Two hundred and eight cases of failed dacryocystorhinostomy presenting to the Lacrimal Clinic at Moorfields Eye Hospital between 1970 and 1985 were reviewed. All cases underwent a further operation. The reasons for failure were usually apparent on reoperation. The surgical technique is described. A second dacryocystorhinostomy is a highly successful technique that spares both patient and surgeon the lifelong commitment to a bypass tube. At the time of operation the appropriate procedure was performed by a technique described more completely below. Possible reasons for failure of the primary operation were noted. After discharge the day after operation patients were seen one week postoperatively, at six weeks, and again at three months. Canalicular tubing, if introduced, was removed three months later. The 152

SummaryThe results after implantation of Lester Jones canalicular bypass tubes in 326 eyes (310 patients) are reviewed. The bypass tubes were implanted after canalicular obstruction from a variety of causes, of which post-herpetic or post-traumatic obstruction accounted for one-half of all cases.With up to 23 years' follow-up, replacement of the bypass tube was needed in 142 (44%) patients, the majority after spontaneous loss. The median interval to first replacement may be estimated as about ten years for spontaneous loss and five years for all causes. Despite complications and the need for further surgery in many patients, most patients (91 %) were pleased with the functional result of surgery.The principles, techniques and complications of lacrimal canalicular bypass sur gery are presented and the long"term care of bypass prostheses is discussed.

Of 258 cases of dacryocystorhinostomy performed on children in the period September 1981 to September 1991, 130 were for simple, unresolved congenital nasolacrimal duct obstruction. Other indications for surgery included punctal agenesis, lacrimal fistula, post-traumatic and post-inflammatory canalicular obstruction. Of 177 children without canalicular pathology, 171 (96%) were relieved of symptoms with one operation, without canalicular intubation. Of 81 cases with canalicular disease, 55 of 70 (79%) who underwent DCR plus canalicular intubation, and 10 of 11 who underwent DCR plus Lester-Jones tube, were substantially improved with one operation. No child required peroperative or postoperative blood transfusion. Dacryocystorhinostomy in childhood, in experienced surgical hands, is a safe procedure, achieving relief of symptoms in most cases, particularly in the absence of canalicular disease.

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