Downloaded 609 times
Uploaded byAusaf Khan
Endoscopic (DCR) Dacryocystorhinostomy
The document outlines the techniques, anatomy, and considerations related to endoscopic dacryocystorhinostomy (DCR) for treating epiphora due to nasolacrimal duct obstruction. It discusses various causes of epiphora, the advantages of endoscopic DCR over external methods, and the necessary pre-operative assessments and instruments required for the procedure. The document also highlights potential complications and causes of failure related to DCR surgeries.
More Related Content
Similar to Endoscopic (DCR) Dacryocystorhinostomy
Endoscopic (DCR) Dacryocystorhinostomy
- 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
- 2.
- 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 (excessivetearing) 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,
- 6. Epiphora/Excessive tearing causes Irritationof 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 ofthe 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
- 8. Anatomy of the LacrimalApparatus
- 9. Anatomy of Lacrimal apparatus 1.Lacrimal Gland 2. Lacrimal Ducts 3. Lacrimal Puncta 4. Lacrimal Canaliculi 5. Lacrimal Sac 6. Naso-lacrimal Duct 7. Valves
- 10. Anatomy of Lacrimalapparatus 1 – Lacrimal GLAND & Ducts
- 11. Anatomy of Lacrimalapparatus 2 – Lacrimal PUNCTA U/L Punctum width : 0.1-0.4mm Distance from med. canthus: 0.6mm
- 12. Anatomy of Lacrimalapparatus 3 – Lacrimal CANALICULI Vertical part : 2-2.5 mm Ampulla : V/H junction 90 Horizontal part : 7-10 mm Common canaliculus : 1-3 mm
- 13.
- 14. Anatomy of Lacrimalapparatus 4 – The Lacrimal SAC Lacrimal sac
- 15. Medial wall ofright orbit… FP frontal process of maxilla, ALC anterior lacrimal crest, PLC posterior lacrimal crest, H hammulus, LMS lacrimo- maxillary suture, FES fronto-ethmoid suture, LP lamina papyracea, LB lacrimal bone, AF anterior foramen (AE Artery), PF LF
- 16. Anatomy of Lacrimalapparatus 4 – The Lacrimal SAC
- 17. Anatomy of Lacrimalapparatus 5 – Naso-lacrimal DUCT (NLD) Right nasolacrimal canal. View from the lacrimal fossa.
- 18. Anatomy of Lacrimalapparatus 5. Naso-lacrimal DUCT (NLD) ILP SLC SLP ILC CC NLD Cadaver dissection of the Lacrimal drainage system LS * *
- 19. Projection of Lacrimalsystem 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 openingin 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 outliningthe lacrimal sac (S) and duct (D). Small arrows denote the common wall with the agger nasi cell.
- 22. Sagittal view withthe lacrimal sac and duct marsupialized by completely removing the medial bony and membranous wall.
- 24. (a) Lacrimal system, Endoscopicview. 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 Lacrimalapparatus 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 * *
- 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 keyfor 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 ?
- 31. Comparison of the3 techniques of DCR
- 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 requiresspecialized 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 Carefulhistory 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 Officeassessment 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 Surgeryis 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 septoplastyis 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.
- 38.
- 39. Instruments needed for Endoscopic-DCR 0 and 30 degree endoscopes Light source/Camera/monitor Suction No. 15 surgical blade Pointed diathermy Plester knife Rosen’s knife Sickle knife House (meatal) elevator Suction elevator, Freer’s Kerrison bone punch Hajek-Kofler punch Blakesely forceps Thru-cut forceps Ball probe Lacrimal probe Punctal dilator DCR tube
- 40. Inspection and Identification oflandmarks
- 41. Inspection and Identification oflandmarks UP B
- 45. Dimensions of lacrimalsac/flap The lacrimal sac extends approx. 10 mm above the axilla of MT.
- 46. Topical and localanesthesia Perform a septoplasty if needed: Limited access restricts surg.
- 48. Dimensions of thenasal mucosal flap A 30 endoscope provides better view of LNW.
- 49. Endoscopic view showingincision 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.
- 50. Incision given by#15 blade
- 51. The lacrimal sacextends approx. 10 mm above the axilla of MT.
- 52. Incision given bymonopolar diathermy
- 53.
- 55. Removal of flakesof Lacrimal bone
- 56. The lacrimal boneextends 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.
- 57. Removal of flakesof Lacrimal bone Using Sickle and Rosen knifes
- 58. Removal of flakesof 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.
- 59.
- 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 Whenusing the Hajek-Koffler punch, release the jaws after each bite : this will prevent inadvertent trauma to sac.
- 62. Use of DIAMONDBURR for bone removal Use diamond burr only when the punch is unable to grip the bone adequately.
- 63.
- 64. Incising flap using KERATOME Tentingthe sac using lacrimal probe Make an incision into the sac only when lacrimal probe can be clearly seen through the sac wall.
- 65. When probingthe lacrimal system, do so delicately : avoid trauma and a false passage.
- 66.
- 67.
- 68. f Flap opened using15 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.
- 69.
- 70.
- 71. Flap marsupialized Approximation ofnasal flap with sac wall using ball probe
- 72. Trimming of mucosalflap Final approximation of flaps
- 73.
- 74. Use of DCRtube Working as a team with an oculoplastic surgeon : they have requisite skills in probing and examining the lacrimal system.
- 75. Causes of failureof DCR Inadequate osteotomy, Incomplete sac marsupialization, Cicatricial closure of the ostium Granuloma formation
Editor's Notes
- #28 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
- #29 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
- #35 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