We would like to congratulate the authors about their study. However, we have some concerns and comments about the study.
1. Considering the data of the study, the success rate of transcanalicular laser-assisted dacryocystorhinostomy TCLA-DCR) surgery in this issue is fairly low. Recent studies have shown that the success rates of classical DCR surgery and endonasal surgery were 90–95% and 70–80%, respectively. On the other hand, the success rate of early (3 months) and late results of TCLA-DCR were published as 64–90% and 87.5–90%, respectively. Although these data show the superiority of the success rate of classical DCR surgery, some studies, on the contrary, reported more successful results with endonasal DCR surgery. Hartikainen et al., found the results of endonasal DCR surgery more successful than the ones with classical DCR. In a study with large case series with 244 patients, Linberg et al., found the success rates of external DCR and endonasal DCR as 92.6% and 93.4%, respectively, with 18 months follow-up. This result was explained by lachrymal pump dysfunction, with the injury of medial chantal anatomy in external DCR. Plaza et al., reported their TCLA-DCR surgery success rate as 88% with 36 months follow-up. Narioka and Ohashi reported the success rate as 80% with TCLA-DCR of the patients who had undergone failed external DCR surgery.
2. The success rate of the results of laser-assisted DCR surgery in this article was reported with a considerably low rate (44%). This is the lowest success rate reported in the literature. This result might be due to improper patient selection or inadequate surgical procedure. In this article, previous data about the TCLA-DCR surgery was not mentioned. Three patients reported with fistulous tract over the sac area (9%) before external DCR surgery in the article. Knowing the fact that these fistulas also existed before TCLA-DCR surgery, it can be considered that patient selection of the study should be overviewed.
The most important factor that affects the success of TCLA-DCR surgery is the size and location of osteotomy. However, according to some authors, wound healing and tissue response affects the survival of the fistula without dependence of osteotomy size. Granulation tissue due to laser and silicone tube in the early period and formation of fibrosis in the late period causes the obstruction. In addition, presurgical anatomic defect or postsurgical trauma and infection may cause secondary obstruction. Therefore, using mitomycine or silicone stent for fistula maintenance has been used as an adjunctive for this surgery. Also, for high success rates of TCLA-DCR surgery, resection of granulation tissue and opening synechias is efficacious.
3. Is it preferable to perform classical DCR surgery after a failed TCLA-DCR surgery? With the aid of a flexible microendoscope, direct visualization of pathologic changes in the lachrymal passages makes it possible to detect the localization and identify the reason of obstruction instantly and facilitate the management of these pathologic changes. This secondary attempt after TCLA-DCR surgery is more easy and comfortable than external DCR surgery.
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2. Mullner K, Wolf G, Luxenberger W. Laser-assisted transcanalicular dacryocystorhinostomy.Initial results Ophthalmologe. 2001;98:174–7
3. Hartikainen J, Grenman R, Puukka P, Seppä H. Prospective randomized comparison of external dacryocystorhinostomy and endonasal laser dacryocystorhinostomy Ophthalmology. 1998;105:1106–13
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5. Narioka J, Ohashi Y. Transcanalicular-endonasal semiconductor diode laser assisted revision surgery for failed external dacryocystorhinostomy Am J Ophthalmol. 2008;146:60–8