1. Anaesthesia. General anaesthesia is preferred,
however, it may be performed with local infiltration
anaesthesia in adults.
2. Skin incision. Either a curved incision along the
anterior lacrimal crest or a straight incision 8 mm
medial to the medial canthus is made.
3. Exposure of medial palpebral ligament (MPL)
and Anterior lacrimal crest. MPL is exposed by
blunt dissection and cut with scissors to expose
the anterior lacrimal crest.
4. Dissection of lacrimal sac. Periosteum is separated
from the anterior lacrimal crest and along with the
lacrimal sac is reflected laterally with blunt
dissection exposing the lacrimal fossa.
5. Removal of lacrimal sac. After exposing the sac,
it is separated from the surrounding structures
by blunt dissection followed by cutting its
connections with the lacrimal canaliculi. It is then
held with artery forceps and twisted 3-4 times to
tear it away from the nasolacrimal duct (NLD).
6. Curettage of bony NLD. It is done with the help
of a lacrimal curette to remove the infected parts
of membranous NLD.
7. Closure. MPL is sutured to periosteum, orbicularis
muscle is sutured with 6-0 vicryl and skin is
closed with 6-0 silk sutures.