|POST GRADUATE SECTION
|Year : 2014 | Volume
| Issue : 3 | Page : 161-165
Step-by-step dacryocystorhinostomy for beginners: An expert's view
Shrikant Deshpande, Anjaneya Agashe, Abhinav Loomba, Neha Dhiware
Department of Ophthalmology, Mahatma Gandhi Mission Medical College, Navi Mumbai, Maharashtra, India
|Date of Submission||03-Jun-2014|
|Date of Acceptance||28-Jun-2014|
|Date of Web Publication||16-Aug-2014|
Dr Anjaneya Agashe
Department of Ophthalmology, Mahatma Gandhi Mission Medical College, Kamothe, Navi Mumbai - 410 206, Maharashtra
Source of Support: None, Conflict of Interest: None
Chronic dacryocystitis occurs usually due to obstruction of lacrimal passage at the junction of the lacrimal sac and the nasolacrimal duct or within the bony nasolacrimal duct. Reconstruction of the lacrimal passages in such cases can be achieved by several surgical techniques, although external dacryocystorhinostomy (DCR), proposed by Ohm and by Dupuy-Dutemps and Bourguet in 1921, is still the most successful operation. Despite ease and decreased morbidity of endonasal DCR, external DCR is procedure of choice as it is more successful. Several ophthalmologists fear performing DCR because of bleeding and unfamiliarity of structure. This article tries to provide few tips to make DCR easy and stress-free. Proper case selection, pre-operative workup and adequate exposure go a long way in making DCR stress-free and successful. Excessive bleeding, a common hindrance in DCR surgery can be successfully tackled by proper positioning of patient, use of adrenaline, suction, and adjustment of nasal pack.
Keywords: Chronic dacryocystitis, dacryocystorhinostomy, nasolacrimal duct obstructions
|How to cite this article:|
Deshpande S, Agashe A, Loomba A, Dhiware N. Step-by-step dacryocystorhinostomy for beginners: An expert's view. J Clin Ophthalmol Res 2014;2:161-5
|How to cite this URL:|
Deshpande S, Agashe A, Loomba A, Dhiware N. Step-by-step dacryocystorhinostomy for beginners: An expert's view. J Clin Ophthalmol Res [serial online] 2014 [cited 2022 Dec 3];2:161-5. Available from: https://www.jcor.in/text.asp?2014/2/3/161/138865
Chronic dacryocystitis occurs usually due to obstruction of lacrimal passage at the junction of the lacrimal sac and the nasolacrimal duct or within the bony nasolacrimal duct. Reconstruction of the lacrimal passages in such cases can be achieved by several surgical techniques, although external dacryocystorhinostomy (DCR), proposed by Ohm and by Dupuy-Dutemps and Bourguet in 1921, is still the most successful operation.  The external approach is performed through a cutaneous incision to access the lacrimal sac. The procedure gained popularity due to its efficacy and relatively low complication rates. Endoscopic endonasal DCR has recently gathered momentum with direct visualization under endoscopic guidance. Caldwell first introduced the endonasal approach for lacrimal surgery in 1893. However, endoscopic endonasal DCR has only recently been employed with new endoscopy instruments and technique. This approach avoids an external scar and neurovascular disruption along the tract exposing the lacrimal sac. The reported success rates of both procedures range from 63% to 97%.  Despite ease and decreased morbidity of endonasal DCR, external DCR is the procedure of choice as it is more successful. A lot of ophthalmologists fear performing DCR because of bleeding and unfamiliarity of structure. This article tries to provide few tips to make DCR easy and stress-free.
| Basic Evaluation|| |
Case selection is very important for beginners attempting to do DCR. Best sac for doing DCR is the one with mucocele because sac is bigger and flaps are easily made. While the best patient for doing DCR is a thin, frail, elderly patient with roomy nostril due to ease of bone punching and less bleeding, any well-evaluated patient without any ear, nose and throat (ENT) abnormality, may be taken up. Patients with positive regurgitation test are ideal candidates. Patients with common canalicular block usually require complicated procedure, which may require stenting and intubation.
Blood pressure control is very important to decrease the risk of bleeding. The ENT evaluation should be done to rule out atrophic rhinitis and other nasal abnormalities. Blood thinners and anti-coagulants should be withheld in consultation with the treating physician to further decrease bleeding.
Ethamsylate is a hemostatic drug, which not only promotes platelet adhesion but also inhibits platelet disaggregation. It should be started at a dose of 250 mg twice one day prior to the surgery. Nasal decongestant such as otrivin drops should be given twice a day to reduce nasal congestion. Patient is kept nil by mouth for ease of sedation. There should always be a standby anesthesiologist to provide sedation and to deal with systemic complications.
| Intraoperative Tips|| |
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.
Apart from DCR set, there should be plenty of tightly wound peanut-shaped swabs soaked in lignocaine-adrenaline. The following should also be kept ready:
- Gauze pieces.
- Few cotton buds.
- Roller gauze for nasal packing.
- Suction machine with thin catheter or infant feeding tube ready.
- Viscoelastic for sac inflation OR chloro applicabs (chloramphenicol ointment).
Proper nasal packing is very important to reduce the bleeding. 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 medial palpebral ligament (MPL), insinuated and negotiated as deep as possible The direction of nasal packing is superior, then posterior, then inferior.
Local anesthesia with sedation is preferred as it reduces stress, which in turn decreases bleeding. Lignocaine with adrenaline is used which decreases bleeding unless systemically contraindicated. With anesthetist's permission, full 12 cc of 1:1,00,000 lignocaine-adrenaline is loaded in 10 cc syringe; of this, 4-5 cc is sprinkled on the nasal pack (roller gauze) and 7-8 cc is used for infiltration.
We prefer a single point block in DCR surgery. The preferred site of infiltration is upper inner angle of orbit just medial to medial canthus, where the MPL is situated. At the MPL insertion, the bone is hit with the 26-gauge needle and 2-3 cc injected, then the bevel of the 26-numberneedle rotated superiorly and 2-3 cc injected and then rotated inferiorly while injecting the remaining 2-3 cc. Firm pressure is applied for 5-10 min for the anesthetic to act. Cleaning is done with spirit and betadine right up to the upper lip.
| Surgical Steps|| |
A J-shaped groove is created with back-end of BP handle medial to the medial canthus. In the groove, created by firm pressure, 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 [Figure 1] and [Figure 2]. MPL insertion is reached by blunt dissection of orbicularis fibers [Figure 3] with artery forceps in the region of MPL (medial to medial canthus). Identification and exposure of MPL is a very important step in DCR surgery [Figure 4] and [Figure 5]. 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.
|Figure 4: Skin excised. Orbicularis oculi fibres separated to expose thick, white Medial Palpebral Ligament (MPL)|
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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 [Figure 6] and [Figure 7]. With a sharp dissector, the lamina is punctured breaking it outwards and removing the pieces with forceps.
|Figure 6: MPL dissected (held in forceps); periosteum elevated to expose shiny ivory white bone. 1. Anterior lacrimal crest in continuation with inferior orbital rim (thick dotted line). 2. Deep inside the cavity, papery thin pinkish Lamina Papyracea (Lacrimal Bone)|
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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. 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. [Figure 8]
|Figure 8: Large osteotomy (as indicated by thin 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|
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Adjustment of the nasal pack during bone punching may be required to reduce bleeding. Suction with infant feeding tube or Ryle's tube should be used to aid exposure in case of bleeding.
Dilate the upper punctum with punctum dilator. Inflate the sac with viscoelastic or chloro ointment in a 2-cc syringe with a 26 number cannula. 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 [Figure 9] and [Figure 10]. Vertical long top to bottom incision with a 11 number blade should be made on nasal mucosa such that posterior flaps can appose well and anterior flap is large. Small horizontal cuts may be required on the posterior nasal mucosal flap to help it revert and appose well with posterior lacrimal sac flap. Anterior horizontal cuts are made later, after suturing the posterior flaps.
|Figure 9: Lacrimal sac inflated with viscoelastic or chloramphenicol eye ointment with 26 no. cannula through upper punctum. 1. Inflated buldging lacrimal sac. 2. Site of incision on lacrimal sac for creating anterior and posterior flap|
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|Figure 10: 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|
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Posterior flaps are sutured so that the posterior sac flap does not block common canalicular ostium in sac. The 6-0 vicryl needle is slightly bent in the middle of its shaft for easy suturing of the posterior flaps in the depths. One suture usually is sufficient for posterior flap. Care should be taken to avoid nasal pack in the suture [Figure 11]. Anterior nasal flap is now opened with 11 number blade and sutured to the anterior sac flap with minimum two 6-0 vicryls sutures (sometimes three) [Figure 12]. Inserting lacrimal probe helps to confirm proper flap suturing. 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. Before closures, conjunctival sac should be irrigated to remove any bone pieces. Chloramphenicol ointment should be applied on the wound and in the eye. Quarter folded pad on the wound and half-folded pad on the eye should be applied. Full pad can be put over this. Minimum 4-5 micropore tapes in a criss-cross fashion with one tape to secure the nasal pack in position should be applied.
|Figure 11: Posterior flaps sutured with one or two sutures. Incision 3 not yet made. Inferior flap not yet created. Shaded portion in between: Nasal cavity with nasal pack visible|
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|Figure 12: Anterior nasal flap created and sutured with two stutches to the anterior nasal flap. Suture passed through thick stem of MPL for reattachment to periosteum on nasal side|
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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) - Serratiopeptidase combination and ethamsylate should be given routinely for five days. Dressing and nasal pack removal to be done after 24 hours. Local treatment includes otrivin-P nasal drops twice daily, chloramphenicol 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.
| Results|| |
We have operated 250 cases in the past 2 years with 95% success rate.
| Conclusion|| |
Proper case selection, pre-operative workup and adequate exposure go a long way in making DCR stress-free and successful. Excessive bleeding, a common hindrance in DCR surgery can be successfully tackled by proper positioning of patient, use of adrenaline, suction, and adjustment of nasal pack.
| References|| |
|1.||Baldeschi L, Nardi M, Hintschich CR, Koornneef L. Anterior suspended flaps: A modified approach for external dacryocystorhinostomy. Br J Ophthalmol 1998;82:790-2. |
|2.||Karim R, Ghabrial R, Lynch T, Tang B. A comparison of external and endoscopic endonasal dacryocystorhinostomy for acquired nasolacrimal duct obstruction. Clin Ophthalmol 2011;5:979-89. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]