This document describes different surgical procedures for lacrimal sac obstructions, including dacryocystorhinostomy (DCR) and dacryocystectomy. It outlines the anatomy, indications, preoperative requirements, steps of conventional DCR including osteotomy of the lacrimal bone and suturing of nasal and sac flaps, and post-operative care. It also discusses endoscopic and endolaser techniques for DCR and the indications for dacryocystectomy. Complications of DCR include wound infections, synechiae formation, and osteotomy stenosis leading to procedure failure.

1. LACRIMAL
SAC SURGERIES

2. ANATOMY

4. CONVENTIONAL
DACRYOCYSTORHINOSTOMY
 DCR is indicated for obstruction beyond the medial
opening of the common canaliculus
 In principle the operation involves anastomosing the
lacrimal sac to the nasal mucosa of the middle nasal
meatus.

7. SURGICAL INDICATIONS
 Persistent congenital lacrimal duct obstructions
unresponsive to previous therapies.
 Congenital lacrimal duct obstructions associated with
mucocele, dacryocystitis, and not responsive to other
treatments.
 Primary acquired nasolacrimal duct obstructions
(PANDO).
 Secondary acquired nasolacrimal duct obstructions
(SALDO).

8. Preoperative requisites
 Confirmation of the diagnosis and clinical findings.
 Hemoglobin levels.
 Bleeding and clotting times.
 Blood pressure measurement.
 Random blood sugars.
 ENT evaluation
 Additional general anesthesia investigations when
required.

9. Pre-operative medications
 Nasal decongestant such as otrivin drops should be
given to reduce nasal congestion
 Patient is kept nil by mouth for ease of sedation

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 in
the direction of middle meatus, insinuated and negotiated
as deep as possible
 The direction of nasal packing is superior, then
posterior, then inferior.

12.  ANAESTHESIA – General anaesthesia is preferred ,
however it may be performed with local anaesthesia in
adults
 Local anesthesia is given by both infiltration as well as
topical application. For infiltration 2% lignocaine with
0.5% Bupivacaine with or without adrenaline is used.
Infratrochlear nerve that supplies the lacrimal
apparatus is blocked first. The nondominant hand
marks the supraorbital notch and the needle is
inserted into the medial third of the eyebrow and
advanced to just medial to medial canthus and 2cc of
the drug is injected.

13.  The tissues along the anterior lacrimal crest is
infiltrated subcutaneously and the needle enters
deeper at about 3 mm medial to medial canthus, and
without withdrawing the needle the drug is injected
into deeper tissues up to periosteum both superiorly
and inferiorly.

14. POSITION
 Patient should be comfortably supine with head high 10-20
degree.
 Surgeon should be at the head-end, as it provides easy
access to both sides of the head.
 The table height should be adjusted depending upon
whether the surgeon is operating in standing or sitting
position.
 The light in operating room should be an overhead,
shadowless light, which must reach the depth of surgical
field (usually between surgeon's and assistant's head).
 Light should have adequate illumination because of small
field of illumination.

15. SKIN
 Either a curved incision along lacrimal crest or a
straight incision 8-11 mm medial to medial canthus is
made
 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

18. 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 (not dividing) of MPL is done at the
anterior lacrimal crest by cutting on the bone at
insertion with 11 number blade.

20. EXPOSURE OF BONE
 Dis-insertion of MPL automatically opens up the
periosteum, which is now separated along the entire
length of the incision with sharp dissector or
periosteum elevator.
 Lacrimal sac is retracted with periosteum elevator.
Baring of periosteum is done to decrease pain and to
aid bone punching.
 Periosteum is elevated posteriorly till the lamina
papyracea. Lamina papyracea is a thin bone with
consistency and color different from lacrimal bone.
Periosteum also elevated anteriorly, inferiorly and
superiorly as much as reasonably possible

21. EXPOSURE OF NASAL MUCOSA
 Bone removal is started with a small punch and then
with a big punch.
 The correct method of using bone punch is as follows:
insinuate, engage the bone with the punch, support
with left thumb, hitch back, crush properly and then
gentle rocking movement to remove the bone.
 Bone punch should always be perpendicular to the
punching surface. Clear the punch of bone pieces with
20G needle.
 Osteotomy should be as large as possible and should
be of size of thumbnail.

22.  Extent of osteotomy should be as follows:
Posteriorly: Till lamina papyracea.
Superiorly: At or slightly above level of MPL.
Anteriorly and inferiorly: As much as possible

24. 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

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

27. SUTURING OF FLAPS
 Posterior flaps are sutured so that the posterior sac
flap does not block common canalicular ostium in sac.
 One suture usually is sufficient for posterior flap.
 Care should be taken to avoid nasal pack in the suture
Anterior nasal flap is now sutured to the anterior sac
flap with minimum two 6-0 vicryl sutures (sometimes
three). Inserting lacrimal probe helps to confirm
proper flap suturing.

28.  . MPL re-attachment is done with periosteum using deep
down to the bone bite of 6-0 vicryl on the medial incision
edge at MPL level.
 Movement of the head when suture is pulled confirms the
firm suture attachment to periosteum.
 Additional 3-4 orbicularis closure stitches are taken.
 Skin closure can be achieved with either interrupted or
continuous sub-cuticular sutures..
 Quarter folded pad on the wound and half-folded pad on
the eye should be applied.
 . Minimum 4-5 micropore tapes in a criss-cross fashion
with one tape to secure the nasal pack in position should
be applied

30. Adjunctive measures (use of
mitomycin C and intubation)
 Mitomycin C in a concentration of 0.04% is used if
there are intra-sac synechiae, soft tissue scarring like
in failed DCR's and in the presence of a complicated
surgery.
 Intubation is also advisable for similar indications but
in addition it is also used in the presence of canalicular
problems and inadequate flaps

32. 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.

33.  Dressing and nasal pack removal to be done after 24
hours. Local treatment includes otrivin-P 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 gently once in 2-3 days
for the first week or 10 days to remove blood clots.
Suture removal to be done after 1 week

34. 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. There is thus a
dilated lacrimal sac lateral to and below the level of
the inferior margin of the ostium, in which secretions
collect, unable to gain access to the ostium and thence
the nasal cavity.

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

36.  Early complications include wound dehiscence ,
wound infection, tube displacement, excessive
rhinostomy crusting , and intranasal synechiae.

38.  Intermediate complications include granulomas at the
rhinostomy site, tube displacements, intranasal
synechiae, punctal cheese-wiring , prominent facial
scar, and nonfunctional DCR

39.  Late complications include rhinostomy fibrosis,
webbed facial scar, medial canthal distortion, and
failed DCR.

40. Endoscopic surgery
Endoscopic DCR is performed under general
anaesthesia.
Advantages over conventional DCR include the lack of
a skin incision, shorter operating time, minimal blood
loss and less risk of cerebrospinal fluid leakage.
Disadvantages include lower success rates, difficulty in
examining the common canalicular opening and
reverse probing of the canaliculus in cases with
proximal canalicular obstruction.

41.  1 Technique. A slender light pipe is passed through the
lacrimal puncta and canaliculi into the lacrimal sac and
viewed from within the nasal cavity with an endoscope.
The remainder of the procedure is performed via the
nose.
 a The mucosa over the frontal process of the maxilla is
stripped.
b A part of the nasal process of the maxilla is removed.
c The lacrimal bone is broken off piecemeal.
d The lacrimal sac is opened.
e Silicone tubes are passed through the upper and lower
puncta, pulled out through the ostium and tied within the
nose.
2 Results. The success rate is up to 90%.

42. Endolaser DCR
Performed with a Holmium:YAG or KTP laser, this is a
relatively rapid procedure which can be carried out
under local anaesthesia. It is therefore particularly
suitable for elderly patients.
Laser is used to ablate the mucosa and thin the
lacrimal bone.
The bony opening is 4-6mm in size which is smalller
than in conventional DCR and is one major reason for
lower success rate (70%)

44. DACROCYSTECTOMY
 Refers to removal of lacrimal sac
 Indicated in patients with NLDO who are unfit for
DCR ( too young –less than 4 yrs , or old - >70 yrs)
 Preferable to DCR in cases of NLDO a/w dry eyes
 Indicated for granulomatous lesions and tumors of the
lacrimal sac

45. PROCEDURE
 Initial steps are similar to DCR
 Removal of lacrimal sac – After exposing the sac it is
separated from surrounding strucutures by blunt
dissection followed by cutting its connections with
lacrimal canaliculi
 It is then held with artery forceps and twisted 3-4
times to tear it away from NLD
 Curretage of bony NLD – with help of lacrimal currette
to remove infected parts of membranous NLD
 Closure similar to DCR