During our first experiences with endoscopic DCR our rate of minor complications was high, although without severe sequelae. In 1996 we published an incidence of ecchymosis of the cheek in 44%, subcutaneous emphysema in 9% and orbital emphysema in 2.6% [1]. Presently, these figures have been considerably reduced. We rarely see emphysemas at all, and if so, it is because the patient has sneezed with the mouth closed, or blown the nose before 1 week after surgery. Ecchymosis of the cheek appears from time to time especially in patients where the soft tissue of the cheek has been exposed before reaching the lacrimal sac. The rate of complications may be higher if extended surgery has been simultaneously performed; thus, Fayet et al. [2] report on moderate and severe intraoperative bleeding in 82 (27.3%) and 35 cases (11.6%), respectively, when an uncinectomy was included.

The hammer and chisel technique to remove the bone reports rate of minor intraoperative bleeding of about 18% (8 of 44 patients) [3].

Probably the most common minor complication reported has been postoperative eyelid hematoma in cases where orbital fat was exposed, which has happened in 12.5% of cases [4]. In our hands, inadvertent incision of the periorbita achieved a rate of 10.5% (16 patients) [1].

Dolman found 11 (5.5%) cases of epistaxis requiring perioperative nasal packing and inadvertent lesion of the periorbit in five patients. One patient reported transient diplopia after the medial rectus was inadvertently pulled [5]. In our series we had no such case.

Lesion of the sphincter of the canaliculi was not reported, although probing has been used in most

Fig. 8.1. Emphysema after DCR. Note the air in the inferior eyelid and in the conjunctiva. Spontaneous resolution may be expected. In cases with lacrimal sac infection prophylactic antibiotics should be prescribed. Courtesy Dr. Manuel Tomás, Mallorca, Spain
Fig. 8.2. Ecchymosis of the cheek after endoscopic DCR. Heparin ointment applied to the skin speed up the resorption

cases. A spontaneous retraction of the dilated sphincter can probably be assumed. Postoperative complications, such as eyelid ecchymosis, punctal granuloma, cyst of the punctum, or adhesion between the superior and inferior punctum, seem to be very rare [6]. Premature loss of silicone tube has no influence on the outcome.

Granulation tissue at the internal ostium can vary from 17.5 to 6.6% [1, 6]. Minor sinechiae between the head of the middle turbinate and the lateral wall has been observed in 22.4% of cases, with obliterative scarring leading to a revision surgery in only 5 patients (3.3%) [1].

Retrobulbar hemorrhage may occur after peribulbar injection of local anesthetics [7], rather than from surgery itself.

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