DACRYOCYSTORHINOSTOMY (DCR) - Powerpoint

Dacryocystorhinostomy or DCR is among the common oculoplastic surgeries performed for managing epiphora due to nasolacrimal duct obstruction

2. OUTLINE
Introduction
Statement Of Surgical Importance
Epidemiology
Historical Perspective
Indications
Contraindications
Relevant Anatomy
Preoperative Management
History
Examination
Investigations
Instruments
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3. OUTLINE
Anaesthesia
Position
Procedure
Approaches
PostOperative Management
Complications
Prognosis
Future Trends
Conclusion
References
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4. INTRODUCTION
Dacryocystorhinostomy or DCR is among the common
oculoplastic surgeries performed for managing
epiphora due to nasolacrimal duct obstruction
There are two clear goals of DCR procedure. One is to
make a large bony ostium into the nose. Second is to
have a mucosal lined anastomosis.
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5. STATEMENT OF SURGICAL IMPORTANCE
DCR is a bypass procedure that creates an anastomosis
between the lacrimal sac and the nasal mucosa via a
bony ostium
It may be performed through an external skin incision
or intranasally
This presentation will discuss the goals, indications,
contraindications, simple techniques for a successful
DCR.
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6. EPIDEMIOLOGY
The occurrence of both acquired and congenital
nasolacrimal duct obstruction is common
For acquired nasolacrimal duct obstruction,
theestimated incidence is 20.24 per 100 000 persons
For congenital nasolacrimal duct obstruction, 5% to
20% (mean of 6%) of newborns are affected
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7. EPIDEMIOLOGY
in 31.8% of cases of all chronic epiphora, the cause is
nasolacrimal duct obstruction
Dacryocystitis occurs in 1/3884 of live births
Acquired nasolacrimal duct obstruction more
commonly affects Caucasians than Negroes
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8. HISTORICAL PERSPECTIVE
12th-Century Muhamad Ibn Aslam Al Ghafiqi
described the principles of lacrimal surgery in his
book "The Right Guide to Ophthalmology."
He reported using a small spear-shaped instrument
perforating the lacrimal bone in a nasal direction
"until blood flows through the nose and mouth with
care given not to direct the instrument downward as
this would be the incorrect direction."
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9. HISTORICAL PERSPECTIVE
Established the principle of fistulization which
remains the same to date
20th century, Addeo Toti in 1904 in the Italian
literature, described the currently accepted technique
of external-approach DCR and later modified by
Dupuy-Dutemps and Bourguet
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10. HISTORICAL PERSPECTIVE
Kuhnt in 1914 introduced the suturing of the nasal
mucosal flaps to the periosteum to reduce granulation
tissue
Ohm, in 1962, essentially described a procedure very
similar to the one described byDupuy-Dutemps and
Bourget and sutured the nasal mucosa to the lacrimal
sac
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11. HISTORICAL PERSPECTIVE
Caldwell in 1893, introduced Endonasal DCR, he used
an endonasal electric burr to remove the bone once a
metal probe had been passed through the canaliculus
and into the lacrimal sac.
Modified by West in 1910 and Halle in 1914
Real endonasal surgical improvements came with the
rigid nasal endoscopes, which paved the way for
advances in the field of endoscopic DCR.
The modern-day approach to endonasal
dacryocystorhinostomy was first reported by
McDonogh and Meiringin 1989.
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12. INDICATIONS
Persistent Nasolacrimal duct obstruction unresponsive
to non operative management
Dacryocystitis
Symptomatic Dacryoliths
Trauma
Lacrimal sac diverticuli
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13. CONTRAINDICATIONS
Uncontrolled bleeding dyscrasia
Active Dacryocystitis
Lacrimal sac tumor
Prior radiotherapy in the medial canthal region
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14. RELEVANT ANATOMY
An appreciationof precise anatomy is essential to
understand the process of DCR
The lacrimal drainage pathway includes the lacrimal
punctum (plural: puncti or puncta), the canaliculus
and nasolacrimal sac, nasolacrimal duct and the nose.
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15. RELEVANT ANATOMY
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16. RELEVANT ANATOMY
Lacrimal Punctum
Is located on the lacrimal papillae, facing slightly
towards the globe, on both the upper and lower lids.
Approximately 0.3mm diameter allows the flow of
tears into the canaliculus and is part of the lacrimal
pump by means of a siphoning action.
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17. RELEVANT ANATOMY
Canaliculus
The upper and lower eyelids have one canaliculus
each.
The canaliculus initially travels about 2 mm vertically,
and then turns horizontally in parallel with the eyelid
margin.
In most individuals (94%), the canaliculus from the
upper and lower lid converge and join to form the
common canaliculus.
The length of the upper canaliculus =8mm; lower
canaliculus =10 mm.
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18. RELEVANT ANATOMY
The upper and lower canaliculi each angle slightly
posteriorly, but the common canaliculus, in turn, may
angle anteriorly.
Awareness of this change in direction is essential for
safe, atraumatic syringing and probing, which
constitutes part of the assessment and pre-operative
workup.
The common canaliculus then pierces the periorbita
and enters the lacrimal sac.
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19. RELEVANT ANATOMY
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20. RELEVANT ANATOMY
Lacrimal Sac and Duct
The nasolacrimal sac and duct are continuous rather
than separate structures that are lined with non-
ciliated columnar epithelium.
The sac sits within the lacrimal fossa
Its dimensions are 12 to 15 mm in height and 4 to 8 mm
anteroposteriorly.
The superior fundus of the sac extends 3 to 5 mm
above the medial canthal tendon.
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21. RELEVANT ANATOMY
The nasolacrimal duct extends inferolaterally and
posteriorly through the bone for approximately 12 mm.
The nasolacrimal duct ostium is located 25 to 30 mm
posterior to the anterior nares.
The exit of the nasolacrimal duct into the nose can be
round or slit-like and is protected by a mucous
membrane covering, called the valve of Hasner or plica
lacrimalis.
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22. RELEVANT ANATOMY
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23. RELEVANT ANATOMY
The nose has three turbinates, each of which has a
corresponding meatus inferior to it.
Though the nasolacrimal duct opening lies within the
inferior meatus, it is the middle turbinate which
guides the DCR surgeon.
The middle meatus contains the uncinate process, the
bulla ethmoidalis, the frontal recess, and the maxillary
sinus ostium.
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24. RELEVANT ANATOMY
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25. RELEVANT ANATOMY
The lacrimal fossa is situated
superiorly, anteriorly and
laterally to the axilla of the
middle turbinate.
The sac extends 8 to 10 mm
above the superior extent of the
middle turbinate and about 4
mm below its inferior border.
It is essential to appreciate the
extent of the sac with respect to
the middle turbinate to perform
successful endoscopic DCR.
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26. RELEVANT ANATOMY
The uncinate process attaches to
the lateral nasal wall at the
frontal process of the maxilla.
Inferiorly, it attaches to the
ethmoidal process of the
inferior turbinate.
During the creation of the bony
ostium, the uncinate process
helps define the posterior-
inferior extent of bone removal
involving the lacrimal bone
covering the lacrimal sac.
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27. RELEVANT ANATOMY
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28. No 11 and 15 surgical blade
Diathermy
Freer’s elevator
House’ meatal elevator
Lacrimal probe
Punctal dilator
Suction
Kerrison bone punch
Hajek-kofler punch
6-0 polyglactin 910 suture on
half circle needle and Prolene
INSTRUMENTS
Blakesley forceps
0 and 30 degree endoscopes
Light source, camera,
monitor
Rongeurs
Laser
Long dental needle
Dental syringe
Mini-Monoka or Crawford
tubes for nasolacrimal
intubation
Gelsponge soaked with
triamcinolone
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29. PREOPERATIVE MANAGEMENT
A detailed history is taken, and anophthalmic and
endoscopic nasal examination performed
preoperatively.
History of Epiphora, medial canthal region pain,
mucoid discharge from the eye
Previous facial trauma
Previous rhinitis/rhinosinusitis
In the paediatric patient: obstetric and birth history,
prematurity, diagnosis of other medical issues, or
syndromes.
Previous nose or sinus surgery
Current medications, eg anticoagulants
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30. PREOPERATIVE MANAGEMENT
Previous ophthalmic problems -dry eyes, previous
refractive surgery
Previous treatments for epiphora
Palpation for swelling of the lacrimal sac, mucocele,
site of swelling (above or below the medial canthal
tendon)
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31. PREOPERATIVE MANAGEMENT
Examination
A comprehensive examination of epiphora begins with
careful study of the lids.
The eyelashes should also be inspected to make sure
they are not rotated and causing ocular irritation.
The position of the punctum should approximate the
globe.
Ectropion or entropion will lead to abnormal punctal
position.
Evaluation of lacrimal pump problems.
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32. PREOPERATIVE MANAGEMENT
Examination
The nasolacrimal sac area should be inspected for the
presence of swelling or a mucocele.
Any swelling above the medial canthal tendon is
atypical
Digital pressure is applied to the sac area, and the
punctum is observed for any mucoid reflux indicative
of a mucocele
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33. PREOPERATIVE MANAGEMENT
Lacrimal scintillography is indicated to identify those
cases with partial obstruction that can still benefit
from DCR
Dacryocystogram, Fluorescein dye disappearance test,
Diagnostic Irrigation of the Lacrimal System,
Nasendoscopy
CT PNS
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34. PREOPERATIVE MANAGEMENT
FBC
EUCr
RBG
Clotting profile
Additional general anaesthesia investigations when
required.
Obtain an informed and written consent
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35. ANAESTHESIA
The surgery can be done under general anaesthesia or
local anaesthesia.
The latter is the most commonly employed modality.
Local aneasthesia is given by both infiltration as well
as topical application.
Consider hypotensive anaesthesia
Nasal mucosa is prepared
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36. PROCEDURE
Approaches –Intranasal and External
Intranasal (Endoscopic) DCR considerations
In the setting of acute dacryocystitis, endoscopic DCR
is particularly useful, as it drains an anaerobic abscess
cavity into an aerated space, creating excellent
drainage without involving other tissue planes and
giving long term relief from epiphora
Primary and Secondary acquired nasolacrimal duct
obstruction.
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37. PROCEDURE
Intranasal (Endoscopic) DCR considerations
Persistent congenital nasolacrimal duct obstruction
Functional nasolacrimal duct obstruction
Acute and Chronic dacryocystitis, unresponsive to
medical treatment
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38. PROCEDURE
External DCR considerations
In the elderly patient, unfit for G.A, an external DCR is
an ideal option as it can be performed with minimal
sedation under L.A
Biopsy of the lacrimal sac, when needed, is perhaps
somewhat easier with the external approach.
In patients with previous facial fractures or unusual
anatomy.
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39. PROCEDURE
External DCR considerations
Where a septoplasty is required for adequate access to
perform successful endonasal-approach DCR, an
external approach may be preferred to avoid the need
for a septoplasty.
In patients with proximal or mid canalicular stenosis,
external DCR allows for retrograde intubation.
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40. PROCEDURE
Once the patient is anaesthetized, he/she is then
prepped and draped in the standard fashion.
Appropriate positioning is established
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41. PROCEDURE
Intranasal (Endoscopic) DCR
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42. PROCEDURE
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43. PROCEDURE
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44. PROCEDURE
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45. PROCEDURE
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46. PROCEDURE
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47. PROCEDURE
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48. PROCEDURE
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49. PROCEDURE
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50. PROCEDURE
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51. PROCEDURE
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52. PROCEDURE
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53. PROCEDURE
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54. PROCEDURE
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55. PROCEDURE
External DCR
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56. PROCEDURE
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57. PROCEDURE
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58. PROCEDURE
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59. PROCEDURE
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60. PROCEDURE
Extent of ostium widening;
Anteriorly till the punch cannot be inserted between
the bone and the nasal mucosa.
Posteriorly till removal of aerated ethmoid.
Superiorly till 2 mm above the medial canthus.
Inferiorly till the nasolacrimal canal is partly deroofed.
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61. PROCEDURE
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62. PROCEDURE
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63. PROCEDURE
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64. PROCEDURE
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65. PROCEDURE
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66. POST OPERATIVE MANGEMENT
Reassure the patient.
Nasal packing is optional.
The patient is started on oral antibiotics, analgesics
POD1 nasal pack (if any) is gently removed and
hemostasis assessed.
The wounds are cleaned with 5% betadine, and the
patient is discharged on oral and topical antibiotics,
analgesics, nasal decongestants and steroids
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67. POST OPERATIVE MANAGEMENT
POD7 the sutures are removed, oral medications
discontinued, topical steroids are tapered, however
nasal medications continued for two more weeks.
The patient is reviewed at 6 weeks, 12 weeks, and 6
months.
If the patient is intubated then tube removal is usually
done at 12 weeks.
The patient should avoidblowing the nosefor the first
week and sneeze with the mouth open
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68. COMPLICATIONS
Early (1-4 weeks), intermediate (1-3 months) and late
(>3 months).
Early complications:
wound dehiscence
wound infection
tube displacement
excessive rhinostomycrusting
intranasal synechiae
CSF rhinorhoea
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69. COMPLICATIONS
Late complications:
rhinostomy fibrosis
webbed facial scar
medial canthal distortion
failed DCR
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70. COMPLICATIONS
EndoscopicDCR
Damage to the nasal mucosa with adhesion formation
Orbital fat prolapse
Injury to the medial rectus muscle.
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71. COMPLICATIONS
External DCR
External DCR will have a scar at the location of the
skin incision.
Facial nerve injury is common and can cause variable
lagophthalmos.
Occasional “pump-failure”
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72. Endoscopic view of post DCR
scarring
Early wound dehiscence following
an external DCR
COMPLICATIONS
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73. PROGNOSIS
DCR is successful when there is both anatomical and
functional patency.
The reported success rates of external DCR in
literature varies between 85-99%
Endoscopic procedures that remove the adequate bone
for full lacrimal sac exposure, marsupialization, and
mucosal flap apposition have very high success rates,
ranging between 90% to 100%
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74. FUTURE TRENDS
Use of mitomycin C is a novel treatment modality for
both external and endoscopic DCR, however further
studies are needed to define the optimal dosing and
application regimen
A Japanese neurosurgical ultrasound device (Sonopet
OMNI) has been applied to DCR
The latest version of the machine utilizes both a
longitudinal and torsional motion of the tip
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75. FUTURE TRENDS
Endonasal Laser assisted DCR
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76. Sonopet Omni
FUTURE TRENDS
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77. CONCLUSION
Excellent knowledge of lacrimal, eyelid, and nasal
anatomy is needed to perform DCR successfully
Today’s endoscopic DCR is a reliable and effective
technique that is comparable to external DCR in
outcome measures.
One-on-one training is essential to learn the
endoscopic approaches
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78. REFERENCES
Harish V, Benger RS. Origins of lacrimal surgery, and evolution of
dacryocystorhinostomy to the present.Clin. Experiment. Ophthalmol.2014
Apr;42(3):284-7.
Patel BC. Management of acquired nasolacrimal duct obstruction: external and
endonasal dacryocystorhinostomy. Is there a third way?Br J Ophthalmol.2009
Nov;93(11):1416-9.
Brad Bowling, Lacrimal drainage system Kanski’s clinical ophthalmology 8th
Edition, 2016 chapter 2: pp 64-75
Olver J.Colour Atlas of Lacrimal Surgery.1st ed. Oxford: Butterworth-
Hienemann; 2006. External dacryocystorhinostomy.
Wormald PJ. Powered endoscopic dacryocystorhinostomy. Otolaryngol Clin
North Am. 2006;39:539-549.
Wormald PJ. Powered endoscopic DCR. In: Endoscopic Sinus Surgery:
Anatomy, Three-Dimensional Reconstruction, and Surgical Technique. 2nd ed.
New York: Thieme; 2008.
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79. THANK YOU
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