dacrocystorhinostomy,,advantages and dis advantages of both external and endoscopic d.c.r.

3.  Tears secreted by lacrimal glands pass
through laterally across ocular surface to
lower canaliculi
 They finally pass through lacrimal sac to
nasolacrimal duct
 Nasolacrimal duct opens into anterior part
of outer wall of inferior meatus
 This opening is guarded by valve of hasner

4. Lacrimal gland
Zygomatic & zygomatico temporal nerve
Pterygopalatine ganglion
Nerve of pterygoid canal
Greater petrosal nerve
Geniculate ganglion
Nervus intermedius
SUPERIOR SALIVATORY NUCLEUS & NTS
LACRIMAL NUCLEUS

5. Dacrocystitis(acute;chronic &
congenital)
Canaliculitis
Congenital nasolacrimal duct
obstruction
Punctal stenosis
Dacryoadenitis
Sjogrens syndrome

6.  OCULAR EXAMINATION:
to rule out conditions
of uvea ;cornea &
conjuctiva resulting in
lacrimal apparatus
disease
 REGURGITATION
TEST:when steady
pressure is applied over
lacrimal sac above
medial palpebral
ligament results in
reflex of mucopurulent
discharge

7.  normal saline is
pushed into
laacrimal sac from
lower punctum
with a syringe
after instillation
of 4% xylocaine.
 Free passage rules
out obstruction
but in case of
obstruction it
reflexes from
punctum

8.  After topical anaesthesia, curved lacrimal
cannula on a saline filled syringe is gently
inserted into lower punctum & advanced
 Canula comes to either hard or soft stop
Hard stop:it comes to stop at medial
wall of sac through which rigid lacrimal
bone is felt…this indicates obstruction of
nasolacrimal duct

9. Soft stop:it comes
to stop at junction
of common
canaliculus &
lacrimal
sac(lateral wall)….
it indicates
common
canalicular block

10.  Flourescein dye injected
into both conjuctval sacs
& observed for 2
minutes…normally no dye
is seen…
 Prolonged retention
indicates obstruction to
lacrimal apparatus

11.  Primary test: a drop of 2%
fluoresceine is instilled into
conjunctiva..after 5 min.a
cotton bud is inserted
under inf.turbinate.
 Positive: Fluoresceine
recovered from nose
indicates patency of
drainage system.
negtive: no dye is
recovered ..indicates
partial obsruction or pump
failure
 Primary test differentiates
watering from partial
obstrctn from primary
hypersecretion of tears

12.  Secondary dye
test:the drainage
system is irrigated
with saline with a
cotton bud at
inf.turbinate.
 Positive: fluroscine
stained saline is
recovered..indicates
functional patency of
upper passages.
 Negative: unstained
saline recovered
indicates obstruction
of upper passages or
pump failure..

13.  Contrast
Dacryocystography:
for site ;extent &
nature of block
 Lacrimal
scintillography:
detects functional
efficiency of
lacrimal
apparatus(detected
using gamma
camera)

14.  Massage
 Probing
 Syringing
 Punctal dilation
 Antibiotic therapy
 Dacryocystorhinostomy
 conjuctivodacryocystorhinostomy
 Dacryocystectomy(done only if dcr is
contraindicated—age; chronic
diseases;fibrosed sac;tumours of sac)

15. Types: 1. conventional DCR
2. endonasal/endoscopic DCR
3. endolaser DCR

16. Steps:
 Under GA;curved incision along medial to medial
canthus is given
 Medial palpebral ligament is exposed by blunt
dissection to expose anterior lacrimal crest
 Periosteum is seperated from anterior lacrimal
crest & lacrimal sac is reflected laterally with
blunt dissector
 Expose nasal mucosa
 Probe is introduced into sac through lower
canaliculus & sac is incised vertically

18. Fashoning of nasal mucosal flaps by
converting them to H shape is done
Suturing of flaps by 6-0 vicryl is done
Medial palpebral ligament is sutured to
periosteum;orbicularis muscle sutured
with 6-0 vicryl
Skin is closed with 6-0 silk sutures
The success rate is over90%

19. INDICATIONS:
Failure of conservative
treatment
Chronic dacryocystitis
Failure of conventional DCR

20. STEPS:
Conjuctival sac is infiltrated with 2%
lignocaine
Identification of sac area with
endoscope & further inject
lignocaine.
Then the mucosa over frontal
process of maxilla is stripped.
A part of nasal process of maxilla is
removed.
The lacrimal bone is broken off
piecemeal.

21. Lacrimal sac is opened
Silicon tubes are passd through
the upper and lower
puncta,pulled out through ostium
and tied with in nose.
Nasal packing & dressing is done
The success rate is around 85%

22. Post op care:
 nasal packs removed
after 24hrs
 advice pt to use
decongestant;
antibiotics;steroid
nasal drops
 Remove stents after
8-12 wks
Complications:
Hemorrhage
Orbital
emphysema
Trauma to
canaliculi by tubes
Infection
Anastomotic block

23. causes of failure:
Inadequate bony
opening
Anastomotic block
Iatrogenic
obstruction
Nasal pathology
overlooked preop
contraindications
Lacrimal sac
tumours
Dacryoliths
Large abscess of
lacrimal sac

24. External DCR Endoscopic DCR
More success rate
Easy to perform
No scarring
Blood less surgery
Cheap
No need for endoscopic
skill
Better visualization
Less time consuming
Cutaneous scarring
Bleeding more
Less success rate
expensive
Postop morbidity more
More time
Requires skill

25. Using holmium YAG laser under
LA;DCR is done
quick procedure
Success rate is only 70%

27.  Endoscopic technique is able to treat
disorders of drainage system much more
successfully.
 The success rate is different in hands of
experienced and in experienced hands.
 The important things being right selection
of pt.s,site of incision and associated
anatomical defects.

28.  60 pts referred over a period of 10 yrs
from 1998 to 2008 were selected.
 Pts had undergone surgery else where and
referred due to persistence of symptoms
 All cases were revised and likely cause of
failure of 1st surgery was analysed.

29.  Assessment done as follows
1. Examination of eyes and lids
2. Watering or purulent discharge in medial
canthal area
3. ROPLAS(regurgitation on pressure over
lacrimal sac area) test done as a spot
diagnosis for NLD block.
4. Probing and syrenging
5. Examination of nose to rule out any high
posterior deviation of septum blocking the
rhinostomy or synechia formation.
6. Nasal endoscopy

30. No. Causes No.of
cases
Total no.of
cases
%
1. Improper selection 2 60 3.3%
2. Low rhinostomy 30 60 50%
3. Inadequate sac opening 17 60 38.5%
4. Contracture at rhinostomy 6 60 10%
5. Associated
canaliculitis(laser)
2 60 3.3%
6. Laxity of lids and atonic
area
2 60 3.33%
7. Pre existing canaliculitis 1 60 1.6%

31. What to do to improve success rates
of endoscopic DCR???
1.SELECTION OF CASES:
 Thorough assesment of lid,atonic
sac,canaliculi for block,canaliculitis is
required.
 Revision cases should be taken after ruling
out irreversible complications like charred
puncta,slitting of puncta.

32. 2.INCISION:
 Incision line should be extend above the
anterior end of middle turbinate.
 Incision should be at least 1 to 1.5 c.m. anterior
on the lateral wall.
 3.RHINOSTOMY:
 Height at which rhinostomy is made should be
judged by probing.
 Once the sac wall is removed,the lumen of the
sac should be inspected.

33.  4.FLAPS:
 The flap needs to be cut in the centre to
reposit the upper part up and lower part down.
 The lower half of the flap should not be too
small as it may slip between the lateral wall
and middle turbinate leading to nasal block
post op.
 5.STENTING:
 Stenting should never be done as primary
procedure
 Silicon stent should be avoided in revision cases
also unless there is associated canalicular
stenosis

34.  Despite much debate, many still believe that
external DCR provides a high success rates
than endoscopic DCR
 Though many types of endonasal approaches
have been attempted, long term success
rates are less than ext.DCR
 But if we take some imp. precautions we can
improve the success rates of endoscopic DCR.

35.  Kanski text book of opthalmology
 Khurana text book of opthalmology
 Endoscopic sinus srgery by Peter john
wormald