The history of the treatment of lacrimal duct stenosis dates back to the ancient world. Modern lacrimal duct surgery began with the description of external dacryocystorhinostomy (DCR) by Toti and the endonasal procedure by West. Modifications include construction of a mucous membrane flap and the use of different instruments such as microscopes, endoscopes, and laser. This article reviews the various methods currently in use, although the analysis makes clear how difficult it is to compare studies. Because of the high success rate and the possibility of correcting multiple disturbing factors of the lacrimal drainage system, external DCR remains the gold standard for the ophthalmologist; other methods must be measured by the success rate of external DCR. The future of lacrimal duct surgery lies in a better understanding of wound healing and thus the possibility for precise modulation. Better results may be possible by combining different surgical methods. Prospective studies are urgently necessary.

Dear Editor, Remnants of pupillary membranes are a common clinical finding in about 95% of healthy neonates [1] and 20% of adults. They represent an incomplete involution of the tunica vasculosa lentis, and do not affect the vision in the vast majoritiy of cases.However, bilateral dense persistent pupillary membranes (PPM) are a rare congenital abnormality. They can be associated with other ocular pathologies [2]. If they seem to be dense and to cover the visual axis, the management of these patients remains controversial, and a case-dependent decision of balancing the risks of surgery against amblyopia needs to be made.A 6-month-old female was referred by her pediatrician because of uncommon-looking pupils. She was an otherwise healthy infant, born full-term without a history of pregnancy complication or a family history of ocular disease. On ocular examination under general anesthesia, we found dense PPM covering the visual axis of both eyes ( Fig. 1a-d). Anterior segments, including chamber angles, were otherwise unremarkable, and fundus examination did not reveal any pathological findings. The intraocular pressure was not elevated. As fixation was normal for her age group and no squinting detectable, an observant management was adopted. The patient was seen regularly within the following years. She did not develop strabism.Retinoscopy led to a prescription of spectacles with a refraction of +9.0−2.0 axis 15°OD and +9.0−2.0 axis 175°O S at the age of 4.5 years. With this correction, the visual acuity was 20/32 on both eyes. About a year later, amblyopia therapy was performed with optical penalization of her right eye for 6 months, leading to a VA of 20/40 on both eyes. Up to today, her vision has continually improved to 20/20 in both eyes with small variations, and a stable refraction of +8.25−3.5 axis 2°OD and +8.25−3.25 axis 174°OS, respectively (Fig. 2). The PPMs remain unchanged.PPMs are a rare finding. The probability of regression may depend on the composition of membranes. Histopathology of excised membranes has revealed large amounts of collagen bundles with fibroblasts and some macrophages [4]. Steuhl et al. speculate that an increased amount of collagen and blood vessels within the membranes could inhibit regression. Although description of autosomal dominant inheritance does exist [3], sporadic cases of PPM seem to prevail [4]. Conventional surgical treatments [4,5] and laser treatments with a Neodym-YAG laser [6,7] have been described as leading to good visual results. Nevertheless, potential complications including infection, bleeding and mainly induction of cataract play an important role when planning treatment for an individual patient. The case described herein, and others, demonstrate that even dense PPM can lead to satisfying visual results with a

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In German there is no word for the term "festoon" but it can be used to describe folds due to gravity of the upper and the lower lid, sometimes accompanied by an oedema. The manuals of eyelid surgery (Neubauer or Heilman and Paton) recommend a direct excision, perhaps in combination with a shortening of the lid. But the postoperative result may show a poor scar and a persisting oedema. In cases of low grade festoon a temporary therapy using hyaluronic acid is possible. A combination of different surgical steps, such a subciliary incision, arcus marginalis release, a lift of the malar region, thinning out the subcutaneous oedematous skin region, skin excision and optionally a resurfacing may lead to a better cosmetic outcome.