Difficulties included adequate visualization, bleeding, accurate bone, and soft tissue removal. Ohm, in 1962, essentially described a procedure very similar to the one described by Dupuy-Dutemps and Bourget and sutured the nasal mucosa to the lacrimal sac.Įndonasal DCR was first introduced by Caldwell in 1893, who used an endonasal electric burr to removed the bone once a metal probe had been passed through the canaliculus and into the lacrimal sac. Various improvements in the original procedure were made: The success was hampered by many factors, including the degree of bone and mucosal removal, secondary granulation formation, adhesions, and adequacy of external pressure. The aim was to create pressure so that the lateral lacrimal sac became the lateral nasal wall with the direct opening of the canaliculi into the nose. Pressure was applied externally to push the lateral wall of the lacrimal sac inward, towards the nasal opening. He then excised the medial wall of the lacrimal sac and removed the adjoining lacrimal and maxillary bone, together with the mucosa: he achieved this with a hammer and chisel. Toti's procedure exposed the lacrimal sac via an external incision. The currently accepted technique of external-approach dacryocystorhinostomy (DCR) was first described at the beginning of the 20th century by the Florentine professor of otolaryngology, Addeo Toti in 1904 in the Italian literature, and later modified by Dupuy-Dutemps and Bourguet. The aim of performing a dacryocystorhinostomy is to create a fistula between the nasolacrimal sac and the nose, thus bypassing any obstruction and allowing passage of tears directly into the nose. Indeed, this principle of fistulization remains the same to date as that of contemporary conjunctivodacryocystorhinostomy. Considering how little was known of the lining of the lacrimal passages and nose and just as little of the three-dimensional anatomy of the lacrimal system, this was a remarkable procedure. This, then, could be described as the first description of creating an opening from the conjunctival fornix into the nose with secondary granulation and epithelialization, thereby forming a functioning fistula. The 12th-Century Andalusian oculist Muhamad Ibn Aslam Al Ghafiqi described the principles of lacrimal surgery in his book "The Right Guide to Ophthalmology." He reported using a small spear-shaped instrument perforating the lacrimal bone in a nasal direction " until blood flows through the nose and mouth with care given not to direct the instrument downward as this would be the incorrect direction." The probe was then wrapped in cotton that was either " dry or soaked in ox fat." This would then be exchanged every day to maintain the patency of the created fistula. Lacrimal surgery to restore tear drainage is usually the definitive treatment and involved one of the types of dacryocystorhinostomy. In longstanding NLDO, mucus can accumulate, resulting in a mucocele in the nasolacrimal sac or even acute or chronic dacryocystitis. This activity will address nasolacrimal duct obstruction (NLDO), which often results in intractable, bothersome epiphora.