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The lower eyelid, tethered medially and laterally by the canthal tendons, is normally suspended at the level of the inferior limbus with the aid of orbicularis tone counterbalanced by the force of the lower eyelid retractors and gravity. The lower eyelid is apposed to the globe because of the posterior position of the canthal tendon insertions relative to the projection of the globe. Disruption of the normal anatomic relationships from trauma or inflammatory disease or as a result of surgical resection of tumors can result in a poorly functioning lower eyelid with poor cosmesis. The lower eyelid has been conceptualized as consisting of three layers or lamellae. The anterior lamella is composed of skin and orbicularis muscle; the middle lamella is composed of the lower eyelid retractor (capsulopalpebral fascia) and fat; and the posterior lamella is composed of tarsus and conjunctiva. One or more of the lamellae may be disrupted following trauma or tumor resection, and each layer must be addressed in order to reconstruct a normal-appearing and -functioning lower eyelid. Imbalance of tension at the anterior and posterior lamellae, especially in the setting of lower eyelid laxity, can result in malrotation of the eyelid margin, causing entropion or ectropion. For example, inflammation and scarring of the conjunctiva from Stevens-Johnson syndrome or ocular cicatricial pemphigoid will produce entropion, whereas contraction of vertical cutaneous scar or ichthyosis will cause ectropion. A balance of tension of the lamellae must be maintained during reconstruction of the lower eyelid in order to prevent secondary malrotation. Disruption of normal anatomy as often seen following trauma can be addressed by reapproximation of the disrupted segments to their normal anatomic positions. Only rarely will trauma to the lower eyelid result in loss of tissue. Reconstruction with local flaps or free grafts is occasionally needed in traumatic cases that present in a delayed fashion. Local flaps and free grafts are needed to fill and reconstruct a defect in the lower eyelid, a situation that most often presents following resection of tumor.

The common complaint of a watering eye may be caused by a variety of problems, including lacrimal hyposecretion, lacrimal hypersecretion, or blockage of the lacrimal drainage system. This system is a complex membranous channel whose function depends on the interaction of anatomy and physiology. Effective tear drainage depends on a variety of factors, including the volume of tear secretion, eyelid position, and anatomy of the lacrimal drainage passages. Epiphora is defined as an abnormal overflow of tears down the cheek. The patient with symptomatic tearing may have a normal lacrimal drainage system overwhelmed by primary or secondary (reflex) hypersecretion or a drainage system that is anatomically compromised and unable to handle normal tear production. On the other hand, a patient with partial drainage obstruction may have a concomitant reduction in tear production and therefore be completely asymptomatic or may even suffer from symptomatic dry eye syndrome. Epiphora is determined by the balance between tear production and tear drainage, not by the absolute function or dysfunction of either one. The causes of lacrimal drainage problems can be divided into two categories: anatomic and functional. Anatomic obstruction refers to a mechanical or structural abnormality of the drainage system. The obstruction may be complete, such as punctal occlusion, canalicular blockage, or nasolacrimal duct fibrosis, or partial, caused by punctal stenosis, canalicular stenosis, or mechanical obstruction within the lacrimal sac (i.e., dacryolith or tumor). In patients with functional obstruction, epiphora results not from anatomic blockage but from a failure of lacrimal drainage physiology. This failure may be caused by anatomic deformity such as punctal eversion or other eyelid malpositions, but can also result from lacrimal pump inadequacy caused by weak orbicularis muscle action. It is helpful to determine whether the patient’s complaint is true epiphora or a “watery eye.” Detailed history-taking and careful examination will help direct the evaluation of a tearing eye. A host of clinical tests have been described, and the selection of appropriate tests will depend on the initial history and ophthalmic examination. 13-1-1 History-Taking. Any clinical evaluation should begin with a thorough history. A complaint of watery eye does not necessarily imply a lacrimal drainage problem.

Obstruction of the tear outflow system can occur anywhere along its course from the tear lake to the inferior meatus of the nose. Surgical techniques designed to relieve this functional or complete obstruction have been available for a long time. Toti of Italy described the dacryocystorhinostomy (DCR) procedure in 1908 as a treatment modality for obstruction of the nasolacrimal duct. His technique did not make use of mucosal flaps. Dupuy-Dutemps of France, on the other hand, encouraged the use of flaps. He recommended suturing together the nasal mucosal and lacrimal sac flaps. The success rate of the operation improved dramatically. Today the external DCR procedure makes use of modifications of both of these historically described procedures. In recent years, intranasal DCR has enjoyed renewed popularity. This procedure had been performed by Lester Jones and others for years but was dropped because the success rate was 80% at best. Although the use of endoscopic techniques and laser technology has been advocated by some authorities, the success rate (approximately 70%) with relatively short-term follow-up has limited its acceptance. More recently, Javate and associates reported a series of patients undergoing endoscopic DCR with the radiofrequency Ellman unit. Their reported success rate of 90% compared favorably with a 94% success rate in 50 age-matched patients undergoing external DCR with a follow-up of 9 months. This rate also compares favorably to the present authors’ success rate of approximately 95% in uncomplicated cases undergoing external DCR and a similar rate with the endoscopic approach without use of a laser. Therefore, the laser does not appear to offer any significant advantage over more traditional intranasal approaches, and the cost may actually be a financial disincentive to its use. The benefit of mitomycin continues to be debated. You and associates performed a prospective study showing favorable long-term success rates with the use of mitomycin. On the other hand, Liu and associates performed a prospective study that demonstrated no benefit. While the DCR works well for lacrimal sac or nasolacrimal duct obstruction, it does not address obstructions of the puncta and canaliculi.