Reply re

Abstract

We appreciate the interest shown by Drs Kashkouli and Shahrzad in a surgical technique we recently described 1 and the opportunity to redress certain important issues in greater detail.While we can agree with the possible confounding effect of silicone intubation (SI) in our cases, the efficacy of balloon dilatation (BD) in a stenotic dacryocystorhinostomy ostium cannot entirely be discredited. Our experience with BD in stenotic surgical ostia (SSO) has been encouraging. 2,3 BD in the management of SSO was added after experiencing that simple SI was not very helpful in preventing a restenosis ( Fig.). Numerous studies that were quoted by Dr Kashkouli were all related to nasolacrimal duct stenosis and cannot strictly be extrapolated to SSO's postendoscopic dacryocystorhinostomy. If we go by similar arguments, then our data in adults with partial primary acquired nasolacrimal duct obstructions (PANDOs) suggest otherwise. 4 We showed a success of 71% at 6 months' follow up and failure was noted, despite the dilatation effect of SI for 3 months! The argument that SI also works with a similar mechanism may not be entirely true because the nasolacrimal duct diameters in adults with partial PANDO are way smaller than that of a stenotic ostium. In addition, BD helps in clearing the area in front of the internal common opening, 1 whereas a silicone tube can only at the most dilate the canaliculus (which is anyways not obstructed in internal ostium stenosis) and not the constricting fibrous tissues in the vicinity. 1 We believe that it would be inappropriate to simply place a tube, in the hope that it would slowly cause dilatation of the ostium and the mucosa will grow around it before a fibrous scar can form. We also do not agree that BD is a complex procedure. BD is a far simpler and minimally invasive procedure as against revising a cicatrized ostium. To answer all these questions with more conviction, a multicentric randomized controlled trial with BD + SI in one arm and SI alone in other is desirable. Lee et al. 1 have recently published their results on the effectiveness of balloon dacryoplasty (BD) in the opening of stenotic internal ostium after endoscopic dacryocystorhinostomy (EnDCR), which was interesting. They performed BD and bicanalicular silicone intubation (SI) to open the stenotic ostium and concluded that BD is a minimally invasive, simple, and safe procedure in the treatment of post-EnDCR internal ostium stenosis. 1 Gunton et al. 2 reported no statistically significant difference between the success rate of BD and probing for the treatment of congenital nasolacrimal duct obstruction (NLDO) in children older than 18 months. Likewise, Couch and White 3 performed BD and SI in adults with incomplete NLDO and raised a question whether BD was any more effective than SI alone. Furthermore, BD plus SI was compared with SI alone in adults with incomplete NLDO and showed a statistically insignificant difference in the success rate. 4 Inflation of the balloon results in a dilation in the stenotic mucosa. SI ...