Endoscopic DCR vs External DCR: What's Best in the Acute Setting?

251 Dacryocystorhinostomy (DCR) for the treatment of nasolacrimal duct obstruction (NLDO) has been practiced for over a century. First described by Addeo Toti in 1904,[1] primary external DCR has traditionally been considered the gold standard technique demonstrating success rates that approach 98% in patients with primary acquired NLDO.[2,3] Caldwell first described the endonasal (non‐endoscopic) approach in 1893.[4] However, this approach fell out of favor because of difficult visualization of the endonasal anatomy with the instrumentation at that time. The modern endoscopic transnasal DCR was described by McDonogh and Meiring in 1989.[5] With newer, more advanced instrumentation, endoscopic surgery has become more and more popular, and with increased experience, the success rates have begun to approach those of external DCR.[6‐8] There are many variations in technique in both endonasal and external DCR. These include but are not limited to the use of endoscope, lasers, use of stents, duration of stent placement, use of mitomycin‐C, use of powered tools (high speed drill and ultrasonic handpieces) vs non‐powered tools (rongeurs), formation of sac/nasal mucosal flaps and whether or not they are sutured, glued, or just approximated, and the use of post‐operative antibiotics and steroids (oral and/or topical). There are so many variables that it is difficult, if not impossible, to determine the optimal method of performing the DCR, and there are almost as many variations as there are surgeons. Furthermore, the differences in the etiology of nasolacrimal duct obstruction (NDO), i.e., primary acquired nasolacrimal duct obstruction (PANDO) vs secondary acquired (SANDO) may affect success rates. Despite all these variables and variations, it cannot be denied that the success rates of endoscopic DCR have improved in the last 2 decades.[6‐8] Furthermore, the improvements in techniques and instrumentation have led to increased use of this technique in SANDO, and in cases with known increased risk of failure. These include patients with prior external or endoscopic DCR (revision Endoscopic DCR vs External DCR: What’s Best in the Acute Setting?