Recent advances in dcr

RECENT ADVANCES IN
MANAGEMENT OF
OBSTRUCTION OF LACRIMAL
DRAINAGE SYSTEM
DR.M.DINESH

Overview
1. History
2. External dcr
1. Modified Lynch Incision
2. Nasojugal or the Angular Incision
3. Subciliary Incision
4. Transconjunctival DCR (TC-DCR)
3. Endoscopic endonasal DCR(EEDCR)
4. Ultrasonic or piezoelectric-assisted or powered endoscopic DCR
5. Non-laser, non-endoscopic endonasal DCR (NEN-DCR)
6. Endocanalicular ( transcanalicular )laser DCR (ECLDCR)
7. Endoscopic balloon-assisted DCR (EBA-DCR)
8. Balloon dacryoplasty(dcp)
9. Conjunctivodcr (CDCR )

HISTORY:
• 1904, Addeo Toti described a procedure in which a conduit for tear
flow could be created between nose and lacrimal sac by resecting
portions of the lacrimal sac mucosa, bone, and nasal mucosa.
• 1920s, Dupuy-Dutemps and Bourguet made important
modifications in which nasal and lacrimal flaps were approximated to
create an epithelium-lined fistulous tract.

• In 1894, an intranasal approach to DCR had been described by Caldwell,
did not gain popularity because of the often-poor monocular view and
problematic bleeding of the intranasal approach.
• The arrival of the endoscope that permitted adequate visualization of the
operative site and by laser technology allowing the creation of intranasal
ostia with minimal bleeding.

• 1990 the endocanalicular DCR, that also used lasers to create the ostia.
• Together, the endonasal and endocanalicular approach are referred
to as skin incision-sparing DCR techniques.
• skin incision-sparing DCR ,current mainstay of treatment of acquired as
well as congenital NLD obstruction that has been refractory to probing
and silicone intubation.

EXTERNAL DCR - INDICATIONS
1. Congenital NLDO after failed prior probing or intubation
2. Primary acquired NLDO(PANDO)
3. Secondary acquired NLDO (SALDO)
1. due to prior midfacial trauma,
2. chronic nasal or sinus inflammation,
3. nasal surgery,
4. neoplasms,
5. Dacryoliths
4. Functional obstruction of outflow, due to lacrimal pump
weakness or after facial nerve palsy
5. History of dacryocystitis

6. After incisional surgery into the nasolacrimal sac for removal of a
foreign body
7. As an operative component in the repair of common canalicular
laceration or stenosis (canaliculoDCR)
8. As a preliminary procedure to the placement of a Jones tube in
conjunctivoDCR
9. In the treatment of incomplete NLD obstruction or flaccid lacrimal
passages as suggested by Jones testing or by dacryoscintigraphy

Preoperative work up
1.Hb levels.
2.Bleeding and clotting times.
3.Blood pressure control (to dec risk of bleeding)
4.RBS
5.PAC
6.ENT evaluation to r/o atrophic rhinitis and other nasal abnormalities.
Pre-operative medications
1.Stop anti-coagulants (on physician advice)
2.Ethamsylate (hemostatic drug not only promotes platelet adhesion but also
inhibits platelet disaggregation) 250 mg BD one day prior to the surgery.
3.Nasal decongestant otrivin drops BD a day prior to reduce nasal
congestion.

Instruments
1. DCR set
2. swabs soaked in lignocaine-adrenaline
3. Gauze pieces.
4. Few cotton buds.
5. Roller gauze for nasal packing.
6. Suction machine with thin catheter or infant feeding tube
7. Viscoelastic for sac inflation OR chloro applicabs (chloramphenicol
ointment)

Nasal packing
1. to keep the mucosa taut and reduce bleeding.
2. 4% topical lignocaine instilled first in the I/L nostril
3. nasal pack (roller gauze soaked in 2% lignocaine-adrenaline) inserted in
the I/L nostril with the help of nasal packing forceps in the direction of
medial palpebral ligament (MPL)
4. The direction of nasal packing is superior, then posterior, then inferior.

Surgical steps :
1.Anaesthesia
1. Delineating the incision with a marking pencil before infiltration of local
anesthetic is recommended because the local infiltration distorts soft
tissues and anatomic landmarks.
2. Local anesthesia 1:1,00,000 lignocaine-adrenaline
3. single point block
4. site of infiltration -medial to medial canthus, where the MPL is situated.
5. At MPL insertion
1. bone is hit with the 26G needle and 2-3 cc injected,
2. then the bevel of needle rotated superiorly and 2-3 cc injected and
3. then rotated inferiorly while injecting the remaining 2-3 cc.
4. Firm pressure is applied for 5-10 min for the anesthetic to act.
6. It blocks the ethmoid nerve and the infratrochlear nerve

2.Incision :
• J shaped curvilinear incision is taken (skin deep and not bone thick) 3-4
mm from medial canthus, starting 2-3 mm above MPL, about 1.5-2 cm in
length
• The most cephalad point on the skin is immediately inferior to the medial
canthal tendon.
• This incision is therefore above or medial to the angular vessels.

3.Dissection of the Lacrimal Sac
1. Blunt dissection is carried on to reach the periostium.
2. MPL insertion is reached by blunt dissection of orbicularis fibers with
artery forceps in the region of MPL (medial to medial canthus).
3. Identification and exposure of MPL
4. sac is reflected laterally with periosteum(Freer’s) elevator to reveal
lacrimal sac fossa and the lacrimal bone

4. Exposure of bone
1. MPL is exposed by dissection and cut with scissors to expose anterior lacrimal
crest.
2. Baring of periosteum is done to decrease pain and to aid bone punching.
Periosteum is elevated posteriorly till the lamina papyracea.
3. It is a thin bone with consistency and color different from lacrimal bone.
4. Periosteum - elevated anteriorly, inferiorly and superiorly as much as possible
5. With a sharp dissector, the lamina is punctured breaking it outwards and
removing the pieces with forceps

5.Bone punching
1. should be started at the junction of lamina paparycea of the ethmoid
and lacrimal bone.
2. started with a small punch and then with a big punch.
3. The correct method of using Kerrison rongeur bone punch is as follows:
1. insinuate,
2. engage the bone with the punch,
3. support with left thumb,
4. hitch back,
5. crush properly and then
6. gentle rocking movement to remove the bone.
4. Bone punch should always be perpendicular to the punching surface.
5. Clear the punch of bone pieces with 20G needle.
6. Osteotomy should be as large as possible and should be of size of
thumbnail.

Extent of osteotomy should be as follows:
1. Posteriorly: Till lamina papyracea(post extent of lacrimal sac.)
2. Superiorly: At or slightly above level of MPL.(2 mm above medial
canthus.)
3. Anteriorly: 10-12 mm beyond ant lacrimal crest .
4. Inferiorly :till sup portion of NLD is partially de-roofed/sac-NLD jn.
Large osteotomy (dotted line) extending superiorly
slightly above level of MPL, inferiorly till the level of
inferior orbital margin, posteriorly from lamina
papyracea as much as required and anteriorly for
good nasal flap

Kerrison punch being used to create a bony osteum A large bony osteum exposing the nasal mucosa

6. Flap Formation
Lacrimal sac flaps
1. Dilate the upper punctum with punctum dilator.
2. Inflate the sac with viscoelastic or chloro ointment in a 2-cc syringe
with a 26G cannula or Bowman's probe is passed through the lower
punctum to tent the sac as posterior as possible to create
3. Long vertical top to bottom incision is taken with 11 number blade and
spring scissors on the medial sac wall to create largeranterior and
smaller posterior flaps
Nasal mucosal flaps
1. Vertical long top to bottom incision with a 11 number blade should be
made on nasal mucosa along the bony ostium except superiorly to
have a superior hinged flap

5) Small horizontal cuts may be required on the posterior nasal
mucosal flap to help it revert and appose well with posterior
lacrimal sac flap.
6) Anterior horizontal cuts are made later, after suturing the
posterior flaps.
1. Inflated bulging lacrimal sac. 2. Site of incision on
lacrimal sac for creating anterior and posterior flap
Fashioning the anterior and posterior nasal mucosal
flaps. 1. Straight vertical incision 2. Small horizontal
cuts to create posterior flap. 3. Large horizontal cuts
to create anterior flap

7. Flap Anastamosis
1) Posterior flaps are sutured so that the posterior sac flap does not
block common canalicular ostium in sac. One suture usually is
sufficient
2) Care should be taken to avoid nasal pack in the suture
3) Anterior nasal flap is now opened with 11 number blade and sutured
to the anterior sac flap with 2-3 6-0 vicryls sutures
4) Inserting lacrimal probe helps to confirm proper flap suturing.

8. Wound closure
1) MPL re-attachment is done with periosteum using bone bite of 6-0 vicryl
on the medial incision edge at MPL level.
2) Movement of the head when suture is pulled confirms the firm suture
attachment to periosteum.
3) 3-4 orbicularis closure stitches are taken.
4) Skin closure can be achieved with interrupted/continuous sub-cuticular
sutures.
5) Before closures, conjunctival sac should be irrigated to remove any bone
pieces.
6) Chloramphenicol ointment should be applied on the wound and in the
eye.

Adjunctive measures (use of mitomycin C and intubation)
1. Mitomycin C 0.04% & Intubation - used if there are
1. intra-sac synechiae,
2. soft tissue scarring like in failed DCR's and
3. in the presence of a complicated surgery.
2. Intubation in addition is also used in the presence of
1. canalicular problems and
2. inadequate flaps

Intubation: upper canaliculi intubated. The bodkins
are being retrieved by a transnasal artery forceps
tubes being secured in the nose
tubes in place before flap anastomosis

1. The nasal pack removed on day 1 and hemostasis assessed.
2. The wounds are cleaned with 5% betadine, and the patient is
discharged on oral antibiotics and analgesics, topical antibiotics and
steroids, nasal decongestants, and steroid nasal sprays.
3. One week postoperative the sutures are removed, oral medications
discontinued, topical steroids are tapered and nasal medications
continued for two more weeks.
4. The patient is reviewed at 6,12 weeks,
and 6 months. If the patient is intubated
then tube removal is done at 12 weeks.

Complications
Early 1-4 weeks
1. wound dehiscence,
2. wound infection,
3. tube displacement,
4. intranasal synechiae.
5. Excessive rhinostomy scarring
Intermediate 1-3 months
1. granulomas at the rhinostomy
site,
2. tube displacements,
3. Intranasal synechiae,
4. punctual cheese-wiring,
5. prominent facial scar
6. nonfunctional DCR.
Late > 3 months
1. rhinostomy fibrosis,
2. webbed facial scar,
3. Medial canthal distortion
4. failed DCR.

Skin Incisions for External DCR
1.The Modified Lynch Incision
or the Straight Incision
2.The Nasojugal or the Angular Incision
This is a curvilinear incision on the
anterior lacrimal crest and is known to
allow easy access to the lacrimal sac

3.The Subciliary Incision
The eyelid subciliary incision is an established approach for several
orbital and eyelid procedures and is known to provide excellent
cosmesis

4.Transconjunctival DCR (TC-DCR)
1. The conjunctival incision site and medial canthal area are infiltrated by
approximately 1–4 ml 2 % lidocaine with similar adrenaline
concentration.
2. A soft contact lens or a lubricated acrylic corneal protector is placed to
protect cornea.
Surgical Steps
1. The lower eyelid is retracted gently away from the eyeball.
2. Inferomedial vestibular transconjunctival incision of 2–3 cm, similar to
medial
transconjunctival blepharoplasty incision is performed starting from a
point 4–5 mm below the caruncle
3. The medial fat pad and inferior oblique muscle are exposed and gently
retracted laterally to reach the anterior lacrimal crest

Advantages
1. Avoids facial scar
2. Minimal trauma to medial canthal structures
3. Preserved lacrimal pump
4. Enables flap anastomosis
5. Surgery with basic DCR equipment
6. No need for endoscopy and laser assistance

Difficulties and disadvantages
1. Difficult visualization of deeper planes
2. Difficult access to the sac and lacrimal fossa
3. Tight lower eyelids are prone to injury
4. Manipulation and maneuvering difficulties (Ethmoid cell entry,
agger nasi cell, orbital fat prolapse)
5. Longer procedure time
6. Variable learning curve

Endoscopic endonasal DCR(EEDCR)
Surgical Technique
1. Anesthesia
1) 2%xylocaine with 1:200,000 adrenaline regional transcaruncle,
infratrochlear, and infraorbital nerve block.
2) With the patient in supine position, the patient’s head should be slightly
elevated and neck slightly extended so as to facilitate superior osteotomy
3) Nasal packing using ribbon gauze soaked in alpha-adrenergic VC ‘s is
placed along the middle meatal area and lateral nasal wall to decongest
the nasal mucosa.
4) Using a 0° nasal endoscope for visualization, the mucosa of
the lateral nasal wall above and below the level of the axilla of middle
turbinate infiltrated with 2 % xylocaine with 1:80,000 adrenaline before
incision.

Endoscopic Landmarks
1. The most useful endonasal landmark to identify the lacrimal sac is the
axilla of the middle turbinate
2. An endoilluminator probe may be used to visualize the lacrimal sac
through the canaliculus and advance into the lacrimal sac.
3. The fundus of the lacrimal sac usually extends above the level of the
axilla of middle turbinate
4. The maxillary line is an important landmark in endoscopic
dacryocystorhinostomy.

1. maxillary line is a curvilinear ridge on the lateral nasal wall that runs from
the axilla of middle turbinate to the root of the inferior turbinate.
2. suture line formed by the thick maxillary bone anteriorly and the thin
lacrimal bones posteriorly.
3. The lacrimal sac often extends posteriorly behind the maxillary line
beneath the middle turbinate.
4. Exposure of the posterior half of
sac requires removal of the thin
lacrimal bone behind the maxillary line &
a part of the uncinate process inferiorly.
5. Exposure of the anterior half of sac
requires removal of the thick frontal
process of maxilla.

6. The inferior end of the lacrimal sac tapers as the sac-duct junction
when it enters the nasolacrimal canal, formed by the maxillary,
lacrimal, and inferior turbinate bones.
2.Fashioning the Nasal Mucosa Flaps
1. A crescent or sickle knife or a radio frequency device is used to make
the incision over the lateral nasal mucosa down to the periosteum in
front of the maxillary line
2. The first vertical incision is made around 10 mm anterior to the
maxillary line with a length of about twothirds of the vertical height of
the middle turbinate starting from the level slightly above the axilla of
middle turbinate.
3. A horizontal incision is then made at right angle at the inferior end of
the vertical incision until reaching the maxillary line.

4. The upper horizontal incision can be completed with the knife or a
pair of Westcott scissors starting from the top of the vertical line
over and cut beyond the axilla of the middle turbinate
5. A Freer periosteal elevator is then used to elevate the
mucoperiosteal flap and folded around the middle turbinate to
keep it out of the
operating field.
3.Osteotomy
1. A Kerrison Rongeur punch is used to
enlarge and remove
frontal process of the maxilla,
starting from the maxillary line

2. Removal of maxillary bone should expose inferior half of lacrimal
sac
3. Bone removal is continued anteriorly and as far superiorly as
possible

4. lacrimal bone at posterior half of sac is elevated with Freer elevator &
removed using a pair of Takahashi forceps
5. An osteotomy of at least 15 mm in vertical length is required to expose
the lacrimal sac from fundus to sac-duct junction.
6. All bones over sac fundus and common canaliculus opening should be
removed.

Boundaries of the Ostium
1. Superoanteriorly, the orbicularis oculi muscle is often exposed
2. Superoposteriorly, the agger nasi air cells or operculum of the middle
turbinate is entered to ensure full fundus exposure

3. Posteriorly, a limited anterior ethmodiectomy may be required and
part of the medial periorbita can get exposed.
4. This allows maximal superior bone removal without using powered
instruments and posterior lacrimal sac flap to lie flat.
5. Lacrimal sac fundus is reached when orbicularis muscle is also
exposed superiorly.
6. Alternately, Malhotra punch, powered drills, or piezoelectric energy
to
perform a superior osteotomy.
7. Inferior boundary of the osteotomy is the NLD which
is noted after the canal is de-roofed.

4.Fashioning Lacrimal Sac Flaps
1. The position of the internal punctum can be verified using a Bowman
probe, passing through the lacrimal canaliculus into the lacrimal sac
and tenting the medial sac wall.
2. With the Bowman probe passed horizontally tenting the medial wall
of the lacrimal sac, at least 2 mm space should be left between the
tented lacrimal probe tip and the superior edge of the osteotomy.

3. Once tenting the medial wall of the lacrimal sac is achieved a crescent
or sickle knife is used to make a vertical incision along the entire
length of the lacrimal sac from the fundus down to the nasolacrimal
duct

4. An “I”- or “Y”- shaped incision is then completed with upper and lower
horizontal releasing cuts at the top and the bottom using Westcott
scissors or crescent knife
5. The lacrimal sac is then completely marsupialized and both the anterior
and posterior sac flaps are laid open and flat on the lateral nasal wall
6. Irrigation using the fluorescein-stained saline confirms the patency of
the common internal punctum intraoperatively

5.Edge-to-Edge Mucosal Apposition
1. Once both the nasal mucosal and lacrimal sacs are fashioned, an edge-
to-edge approximation is performed so as to achieve healing by primary
intention.
2. A maxillary ostium seeker probe is useful to spread open the lacrimal
sac flaps
thereby avoiding excessive sharp dissection within the sac, particularly
around the internal ostium.
3. The nasal mucosal flap can then
be trimmed in the center and edges
are repositioned back and approximate
the posterior edge of the
marsupialized lacrimal sac flap

Complications - intraoperative:
1. Hemorrhage – minimize by anesthetic vasoconstriction, cautery, and bone
wax. Avoid excessive cauterization of the nasal mucosa that could induce
scarring.
2. Injury to
1. Internal opening of the common canaliculus when opening the sac
2. Canaliculi from improper probing
3. Orbital contents from rongeurs or drill
3. CSF leak d/t penetration of the cribriform plate
4. Shredding of lateral nasal mucosa d/t improper bone removal
5. Failure to completely open inferior portion of the lacrimal sac, resulting in a
lacrimal sump syndrome.
6. Failure to adequately drain and remove a lacrimal sac diverticulum

Postoperative:
• Hemorrhage
• Infection
• Incomplete improvement, persistent tearing
• Early loss of the silicone tube
• Fibrosis occlusion of the ostium
• Synechiae between the middle turbinate, nasal septum, or lateral wall
• Need for additional surgery
• Sinusitis

Follow up
• No heavy lifting, exercise, or strenuous activity that may induce bleeding.
• Hot drinks and food should be avoided for the first 12-24 hours postoperatively
in order to decrease the risk of epistaxis caused by heat-induced nasal
vasodilation.
• Ice/cold compresses are placed on the incision site for 48 hours while awake to
minimize swelling and bruising.
• The patient’s head should remain elevated at all times at a 45 degree angle and
the patient instructed to avoid nose blowing for one week to decrease the risk of
hemorrhage.
• Skin sutures are removed one week postoperatively if nonabsorbable sutures
were used, and the silicone tube is removed typically at 4-8 weeks after surgery.

The endonasal DCR is contraindicated for patients with
1. Suspected lacrimal system neoplasm
2. Lacrimal sac diverticulae
3. Lacrimal system stones
4. Common canalicular stenosis
5. Severe midfacial trauma

Ultrasonic or piezoelectric-assisted or powered endoscopic DCR
1. first performed by Krasnov in 1971 & reintroduced in 2005 by Sivak-
Callcott et al
Instruments and Setup
Synthes Piezoelectric System which
consists of
1. a main device or console,
2. foot pedal,
3. handpiece,
4. various tips for cutting bone
5. bone substitutes

Osteotomy
1. A diamond cutting tip at a flow rate of 30 ml/min with D2 program
with power of 5 is used to begin the osteotomy from the inferior end
of the maxillary line.
2. Place the diamond tip perpendicular to the target bone (Fig. 22.16)
and start emulsifying the bone in a brush-stroke movement. Only a
slight pressure can be used but force is never needed.

3. A trench is initially created and subsequently deepened by slight back
and forth movement in line with the initial cut, till entire bone is
emulsified, exposing the underlying nasolacrimal duct
4. The osteotomy is then created anteriorly and posteriorly.
Simultaneous suction would help in clearing the emulsified debris.
5. The extent of osteotomy anteriorly and posteriorly should be 2 mm
beyond
complete exposure of the lacrimal sac.
6. One would realize that the cutting tip does not work if it touches the
lacrimal sac or surrounding soft tissues

7. Once the superior part of the ostium is reached, a flow rate of 40–50
ml/min with D1 program with power of 5 is used since the bone is
very thick here

Non-laser, non-endoscopic endonasal DCR (NEN-DCR)
Indications
1. Primary acquired NLDO (PANDO)
2. Acute dacryocystitis with lacrimal abscess
3. Revision in failed external or endonasal DCR
4. NLDO with associated nasal pathology
5. Posttraumatic secondary acquired nasolacrimal duct obstruction
(SANDO)
6. Persistent congenital NLDO (CNLDO)
NEN-DCR is usually not preferred in
1. Suspected lacrimal sac neoplasm
2. Severe midfacial trauma with hyperostosis around lacrimal sac & NLD
3. Lacrimal sac diverticulae/fistulae extending to eyelid skin
4. Thick bones causing difficulty in initiating osteotomy
5. Down’s syndrome

Surgical Technique
Instruments
1. Endoilluminator and 23G Vitrectomy retinal light pipe
2. Long- (5 cm) bladed nasal speculum with self-lock
3. Myringotomy sickle knife
4. Freer’s or Cottle’s periosteal elevator
5. Straight Weil-Blakesley ethmoid forceps
6. 2 and 3 mm right-angled Kerrison-Ruggles ronguer
7. Suction apparatus with canula

(a) Surgeon's position
(b) instrumentation

Surgical technique
1. under LA orGA
2. After punctal dilation with a
Nettleship dilator, a 23-
gauge vitrectomy light pipe
was gently introduced
through the upper
canaliculus until a hard stop
was felt
3. A nasal speculum with 5 cm
long blades and a guard was
introduced into the nasal
cavity.(a) Transillumination of the lacrimal sac with the
vitrectomy light pipe touching the medial wall of the nasal
cavity; (b) transnasal view of the glow in the medial wall of
the nasal cavity

4. A myringotomy sickle knife was used to incise the lateral nasal
mucosa showing the transillumination effect.
5. The incision for the mucosal flap was begun 8 mm above the insertion
of the middle turbinate and then carried out vertically or in a
curvilinear fashion down to the bone.
6. A freer periosteal elevator was used to elevate the incised nasal
mucosa and expose the frontal process of the maxilla.

7. The posteriorly-hinged nasal mucosal
flap was excised with Weil-Blakesley
forceps.
8. With the use of a 3 mm forward-biting
straight Kerrison rongeurs, the thick
bone of the frontal process of the
maxilla was sequentially removed, and
the osteotomy was gradually enlarged
9. An ostium was considered to be of an
optimum size and position if it allowed
easy passage of a horizontally directed
light pipe from the lower canaliculus
into the lacrimal sac.(c) bony ostium being made with the Kerrison rongeur; (d) the lateral nasal wall shows bony ostium
(small arrow) with the pale lacrimal sac mucosa showing through the ostium (arrowhead), and the
nasal mucosal edge above it (large arrow);

7. Finally, the medial wall of the
lacrimal sac was incised with a
myringotomy sickle knife to
create a marsupialized sac
8. Irrigation through the lower
canaliculus confirmed patency
of the drainage system [Figure
2]h.
9. Mitomycin C (MMC) 0.04% was
applied for 3
10. Bi-canalicular silicone tubes
were introduced and secured in
all patients.
e) transillumination of lacrimal sac after bony osteotomy; (f and g) Incision on the sac wall with a
myringotomy sickle knife

g) Incision on the sac wall with a myringotomy sickle knife
h) free flow of viscoelastic substance stained with fluorescein through the
ostium at the conclusion of surgery
NEN-DCR
1. average intraoperative bleeding is minimal
(≤12 ml)
2. retains the benefits of an endonasal approach
3. alleviates the need for expensive video-
endoscope or laser systems.
4. The posterior landmark to the lacrimal sac is
the uncinate process of the ethmoid bone and
therefore surgical manipulations must be
restricted to the area anterior to this landmark

Complications
1. orbital fat prolapse and medial rectus incarceration (More serious
)
2. Mild postoperative epistaxis
3. failure in 5–10 % (MC)
4. cicatrization at the ostium,
5. synechiae between ostium and middle turbinate and/ or nasal
septum,
6. granuloma formation within the ostium Canalicular obstruction,
7. orbital and subcutaneous emphysema,
8. conjunctival fistula formation,
9. retrobulbar hemorrhage, transient medial rectus paresis (rare )
10. Tube-related complications punctal erosion, granuloma
formation,
and spontaneous extrusion

Endonasal DCR assisted by
endoscope/LASER
NEN-DCR
Equipment Complex, Endoscope and LASER Simple – Halogen/LED light source
endoilluminator 23G/20G
Technique Steeper learning curve:
familiarity with the nasal anatomy
Easier to learn; lacrimal sac
transillumination makes procedure easier
for a novice surgeon
follow-ups Required for nasal lavage Not required as less damage to nasal
mucosa
Portability Difficult easily transported;
Operation cost High; maintenance of LASER,
endoscope
Affordable

Endocanalicular ( transcanalicular )laser DCR (ECLDCR)
Endocanalicular lacrimal surgery was proposed in the early 1990s by Levin and
Stormo-Gipson This was first clinically utilized by Michalos et al.
Indications
1.primary acquired NLDO
2.chronic epiphora without infection and discharge
Oculo-lacrimal contraindications
1. Acute dacryocystitis
2. Chronic dacryocystitis with mucopurulent discharge
3. Mucocoele
4. Lacrimal fistula
5. Suspected dacryolithiasis
6. NLDO secondary to Sarcoidosis or Wegener’s graulomatosis
7. Previous lacrimal surgery
8. Lacrimal tumors

Nasal contraindications
1. Previous nasal surgery (e.g., functional endoscopic sinus surgery)
2. Extensive nasal polyposis
3. Severe allergic rhinitis
4. Atrophic rhinitis
5. Naso–orbito–ethmoid facial fractures involving NLD
6. Nasal malignancy

Different types of lasers in ECLDCR
Laser Wave
length
(nm)
Power
(W)
Fiber
size
(um)
Comments
Diode 810–980 0.5–60 400–
1,000
Good cutting effect, hemostasis, coagulation
Less collateral damage
Nd: YAG 1,064 3–10 600 Good cutting ability ,More collateral damage
KTP :YAG
(Potassium Titanyl
phosphate )
532 10 300 Good cutting effect ,coagulation
Need protective wear
Er:YAG(Erbium) 2,940 0.1–
0.4
350–425 Good bone ablation ,Poor coagulation
Okay for canaliculoplasty
Ho:YAG(Holmium) 2,140 2.5–20 300–
1,000
Adequate coagulation ,Soft tissue ablation
Easily penetrates bone

1. The diode laser setting used is at an average of 10 W with continuous
laser delivery using the contact mode.
2. 600 um semirigid laser fiber optic is inserted in lower punctum into
the canaliculus up to the level of the lacrimal sac in a 45° fashion
3. 0° nasal video endoscope attached to a TV monitor is inserted
through the nostril to visualize the transilluminated laser light (laser
glow )from sac

3. the laser glow will reveal the thinnest portion of the lacrimal bone
which is anterior and inferior to insertion of middle turbinate
4. A periosteal elevator - used to medialize middle turbinate for good
exposure during laser procedure while protecting it from heat of
laser

6. probe Laser osteotomy is done by first puncturing the laser fiber optic
through the lacrimal bone and nasal mucosa via contact energy mode
with continuous setting. This is called “laser puncture”
7. With laser penetration ,an area of coagulation and necrosis seen on
the nasal mucosa surrounding the laser optic.
8. the fiber optic can be moved sideways, upward, and downward in a
circular fashion, thereby enlarging the osteotomy
9. The direction of the laser fiber optic is emphasized mostly on inferior
area.
10. A 10-mm cotton ball is soaked with 0.1 ml of a 0.2 mg/ml of
Mitomycin-C
placed on osteotomy site for 5 min with no irrigation after the
application
11. The silicone stents are guided through the inferior and superior
canaliculi and are tied in a square knot and encircled using 6–0 silk
sutures.

Advantages of ECLDCR
1. Absence of a skin incision
2. Preservation of the medical canthal structures
3. Preservation of the lacrimal pump mechanism
4. Less operative time
5. Local anesthesia and outpatient surgery
6. Laser directed away from the orbit
7. Minimal intraoperative and postoperative bleeding
8. Decrease or no periorbital swelling postoperatively
9. Low morbidity
10. Shorter functional recovery

Complications of ECLDCR
1. Occasional bleeding
2. Eyelid hematoma
3. Preseptal cellulitis
4. False passage
5. Canalicular stenosis and obstructions
6. Lacrimal sump syndrome
7. Tissue necrosis
8. Nasocutaneous fistula
9. Orbital infarction syndrome

External DCR Endocanalicular
DCR
Endonasal DCR
Direction
of laser energy
None Directed away
from globe
None or
directed towards
globe
Incision Yes No No
Operating time Variable Very brief Variable
Hemostasis Good Excellent Variable
Anesthesia General or
MIVA
MIVA General or MIVA
Lacrimal sac
biopsy
Yes Unreliable Unreliable
Dacryolithiasis Yes Contraindicated Variable
Recovery Several days Half day VariableMIVA –monitored IV anaesthesia

Endoscopic Balloon-Assisted DCR (EBA-DCR)
1. offers the experienced lacrimal surgeon a simpler, shorter, and less
invasive procedure.
2. there is a steep learning curve,a very low complication rate.
3. 5 mm balloon which is used via the trans-canalicular route,
4. the 9 mm can only be used transnasally
Indications :
1. most cases of nasolacrimal duct obstruction.
2. relative nasolacrimal obstruction which are nonresponsive to other
treatment can be considered.
Contraindications:
1. lacrimal sac tumor,
2. severe deviated nasal septum
3. canalicular obstruction

Equipment
• 25 gauge spinal needle
• Punctal dilators
• Reinforced stainless steel 3–4
Bowman probe
• Blakesly/true-cut forceps
• Backbiting forceps
• Freer elevator
• Turbinate scissors
• Nasal speculum
• Headlight
• Sinuscope, 4.0/2.7 mm, 0°,
• 5 or 9 mm Lacricath balloon
• Inflation device
• Frazier suction
• Neurosurgical cottonoids
• 4 % Cocaine/Afrin
• Lidocaine
• Irrigating canula

Surgical technique :
1. the puncta are gently dilated progressively to allow number 3 or 4
reinforced bowman’s probe to be passed into the lacrimal sac.
2. The probe is directed towards the inferoposterior part of the lacrimal
fossa, since it is very thin and can be easily overcome.
3. Once the bone is overcome, the position of the middle turbinate is
assessed and if needed a mild medialization of the middle turbinate is
carried out.
4. The probe is then passed inferiorly and superiorly in a honeycomb
pattern initially followed by opening of the lacrimal sac in a ‘filleting
open’ motion.
5. A blakesly true-cut forceps is then introduced into this small opening
and pulled back into the nose with its mouth wide opened.
6. Bits of tissues around now can be gently removed.

7. The 9 mm balloon catheter is now connected to the inflation device
and introduced into the nose with the balloon end going in first.
8. Under the guidance of the bowman’s probe, the catheter is introduced
into the newly made ostium and inflated to 8 atmospheres for 90
seconds.
9. It is then pulled into the nose backwards with the balloon still inflated
10. The balloon is deflated, introduced into the ostium again and reinflated
for 60 seconds and again pulled back in the inflated state.
11. This makes ostium big and fragments of bone and mucosa are then
removed.
12. Once the ostium is of adequate size, intubation is carried out with
Crawford tube or the specially designed large diameter Stent tubes.
13. The nose is then packed using cellulose sponges
14. A single intravenous dose of 8 mg dexamethasone is administered.

advantages :
1. absence of a skin incision,
2. absence of edema,
3. Reduced operative trauma
4. Less bleeding
5. Faster and less time consuming
6. No need for powered endoscopic instruments
7. Less post-operative morbidity
8. Early rehabilitation
9. High success rates

BALLOON DACRYOPLASTY(DCP)
Balloons were first used by Becker and Berry in 1989.
Indications :
Congenital NLDO
1. Failed Probing
2. Failed intubation
3. Older children (>12 months of age)
4. Down’s syndrome or any syndromic association with CNLDO
In adults
1. incomplete obstruction
2. when their general condition does not permit a DCR operation.

Typical Balloon dilatation set
1. 2 mm, 3mm, 5mm or 9mm balloon catheters
2. Inflation device
3. Lacrimal probes
4. Punctum dilator
5. Dandy’s nerve hook
6. Intubation set with retrieval device

PROCEDURE
1. Balloon dacryoplasty combines traditional probing and irrigation
with an added ability to expand the nasolacrimal duct with an
inflatable balloon.
2. The nasal cavity is packed with gauze containing vasoconstrictor
agent. Local anaesthesia of nasal mucosa, eyes and infratrochlear
nerve block/ general anaesthesia is given.
3. After dilation of the puncta, a Bowman probe is passed through the
system until it reaches and passes through the valve of Hasner.
4. Passage of the probe into the nasal cavity is confirmed by inserting a
Bowman probe of larger diameter through the nostril to establish
metal to metal contact or by direct visualization using an endoscope
.

5. The Bowman probe is then withdrawn and the balloon catheter is
inserted through the upper punctum. .
6. The balloon length is 15mm and overall length of the catheter is 24
cm.
7. The catheter is advanced until a marking 10mm above the edge of
the working segment of the balloon lies at the threshold of the
upper punctum.
8. In this position, the balloon sits primarily within the nasolacrimal
duct. It can be visualized directly in the inferior meatus using an
endoscope .

9. Using a standard cardiac balloon inflation system (consisting of a
syringe with volume 10 cc and a pressure gauge ranging from 0-15
atm ), the balloon is inflated to a pressure of 8 atm for 90 seconds and
then deflated for five to 10 seconds. A repeat inflation of eight
atmospheres is then performed for 60 seconds.
10. After both inflations, the balloon is deflated and then retracted
approximately 5mm. At this level, the balloon rests at the junction of
the lacrimal sac and the nasolacrimal duct .
11. Two more inflations are performed in the same manner as described
above. The catheter is then fully deflated and dialed out through the
punctum in a clockwise fashion.

12. In order to determine if patency has been achieved, the system is
irrigated with a sterile saline solution mixed with fluorescein dye.
13. Any solution that passes through the system is aspirated by a
suction catheter inserted into the nose.
14. The presence of fluorescein dye in the aspirated fluid confirms that
an open pathway has been established by the procedure.
15. In cases done under fluoroscopic guidance, a dacrycystogram(DCG)
is done after the procedure to confirm the patency.

Contraindications:
• Active dacryocystitis, dacryolithiasis, anatomic malformation in the
canal, bony canal and post traumatic lesions
Postop care:
• Post-operatively, the patient is placed on nasal spray decongestant,
and a combination of steroids and antibiotics that are administered
both systemically and topically.
• This combination of agents helps to ensure proper healing and to
prevent secondary scarring from any trauma induced by the surgery
itself

Complications:
• nosebleeds,
• canalicular damage and the
• creation of false passages.
• Failure in balloon dacryoplasty as in probing and silicone intubation is
typically due complicated factors like creation of a false passage,bony
anomalies, or infection and scarring following the procedure.

ConjunctivoDCR (CDCR )
1. initially described by Von Hoffman in 1904 ,later with Jones tubes
by Lester Jones in 1962
2. a new passage is created for drainage of tears from the
conjunctival cul-de-sac directly into the nasal cavity.
3. can be performed via
1. An external approach (external CDCR),
2. an endoscopic approach (endoscopic CDCR),
3. a minimally invasive approach (MICDCR), or
4. an endoscopic conjunctivorhinostomy (CR) without a DCR

Indications
1. Punctal agenesis
2. Canalicular agenesis
3. Proximal canalicular obstructions
4. Post-dacryocystectomy rehabilitation
5. Multiple times failed DCR with canalicular obstructions
6. Lacrimal pump failures
7. Unresolved epiphora following a patent DCR

Contraindications :
1. Scarred medial canthus
2. Gross eyelid anomalies
3. Gross nasal deformities
4. Early childhood
5. Mentally unstable patients
6. Unrealistic expectations or patients not keen
on tube maintenance
7. Poor systemic health
8. Patient who cannot come for follow-ups

1. The ideal bypass tube is nonhydrophobic, nonreactive with the tissues,
and rigid enough not to collapse.
2. The original Jones tubes are a set of pyrex glass tubes of varying sizes;
3. Straight tubes are more commonly used than curved tubes
4. Flanges with holes have also been designed to secure the tube by
passing suture through the holes.
5. Gold-plated dilators and tube measuring slabs are available with the
complete set

Jones pyrex tube
1. lengths vary from 9 to 28 mm
2. The ocular end has a flange with a diameter of 3, 3.5, or 4 mm.
3. The nasal end has a gentle flange.
4. The outer diameter of the tube is 2.5 mm,
inner diameter is 1.5–1.7 mm.
JONES PYREX TUBE

1. The Gladstone– Putterman modification
of the Jones tube has a flange section in
the middle, and is said to have less
chance of dislocation
2. Frosted glass Jones tubes and porous
polyethylene-coated
tubes have also been used to reduce the
incidence of dislocated tubes

1. In this operation, a DCR is performed in the usual manner to the
point of suturing the posterior tear sac and nasal mucosal flaps.
2. After closure of the posterior flaps, the caruncle, if prominent, is
removed partially or entirely, although a small, flat caruncle need
not be resected.
3. A curved 23-gauge needle is inserted in the medial canthus just
beneath the lower lid 2 mm posterior to the cutaneous margin of
the medial commissure and advanced in a direction that enables its
point to emerge just posterior to the anterior lacrimal sac flap
midway between the tear sac fundus and the isthmus, but anterior
to the body of the middle turbinate.

4. After enlarging the path with the help of a trephine the needle is
removed.
5. Jones tube of the approximate correct length (average 18 mm with a
collar of 4 mm) is threaded collar first over a Bowman probe, which is
subsequently passed down the path previously created.
6. The Jones tube is pushed down the Bowman probe to its final resting
position, and the probe is removed .
7. The tube should clear the lateral wall of the nose by 2 mm and should
also clear all intranasal structures (i.e., the nasal septum and the
turbinate).
8. Anterior flap, soft tissue, and skin closure is performed

Follow up
1. The patient should be instructed to avoid blowing his or her nose for the
first week after surgery, as it can cause intranasal bleeding.
2. During the initial three to six months postoperatively, the patient should
place a finger over the tube in the medial canthal area during sneezing,
nose blowing, or coughing to prevent dislocation of the tube.
3. Once the medial canthal tissue has contracted around the tube, there is
less chance of displacement.
4. Patients are usually seen one week, six weeks, and three to six months
following surgery. During these visits, tube function can be measured by
irrigating the tube

four categories to assess drainage
Class I drainage: Spontaneous fluid drainage.
Class II drainage: There is no spontaneous drainage but the fluid
disappears on exaggerated nasal respiration.
Class III drainage: Fluid does not drain with respiration but the tube can be
irrigated.
Class IV drainage: The tube cannot be irrigated.

Complications
1.Tube extrusion
2. Tube migration
3. Conjunctival granuloma
4. Peritubal soft tissue infections
5. Septum irritation
6. Tube blockage
7. Tube breakage (trauma)
8. Conjunctival pressure necrosis

Ref :
1. Step-by-step dacryocystorhinostomy for beginners: An expert's view
JCOR year=2014;volume=2;issue=3;page=161;
2. AIOS cme series 33 DCR
3. AAO 2016-17
4. IJO Nonendoscopic endonasal dacryocystorhinostomy: Outcome in 134
eyes Year : 2016 | Volume : 64 | Issue : 3 | Page : 211-215
5. Principles and Practice of Lacrimal Surgery Mohammad Javed Ali
THANK YOU

1. Injection is subcutaneous
2. parallel and anterior to the anterior lacrimal crest;
3. posterior to the anterior lacrimal crest in the lacrimal sac fossa;
4. and superior and posterior to the medial canthal tendon.
11

Canaliculo DCR
1. Stricture or closure of the common canaliculus or the distal ends of the
inferior and superior canaliculus can be surgically corrected by
canaliculoDCR.
2. involves reanastomosis of the canaliculi to the marsupialized nasolacrimal
sac after excision of the intervening scar or stricture.
3. After the creation of the bony ostium, a Bowman probe is placed in a
canaliculus to tent the nasolacrimal sac.
4. The lateral wall of the operative site will bulge; the apex of the bulge is
grasped with a forceps, and the lumen of the nasolacrimal sac, if present,
is entered with a No. 11 blade.
5. Anterior and posterior flaps of the nasolacrimal sac are created in the

6. Corresponding flaps in the nasal mucosa are created, and the posterior
flaps of the tear sac and nasal mucosa are approximated.
7. With the assistance of a Bowman probe, the site of obstruction is
observed by a bulge in the lateral wall of the nasolacrimal sac.
8. This bulge is grasped and a circular button of scarred tissue is
removed. If visualization is difficult, the anterior flap may be bisected
by dividing it in the horizontal plane to dissect down to the area of
stricture
9. The area of obstruction can be excised to expose the lumen of the
lacrimal canaliculi.
10. The canalicular epithelium is sutured to the nasolacrimal sac by
multiple 7–0 gut or polyglactin sutures.

Advantages in Endoscopic DCR
• Easy osteotomy
• Easy superior osteoplasty
• Minimal heat/no necrosis
• Minimizes bleeding
• Safe for sac and soft tissues
• Enhanced visualization (LED)
• Quicker surgery
• Low surgeon fatigue
• Superior histological healing
• Good for beginners

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