Advocates against routine intubation believe there is no evidence in the literature to suggest improved anatomical patency in DCR for anatomical obstructions at either the canalicular or the ostial level. Furthermore, intubation-related morbidity such as punctal or canalicular cheese-wiring, granuloma formation, nasal irritation, corneal erosions, nasal bleeds, and displacements have been reported [14]. Intubation in DCR surgery also increases the cost and the duration of DCR surgery in addition to requiring removal at a later date.

The studies on behavior of the postoperative ostium has shed important light on its evolution [11, 15, 16]. Advocates supporting intubation report an increased patency rate, due to maintenance of the ostium of the lacrimal sac into the middle meatus and correction of presaccal stenosis. Older reported a success rate of 94 % with the routine use of silicone tubes in a series of 70 patients [17]. Seven years later, Rosen et al. presented a series of 253 cases with routine intubation. Although they acknowledged that their success rate was not significantly higher than that reported with other techniques, they listed some advantages of silicone intubation. They found that the surgery was easier to complete in the presence of excessive bleeding or inadvertent mucosal tears and that the suturing of anterior flaps was easier with the tubes in place. They also commented that the stent can act as a support structure for torn anterior flaps [14].

In a retrospective review of 338 DCR cases that excluded patients with common canalicular pathology, Panday and colleagues found that intubation time of longer than 6 months was associated with better outcome compared with shorter intubation times [18].

Many lacrimal surgeons have advocated “selective” silicone intubation in PANDO cases, where there is an intraoperative appearance of a tight common canaliculus [19, 20]. Other putative indications used by some surgeons include previous history of dacryocystitis, revision procedures, small sacs, narrow nasal cavities, excessive intraoperative hemorrhage, and poor mucosal flap formation [3, 21, 22].

Many recent studies comparing the surgical success of endoscopic DCR with and without silicone intubation have reported that a functionally patent DCR can be achieved without the need for routine nasolacrimal stenting [23–29].

Gu et al. [28] in their meta-analysis of endoscopic DCR and simultaneous intubation retrieved 4 trials and could appraise only 2 trials involving 84 patients that met their inclusion criteria for analysis. There was no statistically significant heterogeneity between the studies. Their analysis revealed using the fixed-effects models, that the pooled risk ratio for DCR failure in the nonintubated group was 0.85 (95 % confidence interval: 0.71–1.02). Feng et al. [30], in a meta-analysis that included five randomized controlled trials and four cohort studies, reported that there was no benefit from silicone tube intubation in primary DCR cases. However, this meta-analysis had many potential limitations, which included analysis from follow-ups of different duration (4–96 months), and inclusion of many clinical trials that were not randomized. Chong et al. [12] in a prospective randomized trial with a 12-month follow-up of bicanalicular silicone intubation in endonasal endoscopic mechanical dacryocystorhinostomy (EEM-DCR) for PANDO reported no statistical difference in the success rates between patients with (96.3 %) and without (95.3 %) intubation. The odds ratio of failure without silicone intubation was analyzed to be 1.28 (95 % confidence interval: 0.21–7.95). There was no difference in the incidence or the time taken to develop granulation tissue between the two groups of intubation and nonintubation [12].

In a single comparative study, Unlu et al. [29] described 91.7 % anatomical success in intubated cases compared to 92.3 % in their nonintubated subgroup. Smirnov et al. [27] in a 46-patient, randomized controlled, intubation versus nonintubation primary endo DCR study (absence of canalicular pathology confirmed in these cases) performed by three rhinologists reported a 100 % anatomical and functional success in the nonintubated group, in comparison to 78 % in the intubated subgroup, a difference that was statistically significant. In an another study by Unlu et al. [26] with postoperative endoscopic examination revealed that the rhinostomy opening could be visible in 89.5 % of the intubated cases and 94.7 % without intubation. Cannon et al. [31] report a single-surgeon prospective study of 163 endoscopic DCR with nonintubation cases and a zero incidence of canalicular closure at 12-months follow-up and found an anatomic patency rate of 98.5 % and a combined anatomical and functional success rate of 90.7 %.