DACRYOCYSTORHINOSTOMY DACRYOCYSTORHINOSTOMY

EXTERNAL EXTERNAL

VS VS

ENDOCANALICULAR DCRENDOCANALICULAR DCR

(ECL-DCR)(ECL-DCR)

IntroductionIntroduction

Epiphora is a relatively frequent Epiphora is a relatively frequent

problem in ophthalmology .problem in ophthalmology .

Standard surgery is Standard surgery is

Dacryocystorhinostomy.Dacryocystorhinostomy.

Recent advent of laser Recent advent of laser

technology.technology.

Inclusion CriteriaInclusion Criteria

Primary acquired nasolacrimal duct Primary acquired nasolacrimal duct

obstruction with / without chronic obstruction with / without chronic

dacryocystitisdacryocystitis

Patent canaliculiPatent canaliculi

Normal eyelid functionNormal eyelid function

Patients age less than 40 yearsPatients age less than 40 years

Exclusion CriteriaExclusion Criteria

Sac pathologySac pathology

History of previous sac surgeryHistory of previous sac surgery

Lacrimal fistulaLacrimal fistula

Turbinate hypertrophyTurbinate hypertrophy

Gross deviated nasal septumGross deviated nasal septum

Nasal Pathology(Atrophic Rhinitis,Polyp)Nasal Pathology(Atrophic Rhinitis,Polyp)

Pre-Operative EvaluationPre-Operative Evaluation

HistoryHistory

Clinical evaluationClinical evaluation

– Examination of lidsExamination of lids

– Assessment of punctumAssessment of punctum

– Examination of sac areaExamination of sac area

Nasal examination Nasal examination

Diagnostic TestsDiagnostic Tests

– Flourescein Dye Disappearance Test Flourescein Dye Disappearance Test

– Lacrimal syringingLacrimal syringing

Follow upFollow up

At 10th day, one and six months post surgery At 10th day, one and six months post surgery

Results were graded as :Results were graded as :

Full SuccessFull Success –– NO TEARSNO TEARS NO INFECTIONNO INFECTION NO REFLUXNO REFLUX

Partial SuccessPartial Success -- LESS TEARING THAN BEFORELESS TEARING THAN BEFOREPARTIAL REFLUXPARTIAL REFLUX

Surgical Failure Surgical Failure - - PERSISTENT TEARINGPERSISTENT TEARINGCLOSED OSTIUMCLOSED OSTIUM

1. Skin incision 1. Skin incision

2. Bone osteotomy 2. Bone osteotomy

3. Dissection of sac flap 3. Dissection of sac flap

4. Anastomosis of flap 4. Anastomosis of flap

Steps Of External DCR

Steps of External DCRSteps of External DCR

Procedure for ECL-DCRProcedure for ECL-DCR

Anesthetise the Anesthetise the nasal cavity nasal cavity with 10% with 10% Xylocaine spray Xylocaine spray

Dilate the Dilate the punctumpunctum

Probing. Probing. Feel the bone. Feel the bone.

WavelengthWavelength 980nm980nm

Optical powerOptical power 10 Watt10 Watt

Aiming BeamAiming Beam 635nm, 4mW; 635nm, 4mW; brightness brightness adjustableadjustable

Operating ModeOperating Mode cw, pulsedcw, pulsed

Dimensions (H x Dimensions (H x W x D)W x D)

12 X 26 X 3012 X 26 X 30

Weight Weight 5Kg5Kg

ProcedurProceduree

Keep the initial power at 7 watt. Keep the initial power at 7 watt. Insert the 600Insert the 600µ fiber into the µ fiber into the

cannaliculus upto the lacrimal bone.cannaliculus upto the lacrimal bone. Focus endoscope in a way that the Focus endoscope in a way that the

middle turbinate remains in central middle turbinate remains in central vision when the red aiming beam is vision when the red aiming beam is seen above or in front of the anterior seen above or in front of the anterior end of middle turbinateend of middle turbinate

Press the laser footswitch maintaining Press the laser footswitch maintaining moderate pressure against bone with moderate pressure against bone with the DCR cannula.the DCR cannula.

ProcedureProcedure

Fire the laser. Fire the laser. On any resistance from the bone or On any resistance from the bone or

sac, increase the power. sac, increase the power. Manipulate the cannula and keep firing Manipulate the cannula and keep firing

the laser to increase the size of the the laser to increase the size of the opening (4-5mm). opening (4-5mm).

Syringing at the end of the surgery Syringing at the end of the surgery with normal saline water, then with with normal saline water, then with dilute povidone iodine solution or dilute povidone iodine solution or Betadine, Betadine,

Steps of ECL-DCRSteps of ECL-DCR

Operative ComplicationOperative Complication

BleedingHard bone

None

S1

S2

21

22

7

2

16

0

5

10

15

20

25

CA

SE

S

COMPLICATIONS

OPERATIVE COMPLICATIONS

Series1

Series2

Operative Operative complicationscomplications

EXTERNALEXTERNALDCR DCR

ECL-ECL-DCRDCR

BleedingBleeding 7(28%)7(28%) 2(8%)2(8%)

Hard boneHard bone 2(8%)2(8%) 1(4%)1(4%)

NoneNone 16(64%)16(64%) 22(88%)22(88%)

SuccessSuccess

SuccessSuccess

Full Full succesucce

ssss

Partial Partial succesucce

ssssFailureFailure

EXTERNALDCREXTERNALDCR 23(92%)23(92%) 2(8%)2(8%) 00

ENDOLASERDCENDOLASERDCRR 21(84%)21(84%) 1(4%)1(4%)

3(12%3(12%))

EXTERNAL DCR

ENDOLASER DCR

23

20

21

1

3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SUCCESS

Full success Partial success Surgical failure

Major Postoperative Major Postoperative ComplicationComplication

External DCR – Scar Related

Post operative complicationsPost operative complications

External DCRExternal DCR

Prominent scarProminent scar 80%80%

Faint scarFaint scar 20%20%

ECL DCR– Osteotomy Related

Major Postoperative Major Postoperative Complication Complication

ECL-DCRECL-DCR

Closure of osteotomyClosure of osteotomy 12%12%

Patent osteotomyPatent osteotomy 88%88%

ResultsResults

External External DCRDCR

EndocanalicEndocanalicular DCRular DCR

Full SuccessFull Success 92%92% 84%84%

Partial Partial SuccessSuccess

8%8% 4%4%

FailureFailure NilNil 12%12%

ResultsResults

The Success in the External The Success in the External

DCR :DCR :

--Immediate mucosa lined fistula Immediate mucosa lined fistula

via the closure of the mucosal via the closure of the mucosal

flaps.flaps.

ResultsResults

The failure in the laser DCR The failure in the laser DCR

group :group :

- Anatomic variations - Anatomic variations

- Post-operative inflammation and - Post-operative inflammation and

fibrosis.fibrosis.

- Inability to create an adequate Inability to create an adequate

opening.opening.

- Wrong selection of patients.Wrong selection of patients.

External DCR - The Gold External DCR - The Gold StandardStandard

Large bony osteotomy.Large bony osteotomy.

Lacrimal sac is exposed -Lacrimal sac is exposed -

canalicular DCR.canalicular DCR.

Success rate of 95%Success rate of 95%

Limitations of External Limitations of External DCRDCR

Per-operative haemorrhagePer-operative haemorrhage

Surgery is lengthy (variable).Surgery is lengthy (variable).

Risk of sump syndrome. Risk of sump syndrome.

Re-do surgery -fibrous tissue.Re-do surgery -fibrous tissue.

The cutaneous scar.The cutaneous scar.

Laser Procedures in Laser Procedures in DCRDCR

Advantage over Surgical Approach-Advantage over Surgical Approach-

-- Cutaneous Scarring is eliminated.Cutaneous Scarring is eliminated.

- Minimal tissue disruption.- Minimal tissue disruption.

-- Minimal bleeding.Minimal bleeding.- CSF leaks unlikely.CSF leaks unlikely.- Can be used in deabilitated patients.Can be used in deabilitated patients.

Definitive edge of EndoDefinitive edge of Endocanalicular DCRcanalicular DCR

Laser energy is directed away Laser energy is directed away from eye from eye

Ophthalmologist friendly.Ophthalmologist friendly. Nasal endoscopy and Nasal endoscopy and

Instrumentation unneccesary.Instrumentation unneccesary.

ConclusionsConclusions

Which procedure to Which procedure to choose????choose????

ConclusionsConclusions

PATIENT SELECTIONPATIENT SELECTION

-Right procedure for -Right procedure for right patientright patient

ConclusionsConclusions

DISCUSSION WITH PATIENT

•Viable option treatment.

•Discuss the advantages and disadvantages with patients.

ConclusionsConclusions

FOLLOW UP… More frequent and regular

follow-up for ECL-DCR patients

If two different techniques If two different techniques give the same result, use give the same result, use the one that is easier and the one that is easier and faster faster

But if a more difficult and But if a more difficult and longer operation yields a longer operation yields a superior result, use it .superior result, use it .