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
THANK YOU
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