Dacryocystorhinostomy (DCR) surgery is performed to restore tear drainage from the lacrimal sac into the nose when the nasolacrimal duct is blocked. There are several types but external DCR involves making incisions in the skin and nasal mucosa to create flaps and suturing them together to bypass the blockage. Preoperative testing and nasal packing is done prior to general anesthesia. The procedure exposes and removes bone between the lacrimal sac and nose to join the spaces. Silastic tubes may be placed short term and patients are monitored after for potential early, intermediate or late complications like infection, scarring or restenosis.

1. DACRYOCYSTORHINOSTOMY (DCR)
SURGERY

2. ANATOMY

7.  Definition: surgical procedure to restore the flow of
tears into the nose from the lacrimal sac when the
nasolacrimal duct does not function.
Types:
1. Conventional/ External
2. Endoscopic/ Endonasal
3. Endolaser
4. Conjunctivo DCR

8. EXTERNAL DCR
Indications:
1. Primary acquired nasolacrimal duct
obstruction.
2. Secondary acquired nasolacrimal duct
obstruction, such as due to prior
midfacial trauma.
3. Congenital nasolacrimal duct
obstruction, after failed prior probing or
intubation.

9. PREOPERATIVE REQUISITES
 Confirmation of the diagnosis and clinical findings.
 Complete blood count: TLC, DLC, Hb, ESR.
 Bleeding and clotting times (BT and CT)
 Blood pressure measurement.
 Random blood sugars
 HIV
 HBsAg
 HCV
 ENT evaluation
 Additional general anesthesia investigations when required :
Chest X-ray, ECG in elderly

10. STEPS
 NASAL PACKING
It is done to keep the mucosa taut and reduce bleeding.
Nasal packing should be explained to the patient.
 Few drops of 4% topical lignocaine should be instilled
first in the ipsilateral nostril,
 Then nasal pack (roller gauze soaked in 2% lignocaine-
adrenaline jelly) inserted in the ipsilateral nostril with the
help of nasal packing forceps

12.  ANAESTHESIA – General anaesthesia is preferred ,
however it may be performed with local anaesthesia in
adults
 Local anesthesia

13. POSITION
 Patient should be comfortably supine with head high 10-
20 degree.
 Surgeon should be at the head-end or side of the patient
in which DCR is going to be done.
 The table height should be adjusted depending upon
whether the surgeon is operating in standing or sitting
position.
 Light should have adequate illumination because of small
field of illumination. Headlight is used by the surgeon.

14. SKIN
Incision:
1. Curvilinear incision: 2mm medial to medial canthus
2. Straight incision: 10mm medial to medial canthus
avoiding the angular vein.
 Orbicularis is split in the line of incision and and a
lacrimal retractor inserted so as to retract it with
skin
 Angular vessels should be avoided

16. EXPOSURE OF MPL AND ANTERIOR
LACRIMAL CREST
 Identification and exposure of MPL is a very
important step in DCR surgery
 Once MPL is exposed, the orbicularis fibers are
separated along the entire length of the incision.
 Dis-insertion of MPL is done at the anterior lacrimal
crest by cutting on the bone at insertion.

17. EXPOSURE OF BONE
 Dis-insertion of MPL automatically opens up the
periosteum.
 Lacrimal sac is retracted with periosteum elevator.
 Lamina paparecyea is then exposed inferiorly

18. EXPOSURE OF NASAL MUCOSA
 Bone removal is started with a small punch and
then with a big punch.
 Osteotomy should be as large as possible and
should be of size of thumbnail.
 Once nasal bone is removed, nasal mucosa is
exposed

19. PREPARARTION OF FLAPS OF SAC
A probe is introduced into the sac through the lower
canaliculus and the sac is incised vertically .
To prepare anterior and posterior flaps the incision is
converted into H shape

21. FASHIONING OF NASAL MUCOSAL
FLAPS
 It is also done by vertical incision converted into H
shape

22. SUTURING OF FLAPS
 Posterior flaps are sutured so that the posterior sac
flap does not block common canalicular ostium in
sac. (some surgeons don’t do it)
 One suture usually is sufficient for posterior flap.
 Anterior nasal flap is now sutured to the anterior
sac flap

23.  Orbicularis oculi is closed with continuous suture
 Skin closure can be achieved with either interrupted
sutures.
 Anterior nasal packing done to avoid post operative
bleeding from remaining nasal mucosa
 pad on the eye should be applied.

25. SILIASTIC TUBE INSERTION
 Done in canalicular block
(upper level block)
 Silicon tubes are passed
through both the puncta to
the nose
 All the anterior structures are
sutured in layers.
 Tubes are removed after 2-3
months.
 Success rate of over 90%

26. POST-OPERATIVE CARE
 Complete bed rest in propped up position and chin
extension is recommended for 24 hours.
 Patients should be told to avoid blowing of nose.
 Oral antibiotics, non-steroidal anti-inflammatory drug
(NSAID) - should be given routinely for five days.

27.  Dressing and nasal pack removal to be done after
24 hours.
 Local treatment includes oxymetazoline nasal drops
twice daily, antibiotic ointment on the wound twice
daily and antibiotic with steroid eye drop four times
daily.
 Sac syringing should be done after 1 week.
 Suture removal to be done after 1 week

28. CAUSES OF FAILURE
 Inadequate size and position of the ostium,
 Unrecognized common canalicular obstruction
 Scarring
 ‘Sump syndrome’, in which the surgical opening in
the lacrimal bone is too small and too high.

29. COMPLICATIONS
Complications following DCR surgery can be divided
as
early (1-4 weeks),
intermediate (1-3 months) and
late (>3 months).

30.  Early complications include wound gap, wound infection,
tube displacement

31.  Intermediate complications include granulomas at the
rhinostomy site, tube displacements, punctal cheese-
wiring , prominent facial scar, and nonfunctional DCR

32.  Late complications include rhinostomy fibrosis, and
failed DCR.