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 Tears secreted by lacrimal glands pass
through laterally across ocular surface to
lower canaliculi
 They finally pass t...
Lacrimal gland
Zygomatic & zygomatico temporal nerve
Pterygopalatine ganglion
Nerve of pterygoid canal
Greater petrosal ne...
Dacrocystitis(acute;chronic &
congenital)
Canaliculitis
Congenital nasolacrimal duct
obstruction
Punctal stenosis
Dac...
 OCULAR EXAMINATION:
to rule out conditions
of uvea ;cornea &
conjuctiva resulting in
lacrimal apparatus
disease
 REGURG...
 normal saline is
pushed into
laacrimal sac from
lower punctum
with a syringe
after instillation
of 4% xylocaine.
 Free ...
 After topical anaesthesia, curved lacrimal
cannula on a saline filled syringe is gently
inserted into lower punctum & ad...
Soft stop:it comes
to stop at junction
of common
canaliculus &
lacrimal
sac(lateral wall)….
it indicates
common
canalicu...
 Flourescein dye injected
into both conjuctval sacs
& observed for 2
minutes…normally no dye
is seen…
 Prolonged retenti...
 Primary test: a drop of 2%
fluoresceine is instilled into
conjunctiva..after 5 min.a
cotton bud is inserted
under inf.tu...
 Secondary dye
test:the drainage
system is irrigated
with saline with a
cotton bud at
inf.turbinate.
 Positive: flurosci...
 Contrast
Dacryocystography:
for site ;extent &
nature of block
 Lacrimal
scintillography:
detects functional
efficiency...
 Massage
 Probing
 Syringing
 Punctal dilation
 Antibiotic therapy
 Dacryocystorhinostomy
 conjuctivodacryocystorhi...
Types: 1. conventional DCR
2. endonasal/endoscopic DCR
3. endolaser DCR
Steps:
 Under GA;curved incision along medial to medial
canthus is given
 Medial palpebral ligament is exposed by blunt...
Fashoning of nasal mucosal flaps by
converting them to H shape is done
Suturing of flaps by 6-0 vicryl is done
Medial p...
INDICATIONS:
Failure of conservative
treatment
Chronic dacryocystitis
Failure of conventional DCR
STEPS:
Conjuctival sac is infiltrated with 2%
lignocaine
Identification of sac area with
endoscope & further inject
lign...
Lacrimal sac is opened
Silicon tubes are passd through
the upper and lower
puncta,pulled out through ostium
and tied wit...
Post op care:
 nasal packs removed
after 24hrs
 advice pt to use
decongestant;
antibiotics;steroid
nasal drops
 Remove ...
causes of failure:
Inadequate bony
opening
Anastomotic block
Iatrogenic
obstruction
Nasal pathology
overlooked preop
...
External DCR Endoscopic DCR
More success rate
Easy to perform
No scarring
Blood less surgery
Cheap
No need for endos...
Using holmium YAG laser under
LA;DCR is done
quick procedure
Success rate is only 70%
 Endoscopic technique is able to treat
disorders of drainage system much more
successfully.
 The success rate is differe...
 60 pts referred over a period of 10 yrs
from 1998 to 2008 were selected.
 Pts had undergone surgery else where and
refe...
 Assessment done as follows
1. Examination of eyes and lids
2. Watering or purulent discharge in medial
canthal area
3. R...
No. Causes No.of
cases
Total no.of
cases
%
1. Improper selection 2 60 3.3%
2. Low rhinostomy 30 60 50%
3. Inadequate sac o...
What to do to improve success rates
of endoscopic DCR???
1.SELECTION OF CASES:
 Thorough assesment of lid,atonic
sac,can...
2.INCISION:
 Incision line should be extend above the
anterior end of middle turbinate.
 Incision should be at least 1 ...
 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 ...
 Despite much debate, many still believe that
external DCR provides a high success rates
than endoscopic DCR
 Though man...
 Kanski text book of opthalmology
 Khurana text book of opthalmology
 Endoscopic sinus srgery by Peter john
wormald
DACROCYSTORHINOSTOMY(D.C.R.)by dr.ravindra
DACROCYSTORHINOSTOMY(D.C.R.)by dr.ravindra
DACROCYSTORHINOSTOMY(D.C.R.)by dr.ravindra
DACROCYSTORHINOSTOMY(D.C.R.)by dr.ravindra
DACROCYSTORHINOSTOMY(D.C.R.)by dr.ravindra
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DACROCYSTORHINOSTOMY(D.C.R.)by dr.ravindra

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dacrocystorhinostomy,,advantages and dis advantages of both external and endoscopic d.c.r.

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Transcript of "DACROCYSTORHINOSTOMY(D.C.R.)by dr.ravindra"

  1. 1.  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
  2. 2. Lacrimal gland Zygomatic & zygomatico temporal nerve Pterygopalatine ganglion Nerve of pterygoid canal Greater petrosal nerve Geniculate ganglion Nervus intermedius SUPERIOR SALIVATORY NUCLEUS & NTS LACRIMAL NUCLEUS
  3. 3. Dacrocystitis(acute;chronic & congenital) Canaliculitis Congenital nasolacrimal duct obstruction Punctal stenosis Dacryoadenitis Sjogrens syndrome
  4. 4.  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
  5. 5.  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
  6. 6.  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
  7. 7. Soft stop:it comes to stop at junction of common canaliculus & lacrimal sac(lateral wall)…. it indicates common canalicular block
  8. 8.  Flourescein dye injected into both conjuctval sacs & observed for 2 minutes…normally no dye is seen…  Prolonged retention indicates obstruction to lacrimal apparatus
  9. 9.  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
  10. 10.  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..
  11. 11.  Contrast Dacryocystography: for site ;extent & nature of block  Lacrimal scintillography: detects functional efficiency of lacrimal apparatus(detected using gamma camera)
  12. 12.  Massage  Probing  Syringing  Punctal dilation  Antibiotic therapy  Dacryocystorhinostomy  conjuctivodacryocystorhinostomy  Dacryocystectomy(done only if dcr is contraindicated—age; chronic diseases;fibrosed sac;tumours of sac)
  13. 13. Types: 1. conventional DCR 2. endonasal/endoscopic DCR 3. endolaser DCR
  14. 14. 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
  15. 15. 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%
  16. 16. INDICATIONS: Failure of conservative treatment Chronic dacryocystitis Failure of conventional DCR
  17. 17. STEPS: Conjuctival sac is infiltrated with 2% lignocaine Identification 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.
  18. 18. Lacrimal sac is opened Silicon 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%
  19. 19. Post op care:  nasal packs removed after 24hrs  advice pt to use decongestant; antibiotics;steroid nasal drops  Remove stents after 8-12 wks Complications: Hemorrhage Orbital emphysema Trauma to canaliculi by tubes Infection Anastomotic block
  20. 20. causes of failure: Inadequate bony opening Anastomotic block Iatrogenic obstruction Nasal pathology overlooked preop contraindications Lacrimal sac tumours Dacryoliths Large abscess of lacrimal sac
  21. 21. External DCR Endoscopic DCR More success rate Easy to perform No scarring Blood less surgery Cheap No need for endoscopic skill Better visualization Less time consuming Cutaneous scarring Bleeding more Less success rate expensive Postop morbidity more More time Requires skill
  22. 22. Using holmium YAG laser under LA;DCR is done quick procedure Success rate is only 70%
  23. 23.  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.
  24. 24.  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.
  25. 25.  Assessment done as follows 1. Examination of eyes and lids 2. Watering or purulent discharge in medial canthal area 3. ROPLAS(regurgitation on pressure over lacrimal sac area) test done as a spot diagnosis for NLD block. 4. Probing and syrenging 5. Examination of nose to rule out any high posterior deviation of septum blocking the rhinostomy or synechia formation. 6. Nasal endoscopy
  26. 26. No. Causes No.of cases Total 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%
  27. 27. What to do to improve success rates of 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.
  28. 28. 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.
  29. 29.  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
  30. 30.  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.
  31. 31.  Kanski text book of opthalmology  Khurana text book of opthalmology  Endoscopic sinus srgery by Peter john wormald
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