This is a curvilinear incision on the anterior lacrimal crest and is known to allow easy access to the lacrimal sac [16] (Fig. 19.2).

Harris, in 1989, was the first to demonstrate that external DCR can also be done with a horizontal incision placed on a lower lid crease [17]. This incision extended 10 mm medial to the medial canthus and downward in the first lower eyelid crease. After his first description of this approach in 1989, it was further studied and reported by Putterman [18] in 1994. Putterman also reported a mechanical retraction system. Kim et al. [19] in 2005 used a customized approach where the site of the incision varied. It was either placed in the most prominent wrinkle or in the relaxed skin tension line (4 mm below). Akaishi et al. [20] in 2011 reported good functional and cosmetic outcomes of lower eyelid crease incision. Although there are differences in the location and the extent of incision in all these reports, the common theme is to perform an external dacryocystorhinostomy through an inconspicuous scar.

Harris et al. [17] reported their incision to extend 10 mm medial to the medial canthus and downward in the first lower eyelid crease. Putterman [18] further reported his experience and also introduced the mechanical retraction system. Kim et al. [19] adopted a customized approach where the site of the incision varied. It was placed in either the most prominent wrinkle or relaxed skin tension line (4 mm below). An actual subciliary incision was only used in children without a prominent eyelid crease. The above studies retrospectively analyzed the scars and reported it to be a cosmetically superior approach. The lower eyelid incision within the relaxed skin tension line as reported by Akaishi et al. [20] most closely resembles our approach of the subciliary incision.

The eyelid subciliary incision is an established approach for several orbital and eyelid procedures and is known to provide excellent cosmesis [21, 22]. We explored the possibility of a subciliary incision to perform an Ex-DCR and evaluate whether the cosmetic benefits of a subciliary incision can be combined with the high success rate of an Ex-DCR (Fig. 19.3).

Surgery is performed under general or local anesthesia as per patient preference. All patients receive local anesthetic infiltration (2 % lignocaine admixed with 1:100,000 adrenaline) along the anterior lacrimal crest and the medial half of pretarsal lower eyelid. The nasal cavity is packed with three cotton-tipped applicators soaked with local anesthetic. A 10–15 mm subciliary incision is placed along the medial half of the lower eyelid, reaching up to the medial canthus (Fig. 19.4a). The incision is placed 1–2 mm below the lashline (subciliary), and not within the eyelid crease. It extends from the punctum medially to the midpupillary line laterally (Fig. 19.4a). Subcutaneous dissection is then carried out inferomedially, to reach the anterior lacrimal crest (Fig. 19.4b). At the level of the anterior lacrimal crest, the orbicularis fibers are gently separated, to expose the periosteum over the anterior lacrimal crest (Fig. 19.4c). The remainder of the surgical procedure is performed like a standard Ex-DCR, including creation of the ostium (Fig. 19.4d, e) and anterior mucosal flaps (Fig. 19.4f, g). Upon completion of the flap anastomosis (Fig. 19.4h), the orbicularis and skin are apposed with interrupted 6-0 polyglactin sutures (Fig. 19.4i).

Routine postoperative wound care and medications are prescribed. Postoperatively, the patients are examined on day 1, 1 week, 6 weeks, 3 months, and thereafter every 3–6 months; 1 day, 1 week, and final postoperative photographs of patients undergoing dacryocystorhinostomy through the subciliary approach are shown in Fig. 19.5. One patient underwent a bilateral subciliary DCR with good outcomes (Fig. 19.6).