How to do endoscopic DCR

1. Endoscopic
DCR
Dr. Saied Alhabash
ENT Dep. Damascus
University
Medcare Sharja Hospital

4. FESS Intercontinental ESS
• Rhinology
• Neurosurgery
• Ophthalmology

5. Strength of recommendation/EBM
CRTs
CTs
Others
Experience
Just because
D
C
B
A
X

6. Indications of ESS in Ophtalmology
•Endoscopic DCR
•Exophthalmus
•Optic nerve decompression
•ENdoscopic Orbital Surgery

7. Causes of nasolacrimal duct
obstruction
-Recurrent acute dacryocystitis
-Blockage of the lacrimal duct due to
nasal allergy
septal deviation
sinusitis
tumors
- Other causes such as: surgical trauma, radiation
therapy, external trauma.

8. acute dacryocystitis
acute dacryocystitis

9. Indications for DCR
• Distal obstruction in the lacrimal system
(lacrimal sac and NLD)

10. The key to successful endoscopic
DCR is identification of the full
extent of the lacrimal sac
• Two bones should be identified because
they cover the lacrimal sac : The
Ascending (frontal) Process of Maxilla, The
lacrimal bone .
• You should expose the the widest area of
the sac to get the best results .
• The larger the the opening ,the better the
results.

11. Preoperative measures
• CT scan
• Endoscopic examination of the nose

12. CT scan
CT scan is useful to help to locate the site of the sac, also to diagnose
nasal causes of NLD obstruction

13. Nasal Endoscopy
Middle Turbinate & site
of the sac
MT
Middle meatus , bulla
ethmoidalis
MT
BE
Observe the following structures

14. Nasal Endoscopy
Inferior turbinate Inferior meatus and NLD orifice
I T I T

15. Normal Duct Orifice In Inf. Meatus

16. Methods of Localizing the Site of
Nasal Window Opposite The Sac
1- Anatomical Landmarks
2- Preoperative CT scan
3- Transillumination
4- Probing
5- Measuring the distance

17. Anatomical Landmarks

18. Localization With Preop. CT
Scan
Axial CT shows that the sac lies little
behind the anterior end of middle turbinate

19. Trans-illumination
A fiberoptic light source is put over the site of the sac , the room
is darkened and the trans-illuminated light is observed through
the sac.

20. Trans-illumination
Endoscopic observation of the
transilluminated site
Turn on endoscopic light and
localize the site of the sac

21. Localization with
probing
1-Dilatation of a narrow punctum.
2- introduction of the lacrimal
dilator in a vertical direction
3- then change to horizontal
direction
1
2
3

22. Probing
Push the dilator in a horizontal direction to perforate the
lacrimal bone and observe its exit through the nose

23. Measuring The Distance
Just before drilling the window: The distance of the sac from the
nasal aperture is measured from outside with the drill. The drill is
then introduced in the nose for the same distance and direction

24. Steps of Endoscopic DCR

25. Incision and Elevation of
Mucosa
Incision is done at the site
of the sac
Mucosa flap is elevated using
Cottle dissector

26. Some surgeons use cautery instead of
mucosal flap.

31. Making a Bone Window
This is done by drilling the
bone opposite the sac
A bone cutting (Blacksly) forceps
or punch (Karrison) is also used to
remove bone fragments

32. Introduction Of The Silicone Tube
The probe is first introduced
through the lower punctum
Then pushed towards the
nosal window

33. Introduction Of The Silicone Tube
Endoscopic ispection of the
probe in the nose
Extraction of the probe with the
silicone tube attached to it

36. Introduction Of The Silicone Tube
The silicone tube is seen in the lower
punctum (white arrow)
The probe of the other end of the tube is
introduced in the sup. punctum
Then pushed towards
the nose (balck arrow)

37. Introduction Of The Silicone Tube
Both ends of the tube are extracted
from the nose
They are tied together and
with black silk thread

38. Final Check
Check the tube at the lacrimal
puncta
….and at the nasal window
using the endoscope .

39. Endoscopic Correction Of
Associated Nasal Pathology
The anterior part of the middle turbinate in this case was
hypertrophied so it was excised and removed

40. Endoscopic Correction Of
Associated Nasal Pathology
In this case there was a localized
septal deviation opposite the
nasal window of the lacrimal sac
Local incision of the mucosa is
done opposite the deviated part

41. Excision of the deviated bone by endoscopy.
Excision of the deviated bone by
endoscopy.
Return of mucosal flap in flap
in place

43. Advantages Of Endoscopic
DCR
Diagnostic values:
1- Direct inspection of NLD orifice in the inferior
meatus.
2- Diagnosis of nasal pathology causing obstruction
of NLD orifice
3- Diagnosis of associated nasal pathology opposite
the lacrimal sac window that may cause
postoperative failure
4- Direct inspection of the duct orifice during
syringe test.

44. Advantages Of Endoscopic DCR
Treatment value
1. Avoid external incisions and scars (the main advantage)
2. Precise location of the nasal window opposite lacrimal sac (More of the
lacrimal sac is preserved )
3. Avoid unnecessary injury to the nasal mucosa
4. correction of associated nasal pathology that causes obstruction of the
NLD orifice or the new nasal window of the lacrimal sac
1. Less complications ,There is actually only a 1 in 40 instance of
air regurgitation during nose blowing noted after endoscopic
procedures, while the incidence is higher with the external
procedure. There is also diminished risk of a CSF leak with the
endoscopic DCR.

45. Endoscopic DCR has the following potential
advantages over the standard external DCR
approach NATIONAL INSTITUTE FOR CLINICAL
EXCELLENCE
– The main advantage is that of avoiding facial cosmetic scars between the eye and nose by
approaching into the nasal cavity 1-3,5,6,10-15
– Local anaesthetic usually used in compliant patients15
– Accessing the rhinostomy directly limits tissue damage, surgical trauma and angular vein
damage, preserving the canthal anatomy1,2,5,6,10-15
– Diagnosis and management of predisposing or concomitant nasal and paranasal disorders
that may contribute to nasolacrimal obstruction - simultaneous treatment in one
sitting2,3,6,10,12
– Bilateral cases are performed simultaneously10,14
– Immediate mistakes revised at surgery1
– The possibility of failures being endoscopically investigated1
– Active dacryocystitis (nasal infection) is not a contraindication as with external approach2,6
– Reduced operating time10,11,15
– Reduced intraoperative bleeding10,11,12
– Reduced morbidity4,10
– Performed as an outpatient, day surgery basis11
– Improved cost-effectiveness.11

46. External vs Endoscopic DCR
In the past the (in the beginning of
Endoscopic DCR) the recurrence rate
exceed the external (past studies) But in
the recent studies the rates are equal if it
is not better .

47. External vs Endoscopic DCR
Every step is done under complete vision,
this gives confidence to the surgeon (We
see recurrences of external DCR because
of traumatising and lateralization of the
middle turbinate then adhesions)

48. Dr.Kamel Advice
The theory of them is not enough , You
should make your opinion.

49. The Most important lesson
It is a matter of cooperation not
competition
2 eyes are better than one
And 2 ears are better than 1.
But 2 surgeons mean 4 eyes and 4
ears