2. Definition: surgical procedure to restore the flow of
tears into the nose from the lacrimal sac when the
nasolacrimal duct does not function.
Types:
1. Conventional/ External
2. Endoscopic/ Endonasal
3. Endolaser
3. EXTERNAL DCR
Indications:
1. Primary acquired nasolacrimal duct
obstruction.
2. Secondary acquired nasolacrimal duct
obstruction, such as due to prior
midfacial trauma, chronic nasal or sinus
inflammation, nasal surgery, neoplasms
and dacryoliths.
4. 3. Functional obstruction of outflow, due to lacrimal
pump weakness or after facial nerve palsy
4. Congenital nasolacrimal duct obstruction, after failed
prior probing or intubation.
5. History of dacryocystitis.
5. Anaesthesia:
• Performed under monitored sedation or general
anesthesia.
• Local anesthesia, using an equal mixture of 1-2% lidocaine
and 0.5% bupivacaine with 1:100,000 epinephrine, is
infiltrated into the medial canthus, lower lid incision site
and nasal mucosa.
• Nasal packing soaked in 4% cocaine, lidocaine or afrin
(oxymetazoline) provides additional nasal anesthesia and
mucosal vasoconstriction to the middle meatus.
6. Incision:
1. Curvilinear incision: 2mm above the MPL- 3mm medial to
medial canthus- 4mm down n outwards along the
lacrimal crest- 2mm below the inferior orbital margin.
2. Straight incision 10mm medial to medial canthus avoiding
the angular vein.
Procedure:
Vertical incision
7. The orbicularis is split and lacrimal retractor is
inserted, exposing anterior lacrimal crest and
superificial portion of MPL is divided.
The periosteum is incised and lacrimal bone is
exposed, reflecting the lacrimal sac laterally.
The crest is removed with the gouge and punch,
exposing the nasal mucosa.
Lacrimal bone exposed H shaped incision on sacVertical incision
8. The sac is opened through its nasal wall in an ‘H shape’ to create 2
anterior and posterior flaps
Patency is checked by probing.
Vertical incision in the nasal mucosa to create 2 similar flaps and
sutured with the corresponding sac flaps.
Incision in the nasal mucosa Flaps sutured Closure of skin
9. Silicon tubes are passed through both the puncta to the
nose
All the anterior structures are
sutured in layers.
Tubes are removed after 4-6 months.
Success rate of over 90%
10. Causes of failure:
• Inadequate size and position of ostium
• Unrecognized common canalicular obstruction
• Scarring
• Sump syndrome
Complications:
• Cutaneous scarring
• Haemorrhage
• Cellulitis
• CSF rhinorrhoea
11. CONJUCTIVODACRYOCYSTORHINOSTOMY
Indications:
• Primary: canalicular obstruction <8mm from puncta
lacrimal pump failure
• Secondary: failed DCR
o Procedure:
• DCR is performed as far as suturing the flaps.
• Caruncle is partially excised and a stab incision is made with a
Graefe knife medially till just behind the anterior flap of
lacrimal sac.
• Tract is enlarged using dilators and Lester Jones tube is
inserted.
• Incision is sutured.
12. ENDOSCOPIC DCR
Indication: similar to external
DCR and in failed external DCR.
Anaesthesia: general or local
• Success rate is about 80-85%
13. Procedure:
• slender light pipe is passed through the puncta into sac and viewed
from within the nasal cavity with endoscope.
• Mucosa over the frontal process of the maxilla is stripped
• Lacrimal bone is broken and sac opened
• Silicone tubes are passed and tied
• Tubes are removed after 2-3 months.
14. Cutaneous scar
More bleeding
Injury to adjacent structures
More operating time
Significant PO morbidity
No visualisation of nose
More success rate
Easily performed
Cheap equipment
No external scar
Less bleeding
Less chances of injury
Less time consuming
No PO morbidity
Better visualisation of nose
Less success rate
Requires skilled
ophthalmologists
Expensive
External DCR Endoscopic DCR
15. ENDOLASER DCR
Performed with a Holmium:YAG
or KTP laser.
Anaesthesia: Local
Procedure:
• laser probe is inserted through
the nose and a opening is made in
the medial wall of the nasal
mucosa, bone and sac.
• Rapid process, so carried out in
elderly patients
• Success rate – 70%