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DACRYOCYSTORHINOSTOMY DACRYOCYSTORHINOSTOMY
EXTERNAL EXTERNAL
VS VS
ENDOCANALICULAR DCRENDOCANALICULAR DCR
(ECL-DCR)(ECL-DCR)
IntroductionIntroduction
Epiphora is a relatively frequent Epiphora is a relatively frequent
problem in ophthalmology .problem in ophthalmology .
Standard surgery is Standard surgery is
Dacryocystorhinostomy.Dacryocystorhinostomy.
Recent advent of laser Recent advent of laser
technology.technology.
Inclusion CriteriaInclusion Criteria
Primary acquired nasolacrimal duct Primary acquired nasolacrimal duct
obstruction with / without chronic obstruction with / without chronic
dacryocystitisdacryocystitis
Patent canaliculiPatent canaliculi
Normal eyelid functionNormal eyelid function
Patients age less than 40 yearsPatients age less than 40 years
Exclusion CriteriaExclusion Criteria
Sac pathologySac pathology
History of previous sac surgeryHistory of previous sac surgery
Lacrimal fistulaLacrimal fistula
Turbinate hypertrophyTurbinate hypertrophy
Gross deviated nasal septumGross deviated nasal septum
Nasal Pathology(Atrophic Rhinitis,Polyp)Nasal Pathology(Atrophic Rhinitis,Polyp)
Pre-Operative EvaluationPre-Operative Evaluation
HistoryHistory
Clinical evaluationClinical evaluation
– Examination of lidsExamination of lids
– Assessment of punctumAssessment of punctum
– Examination of sac areaExamination of sac area
Nasal examination Nasal examination
Diagnostic TestsDiagnostic Tests
– Flourescein Dye Disappearance Test Flourescein Dye Disappearance Test
– Lacrimal syringingLacrimal syringing
Follow upFollow up
At 10th day, one and six months post surgery At 10th day, one and six months post surgery
Results were graded as :Results were graded as :
Full SuccessFull Success –– NO TEARSNO TEARS NO INFECTIONNO INFECTION NO REFLUXNO REFLUX
Partial SuccessPartial Success -- LESS TEARING THAN BEFORELESS TEARING THAN BEFOREPARTIAL REFLUXPARTIAL REFLUX
Surgical Failure Surgical Failure - - PERSISTENT TEARINGPERSISTENT TEARINGCLOSED OSTIUMCLOSED OSTIUM
1. Skin incision 1. Skin incision
2. Bone osteotomy 2. Bone osteotomy
3. Dissection of sac flap 3. Dissection of sac flap
4. Anastomosis of flap 4. Anastomosis of flap
Steps Of External DCR
Steps of External DCRSteps of External DCR
Procedure for ECL-DCRProcedure for ECL-DCR
Anesthetise the Anesthetise the nasal cavity nasal cavity with 10% with 10% Xylocaine spray Xylocaine spray
Dilate the Dilate the punctumpunctum
Probing. Probing. Feel the bone. Feel the bone.
WavelengthWavelength 980nm980nm
Optical powerOptical power 10 Watt10 Watt
Aiming BeamAiming Beam 635nm, 4mW; 635nm, 4mW; brightness brightness adjustableadjustable
Operating ModeOperating Mode cw, pulsedcw, pulsed
Dimensions (H x Dimensions (H x W x D)W x D)
12 X 26 X 3012 X 26 X 30
Weight Weight 5Kg5Kg
ProcedurProceduree
Keep the initial power at 7 watt. Keep the initial power at 7 watt. Insert the 600Insert the 600µ fiber into the µ fiber into the
cannaliculus upto the lacrimal bone.cannaliculus upto the lacrimal bone. Focus endoscope in a way that the Focus endoscope in a way that the
middle turbinate remains in central middle turbinate remains in central vision when the red aiming beam is vision when the red aiming beam is seen above or in front of the anterior seen above or in front of the anterior end of middle turbinateend of middle turbinate
Press the laser footswitch maintaining Press the laser footswitch maintaining moderate pressure against bone with moderate pressure against bone with the DCR cannula.the DCR cannula.
ProcedureProcedure
Fire the laser. Fire the laser. On any resistance from the bone or On any resistance from the bone or
sac, increase the power. sac, increase the power. Manipulate the cannula and keep firing Manipulate the cannula and keep firing
the laser to increase the size of the the laser to increase the size of the opening (4-5mm). opening (4-5mm).
Syringing at the end of the surgery Syringing at the end of the surgery with normal saline water, then with with normal saline water, then with dilute povidone iodine solution or dilute povidone iodine solution or Betadine, Betadine,
Steps of ECL-DCRSteps of ECL-DCR
Operative ComplicationOperative Complication
BleedingHard bone
None
S1
S2
21
22
7
2
16
0
5
10
15
20
25
CA
SE
S
COMPLICATIONS
OPERATIVE COMPLICATIONS
Series1
Series2
Operative Operative complicationscomplications
EXTERNALEXTERNALDCR DCR
ECL-ECL-DCRDCR
BleedingBleeding 7(28%)7(28%) 2(8%)2(8%)
Hard boneHard bone 2(8%)2(8%) 1(4%)1(4%)
NoneNone 16(64%)16(64%) 22(88%)22(88%)
SuccessSuccess
SuccessSuccess
Full Full succesucce
ssss
Partial Partial succesucce
ssssFailureFailure
EXTERNALDCREXTERNALDCR 23(92%)23(92%) 2(8%)2(8%) 00
ENDOLASERDCENDOLASERDCRR 21(84%)21(84%) 1(4%)1(4%)
3(12%3(12%))
EXTERNAL DCR
ENDOLASER DCR
23
20
21
1
3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
SUCCESS
Full success Partial success Surgical failure
Major Postoperative Major Postoperative ComplicationComplication
External DCR – Scar Related
Post operative complicationsPost operative complications
External DCRExternal DCR
Prominent scarProminent scar 80%80%
Faint scarFaint scar 20%20%
ECL DCR– Osteotomy Related
Major Postoperative Major Postoperative Complication Complication
ECL-DCRECL-DCR
Closure of osteotomyClosure of osteotomy 12%12%
Patent osteotomyPatent osteotomy 88%88%
ResultsResults
External External DCRDCR
EndocanalicEndocanalicular DCRular DCR
Full SuccessFull Success 92%92% 84%84%
Partial Partial SuccessSuccess
8%8% 4%4%
FailureFailure NilNil 12%12%
ResultsResults
The Success in the External The Success in the External
DCR :DCR :
--Immediate mucosa lined fistula Immediate mucosa lined fistula
via the closure of the mucosal via the closure of the mucosal
flaps.flaps.
ResultsResults
The failure in the laser DCR The failure in the laser DCR
group :group :
- Anatomic variations - Anatomic variations
- Post-operative inflammation and - Post-operative inflammation and
fibrosis.fibrosis.
- Inability to create an adequate Inability to create an adequate
opening.opening.
- Wrong selection of patients.Wrong selection of patients.
External DCR - The Gold External DCR - The Gold StandardStandard
Large bony osteotomy.Large bony osteotomy.
Lacrimal sac is exposed -Lacrimal sac is exposed -
canalicular DCR.canalicular DCR.
Success rate of 95%Success rate of 95%
Limitations of External Limitations of External DCRDCR
Per-operative haemorrhagePer-operative haemorrhage
Surgery is lengthy (variable).Surgery is lengthy (variable).
Risk of sump syndrome. Risk of sump syndrome.
Re-do surgery -fibrous tissue.Re-do surgery -fibrous tissue.
The cutaneous scar.The cutaneous scar.
Laser Procedures in Laser Procedures in DCRDCR
Advantage over Surgical Approach-Advantage over Surgical Approach-
-- Cutaneous Scarring is eliminated.Cutaneous Scarring is eliminated.
- Minimal tissue disruption.- Minimal tissue disruption.
-- Minimal bleeding.Minimal bleeding.- CSF leaks unlikely.CSF leaks unlikely.- Can be used in deabilitated patients.Can be used in deabilitated patients.
Definitive edge of EndoDefinitive edge of Endocanalicular DCRcanalicular DCR
Laser energy is directed away Laser energy is directed away from eye from eye
Ophthalmologist friendly.Ophthalmologist friendly. Nasal endoscopy and Nasal endoscopy and
Instrumentation unneccesary.Instrumentation unneccesary.
ConclusionsConclusions
Which procedure to Which procedure to choose????choose????
ConclusionsConclusions
PATIENT SELECTIONPATIENT SELECTION
-Right procedure for -Right procedure for right patientright patient
ConclusionsConclusions
DISCUSSION WITH PATIENT
•Viable option treatment.
•Discuss the advantages and disadvantages with patients.
ConclusionsConclusions
FOLLOW UP… More frequent and regular
follow-up for ECL-DCR patients
If two different techniques If two different techniques give the same result, use give the same result, use the one that is easier and the one that is easier and faster faster
But if a more difficult and But if a more difficult and longer operation yields a longer operation yields a superior result, use it .superior result, use it .