College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
Endoscopic DCR Made Easy
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
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,
5.
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
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
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.
23.
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
*
*
26.
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 ?
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.
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.
47.
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.
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.
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.
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.
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.
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.
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
Editor's Notes
The first report of dacryocystorhinostomy (DCR) was by Caldwell in 1893. An ENT surgeon by profession, Caldwell created a rhinostomy using an intranasal approach by removing a portion of the inferior turbinate and following the nasolacrimal duct to the lacrimal sac. As can be imagined this would have involved considerable skill given the equipment available at the time and it did not gain popularity. Toti, in 1904, is credited with first description of an external approach more than a decade after Caldwell had described the operation via the endonasal approach. The external approach was subsequently modified by many surgeons including Dupuy- Dutemps and Bourget, who emphasized the importance of sutured mucosal flaps.
With the development of modern nasal endoscopes almost 100 years later a resurgence of interest in the endonasal approach has taken place. The early results by this approach included those described by Steadman and McDonagh and Meiring although the instruments in the 1980s were not ideal and these have since been refined with improved results.
Massaro et al. produced the first report using a laser technique to aid endonasal DCR using an argon bluegreen laser, and Gonnering et al. subsequently reported using both the CO2 and KTP laser.
=======================----------------------================
is a gold standard
traditional surgical approach to treat nasolacrimal
duct obstruction.3,7 Success rate of other techniques
is measured and compared with this method.3
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 elsewhere in the canaliculi or puncti.
In many patients there is some proximal obstruction associated with distal blockage. In such cases, gentle probing and dilatation in conjunction with a DCR and insertion of stents can be performed although the results of such an approach are not as favourable.
Where functional obstruction exists as evidenced by free flow on syringing along with failure of the pump system on scintigraphy, a DCR may be performed but the results of such an approach tend to be variable, indicating that relying on gravity to drain the tears is often insufficient.
===========================------------------------------------
In general, a DCR is indicated where there is 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 elsewhere in the canaliculi or puncti as the operation will not bypass these areas.
In many patients there is some proximal obstruction associated with distal blockage. In such cases, gentle probing and dilatation in conjunction with a DCR andinsertion of stents can be performed although the results of such an approach are not as favourable in cases of pure distal blockage.
Where functional obstruction exists as evidenced by free flow on syringing along with failure of the pump system on scintigraphy, a DCR may be performed but the results of such an approach tend to be variable, indicating that relying on gravity to drain the tears is often insufficient although one recent report provides excellent results.
As 90 percent of tears drain through the inferior canaliculus, obstruction of this or the common canaliculus can be bypassed but requires a more extensive procedure
constant versus intermittent tearing
periods of remission versus no remission
unilateral or bilateral condition
subjective ocular surface discomfort
history of allergies
use of topical medications
history of probing during childhood
prior ocular surface infections
prior sinus disease or surgery, midfacial trauma, or nasal fracture
previous episodes of lacrimal sac inflammation
clear tears versus tears with discharge or blood