The endonasal approach is inappropriate in the presence of malignant lesions of the lacrimal system or the surrounding tissues. In active Wegener's granulo-matosis any instrumentation induces marked adhesions and stenosis, and a DCR by any method is con-traindicated. Dacryoliths usually require an external approach for removal. A relative contraindication is a history of trauma as the bone medial to the sac may be thick. The indications and contraindications for laser DCR are summarized in Table 7.4.
Table 7.4. Indications and contraindications for laser DCR
Indications for laser DCR Distal nasolacrimal duct obstruction Acute dacryocystitis
Revision surgery for failed external DCR Patients unfit for a general anesthetic Patients with a coagulopathy
Contraindications Tumors of lacrimal system Wegener's granulomatosis
Abnormally thick bone (e.g., nasoethmoid trauma) Lacrimal sac pathology
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