at 6th months post operatively and  
early if, and when required. Absence of fluid in nasal  
cavity was labeled as failed DCR. An ENT surgeon  
examined nasal cavity of these patients. The cause of  
failure in our patients was closed osteotomy site due to  
scarring.  
Inadequate  
or  
inappropriate  
sac  
marsupialization is reported to be 60.2% in etiological  
analysis of 100 failed DCR during re-operation.11We  
removed whole sac in long standing dacryocystitis to  
avoid failure and patient’s agony of reoperations.  
Smaller fibrosed sacs are documented to have high  
failure risk12. Diverse aspects of causes of failed DCR  
have been reported in literature ranging from  
cicatricial ostium closure, scarring of common  
canaliculus, distal canalicular obstruction, granuloma  
formation and bone neogenesis16. Incorrect  
localization of sac, inappropriate osteotomy size and  
location, insufficient sac opening, significant deviated  
nasal septum and concha bullosa are few reported  
intraoperative surgical causes that lead to subsequent  
failures16. However, success rate of DCR can be  
increased by the use of intraoperative anti-fibrotic  
agent, Mitomycin C17.  
Two (2.4%) patients came with recurrent  
infections at wound site and they had developed  
fistula. Other studies have reported wound infection to  
be 1.9% after external DCR13,14. The wound of our  
patients was reopened and remnants of the sac were  
removed in these cases. A study conducted in UK,  
reported cellulitis rate of 8 to 18% when systemic  
antibiotic prophylaxis was not given13. This rate of  
infection can be reduced five times with routine  
administration of antibiotics21. In our set up routine  
postoperative broad spectrum antibiotics were given.  
Silicone tube intubation in lacrimal drainage  
system during DCR prevents obstruction of these  
passages by keeping pathway open throughout the  
healing process22. It prevents formation of granulation  
tissue at the osteotomy and anastomosis site and also  
Acquired nasolacrimal duct obstruction usually  
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Erum Shahid, et al  
prevents common canalicular obstruction23. Silicone  
tubes are also being used for small fibrotic sacs, distal  
and common canalicular obstruction24. Cheese wiring  
was seen in 5 (6.1%) patients. Silicone tubing is  
reported to cause cheese wiring of canaliculus8. It was  
observed within a week after surgery which had to be  
manipulated, to break free the tube with adhesions and  
with copious use of lubricating ointment. It was  
witnessed in those patients where it was difficult to  
pass tube due to anatomical variations. Cheese wiring  
can be avoided by gentle dilatation of punctum, gently  
passing the silicone tube through the punctum and  
early recognition for early manipulation.  
Authors’ Designation and Contribution  
Erum Shahid; Assistant Professor: Concept, data  
collection, manuscript writing, statistical analysis,  
critical review.  
Asad Raza Jafri; Associate Professor: Concept, data  
collection, critical review.  
Uzma Fasih; Associate Professor: Concept, literature  
search, critical review.  
Arshad Shaikh; Professor: Concept, critical review.  
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Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
Conflict of Interest  
Authors declared no conflict of interest.  
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