There are a number of reports of DCR surgery without tubes which demonstrate an equivalent success rate compared with surgery using tubes; however, these studies have been non-randomised, retrospective reviews.[2-6] The only prospective, randomised controlled study[7] had only 42 participants and did not state at which point during the surgery the randomisation was revealed; unless the allocation occurs after the ostium has been completed there is the risk of bias since the surgeon may (consciously or inadvertently) create a larger ostium in cases where no tubes are to be used.