ALIE

Dacryocystorhinostomy

Principle : DCR is aimed to re-establish Tear Drainage from Ocular surface to Nasal cavity, bypassing the blocked NasoLacrimal Duct. A bony fistula is created between lacrimal sac and the nasal cavity.

Steps of DCR:

  • Antiseptic dressing and Draping
  • Anaesthesia:
    • Local: in adults, with 2% Lignocaine and 0.5% Bupivacaine.
    • General anaesthesia in case of children.
  • Syringing done — for ruling out pseudoblockage and confirmation of DCR.
  • Dilate the puncta (if not dilated) with Nettleship’s Punctum dilator.
  • Skin Incision:
    • J shaped curvilinear incision 3 mm medial to Medial palpebral ligament to avoid damage to Angular vein.
  • Dissection through orbicularis muscle
    • with Mosquito forceps
    • Down to the underlying periosteum
  • Disinsert Medial Palpebral ligament and a cleavage is made between lacrimal sac and bony lacrimal fossa with Rougine.
  • Periosteum incision given
    • and periosteum is elevated off the bones with periosteum elevator bluntly.
  • Puncture the bone
    • at the floor of lacrimal fossa (can be done with Muscle hook)
    • A bony osteum is made
    • The bony osteum is enlarged using Citeli’s bone punch.
  • Dilate the puncta and insert the Lacrimal probe to identify lacrimal sac.
  • Lacrimal sac flaps are formed
    • by incising the sac mucosa.
  • Anterior and Posterior flaps of Nasal mucosa are formed.
  • Respective anterior and posterior flaps of nasal mucosa and lacrimal sac are sutured with 6-0-vicryl.
  • Skin is closed with interrupted sutures.
  • Nasal packing done
    • A gauze is taken, soaked with Lignocaine gel and Adrenaline, held with Long bend forcep/ Citeli’s nasal forcep and kept insde nose (pack the nose). This step helps decrease bleeding.

Indications of DCR

  • Chronic Dacryocystitis
  • Recurrent lacrimal sac infection d/t stasis (recurrent acute dacryocystitis)
  • Impending Cataract / Intraocular surgery with presence of NLD obstruction.
  • Failed probing in child.

Contraindications of DCR

  • Acute dacryocystitis
  • Suspected malignancy of lacrimal sac or surrounding region
  • Relative C/I
    • Atrophic rhinitis
    • DNS – Chance of bone injury
    • Extremes of age

Techniques of DCR

  • External DCR
    • by External Skin incision
    • done mainly in Ophtha dept
    • Higher success rate (90-95%)
    • Cosmetic problem present
  • Endoscopic DCR
    • Through the nose
    • done mainly in ENT
    • Comparatively lower success rate (80-85%)
    • Cosmetic problem absent
External DCR