A total of 244 eyes with distal NLDO confirmed preoperatively by clinical and paraclinical findings (including epiphora, discharge, and regurgitation test results [backflow from one irrigated punctum to the other], high-resolution computed tomography, scintigraphy of the nasolacrimal apparatus, and diagnostic telescopic endoscopy of the nose in selected cases) were indicated for DCR (210 patients) and included in the study. The patients, who were randomly divided into 2 groups, ranged in age from 21 to 86 years (mean age, 42 years), and the female-male ratio was 1.7:1.0. From January 1999 to December 2002, one group underwent ext DCR, which was performed by the second author (M.F.), as described by Dupuy-Dutemps and Bourguet,11 and the other group underwent ELADCR, which was performed by the first author (M.A.). Particular attention was paid to intranasal abnormalities and any anatomical predisposing conditions. The exclusion criteria consisted of punctual and canalicular abnormalities, lower eyelid deformities, previous DCR, age younger than 15 years, malignancy, previous radiation therapy, trauma, and bone disease. A successful outcome was defined as elimination of epiphora or dacryocystitis and negative irrigation test result (ie, unrestricted flow of irrigated water to the nose) 1 year after surgery. In bilateral cases (32 patients), each side was considered as a separate operation. The predisposing factors, signs, and symptoms of NLDO are presented in Table 1.