Once the balloon catheter is assembled with the manometer as per standard protocols (Fig. 31.5), the balloon is inserted into the nasolacrimal duct just like a probe under endoscopic guidance up to the opening in the inferior meatus (Fig. 31.6) and inflated with an inflation device using saline. Fluorescein can be used to color the saline, making the balloon more visible during inflation in the nose (Fig. 31.7). The balloon is then inflated to 8 atm of pressure for 1 min (Fig. 31.7), deflated (Fig. 31.8), and repositioned higher in the duct, and the inflation is repeated an additional one to two times. Hash marks on the tube can help guide placement of the tube, but due to the variation in anatomy between younger and older patients direct visualization is best to ensure that the balloon is across the valve of Hasner for the first dilation (Fig. 31.4). After that the balloon can be pulled back so the first hash mark is visible at the punctum, then reinflated for a minute, deflated, and pulled back to the second hash mark for a final inflation. The second hash mark typically corresponds to balloon placement in the nasolacrimal sac and proximal duct. A stopcock can be used in bilateral procedure to inflate both balloons simultaneously saving surgical time. At the end of the procedure, a dilated nasolacrimal duct opening is usually noted (Fig. 31.9).

Advantages of the balloon include the lack of an implant in the nasolacrimal system, and the ability to dilate the system much larger than with typical lacrimal probes without traumatizing the canalicular system. Disadvantages to the balloon include their relative cost. However, balloon dacryoplasty is effective following failed probing as well as a primary procedure per physician preference. Some surgeons prefer a balloon in older children; however, the PEDIG NLD1 study showed good results with primary probing even in older children [3, 4].

Postoperative care following balloon dacryoplasty is intended to prevent infection, scarring and restenosis of the nasolacrimal system and should include topical, oral, and intranasal steroids and antibiotics as appropriate. For children it is advisable to use a steroid antibiotic drop such as tobramycin–loteprednol or tobramycin–dexamethasone four times daily for a week. An oral antibiotic such as cephalexin should be given for 7 days. Finally, oral prednisolone 5 mg/5 ml can be used in children at a dose of up to 2 mg/kg per day split in three doses for 3 days, then half the dose for an additional 3 days while a prednisolone taper pack can be used in adults. Intranasal steroids can be added in older children and adults once daily for a few weeks.