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 Table of Contents    
Year : 2011  |  Volume : 4  |  Issue : 1  |  Page : 40-41  

Combined posterior flap and anterior suspended flap external dacryocystorhinostomy

1 Department of Ophthalmology, University College of Medical Sciences and G. T. B. Hospital, Delhi - 110 095, India
2 Department of Ophthalmology, Lady Hardinge Medical College, New Delhi - 110 001, India

Date of Web Publication14-Mar-2011

Correspondence Address:
Ved Prakash Gupta
275, Ground Floor, Gagan Vihar, Delhi - 110051
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-620X.77666

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How to cite this article:
Gupta VP, Gupta P, Gupta R. Combined posterior flap and anterior suspended flap external dacryocystorhinostomy. Oman J Ophthalmol 2011;4:40-1

How to cite this URL:
Gupta VP, Gupta P, Gupta R. Combined posterior flap and anterior suspended flap external dacryocystorhinostomy. Oman J Ophthalmol [serial online] 2011 [cited 2023 Mar 31];4:40-1. Available from: https://www.ojoonline.org/text.asp?2011/4/1/40/77666


We read the article by Deka et al. [1] with keen interest. We wish to express following comments:

External dacryocystorhinostomy (DCR) is the gold standard to relieve epiphora due to chronic dacryocystitis or nasolacrimal duct obstruction. The procedure has been modified to improve the surgical outcome. We appreciate the authors for this study. The authors have described the technique of suspending the anterior flaps. However, while describing the operative steps in the article, they have failed to name Baldeschi et al.,[2] who described the technique for the first time. The authors mention that their technique has the advantage of both double flap dacryocystorhinostomy (DCR) and the anterior suspension of anterior flaps. The authors' conclusion appears to be flawed because of the lack of control group in the study. A high success rate of 98.9% might be attributed to either suturing both the anterior and posterior flaps or to the anterior suspended flap or to both. Ideally there should have been three groups, that is, (1) both anterior and posterior flaps, (2) combined posterior flaps and anterior suspended flap, and (3) Excised posterior flaps and suspended anterior flaps. Despite the controversy regarding the use of a single anterior or posterior flap, or combined anterior or posterior flaps, the success rate of external DCR has been reported to be as high as 93 - 100%. [1],[2],[3],[4],[5] Anastomosis by suturing only anterior flaps and excision of the posterior flaps is easier to perform and does not appear to adversely affect the outcome of DCR surgery. [3] A randomized study suggested that DCR with double-flap anastomosis had no advantage over DCR with only anterior flaps, having success rates of 93.75 and 96.67%, respectively. [3] Elwan has also suggested that excision of the posterior sac mucosa may improve the success rate. [4] Baldeschi et al. anastomosed large and mobile anterior flaps of the lacrimal sac and nasal mucosa and passed sutures through the orbicularis oculi to elevate the flaps forward and did not suture the posterior flaps, with a success rate of 100%. [2] Zaman et al. also sutured only the anterior flaps and engaged them in the muscle layer with a success rate of 98.33%. [5] The figure-of-eight vertical mattress suture technique is a recent technique to keep the anterior flap away from the posterior flaps to prevent mucosal adhesion with a success rate of 99.1%.

We have observed equally high success rates (96-100%) in double-flap anastomosis as well as in only anterior flaps suturing techniques during our 30 years of experience with DCR. Currently we prefer to suture only the anterior nasal mucosal and anterior lacrimal sac flaps, after resecting the posterior lacrimal flap. We anchor the anterior flaps to the orbicularis muscle only if the flaps appear very large, as in cases of mucocele. Trimming of the flaps is yet another option. It is believed that anterior flaps help prevent growth of scar tissue into the ostium and the posterior region in the nose remains wide open, and it is better than the poorly created or sutured posterior flaps. Moreover, endoscopic studies have shown that suturing the posterior lacrimal and nasal flaps does not affect the ultimate ostium size.

   References Top

1.Deka A, Saikia SP, Bhuyan SK. Combined posterior flap and anterior suspended flap dacryocystorhinostomy: A modification of external dacryocystorhinostomy. Oman J Ophthalmol 2010;3:18-20.  Back to cited text no. 1
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2.Baldeschi L, Nardi M, Hintschich CR, Koornneef L. Anterior suspended flaps: A modified approach for external dacryocystorhinostomy. Br J Ophthalmol 1998;82:790-2.   Back to cited text no. 2
3.Serin D, Alagöz G, Karsloðlu S, Celebi S, Kükner S. External dacryocystorhinostomy: Double-flap anastomosis or excision of the posterior flaps? Ophthal Plast Reconstr Surg 2007;23:28-31.  Back to cited text no. 3
4.Elwan S. A randomized study comparing DCR with and without excision of the posterior mucosal flap. Orbit 2003;22:7-13.  Back to cited text no. 4
5.Zaman M, Babar TF, Saeed N. A review of 120 cases of dacryocystorhinostomies (Dupuy Dutemps and Bourget Technique). J Ayub Med Coll Abbottabad 2003;15:10-2.  Back to cited text no. 5


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