**9. Complications**

Complications of endonasal DCR surgery can be divided into intraoperative and early or late postoperative. Early postoperative (up to one month) complications include hemorrhage, crusting, perirhinostomy granuloma, and transnasal synechiae; 1 - 6 months side effects of surgery include surgical failure from impacted tubes, rhinostomy scarring, granuloma, and synechiae. Most of these later complications occur between one and three months after surgery13.

Endoscopic Dacryocystorhinostomy 59

moderate. 18% of patients had moderate pain in the first three days and 6%of them had that

Mitomycin C is a chemotherapeutic antibiotic isolated from the broth of *streptomyces caespitosus*. Mitomycin C is an alkylating agent that is widely used systemically for the treatment of malignancies, and has also gained popularity as a topical adjunctive in the treatment of ocular surface neoplasia. The ability of this drug to modify the normal wound healing pathway by inhibiting fibroblast and endothelial cell growth and replication has made it an attractive adjunct in glaucoma and pterygium surgery, as well as in DCR surgery14.

The primary cause of failure in DCR surgery is closure of the surgical osteotomy due to fibrosis, scarring, and granulation tissue. The intraoperative application of the antimetabolite mitomycin C to the surgical anastamosis can theoretically inhibit such closure, and has been previously shown to increase the ostium size. Mitomycin C application varies

Liao et al. by a randomized trial of 88 eyes undergoing external DCR, showed a significant increase in the number of symptom-free cases from 70.5% to 95.5% with the use of mitomycin C at 10-months follow-up and You and Fang showed increases in both ostium patency and size with the use of mitomycin C during external DCR at a mean follow-up of 3 years. Based on our study, it appeared that patients with nasolacrimal obstruction who underwent endoscopic DCR did not benefit from adjunctive topical application of mitomycin C. However, we suggest further multi-central trials for comparing results in

in different published articles according to duration, manner and procedures14.

much pain in days 4 to 7 13.

different hospital settings14.

Fig. 5.

**13. Setup of endoscopic DCR** 

**12. Mytomycin C and DCR** 

In endonasal surgery, complications are greater with inexperienced surgeons. The complications of endoscopic DCR are similar to those for endoscopic sinus surgery. Excessive bleeding during surgery precludes visualization and accounts for major intraoperative complications such as blindness and cerebrospinal fluid leakage. If excessive bleeding is encountered in endoscopic surgery, the procedure must either be terminated or converted to an open DCR. Severe postoperative epistaxis occurs in less than 5% of cases. Bleeding usually occurs within one week of surgery and is caused by a branch of the sphenopalatine artery supplying the remnant of a partially resected middle turbinate.

Sometimes, during bone removal to uncover the lacrimal sac, orbital fat is exposed. This fat should not be disturbed, otherwise orbital contents such as blood vessels, nerves, and the medial rectus muscle would be injured.

Nasal or orbital infection following DCR is rare. Nevertheless, perioperative antibiotics are administered to avoid this complication.

One of the most common causes of surgical failure for both endoscopic and external DCR is postoperative adhesions. These adhesions usually cause obstruction of the surgically created ostium. In order to decrease this complication, surgical trauma to the turbinate mucosa should be avoided and the anterior end of the turbinate should be resected so that it is not near the ostium. Correction of the deviated septum also reduces the likelihood of postoperative adhesion formation.
