Post-traumatic canalicular fistula following dacryocystorhinostomy surgery

Dear Editor, External dacryocystorhinostomy (Ex-DCR) is one of the most commonly performed surgical procedures in an Oculoplastic setting. While there are several complications of Ex-DCR described in the literature, iatrogenic damage to the punctum–canalicular complex is uncommon and therapeutically challenging. Post-traumatic canalicular fistula (PTCF), a term introduced by Bothra and Ali in 2022, has been reported to occur iatrogenically following canalicular repair or facial cleft surgeries.[1,2] The authors, herein, describe the occurrence of PTCF following Ex-DCR with intubation, which, to the best of our knowledge, has not been described yet [Fig. 1].Figure 1: (A) Case 1, showing lower post-traumatic canalicular fistula (CF) with adjacent normal lower punctum (P), highlighted on fluorescein staining (inset). (B) Case 2, showing a giant, lower CF as a complication of rigorous intubation and consequent punctal cheese-wiring. (C) Case 3 showing silicone tube (T) secured over upper and lower canalicular fistula (CF) with distinct punctal openings (P). (D) Case 4 reveals a lower, blind-ended CF, following Ex-DCR with intubation. The adjacent lower punctum (P) is of normal morphologyAll the cases presented with recurrent epiphora following Ex-DCR, with intubation performed elsewhere. Slit lamp evaluation of a 65-year-old gentleman (Case 1) who presented with recurrent watering in the right eye showed a lower blind-ended canalicular fistula, highlighted on 2% fluorescein staining, with concomitant upper proximal (2 mm) canalicular block [Panel A]. A 10- year-old child (Case 2) diagnosed as right congenital nasolacrimal duct obstruction (CNLDO) underwent DCR with intubation 5 years ago. At presentation, examination revealed regurgitation of fluid on pressure over lacrimal sac (ROPLAS) positivity from a giant lower canalicular fistula with concurrent upper punctal agenesis [Panel B]. Another 74-year-old gentleman (Case 3) presented with persistent epiphora, following Ex-DCR with intubation 25 years ago, and had a silicone intubation tube secured over the upper as well as lower PTCF [Panel C]. The puncta were of normal morphology, and irrigation through the lower canalicular fistula revealed regurgitation of fluid from the opposite fistula with a hard stop. Lacrimal irrigation through the lower canalicular fistula in a 44-year-old gentleman (Case 4), presenting with residual epiphora following DCR with intubation elsewhere, revealed blind-ended lower PTCF [Panel D]. Probing through the lower and upper punctum revealed a soft stop at 2 mm, suggestive of a concomitant proximal bicanalicular block. Two patients were given the option of conjunctivodacryocystorhinostomy (CDCR) or lacrimal targeted therapies (Cases 1 and 4), mainly lacrimal gland botulinum toxin injections, while Cases 2 and 3 were advised revision DCR surgery. The authors believe that rigorous maneuvers involving the punctum and canaliculus, while performing intubation, may have led to the occurrence of PTCF in the post-operative period. Residual epiphora in patients with iatrogenic punctum–canalicular complex damage is a therapeutic conundrum with limited success rates. Through this letter, we underscore the importance of performing meticulous punctal dilatation, probing, and stent intubation to avoid catastrophic damage to the proximal lacrimal drainage system, and advocate for the utilization of Ophthalmic Surgical Competency Assessment Rubric (OSCAR)–Ex-DCR tool by trainees and practicing ophthalmologists, alike, for standardization and self-assessment of surgical skills.[3] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.