DACRYOCYSTORHINOSTOMY

Dacryocystorhinostomy (DCR) operation can be
performed by two techniques:
Conventional external approach DCR, and
Endonasal DCR
Conventional external approach DCR (Fig. 15.11)
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. Exposure of nasal mucosa. A 15 mm × 10 mm
bony osteum is made by removing the anterior
lacrimal crest and the bones forming lacrimal
fossa, exposing the thick pinkish white nasal
mucosa.
6. Preparation of flaps of sac. A probe is introduced
into the sac through lower canaliculus and the
sac is incised vertically. To prepare anterior and
posterior flaps, this incision is converted into H
shape.
7. Fashioning of nasal mucosal flaps. is also done
by vertical incision converted into H shape.
8. Suturing of flaps. Posterior flap of the nasal
mucosa is sutured with posterior flap of the sac
using 6-0 vicryl or chromic cat gut sutures. It is
followed by suturing of the anterior flaps.
9. Closure. MPL is sutured to periosteum, orbicularis
muscle is sutured with 6-0 vicryl and skin is
closed with 6-0 silk sutures.
Endonasal DCR
Presently many eye surgeons, alone or in
collaboration with the ENT surgeons, are pereferring
endonasal DCR over conventional external approach
DCR because of its advantages (described below).
surgical steps of endonasal DCR are (Fig. 15.12):
1. Preparation and anaesthesia. Nasal mucosa is
prepared for 15-30 minutes before operation with nasal
decongestant drops and local anaesthetic agent.
Conjunctival sac is anaesthetised with topically
instilled 2% lignocaine. Then 3 ml of lignocaine 2%
with 1 in 2 lac adrenaline is injected into the medial
parts of upper and lower eyelids and via subcaruncular
injection to the lacrimal fossa region.
2. Identification of sac area. A 20-gauge light pipe is
inserted via the upper canaliculi into the sac. With the
help of endoscope, the sac area which is
transilluminated by the light pipe is identified (Fig.
15.12A) and a further injection of lignocaine with
adrenaline is made below the nasal mucosa in this area.
3. Creation of opening in the nasal mucosa, bones
forming the lacrimal fossa and posteromedial wall
of sac can be accomplished by two techniques:
i By cutting the tissues with appropriate
instruments or
ii By ablating with Holmium YAG laser (endoscopic
laser assited DCR).
Note: The size of opening is about 12 mm × 10 mm
(Fig. 15.12B).
4. Stenting of rhinostomy opening. The outflow
system is then stented using fine silicone tubes
passed via the superior and inferior canaliculi into
the rhinostomy and secured with a process of knotting
(Fig. 15.12C). Nasal packing and dressing is done.
5. Postoperative care and removal of sialistic
lacrimal stents. After 24 hours of operation nasal
packs are removed and patient is advised to use
decongestent, antibiotic and steroid nasal drops for
3-4 weeks. The sialistic lacrimal stents are removed 8-
12 weeks after surgery and the nasal drops are
continued further for 2-3 weeks.