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Prevention of re-obstruction in watery eye treatment: three-flap technique in external dacryocystorhinostomy



To examine the surgical outcome of three-flap external dacryocystorhinostomy (3-flap ex-DCR) based on the most common site of granulation occurrence in no-flap endonasal DCR (no-flap en-DCR).


This was a retrospective observational study. We first examined the location of granulation occurrence in the osteotomy site using nasal endoscopy after no-flap en-DCR on 53 sides of 37 patients (5 male, 32 female) with nasolacrimal duct obstruction. Based on the results of this surgery, we performed 3-flap ex-DCR on 70 sides of 61 patients (18 male, 43 female) with nasolacrimal duct obstruction. Anatomical success was defined as no reflux under lacrimal irrigation and a patent osteotomy site under nasal endoscopic examination at postoperative 12 months. Functional success was defined as no symptoms of watery eyes over the same period.


In the no-flap en-DCR patients, the granulation was formed in 42 sides (79.2 %): 18 sides (34.0 %) on the superior portion, 9 sides (17.0 %) on the inferior portion, 35 sides (66.0 %) on the anterior portion, and only 1 side (1.9 %) on the posterior portion, which was very small. Based on these results, we performed the 3-flap ex-DCR with the anterior, superior, and inferior flaps. Anatomical success with this technique was achieved in all sides (100 %), and functional success was obtained in 66 of 70 sides (94.3 %).


The 3-flap ex-DCR did not cause recurrent nasolacrimal duct obstruction, rendering it a very useful technique in terms of quality of life and medical economics.

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All authors contributed to the work and fit the authorship criteria.

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Correspondence to Hirohiko Kakizaki.

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All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria, educational grants, participation in speakers’ bureaus, membership, employment, consultancies, stock ownership, other equity interests, expert testimony or patent-licensing arrangements) or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval

As there was no ethics committee at Ide Eye Hospital, institutional review board (IRB) approval was obtained from Aichi Medical University Hospital (nos. 2014-H123 and 2015-H135) on behalf of the institution, and followed the tenets of the Declaration of Helsinki. The IRB granted a waiver of informed consent for the study based on the ethical guidelines for medical and health research involving human subjects established by the Japanese Ministry of Education, Culture, Sports, Science and Technology, and by the Ministry of Health, Labour, and Welfare. The waiver was granted because the study was a retrospective chart review, not an interventional study, and because it was difficult to obtain consent from patients who had been treated several years prior. Nevertheless, at the request of the IRB, we published an outline of the study, available for public viewing, on the Aichi Medical University website and on the notice board at Ide Eye Hospital; this also gave patients the opportunity to decline participation. No patient declined to participate. Personal identifiers were removed from the records prior to data analysis.

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Kakizaki, H., Kitaguchi, Y., Takahashi, Y. et al. Prevention of re-obstruction in watery eye treatment: three-flap technique in external dacryocystorhinostomy. Graefes Arch Clin Exp Ophthalmol 254, 2455–2460 (2016).

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  • Three-flap external dacryocystorhinostomy
  • No-flap endonasal dacryocystorhinostomy
  • Granulation
  • Re-obstruction