Careful patient selection is of paramount importance. It is best not to choose patients who underwent a DCR procedure in the past for obvious reason that the nasolacrimal duct in these patients would likely have been violated thereby rendering the nasolacrimal pass unamenable to the self-linking stent. Rarely, those pediatric patients who had persistent complex congenital nasolacrimal duct obstruction with a bony block on probing are not good candidates for self-linked stents since this would as well render the nasolacrimal pass unamenable to the self-linking.

Self-linked stents are just one simple additional step for all the surgeons who regularly perform an external DCR (Fig. 18.4). Our surgical technique was the same as described before by Hui et al. [15] except that the surgery was partly done under endoscopic guidance. Following flaps creation in DCR, a Crawford silicone stent (FCI Ophthalmics, MA, USA) is passed through the canaliculi, and then each arm is brought out through the nasolacrimal duct (Fig. 18.5) rather than the routine middle meatus. Both the arms of the stent are recovered from the inferior meatus under endoscopic guidance (Figs. 18.6 and 18.7). The bodkins are then passed over the inferior turbinate and redirected towards the middle meatus and the osteotomy under endoscopic guidance (Figs. 18.8 and 18.9) and looped around the proximal portions and tied near the lacrimal sac (Fig. 18.10) thus creating a self-linking stent around the inferior turbinate. At the end of surgery, before closing the wound, an attempt to displace the stent superiorly or inferiorly should be met with resistance (Fig. 18.11). At the same time, it is also important to make sure that there is no undue tightening of the silicone stent since this may lead to punctal cheese wiring.