ENDOSCOPIC DACRYOCYSTORHINOSTOMY

1. ENDOSCOPIC DCR

2. Anatomy of the
Lacrimal Apparatus

3. 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

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

5. Anatomy of Lacrimal apparatus
2 – Lacrimal PUNCTA
U/L Punctum width : 0.1-0.4mm
6 mm from med. Canthus

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

7. Lacrimal probing


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

9. Anatomy of Lacrimal apparatus
4 – The Lacrimal SAC

10. 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
*

11. 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
*

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

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

15. (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,

16. 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
*
*

18. Epiphora
Epiphora --Obstrction is either anatomic (70%) or
functional (30%).
• This includes complete blockages anywhere from the
lacrimal punctum to the nasal cavity.
• Functional obstructions--result of either significant
narrowing within the lacrimal system that delays normal
lacrimal flow or a failure of the lacrimal pumping
mechanism.
Dacrocystorhinostomy (DCR) is performed to relieve
epiphora resulting from an obstruction of the nasolac-
rimal system.
The majority of nasolacrimal system obstruction is
unknown

19. History of DCR
• Caldwell – 1st intranasalDCR – 1893 – removed a portion
• of IT & followed NLD till the sac.
• Mosher – tried intranasal approach – 1921 – but later converted to
combined.
• Toti– First external DCR – 1940 – for relief of lacrimal obstruction.
• Advent of endoscope (1950s) – revived the intranasal approach – no scar
and excellent visualisation.
• Now, all DCRs performed with endoscope by ENT surgeon as 80% of
lacrimal pathway is nasal.
• Massaro – 1st reported use of laser (argon blue-green) to aid endonasal
DCR.
• Later Gonnering reported CO2 & KTP laser also.

20. INDICATIONS-DCR
• Persistent epiphora due to chronic dacryocystitis.
• Nasolacrimal duct obstruction
• Secondary causes of lacrimal obstruction like
• trauma,
• infection,
• neoplasm and
• lacrimal stones.
• If canaliculi are obstructed, a conjunctivo-dacryocystorhinostomy
is necessary in order to bypass the blockage and drain tear fluid
directly into the nasal cavity through a Jones tube.

22.  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.
 External DCR is chosen over Endo-DCR
Trauma with medial canthal avulsion
Suspected lacrimal sac diverticuli
Lacrimal sac malignancy
Presacal obstruction

23. Pre-operative assessment
 Careful history & clinical examination
 Examination -eye
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.

24. Epiphora
◆ Punctal stenosis. Obliteration or narrowing of the superior
or inferior punctum.
◆ Canalicular stenosis or obstruction. Superior or inferior
canalicular stenosis or obstruction may follow trauma or
viral infection.
◆ Nasolacrimal duct blockage. Usually from unknown cause.

25. ---ASSESSMENT--
• Massaging or gentle pressure over sac –Regurgitation test
– If discharge from puncti  chronic dacryocystitis
– If bloody discharge  malignancy ?
• Swelling inferolateral to med canthus
 mucocoele

26. ---ASSESSMENT--
• Syringing –
– inability to flush  obstruction at punctum or inf canaliculus.
– Reflux through other canaliculus  more distal obstruction
– Free flow – no obstruction

27. ---ASSESSMENT--
• Probing with a ‘0’ bowman’s probe –
assist in confirming the level of obstruction.

28. Fluorescene 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

29. 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

30. 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..

31. Pre-operative assessment
 EXAMINATION –Nose
 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

32. Dacryocystogram
Contrast Dacryocystography:
for site ;extent &
nature of block.
DCG assesses anatomy but not
function.

33. Lacrimal Scintillography
Lacrimal
scintillography:
detects functional
efficiency of lacrimal
apparatus (Syringing
will be normal)-- Using
radionucleotide 99mTc
(detected using
gamma camera)

34. Operative Techniques
1. External DCR
2. Endoscopic DCR
3. Endonasal laser assisted DCR

35. Pre-operative considerations
 Surgery is performed under general anesthesia
(hypotensive anesthesia)/LA
 The nose is prepared with cottonoids soaked in
xylocaine & adrenaline .
Infiltrate 2% Xylocaine with adrenaline into the axilla
of the middle turbinate and frontal process of maxilla
 Avoid unnecessary manipulation of endoscope and
instruments during packing, avoid mucosal trauma
esp. MT

36.  A septoplasty is performed in case of an
obstructing septal deviation.
 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.

37. 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
 Lacrimal syringe

38. steps
• Incision- in the mucosa overlying ant lacrimal
crest (white vertical ridge immediately ant to
MT)
• Posteriorly based muco-perichondrial flap raised
• Ant lacrimal crest removed using a punch
• Post to ant lacrimal crest & just lat to UP lies thin
bone – resected
• Sac is exposed, has a dark red colour & firmer than nasal mucosa
• Sac divided vertically with either sickle knife or 45 degree beaver scalpel
• Aprobe placed within the sac, tenting it medially, facilitates incision
• Microscissors used sup & inf to create ant & post flaps
• These flaps of sac mucosa are then placed in continuity with nasal
mucosa
• Astent can be inserted if required.
• Adv - Lacrimal sac is widely exposed, common canaliculus can often be
seen

39. Inspection and
Identification of landmarks

40. Inspection and
Identification of landmarks
B
UP

42. Dimensions of the nasal mucosal flap

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

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

45. Incision given by #15 blade

46. Elevation of flap

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

49. 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.

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

51. 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

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

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

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

58. 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.

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

60. Sac completely opened
Flood of pus

62. 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.

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

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

67. Postoperative Care
•Saline nasal spray - within 3 to 4 hours of surgery.
clear blood clots
keep the nasal cavity moist
clear of secretions
•Avoid blowing of the nose
• Broad-spectrum antibiotics for 7 days
• Antibiotic eye drops for 3 weeks.
• If O’Donoghue tubes were placed, they are removed after 4
weeks
Patency of the nasolacrimal system checkedby placing a drop
of fluorescein in the conjunctiva and endoscopically monitoring
the flow of fluorescein from the conjunctiva to the nose.
• If granulations are present they should be removed.

68. Complications
• Epistaxis, occurring in 2% of patients
• obstruction and subsequent rhinosinusitis of the frontal or
maxillary
sinus,
• orbital penetration with damage to the extraocular muscles,
• orbital haematoma
• cerebrospinal fluid leak .

69. 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 than the external

71. Comparison of the 3 techniques of
DCR

72. T
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