The Open Ophthalmology Journal




ISSN: 1874-3641 ― Volume 14, 2020
RESEARCH ARTICLE

Evaluation of the Role of Silicone Intubation in Non-complicated External Dacryocystorhinostomy



Omar M. Massoud1, Molham A. Elbakary1, *, Osama E. Shalaby1, Aiman A. Hashish1
1 Ophthalmology Department, Faculty of Medicine, Tanta University, Tanta, Egypt

Abstract

Aim:

Evaluation of the role of silicone intubation in non-complicated External dacryocystorhinostomy (Ext-DCR).

Background:

Silicone intubation is described as a step of Ext-DCR. It was proposed that it may prevent obstruction involving the osteotomy or the common canaliculus. However, its necessity in non-complicated Ext-DCR is controversial.

Objective:

To study the effect of intubation and its duration on the results of non-complicated Ext-DCR.

Methods:

A prospective randomized interventional study that included 75 Ext-DCRs. Patients with a high risk of failure were not included. Patients were randomly distributed between 3 equal groups with either traditional 3 months intubation (group A), short-term intubation for 2-3 weeks (group B), or non-intubation (group C).

Results:

The success rate was 92%, 96%, and 92% in groups A, B, and C, respectively, with no significant differences (P = 0.853). Temporary foreign body sensation was reported in 16% in group A and 12% in group B. No significant complications were recorded in any of the 3 groups.

Conclusion:

Intubation (either short-term or 3 months) did not affect the results of Ext-DCR, which gives more evidence that it is not necessary in non-complicated cases.

Keywords: Silicone intubation, Dacryocystorhinostomy, Silicone tube, Nasolacrimal duct obstruction, Epiphora, External dacryocystorhinostomy.


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 21
Last Page: 24
Publisher Id: TOOPHTJ-14-21
DOI: 10.2174/1874364102014010021

Article History:

Received Date: 27/12/2019
Revision Received Date: 16/03/2020
Acceptance Date: 01/04/2020
Electronic publication date: 04/06/2020
Collection year: 2020

© 2020 Massoud et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to the author at the Faculty of medicine, Tanta University, postal no. 31527. Tanta, Egypt; E-mail: molhamelbakary@gmail.com





1. INTRODUCTION

External dacryocystorhinostomy (Ext-DCR), since it was first described in 1904, has been well known as the operation of choice for the management of Nasolacrimal Duct Obstruction (NLDO). It helps in tear drainage by communicating the lacrimal sac and nasal mucosa through an ostium in the lacrimal bone [1Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995; 102(7): 1065-70.
[http://dx.doi.org/10.1016/S0161-6420(95)30910-4] [PMID: 9121754]
, 2Warren JF, Seiff SR, Kavanagh MC. Long-term results of external dacryocystorhinostomy. Ophthalmic Surg Lasers Imaging 2005; 36(6): 446-50.
[http://dx.doi.org/10.3928/1542-8877-20051101-03] [PMID: 16355948]
].

The use of a silicone tube for nasolacrimal intubation was first described in 1968. The procedure then has been subjected to modifications and used as a step of Ext-DCR. It was proposed that intubation may prevent obstruction involving the osteotomy or the common canaliculus [3Keith CG. Intubation of the lacrimal passages. Am J Ophthalmol 1968; 65(1): 70-4.
[http://dx.doi.org/10.1016/0002-9394(68)91031-3] [PMID: 5635571]
-5Konuk O, Kurtulmusoglu M, Knatova Z, Unal M. Unsuccessful lacrimal surgery: causative factors and results of surgical management in a tertiary referral center. Ophthalmologica 2010; 224(6): 361-6.
[http://dx.doi.org/10.1159/000313818] [PMID: 20453543]
].

Recently, controversy exists about the necessity of intubation in Ext-DCR surgeries done for acquired NLDO. This study was conducted to evaluate the role of bicanalicular intubation in non-complicated Ext-DCR.

2. PATIENTS AND METHODS

This was a prospective randomized study that included patients presented to the out-patient clinic, Tanta University Eye Hospital, Egypt, over a period of two years with chronic dacryocystitis or primary acquired NLDO. All included patients had chronic epiphora of 6 months or more. The study adhered to the principles of the declaration of Helsinki and was approved by the institutional ethical committee. Patients with a history of previous failed DCR, distal, or common canalicular stenosis, history of medial canthal trauma, NLDO secondary to tumors, or chemotherapy were excluded from the study.

Patients’ evaluation depended on clinical data including full patient history, regurgitation test, Fluorescein Dye Disappearance Test (FDDT), diagnostic probing, and syringing.

The study included 75 patients who were treated by 75 Ext-DCR procedures. They were randomly distributed between 3 groups:

  • − Group A: Included 25 Ext-DCR procedures with conventional 3 months intubation.
  • − Group B: Included 25 Ext-DCR procedures with short-term intubation (2-3weeks).
  • − Group C: Included 25 Ext-DCR procedures without intubation.

Surgeries were performed by the second and third authors (M.E. and O.S.). All patients received combined antibiotic steroid eye drops 4 times daily for 1 week post-operative. They were seen 1 week, 2-3 weeks, 3 months, and 6 months post-operative. They were evaluated for symptomatic relief, FDDT, and lacrimal syringing. Successful surgery was defined as the resolution of epiphora with negative FDDT and patent syringing. Skin sutures were removed after 1 week. The silicone tube was removed after 2-3 weeks in group B and after 3 months in group A.

All patients were subjected to nasal endoscopic examination 1 month, 3 months, and 6 months post-operative to check the patency of the ostium and to detect any nasal tube related complications as synechia or granuloma formation. This was not one of the criteria for evaluation of the success of procedures, which was evaluated on the clinical basis as mentioned earlier.

3. STATISTICAL ANALYSIS

Patients' data were collected and statistically analyzed using the mean value, standard deviation, Chi-square test, and ANOVA test, using SPSS Statistics for Windows. (Version 20.0. Armonk, NY: IBM Corp). A value of p less than 0.05 was considered statistically significant.

4. RESULTS

The study included 42 females (56%) and 33 males (44%). Group A included 14 females (56%) and 11 males (44%), group B included 15 females (60%) and 10 males (40%), while group C included 13 females (52%) and 12 males (48%), with no significant differences between the 3 groups (P=0.736) (Table 1). The mean age in groups A, B, and C were 43.2 ± 11.7 years, 44.3 ± 10.1 years, and 42.1 ± 10.7 years, respectively, with no significant differences between the study groups (P=0.674) (Table 1).

Table 1
Demographic data of the study patients.


At the end of the follow-up period, the final outcome was successful in 23 cases (92%) in group A, 24 cases (96%) in group B, and 23 cases (92%) in group C with no significant difference (P=0.853). Nasal endoscopic examination showed no tube related nasal mucosal complications, such as synechia or granuloma formation, either in short-term or conventional 3 months intubation groups. No other significant tube related complications, such as punctal and canalicular lacerations or tube loss, were recorded in silicone intubation groups. Discomfort and foreign body sensation were reported in 4 patients (16%) in group A and in 3 patients in group B (12%). These were temporary findings noticed during the first 5-7 days post-operative.

5. DISCUSSION

The use of intubation in Ext-DCR and its advantages and disadvantages have been recently a controversial issue. Many studies found the role of intubation is unclear with no evidence favoring its use, especially in cases of routine Ext-DCR done for uncomplicated primary NLDO. They found no benefit of silicone intubation in such cases [6Madge SN, Selva D. Intubation in routine dacryocystorhinostomy: why we do what we do. Clin Exp Ophthalmol 2009; 37(6): 620-3.
[http://dx.doi.org/10.1111/j.1442-9071.2009.02094.x] [PMID: 19702714]
-8Feng YF, Cai JQ, Zhang JY, Han XH. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011; 46(6): 521-7.
[http://dx.doi.org/10.1016/j.jcjo.2011.09.008] [PMID: 22153640]
].

Similar findings were also reported in endonasal dacryocystorhinostomy (EN-DCR). A systemic review and meta-analysis which studied the benefit of silicone stents in primary EN-DCR found the success rate of EN-DCR was 93.4% with silicone tube and 92.2% without silicone tube, with no statistically significant difference in outcomes [9Sarode D, Bari DA, Cain AC, Syed MI, Williams AT. The benefit of silicone stents in primary endonasal dacryocystorhinostomy: A systematic review and meta-analysis. Clin Otolaryngol 2017; 42(2): 307-14.
[http://dx.doi.org/10.1111/coa.12751] [PMID: 27614030]
]. Another systematic review reported a success rate of 92.9% with silicone tube and 91.2% without silicone tube, with no statistically significant heterogeneity among the included studies [10Kang MG, Shim WS, Shin DK, Kim JY, Lee JE, Jung HJ. A systematic review of benefit of silicone intubation in endoscopic dacryocystorhinostomy. Clin Exp Otorhinolaryngol 2018; 11(2): 81-8.
[http://dx.doi.org/10.21053/ceo.2018.00031] [PMID: 29649861]
].

On the other hand, a sequential meta-analysis comparing the rate of success of DCR with and without intubation found that DCR with intubation had a better success rate which was statistically significant [11Xie C, Zhang L, Liu Y, Ma H, Li S. Comparing the success rate of dacryocystorhinostomy with and without silicone intubation: A trial sequential analysis of randomized control trials. Sci Rep 2017; 7(1): 1936.
[http://dx.doi.org/10.1038/s41598-017-02070-y] [PMID: 28512307]
]. A meta-analysis of randomized controlled trials of DCR with and without silicone intubation found a 5% statistically significant improvement in DCR success rate with silicone intubation [12Ing EB, Bedi H, Hussain A, et al. Meta-analysis of randomized controlled trials in dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2018; 53(5): 466-70.
[http://dx.doi.org/10.1016/j.jcjo.2017.12.006] [PMID: 30340712]
].

Other comparative studies found a higher success rate of Ext-DCR with silicone intubation [13Rather S, Singh T. External dacryocystorhinostomy with and without silicon tube intubation in chronic dacryocystitis with nasolacrimal duct block. JK Science 2013; 15: 24-7., 14Afzal MM, Mehmood A, Maqbool R, et al. To compare the success rate of External Dacryocystorhinostomy with and without Silicon Intubation in patients of nasolacrimal duct obstruction. P J M H S 2014; 8: 53-5.]. Rather and Singh mentioned that the better results with intubation can be explained by preventing the obstruction of the common canalicular opening into the lacrimal sac, one of the most important causes of DCR failure. They reported trauma and unnecessary intraoperative probing of the common canaliculus as causes for post-operative common canalicular fibrosis [13Rather S, Singh T. External dacryocystorhinostomy with and without silicon tube intubation in chronic dacryocystitis with nasolacrimal duct block. JK Science 2013; 15: 24-7.]. We believe that avoiding intubation of intact common canaliculus can prevent this unnecessary trauma and its sequelae.

In this study, no difference was found in the success rate between intubation (either short-term or conventional 3 months) and non-intubation groups (P=0.853).

Other authors preserved intubation for DCRs done for complicated cases. Sodhi et al. used intubation as a step of Ext-DCR only in patients with a high risk of failure. Their study included only cases with previous medial canthal trauma, previously failed DCR, or following attacks of acute dacryocystitis. They reported a success rate of 76% [15Sodhi PK, Pandey RM, Malik KP. Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy. J Craniomaxillofac Surg 2003; 31(3): 187-90.
[http://dx.doi.org/10.1016/S1010-5182(03)00020-9] [PMID: 12818607]
]. Hwang et al. studied the results of DCR with canaliculoplasty and double or single silicone intubation. Their study included only cases with distal or common canalicular obstruction. They reported a functional success rate of 88.3% in double intubation and 81.2% in single intubation [16Hwang SW, Khwarg SI, Kim JH, Choung HK, Kim NJ. Bicanalicular double silicone intubation in external dacryocystorhinostomy and canaliculoplasty for distal canalicular obstruction. Acta Ophthalmol 2009; 87(4): 438-42.
[http://dx.doi.org/10.1111/j.1755-3768.2008.01292.x] [PMID: 18700890]
]. In a study done by Choung and Khwarg, intubation was selectively not performed in cases with large lacrimal sac and wide nasal cavity. They reported anatomic patency of rhinostomy in all non-intubation cases and concluded that intubation can be avoided in 50% of Ext-DCR surgeries [17Choung HK, Khwarg SI. Selective non-intubation of a silicone tube in external dacryocystorhinostomy. Acta Ophthalmol Scand 2007; 85(3): 329-32.
[http://dx.doi.org/10.1111/j.1600-0420.2006.00827.x] [PMID: 17488464]
].

In this study, cases with distal or common canalicular problems were excluded. Also, cases with a history of trauma or previous failed DCR were not included.

A few complications have been reported with the use of silicone intubation including punctal and canalicular lacerations, tube loss, foreign body sensation, and conjunctival irritation [15Sodhi PK, Pandey RM, Malik KP. Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy. J Craniomaxillofac Surg 2003; 31(3): 187-90.
[http://dx.doi.org/10.1016/S1010-5182(03)00020-9] [PMID: 12818607]
, 18Allen K, Berlin AJ. Dacryocystorhinostomy failure: Association with nasolacrimal silicone intubation. Ophthalmic Surg 1989; 20(7): 486-9.
[PMID: 2779952]
]. It was also assumed that the silicone tube (as a foreign body) may incite nasal granuloma formation and even predispose to failure of Ext-DCR [18Allen K, Berlin AJ. Dacryocystorhinostomy failure: Association with nasolacrimal silicone intubation. Ophthalmic Surg 1989; 20(7): 486-9.
[PMID: 2779952]
]. Tube prolapse is another rare complication which was reported to occur in 2.5% [19Brookes JL, Olver JM. Endoscopic endonasal management of prolapsed silicone tubes after dacryocystorhinostomy. Ophthalmology 1999; 106(11): 2101-5.
[http://dx.doi.org/10.1016/S0161-6420(99)90490-6] [PMID: 10571344]
].

Another reported disadvantage of intubation is increasing the costs of surgery. Saiju et al. reported that it increased the surgical costs by 20%, while Gul et al. calculated its cost as 25% of the total cost of surgery [7Saiju R, Morse LJ, Weinberg D, Shrestha MK, Ruit S. Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation. Br J Ophthalmol 2009; 93(9): 1220-2.
[http://dx.doi.org/10.1136/bjo.2008.147819] [PMID: 19515642]
, 20Gül A, Duran M, Can E, et al. The effect of silicone tube intubation in external Dacryocystorhinostomy. Acta Med Anatol 2015; 3: 1-4.
[http://dx.doi.org/10.15824/actamedica.31629]
].

In this study, no complications were reported in patients of silicone intubation groups. Nasal endoscopic examination was done to exclude nasal granuloma formation, and it was not found in any case.

The suitable duration to keep the tube is another controversial issue. Some authors recommended its use for 6 months in cases with common canalicular problems or high risk of failure [15Sodhi PK, Pandey RM, Malik KP. Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy. J Craniomaxillofac Surg 2003; 31(3): 187-90.
[http://dx.doi.org/10.1016/S1010-5182(03)00020-9] [PMID: 12818607]
, 16Hwang SW, Khwarg SI, Kim JH, Choung HK, Kim NJ. Bicanalicular double silicone intubation in external dacryocystorhinostomy and canaliculoplasty for distal canalicular obstruction. Acta Ophthalmol 2009; 87(4): 438-42.
[http://dx.doi.org/10.1111/j.1755-3768.2008.01292.x] [PMID: 18700890]
]. While, in non-complicated cases, other authors used it for 3 months [20Gül A, Duran M, Can E, et al. The effect of silicone tube intubation in external Dacryocystorhinostomy. Acta Med Anatol 2015; 3: 1-4.
[http://dx.doi.org/10.15824/actamedica.31629]
, 21Elmorsy S, Fayek HM. Rubber tube versus silicone tube at the osteotomy site in external dacryocystorhinostomy. Orbit 2010; 29(2): 76-82.
[http://dx.doi.org/10.3109/01676830903294891] [PMID: 20394544]
]. Eight weeks of intubation was also reported in association with Ext-DCR [22Vieira GS, Xavier ME. Results and complications of bicanalicular intubation in external dacryocystorhinostomy. Arq Bras Oftalmol 2008; 71(4): 529-33. [English abstract].
[http://dx.doi.org/10.1590/S0004-27492008000400012] [PMID: 18797663]
]. Other investigators used the silicone tubes in patients treated by endoscopic DCR for shorter periods of 6 weeks or 8 weeks [23Smirnov G, Tuomilehto H, Teräsvirta M, Nuutinen J, Seppä J. Silicone tubing is not necessary after primary endoscopic dacryocystorhinostomy: A prospective randomized study. Am J Rhinol 2008; 22(2): 214-7.
[http://dx.doi.org/10.2500/ajr.2008.22.3132] [PMID: 18416983]
-26Reddy YJ, Reddy YM, Kiran M, et al. A Comparative Study of Outcomes of Dacryocystorhinostomy with and without Silicone Stenting. JDMS 2015; 7: 82-5.]. Rather & Singh reported that, with Ext-DCR, the optimum duration of intubation is 4 weeks and keeping it for longer durations increases the possibility of punctal and canalicular erosions [13Rather S, Singh T. External dacryocystorhinostomy with and without silicon tube intubation in chronic dacryocystitis with nasolacrimal duct block. JK Science 2013; 15: 24-7.]. This is, to our knowledge, the first prospective study comparing the conventional duration of intubation (3 months) with a shorter period of intubation (2-3 weeks) in Ext-DCR, and no differences in success rates were recorded. Bazzazi et al. compared the results of DCR after 3 months of intubation with results in patients where the tube was extruded or had to be removed before the planned time, and found no significant difference [27Bazzazi N, Shayaninasab M, Farahani F, Akbarzade S. A study of the relation between silicone tube removal time and results of external dacryocystorhinostomy with intubation. Life Sci J 2013; 10: 633-6.]. In their study, the time of early tube removal was not planned, and tubes were removed or lost at different durations ranged between 7 and 85 days.

CONCLUSION

This study supports the evidence that silicone intubation is not necessary in non-complicated cases of Ext-DCR. No differences in results or complications incidences were found between non-intubation, short-term intubation, and conventional 3 months intubation.

LIST OF ABBREVIATIONS

Ext-DCR  = External Dacryocystorhinostomy.
NLDO  = Nasolacrimal Duct Obstruction.
FDDT  = Fluorescein Dye Disappearance Test.
EN-DCR  = Endonasal Dacryocystorhinostomy.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was approved by the Ethical committee, Faculty of Medicine, Tanta University, Egypt. Approval reference number: 30727/01/16.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the institutional committee and with the Declaration of Helsinki.

CONSENT FOR PUBLICATION

Informed written consent was obtained from all the patients included in the study.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Tarbet KJ, Custer PL. External dacryocystorhinostomy. Surgical success, patient satisfaction, and economic cost. Ophthalmology 1995; 102(7): 1065-70.
[http://dx.doi.org/10.1016/S0161-6420(95)30910-4] [PMID: 9121754]
[2] Warren JF, Seiff SR, Kavanagh MC. Long-term results of external dacryocystorhinostomy. Ophthalmic Surg Lasers Imaging 2005; 36(6): 446-50.
[http://dx.doi.org/10.3928/1542-8877-20051101-03] [PMID: 16355948]
[3] Keith CG. Intubation of the lacrimal passages. Am J Ophthalmol 1968; 65(1): 70-4.
[http://dx.doi.org/10.1016/0002-9394(68)91031-3] [PMID: 5635571]
[4] Connell PP, Fulcher TP, Chacko E, O’ Connor MJ, Moriarty P. Long term follow up of nasolacrimal intubation in adults. Br J Ophthalmol 2006; 90(4): 435-6.
[http://dx.doi.org/10.1136/bjo.2005.084590] [PMID: 16547322]
[5] Konuk O, Kurtulmusoglu M, Knatova Z, Unal M. Unsuccessful lacrimal surgery: causative factors and results of surgical management in a tertiary referral center. Ophthalmologica 2010; 224(6): 361-6.
[http://dx.doi.org/10.1159/000313818] [PMID: 20453543]
[6] Madge SN, Selva D. Intubation in routine dacryocystorhinostomy: why we do what we do. Clin Exp Ophthalmol 2009; 37(6): 620-3.
[http://dx.doi.org/10.1111/j.1442-9071.2009.02094.x] [PMID: 19702714]
[7] Saiju R, Morse LJ, Weinberg D, Shrestha MK, Ruit S. Prospective randomised comparison of external dacryocystorhinostomy with and without silicone intubation. Br J Ophthalmol 2009; 93(9): 1220-2.
[http://dx.doi.org/10.1136/bjo.2008.147819] [PMID: 19515642]
[8] Feng YF, Cai JQ, Zhang JY, Han XH. A meta-analysis of primary dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2011; 46(6): 521-7.
[http://dx.doi.org/10.1016/j.jcjo.2011.09.008] [PMID: 22153640]
[9] Sarode D, Bari DA, Cain AC, Syed MI, Williams AT. The benefit of silicone stents in primary endonasal dacryocystorhinostomy: A systematic review and meta-analysis. Clin Otolaryngol 2017; 42(2): 307-14.
[http://dx.doi.org/10.1111/coa.12751] [PMID: 27614030]
[10] Kang MG, Shim WS, Shin DK, Kim JY, Lee JE, Jung HJ. A systematic review of benefit of silicone intubation in endoscopic dacryocystorhinostomy. Clin Exp Otorhinolaryngol 2018; 11(2): 81-8.
[http://dx.doi.org/10.21053/ceo.2018.00031] [PMID: 29649861]
[11] Xie C, Zhang L, Liu Y, Ma H, Li S. Comparing the success rate of dacryocystorhinostomy with and without silicone intubation: A trial sequential analysis of randomized control trials. Sci Rep 2017; 7(1): 1936.
[http://dx.doi.org/10.1038/s41598-017-02070-y] [PMID: 28512307]
[12] Ing EB, Bedi H, Hussain A, et al. Meta-analysis of randomized controlled trials in dacryocystorhinostomy with and without silicone intubation. Can J Ophthalmol 2018; 53(5): 466-70.
[http://dx.doi.org/10.1016/j.jcjo.2017.12.006] [PMID: 30340712]
[13] Rather S, Singh T. External dacryocystorhinostomy with and without silicon tube intubation in chronic dacryocystitis with nasolacrimal duct block. JK Science 2013; 15: 24-7.
[14] Afzal MM, Mehmood A, Maqbool R, et al. To compare the success rate of External Dacryocystorhinostomy with and without Silicon Intubation in patients of nasolacrimal duct obstruction. P J M H S 2014; 8: 53-5.
[15] Sodhi PK, Pandey RM, Malik KP. Experience with bicanalicular intubation of the lacrimal drainage apparatus combined with conventional external dacryocystorhinostomy. J Craniomaxillofac Surg 2003; 31(3): 187-90.
[http://dx.doi.org/10.1016/S1010-5182(03)00020-9] [PMID: 12818607]
[16] Hwang SW, Khwarg SI, Kim JH, Choung HK, Kim NJ. Bicanalicular double silicone intubation in external dacryocystorhinostomy and canaliculoplasty for distal canalicular obstruction. Acta Ophthalmol 2009; 87(4): 438-42.
[http://dx.doi.org/10.1111/j.1755-3768.2008.01292.x] [PMID: 18700890]
[17] Choung HK, Khwarg SI. Selective non-intubation of a silicone tube in external dacryocystorhinostomy. Acta Ophthalmol Scand 2007; 85(3): 329-32.
[http://dx.doi.org/10.1111/j.1600-0420.2006.00827.x] [PMID: 17488464]
[18] Allen K, Berlin AJ. Dacryocystorhinostomy failure: Association with nasolacrimal silicone intubation. Ophthalmic Surg 1989; 20(7): 486-9.
[PMID: 2779952]
[19] Brookes JL, Olver JM. Endoscopic endonasal management of prolapsed silicone tubes after dacryocystorhinostomy. Ophthalmology 1999; 106(11): 2101-5.
[http://dx.doi.org/10.1016/S0161-6420(99)90490-6] [PMID: 10571344]
[20] Gül A, Duran M, Can E, et al. The effect of silicone tube intubation in external Dacryocystorhinostomy. Acta Med Anatol 2015; 3: 1-4.
[http://dx.doi.org/10.15824/actamedica.31629]
[21] Elmorsy S, Fayek HM. Rubber tube versus silicone tube at the osteotomy site in external dacryocystorhinostomy. Orbit 2010; 29(2): 76-82.
[http://dx.doi.org/10.3109/01676830903294891] [PMID: 20394544]
[22] Vieira GS, Xavier ME. Results and complications of bicanalicular intubation in external dacryocystorhinostomy. Arq Bras Oftalmol 2008; 71(4): 529-33. [English abstract].
[http://dx.doi.org/10.1590/S0004-27492008000400012] [PMID: 18797663]
[23] Smirnov G, Tuomilehto H, Teräsvirta M, Nuutinen J, Seppä J. Silicone tubing is not necessary after primary endoscopic dacryocystorhinostomy: A prospective randomized study. Am J Rhinol 2008; 22(2): 214-7.
[http://dx.doi.org/10.2500/ajr.2008.22.3132] [PMID: 18416983]
[24] Unlu HH, Gunhan K, Baser EF, Songu M. Long-term results in endoscopic dacryocystorhinostomy: Is intubation really required? Otolaryngol Head Neck Surg 2009; 140(4): 589-95.
[http://dx.doi.org/10.1016/j.otohns.2008.12.056] [PMID: 19328352]
[25] Chong KK, Lai FH, Ho M, Luk A, Wong BW, Young A. Randomized trial on silicone intubation in endoscopic mechanical dacryocystorhinostomy (SEND) for primary nasolacrimal duct obstruction. Ophthalmology 2013; 120(10): 2139-45.
[http://dx.doi.org/10.1016/j.ophtha.2013.02.036] [PMID: 23672972]
[26] Reddy YJ, Reddy YM, Kiran M, et al. A Comparative Study of Outcomes of Dacryocystorhinostomy with and without Silicone Stenting. JDMS 2015; 7: 82-5.
[27] Bazzazi N, Shayaninasab M, Farahani F, Akbarzade S. A study of the relation between silicone tube removal time and results of external dacryocystorhinostomy with intubation. Life Sci J 2013; 10: 633-6.
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Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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