DACROCYSTORHINOSTOMY

(DCR)

MODERATOR:Dr.MOHANTYPRESENTER:D.RAVINDRA

ANATOMY OF LACRIMAL APPARATUS

PHYSIOLOGY 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

SECRETOMOTOR PATHWAY

DISEASES OF LACRIMAL APPARATUS Dacrocystitis(acute;chronic &

congenital) Canaliculitis Congenital nasolacrimal duct

obstruction Punctal stenosis Dacryoadenitis Sjogrens syndrome

EVALUATION 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

SYRINGING: 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

PROBING 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

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

it indicates common canalicular block

FLUORESCIEN DYE TEST Flourescein dye

injected into both conjuctval sacs & observed for 2 minutes…normally no dye is seen…

Prolonged retention indicates obstruction to lacrimal apparatus

JONES DYE TEST 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

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..

OTHER TESTS Contrast

Dacryocystography: for site ;extent &

nature of block Lacrimal

scintillography: detects functional efficiency of lacrimal apparatus(detected using gamma camera)

TREATMENT FOR DACROCYSTITIS Massage Probing Syringing Punctal dilation Antibiotic therapy Dacryocystorhinostomy conjuctivodacryocystorhinostomy Dacryocystectomy(done only if dcr is

contraindicated—age; chronic diseases;fibrosed sac;tumours of sac)

DACROCYSTO RHINOSTOMY(DCR)

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

CONVENTIONAL DCR 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

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%

ENDOSCOPIC DCR

INDICATIONS:Failure of conservative treatment

Chronic dacryocystitisFailure of conventional DCR

STEPS:Conjuctival sac is infiltrated with

2% lignocaineIdentification 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.

Lacrimal sac is openedSilicon 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%

Post op care: nasal packs

removed after 24hrs

advice pt to use decongestant;

antibiotics;steroid nasal drops

Remove stents after 8-12 wks

Complications:HemorrhageOrbital

emphysemaTrauma to

canaliculi by tubes

InfectionAnastomotic

block

causes of failure:

Inadequate bony opening

Anastomotic block

Iatrogenic obstruction

Nasal pathology overlooked preop

contraindications

Lacrimal sac tumours

DacryolithsLarge abscess

of lacrimal sac

External DCR Endoscopic DCR

More success rateEasy to perform

No scarringBlood less surgery

CheapNo need for endoscopic skill

Better visualizationLess time consuming

Cutaneous scarringBleeding more

Less success rateexpensive

Postop morbidity moreMore time

Requires skill

ENDO LASER DCR Using holmium YAG laser under

LA;DCR is done quick procedure Success rate is only 70%

JOURNAL

IMPROVING RESULTS IN ENDOSCOPIC DCR

INTRODUCTION

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.

MATERIALS AND METHODS

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.

Assessment done as follows

1. Examination of eyes and lids2. Watering or purulent discharge in medial

canthal area3. ROPLAS(regurgitation on pressure over

lacrimal sac area) test done as a spot diagnosis for NLD block.

4. Probing and syrenging5. Examination of nose to rule out any high

posterior deviation of septum blocking the rhinostomy or synechia formation.

6. Nasal endoscopy

RESULTSNo. Causes No.of

casesTotal 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%

DISCUSSION

What to do to improve success ratesof 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.

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.

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

CONCLUSION 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.

BIBLIOGRAPHY Kanski text book of opthalmology Khurana text book of opthalmology Endoscopic sinus srgery by Peter john

wormald

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