Canaliculorhinostomy—Indications and
Surgical Results
JUNG HYE LEE, STEPHANIE MING YOUNG, YOON-DUCK KIM, KYUNG IN WOO, AND JUNG-HOON YUM

PURPOSE: To report the surgical results of canalicu-
lorhinostomy for patients with distal canalicular
obstruction and lacking a structurally functional
lacrimal sac who would otherwise require a conjuncti-
vodacryocystorhinostomy (CDCR) with Jones tube
placement.

DESIGN: Retrospective observational case series.

METHODS: SETTING: Single tertiary institution.
PERIOD: November 1994 to June 2011. PATIENT POPU-
LATION: Sixteen patients with canalicular obstruction at
or beyond 8 mm from the punctum, with an absent or
unidentifiable lacrimal sac. INTERVENTION: Patients
underwent canaliculorhinostomy, whereby direct
anastomosis of the canaliculi or common canaliculus
to the nasal mucosa was performed. MAIN OUTCOME
MEASURES: Anatomic and functional success.

RESULTS: Our study comprised 16 patients with a
mean age of 44.9 ± 21.9 years. Ten (62.5%) were female
and 6 (37.5%) male. Mean duration of follow-up was 7.8
years. Causes of an absent or unidentifiable lacrimal sac
included previous trauma (n [ 8, 50.0%), previous
dacryocystorhinostomy (n [ 4, 25.0%), chronic dacryo-
cystitis (n [ 3, 18.8%), and previous dacryocystectomy
(n [ 1, 6.2%). Anastomoses between the upper and
lower canaliculi and the nasal mucosa was performed in
6 patients, while that between the common canaliculus
and nasal mucosa was performed in 10. Anatomic and
functional success rates were 87.5% (n [ 14) and
81.3% (n [ 13), respectively.

CONCLUSION: Canaliculorhinostomy has reasonable
success rates and provides an effective surgical alternative
for a group of patients in whom CDCR with Jones tube
placement would otherwise have been indicated. (Am
J Ophthalmol 2017;181:134–139. Ó 2017 Elsevier
Inc. All rights reserved.)
Supplemental Material available at AJO.com.
Accepted for publication Jun 29, 2017.
From the Department of Ophthalmology, Hyemin Eye Hospital, Seoul,
South Korea (J.H.L.); Department of Ophthalmology, National
University Hospital, Singapore (S.M.Y.); Department of
Ophthalmology, Samsung Medical Center, Sungkyunkwan University
School of Medicine, Seoul, South Korea (Y.-D.K., K.I.W.); and Seoul
Samsung Eye Clinic, Seoul, South Korea (J.-H.Y.).
Inquiries to Yoon-Duck Kim, Department of Ophthalmology, Samsung
Medical Center, 50 Ilwon-dong, Kangnam-ku, Seoul 135-710, Korea;
e-mail: ydkimoph@skku.edu
134 © 2017 ELSEVIER INC. ALL
C
ANALICULAR OBSTRUCTIONS, ALTHOUGH RARE,
still represent one of the most difficult lacrimal
conditions to treat.1 The location and extent of
the obstruction influences surgical options, which include
retrograde intubation dacryocystorhinostomy
(DCR), DCR combined with membranectomy, DCR
with microtrephine, and balloon canaliculoplasty.2–11
Conjunctivodacryocystorhinostomy (CDCR) with Jones
tube is used for extensive canalicular obstruction,
congenital agenesis, and failed previous canalicular
surgery,1,12–16 while canaliculodacryocystorhinostomy
(canaliculo-DCR) is reserved for cases of distal canalicular
obstruction.17,18
However, information on the management of canalicular
obstruction with an absent or unidentifiable lacrimal sac is
lacking. This combination can develop from congenital
agenesis, long-standing chronic dacryocystitis, previous
dacryocystectomy, failed prior dacryocystorhinostomy,
tumor removal around the lacrimal sac, and trauma.
Some surgeons consider CDCR with a Lester Jones Pyrex
glass tube as the treatment of choice in these instances,
because this surgery creates a lacrimal drainage route from
the conjunctiva into the nasal space, bypassing the canali-
culi and lacrimal sac.1,12–16 Although a relatively high rate
of anatomic success can be achieved with this procedure,
especially with modifications of the Jones tube such as the
frosted Jones tube, where anatomic success has been
reported to be 100%, it requires a permanent prosthesis
and long-term follow-up, and it is associated with a high
complication rate and poor patient satisfaction in some
studies.14,15,19–25
Canaliculorhinostomy, which has been described as
early as 1935 by Arruga12 and subsequently mentioned
by Rycroft in 1951,26 is a procedure that this study aims
to revisit. It has previously been described as a procedure
of choice in cases where the lacrimal sac had been
removed but where the inferior canaliculus was intact.27
The surgical procedure is similar to a DCR, except the
lacrimal sac flaps are absent and the canaliculi are sutured
to the nasal mucosa for epithelial continuity to be estab-
lished.26 However, though Rycroft stated that ‘‘late re-
sults of permanent drainage by canaliculo-rhinostomy
alone have not been entirely satisfactory,’’ there were
no data provided. In addition, the inferior canaliculus
was brought closely to the nasal mucosa but no direct
anastomosis was made. We have also found that it is
not uncommon for a damaged or absent lacrimal sac to
RIGHTS RESERVED. 0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2017.06.034
accompany distal canalicular obstruction and vice versa.
Hence, the purpose of our study was to discuss canalicu-
lorhinostomy as a surgical treatment option in patients
with canalicular obstruction accompanied by a lack of a
structurally intact lacrimal sac, who would otherwise
require a CDCR with Jones tube.
METHODS
THE CLINICAL STUDY WAS APPROVED BY THE HOSPITAL
Ethics Committee prospectively (before the study began)
and adhered to the tenets of the Declaration of Helsinki.
A retrospective, noncomparative interventional study
was performed. Medical records of 658 patients (766
eyes) who had undergone lacrimal surgery between
November 1994 and June 2011 were retrospectively
reviewed. The exact surgery date range was from November
2, 1998 to August 28, 2009. Of these, 16 patients who had
undergone canaliculorhinostomy were included in the
study. These patients were identified by operative note
search for ‘‘canaliculorhinostomy.’’ Data collection
included patient demographics, etiology of obstruction,
site of lacrimal obstruction, duration of follow-up, and
functional and anatomic success.

PREOPERATIVE SELECTION: Surgical indication of
canaliculorhinostomy included canalicular obstruction at
or beyond 8 mm from the punctum, accompanied by an
absent or unidentifiable lacrimal sac. Canalicular examina-
tion was performed preoperatively to determine whether at
least 8 mm of patent canaliculi remained. Intraoperatively,
the lacrimal sac status was assessed. Patients with a detect-
able lacrimal sac could go on to undergo a canaliculi-DCR.
However, in patients without a detectable lacrimal sac or
with a previously excised lacrimal sac, canaliculorhinos-
tomy was performed.

ASSESSMENT OF SUCCESS RATE: Anatomic success was
determined as follows: (1) endoscopic inspection of a pat-
ent neo-ostium (of at least 2 mm in diameter) and (2)
syringing of the lacrimal system with completely free irriga-
tion, with both criteria required to be considered an
anatomic success. Functional success was assessed from pa-
tient symptoms and fluorescein passage. If the presenting
complaint of watering and/or stickiness resolved
completely or was significantly improved, the operation
was considered a success. Where symptoms only slightly
improved, remained unchanged, or worsened from preoper-
atively, the operation was considered a failure. The func-
tional endoscopic dye test was performed using 2%
fluorescein topical application in the conjunctival fornix
and visualization of a free flow of dye from the neo-
ostium via a nasal endoscope almost immediately after
instillation of dye.
VOL. 181 INDICATIONS AND OUTCOMES OF CANALICULORHINOSTOMY

SURGICAL TECHNIQUE: All patients underwent canali-
culorhinostomy by a single surgeon (Y.-D.K.), under local
anesthesia (for adults) and general anesthesia (for chil-
dren). Intraoperatively, the canaliculi were re-examined
with a lacrimal probe to ensure at least 8 mm of patency
from the punctum (Figure 1, Top left). All patients in
our study had no detectable lacrimal sac found intraopera-
tively owing to previous trauma, DCR surgery, chronic
dacryocystitis, or previous dacryocystectomy. The initial
steps of the surgery were similar to a standard external
DCR, with creation of a bony ostium, while taking care
to avoid injuring the underlying nasal mucosa. Anterior
nasal mucosa flaps were created. A 00 or 0 Bowman probe
was passed into the canalicular system to the point of
obstruction at the distal canaliculus. Soft tissue at the
most medial aspect of the probe was then excised
(Figure 1, Top center). Probes from the upper and lower
canaliculi could then be seen to emerge from their respec-
tive lumens, while a common canalicular obstruction
would result in the probes emerging from a single lumen
(Figure 1, Top right). The canaliculi were intubated with
standard bicanalicular silicone tubes (Visitec Canaliculus
Intubation Set; Beaver-Visitec International, Inc,
Waltham, Massachusetts, USA) and the canaliculi or com-
mon canaliculus were then anastomosed to the nasal
mucosa using interrupted 6–0 Vicryl (polyglactin 910)
suture with a spatulated needle (Figure 1, Bottom left, cen-
ter, and right). In certain cases, the canaliculonasal flaps
were tagged to the periosteum of the medial wall to prevent
collapse of the anastomosis, allowing ample space around
the anastomosis site to avoid any potential obstruction.
This was followed by layered orbicularis and skin closure
as per standard DCR. The silicone tube was left in situ
for at least 6 months postoperatively.
RESULTS
OUR STUDY INCLUDED 16 EYES OF 16 PATIENTS. TEN PA-
tients (62.5%) were female and 6 (37.5%) were male.
The age range was 4–73 years, with a mean age of 44.9 6
21.9 years. The mean duration of follow-up was 7.8 years
(range 0.5–18 years). In terms of laterality, there were
6 right and 10 left eyes affected. The mean duration from
surgery to removal of silicone tubes was 6.9 6 5.2 months,
with a range of 6–26 months.
Table 1 shows the etiology of lacrimal obstruction and the
surgical results in terms of anatomic and functional success.
The most common cause of absent or damaged lacrimal sac
was trauma, followed by previous DCR, chronic dacryocysti-
tis, and previous dacryocystectomy. The mean anatomic and
functional success rates were 87.5% (n ¼ 14) and 81.3%
(n ¼ 13), respectively (Figure 2).
Depending on the level of obstruction, either a common
canaliculorhinostomy or upper and lower
135
FIGURE 1. Canaliculorhinostomy surgical technique. (Top row, Bottom left, and Bottom, second from left) In a common canalicu-
lorhinostomy, the common canaliculus is anastomosed to the nasal mucosa. (Top left) Intraoperatively, the canaliculi are re-examined
with a lacrimal probe to ensure at least 8 mm of patency from the punctum. All patients in our study had no detectable lacrimal sac
found intraoperatively. (Top center) The initial steps of the surgery are similar to a standard external dacryocystorhinostomy (DCR),
with creation of a bony ostium and anterior nasal mucosa. A 00 or 0 Bowman probe is passed into the canalicular system, to the point
of obstruction at the distal canaliculus. Soft tissue at the most medial aspect of the probe is then excised. (Top right) Probes can then
be seen to emerge from the common canaliculus. (Bottom left) The canaliculi are intubated with standard bicanalicular silicone tubes.
(Bottom, second from left) The common canaliculus is then anastomosed to the nasal mucosa using interrupted 6–0 Vicryl. This is
followed by layered orbicularis and skin closure as per standard DCR. (Bottom, second from right, and Bottom, right) In an upper and
lower canaliculorhinostomy, the procedure is similar, except probes are seen to emerge separately from the upper and lower caniculi
(Bottom, second from right). (Bottom, right) After silicone tube intubation, the upper and lower canaliculi are then anastomosed to
the nasal mucosal flap.

TABLE 1. Surgical Results of Canaliculorhinostomy

According to Etiology of Lacrimal Obstruction

Success

Anatomic Functional
Etiology N Eyes Success, N (%) Success, N (%)

Trauma 8 6 (75.0%) 6 (75.0%)

Previous DCR 4 4 (100.0%) 4 (100.0%)
Chronic dacryocystitis 3 3 (100.0%) 2 (66.7%)
Previous dacryocystectomy 1 1 (100.0%) 1a (100.0%)
Total 16 14 (87.5%) 13 (81.3%)

DCR ¼ dacryocystorhinostomy.
a
This patient with previous dacryocystectomy had a small
ostium with patency on syringing but persistent tearing with
negative fluorescein passage postoperatively. After transcana-
licular diode laser–assisted revision to enlarge the mucosal
opening, both functional and anatomic success were achieved.
FIGURE 2. Endonasal view of a patient at 11 years postopera-
tive follow-up, showing a probe passing through a patent
neo-ostium from the canaliculorhinostomy and free flow of fluo-
canaliculorhinostomy was performed. Table 2 shows the rescein in the nasal mucosa. The patient was also asymptomatic
anatomic and functional success rates for each of the 2 sub- for tearing at follow-up, and hence was considered an anatomic
groups. The common canaliculorhinostomy subgroup had and functional success.
slightly higher anatomic success than the upper and lower
canaliculorhinostomy subgroup. Both groups were compa-
rable in terms of secondary functional success. Of the 10 pa-
tients who underwent common canaliculorhinostomy, 2 1 patient in the outpatient clinic, while the other declined
patients had functional failure, for which Jones tube further intervention. Of the 6 patients with upper and
placement was recommended. Jones tube was inserted for lower canaliculorhinostomy, 1 patient with previous

136 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 2017


TABLE 2. Surgical Results of Upper and Lower
Canaliculorhinostomy Compared With Common
Canaliculorhinostomy
Success
N Anatomic Functional
Surgery Eyes Success, N (%) Success, N (%)
Upper and lower 6 5 (83.3%) 5a (83.3%)
canaliculorhinostomy
Common 10 9 (90.0%) 8 (80.0%)
canaliculorhinostomy
a
One patient with previous dacryocystectomy had a small
ostium with patency on syringing but persistent tearing with
negative fluorescein passage postoperatively. After transcana-
licular diode laser–assisted revision to enlarge the mucosal
opening, both functional and anatomic success were achieved.
dacryocystectomy had a small ostium with patency on sy-
ringing, but had persistent tearing with negative fluorescein
passage. In view of the anatomic success but primary func-
tional failure, transcanalicular diode laser–assisted revision
was performed to enlarge the mucosal opening as a day-
surgery procedure under local anesthesia, with subsequent
functional and anatomic success. Another patient with
functional and anatomic failure underwent Jones tube
insertion, which was performed in the outpatient clinic un-
der local anesthesia.
DISCUSSION
THE SUCCESSFUL TREATMENT OF CANALICULAR OBSTRUC-
tions continues to represent a therapeutic challenge.1–18
Focal distal common canalicular obstructions can
effectively be treated with DCR combined with
membranectomy,4 while canaliculi-DCR is indicated in
cases of distal upper, lower, or common canalicular obstruc-
tion, where 8 mm of the lateral canaliculi are patent.17,18
CDCR with the insertion of a Lester Jones Pyrex glass
bypass tube is considered the gold standard for the
treatment of extensive canalicular obstruction and failed
previous canalicular surgery.1,12–16 However, the
management of canalicular obstructions with an absent
or damaged lacrimal sac has not been well discussed.
Under usual circumstances, CDCR with Jones tube
insertion would have been indicated.27
Our study showed a mean anatomic and functional suc-
cess rate of 87.5% and 81.3%, respectively. These rates
compare favorably to that of CDCR with Jones tube. Pri-
mary CDCR with Jones tube has a success rate between
14.0% and 83.9%, although most recent modifications of
the Jones tube, such as the frosted Jones tube, have reported
an anatomic success rate of 100%.19–25 The symptomatic
VOL. 181 INDICATIONS AND OUTCOMES OF CANALICULORHINOSTOMY
success rates of CDCR range from 57.0% to
100%.15,20,28–34 Part of the normal Jones tube
maintenance includes tube replacement, reinsertion, or
repositioning. In addition to modest success rates, many
reports describe problems associated with Jones tubes,
such as infection, bleeding, tube dysfunction, extrusion,
displacement, and poor patient satisfaction, with up to
46.7% of patients being unsatisfied.14,15,19–24,35
There have been few reports of microsurgical approaches
to the problem that would reconstruct rather than bypass
the lacrimal system.12,18,36 Doucet and Hurwitz described
canaliculi-DCR as an alternative to Jones tube for failed
lacrimal surgery.17 Some of their patients had no sac
remaining and in these cases, the common canaliculus
was anastomosed directly to the nasal mucosal flaps. Their
study did not distinguish between proximal, distal, or com-
mon canalicular obstructions. In addition, they created
anterior and posterior canalicular and nasal flaps, whereas
our technique involved a direct anastomosis without flaps,
as we felt that ensuring ample space around the anastomosis
site was important for the success of the procedure. They
reported functional success in more than two thirds of their
patients with a minimum follow-up of 9 months, although
there was no mention of the number of patients or success
rate within each subgroup.17 Back in 1966, Björk reported
12 cases of ‘‘canaliculorhinostomy with intubation,’’ with 9
of 12 cases reporting improvement in epiphora. However,
these cases were composed of intubation of lacrimal sac–
nasal meatus communications in addition to canalicular
system–nasal meatus communications, with no mention
of how the communications were created.36
In our practice, we limit the indications for this proced-
ure to patients lacking a structurally functioning lacrimal
sac and with a distal canalicular or common canalicular
obstruction where more than 8 mm of patent canaliculi
remained from the punctum. A minimum of 8 mm of pat-
ent canalicular system would allow anastomosis without
undue tension.18 Anastomosis of a distal canaliculus or
common canaliculus would be expected to be technically
easier than a proximal one, as the canalicular diameter
would be larger.
Canaliculorhinostomy is a procedure with several advan-
tages: the reconstruction involved is physiological, a Jones
tube and its attendant complications are avoided, long-
term follow-up is not necessary in successful anastomoses,
and long-term anatomic and functional success rates are
satisfactory. Another advantage of the canaliculorhinos-
tomy procedure is that a secondary Jones tube insertion
can be easily performed under local anesthesia on an outpa-
tient basis if the former fails, as the osteotomy has already
been created in the initial canaliculorhinostomy proced-
ure.
The potential disadvantage of canaliculorhinostomy is
that it is technically challenging, especially the microsur-
gical anastomosis between the canaliculus and nasal
mucosal flap. Without a precise understanding of lacrimal
137
drainage system and nasal anatomy, the chance of a suc-
cessful anastomosis is less likely. In our current study, 3 pa-
tients had anatomic failure while 2 had functional failure.
The latter could be attributed to a loss of a ‘‘suction’’ effect
on the tears from the canaliculus to the sac because of an
absent, damaged, or scarred sac. Naturally, any anatomic
deformity or pre-existing nasal mucosal inflammation
following trauma, infection, or dacryocystectomy would
threaten the success of the anastomosis. One possible
step that could facilitate the sutured anastomosis between
a tubular surface and a flat surface, which was not
performed in our series but could be considered by surgeons
FUNDING/SUPPORT: NO FUNDING OR GRANT SUPPORT. FINANCIAL DISCLOSURES: THE FOLLOWING AUTHORS HAVE NO
financial disclosures: Jung Hye Lee, Stephanie Ming Young, Yoon-Duck Kim, Kyung In Woo, and Jung-Hoon Yum. All authors attest that they meet
the current ICMJE criteria for authorship.
Other Acknowledgments: The authors would like to acknowledge Mr Sung Gab Kim from the Medical Information Team Multimedia Section,
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea, for helping with the illustrations of the surgical procedure.
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