This presentation describes the causes and presentation of Epiphora and describe the technique of Endoscopic DCR surgery.

1. ENDOSCOPIC -
DCR
MADE EASY
Dr. Ausaf Ahmed Khan
Professor & Head of Department
ENT/Head and Neck Surgery
Hamdard College of Medicine &
Dentistry
Hamdard University, Karachi

2. 2

3. Topics
 Introduction
 Epiphora
 Causes of epiphora
 Applied &
endoscopic anatomy
of lacrimal
apparatus
 Importance of
endoscopic-DCR
 Endo vs. external
DCR
 Technique of
endoscopic-DCR
 Tips and pearls
 Causes of failure

4. Epiphora
 Epiphora (excessive tearing) is a common
complaint.
 From minor inconvenience to extremely troublesome : a
source of social embarrassment.
 Partial or complete hindrance to lacrimal flow 
stagnation of fluid and debris  purulent infection.
 Lacrimal flow obstruction leads to ; epiphora, mucus
discharge, excessive mattering, conjunctivitis, visual
fluctuations of varying degree, peri-ocular swelling,
dermatitis/cellulitis & abscess formation.
 Estimated incidence of nasolacrimal obstruction :
 approximately 10 % at 40 years,

6. Epiphora/Excessive tearing
causes
 Irritation of eyes
 Foreign Bodies
 Ingrown eyelashes
 Eye infections
 Punctal stenosis
 Misplaced/abnormal puncta
 Congenital malformations
 NLD blockage
 Dacryocystitis
 Dacryoliths
 Defective blink reflex
 Ectropion
 Entropion
 Facial trauma
 Facial palsy
 Canalicular atresia
 NLD stenosis in old age
 Nasal masses/infections
 Lower lid laxicity
 Growth in the sac
 Secondaries in sac region

7.  Obstruction of the NLD usually present with
epiphora, it may also present with a mucocoele,
pyocoele or recurrent acute dacryocystitis.
 In majority of the cases : cause of obstruction is
unknown.
 Endoscopic-Dacryocystorhinostomy (DCR) is a well
established treatment for epiphora caused by
anatomic or functional obstruction of the
Nasolacrimal apparatus.
 A thorough understanding of the endonasal
anatomy, wide marsupialization of the lacrimal
Epiphora

8. Anatomy of the
Lacrimal Apparatus

9. Anatomy of Lacrimal
apparatus
1. Lacrimal Gland
2. Lacrimal Ducts
3. Lacrimal Puncta
4. Lacrimal
Canaliculi
5. Lacrimal Sac
6. Naso-lacrimal
Duct
7. Valves

10. Anatomy of Lacrimal apparatus
1 – Lacrimal GLAND & Ducts

11. Anatomy of Lacrimal apparatus
2 – Lacrimal PUNCTA
U/L Punctum width : 0.1-0.4mm
Distance from med. canthus:
0.6mm

12. Anatomy of Lacrimal apparatus
3 – Lacrimal CANALICULI Vertical part : 2-2.5
mm
Ampulla : V/H junction
90
Horizontal part : 7-10 mm
Common canaliculus : 1-3
mm

13. Lacrimal probing


14. Anatomy of Lacrimal apparatus
4 – The Lacrimal SAC
Lacrimal sac

15. Medial wall of right orbit… FP frontal process of maxilla, ALC anterior
lacrimal crest, PLC posterior lacrimal crest, H hammulus, LMS lacrimo-
maxillary suture, FES fronto-ethmoid suture,
LP lamina papyracea, LB lacrimal bone, AF anterior foramen (AE Artery), PF
LF

16. Anatomy of Lacrimal apparatus
4 – The Lacrimal SAC

17. Anatomy of Lacrimal apparatus
5 – Naso-lacrimal DUCT (NLD)
Right nasolacrimal canal. View from the lacrimal
fossa.

18. Anatomy of Lacrimal apparatus
5. Naso-lacrimal DUCT
(NLD)
ILP
SLC
SLP
ILC
CC
NLD
Cadaver dissection of the Lacrimal drainage system
LS
*
*

19. Projection of Lacrimal system canal in the LNW of Rt. nasal
cavity.
L projection of the lacrimal system, MT middle turbinate, IT
inferior turbinate, ST superior turbinate
*

20. View through opening in the middle turbinate. FS frontal sinus, LC lamina
cribrosa, FP frontal process, UP uncinate process, HS hiatus semilunaris,
BE bulla ethmoidalis, MT middle turbinate, LD lacrimal duct, IT inferior
turbinate, SS sphenoid sinus
*

21. Sagittal view outlining the lacrimal sac (S) and duct (D).
Small arrows denote the common wall with the agger nasi cell.

22. Sagittal view with the lacrimal sac and duct marsupialized by completely
removing the medial bony and membranous wall.

24. (a) Lacrimal system,
Endoscopic view.
FP frontal process of maxilla,
ML maxillary line,
LB lacrimal bone.
*
(b) Dissection of the lacrimal system,
Endoscopic view.
FP frontal process of maxilla,
IT inferior turbinate, LD lacrimal duct,
LP lamina papyracea, S septum
UP uncinate process, MT middle turbinate,

25. Anatomy of Lacrimal apparatus
7 – VALVES
• Valves allow unidirectional flow of tears
 THE VALVE of ROSENMULLER – situated at the
internal opening of the common canaliculus within the
lacrimal sac.
 THE VALVE OF HASNER – lies at the distal
opening of the lacrimal duct at the inferior meatus
*
*

27. History of DCR
 Caldwell in 1893 – first reported case of intranasal DCR
 Created a rhinostomy using an intranasal approach by removing
a portion of the inferior turbinate and following the nasolacrimal
duct to the lacrimal sac – did not gain popularity.
 Toti in 1904 – credited with first description of an
external approach : is gold standard traditional surgical
approach.
 Modified by Louis Dupuy-Dutemps and Bourguet.
 Resurgence of interest in endoscopic technique
 Steadman and McDonagh and Meiring in1980s.
 Massaro et al. produced the first report using an Argon
laser
 Gonnering et al. later reported using both the CO2 and KTP

28. Indications of DCR
 Symptomatic distal obstruction of the
Nasolacrimal duct that is not relieved
by simple probing and syringing.
 It is NOT indicated as the sole procedure where the
site of obstruction lies in the canaliculi or puncti.
 In case of functional obstruction (as evidenced by
free flow on syringing along with failure of the pump
system on scintigraphy) a DCR may be performed but
the results tend to be variable.

29.  The key for a correct indication is to exclude a
presaccal stenosis, which is not suitable for an
endoscopic procedure.
 The best method to assess the site of obstruction
consists of probing the lacrimal pathways: If it is possible
to pass the proximal canaliculi (superior and inferior) and to
enter the superior third of the lacrimal sac through the
common canaliculus, a presaccal obstruction can be
excluded.
 Fluorescein dye tests (Jones I and II) or
dacryocystographies (of any type) are no longer
performed.
 Since dacryocystographies use a probe to apply the
contrast, there is no further need for a radiological

30. Indications for surgery
 Indications for External or Endoscopic-DCR
 NLD and common canalicular obstruction with
epiphora.
 Dacryocystitis.
 Symptomatic dacryoliths.
 External DCR is chosen over Endo-DCR
 Trauma with medial canthal avulsion
 Suspected lacrimal sac diverticuli
 Lacrimal sac malignancy
 Pts with Down’s Syndrome ?

31. Comparison of the 3 techniques of
DCR

32. Advantages of Endoscopic
DCR
 It provides better aesthetic result with no
external scar.
 It allows a one-stage procedure to also correct
associated nasal pathology that may be causative.
 It avoids injury to the medial canthus /scar formation.
 It preserves the pumping mechanism of the orbicularis
oculi ms..
 Active infection of the lacrimal system is not a
contraindication to endoscopic surgery.
 It is superior to the external approach in revision
surgery.
 It is much less bloody and messy than the external

33.  It requires specialized training in nasal
endoscopic surgery.
 The endoscopic equipment/setup is
expensive.
 Need an “open-minded” ophthalmology
colleague ……
Hindrances in doing Endoscopic
DCR

34. Pre-operative assessment
 Careful history
 Examination
 Assessment of eyelids, tear film & lacrimal apparatus
 Rule out reasons for irritaive sources causing
excessive lacrimation; dry eyes, blepharitis, trichiasis,
topical medications and exposure
 Eyelid malposition; ectropion, entropion, horizontal
laxicity
 Punctal anomalies; eversion, stenosis, conjunctival
overlay.

35. Pre-operative assessment
 Office assessment of nasal cavity with nasal
speculum and endoscope.
 Identify pathologies like DNS/spur, AR, acute
infections, nasal polyps and malignancies etc.
 Treat any acute infection or severe allergic
rhinitis before surgery
 Avoid NSAID’s, anticoagulants before surgery.

36. Pre-operative considerations
 Surgery is performed under general anesthesia
(hypotensive anesthesia)
 The nose is prepared with +/- local injections and
vasoconstrictive neurosurgical cottonoids.
 Infiltrate 2% Xylocaine with adrenaline into the axilla
of the middle turbinate and frontal process of maxilla
 Place cottonoids soaked in xynosine/adrenaline in the
middle meatus, along the frontal process of the
maxilla and adjacent to the septum : GIVE ENOUGH
TIME
 Avoid unnecessary manipulation of endoscope and
instruments during packing, avoid mucosal trauma
esp. MT

37.  A septoplasty is performed in case of an
obstructing septal deflection.
 The septal incision is ideally placed on the side
contralateral to the DCR:
 This prevents inadvertent trauma to the septal
flap when the endoscope is inserted into the
nasal cavity.
 It minimizes clouding of the endoscope with blood
from the septal incision.
 Reduces the potential for the development of
postoperative synechiae between the septum and
LNW.

38. Endoscopic-DCR : made EASY

39. Instruments needed for
Endoscopic-DCR
 0 and 30 degree
endoscopes
 Light
source/Camera/monitor
 Suction
 No. 15 surgical blade
 Pointed diathermy
 Plester knife
 Rosen’s knife
 Sickle knife
 House (meatal) elevator
 Suction elevator, Freer’s
 Kerrison bone punch
 Hajek-Kofler punch
 Blakesely forceps
 Thru-cut forceps
 Ball probe
 Lacrimal probe
 Punctal dilator
 DCR tube

40. Inspection and
Identification of landmarks

41. Inspection and
Identification of landmarks
UP
B

45. Dimensions of lacrimal sac/flap
The lacrimal sac extends approx.
10 mm above the axilla of MT.

46. Topical and local anesthesia
Perform a septoplasty if needed:
Limited access restricts surg.

48. Dimensions of the nasal mucosal flap
A 30 endoscope provides
better view of LNW.

49. Endoscopic view showing incision to
create a posteriorly based mucosal
flap to expose the lacrimal bone and
frontal process of the maxilla.
Endoscopic view of the raising
of the mucosal flap.

50. Incision given by #15 blade

51. The lacrimal sac extends approx.
10 mm above the axilla of MT.

52. Incision given by monopolar diathermy

53. Elevation of flap

55. Removal of flakes of Lacrimal bone

56. The lacrimal bone extends from the FP of maxilla anteriorly
to the attachment of the uncinate process posteriorly.
This retrolacrimal region of the lamina papyracea is
extremely thin, and inadvertent disturbance of the uncinate at
this point can lead to orbital penetration.
Remember that the lacrimal bone and sac lie anterior to the
orbit, and therefore the orbit is not at risk unless the surgeon
is inadvertently posterior to these landmarks.

57. Removal of flakes of Lacrimal bone
Using Sickle and Rosen knifes

58. Removal of flakes of Lacrimal bone
Using Sickle and Rosen knifes
Remove the lacrimal bone up to the
insertion of the uncinate : do not
disturb the uncinate itself.
This retrolacrimal region where the
uncinate inserts into the lamina
papyracea is extremely thin, and
inadvertent orbital injury might result.

59. Bone removal
using
Kerrison forceps
or
Hajek-Kofler punch

60. Kerrison forceps
Bone-punch
Hajek-Kofler punch
 The Hajek-Koffler punch is faster at removing
bone than the DCR bur : Perform as much of the
removal of the hard bone of the frontal process of
the maxilla with the Hajek-Koffler punch

61. Superior bone removal
When using the Hajek-Koffler punch,
release the jaws after each bite : this will
prevent inadvertent trauma to sac.

62. Use of DIAMOND BURR for bone removal
 Use diamond burr only when the punch
is unable to grip the bone adequately.

63. LS
NLD
Fl
AN
Very adequately exposed LS & NLD

64. Incising flap
using KERATOME
Tenting the sac
using lacrimal probe
Make an incision into the sac only when lacrimal
probe can be clearly seen through the sac wall.

65.  When probing the lacrimal system, do so
delicately : avoid trauma and a false passage.

66. Sac completely opened

67. Incision without
inserting probe

68. f
Flap opened using 15 blade
Flap marsupialized and gelfoam placed
The common canaliculus opens
high up on the lateral wall of the
sac, and this area must be
exposed in DCR for best results.

69. Flood of pus

70. Horizontal incision
using SICKLE knife

71. Flap marsupialized
Approximation of nasal flap
with sac wall using ball probe

72. Trimming of mucosal flap
Final approximation of flaps

73. Final approximation of flaps

74. Use of DCR tube
 Working as a team with an
oculoplastic surgeon : they have
requisite skills in probing and
examining the lacrimal system.

75. Causes of failure of DCR
 Inadequate osteotomy,
 Incomplete sac marsupialization,
 Cicatricial closure of the ostium
 Granuloma formation