DACRYOCYSTORHINOSTOMY
EXTERNAL
VS
ENDOCANALICULAR DCR
(ECL-DCR)
Introduction



Epiphora is a relatively frequent
problem in ophthalmology .
Standard surgery is
Dacryocystorhinostomy.
Recent advent of laser technology.
Inclusion Criteria

Primary acquired nasolacrimal duct
obstruction with / without chronic
dacryocystitis

Patent canaliculi

Normal eyelid function

Patients age less than 40 years
Exclusion Criteria

Sac pathology

History of previous sac surgery

Lacrimal fistula

Turbinate hypertrophy

Gross deviated nasal septum

Nasal Pathology(Atrophic Rhinitis,Polyp)
Pre-Operative Evaluation

History

Clinical evaluation
– Examination of lids
– Assessment of punctum
– Examination of sac area

Nasal examination

Diagnostic Tests
– Flourescein Dye Disappearance Test
– Lacrimal syringing
Follow up

At 10th day, one and six months post surgery

Results were graded as :
Full Success
–
NO TEARS
NO INFECTION
NO REFLUX
Partial Success
-
LESS TEARING THAN BEFORE
PARTIAL REFLUX
Surgical Failure
-
PERSISTENT TEARING
CLOSED OSTIUM
Steps Of External DCR
1. Skin incision
2. Bone osteotomy
3. Dissection of sac flap
4. Anastomosis of flap
Steps of External DCR
Procedure for ECL-DCR
Wavelength
980nm
Optical power
10 Watt
Aiming Beam
635nm, 4mW;
brightness adjustable
Operating Mode
cw, pulsed
Dimensions (H x W
x D)
12 X 26 X 30
Weight
5Kg
 Anesthetise the
nasal cavity with
10% Xylocaine
spray
 Dilate the
punctum
 Probing.
 Feel the bone.
Procedure
 Keep the initial power at 7 watt.
 Insert the 600µ fiber into the cannaliculus
upto the lacrimal bone.
 Focus endoscope in a way that the middle
turbinate remains in central vision when
the red aiming beam is seen above or in
front of the anterior end of middle
turbinate
 Press the laser footswitch maintaining
moderate pressure against bone with the
DCR cannula.
Procedure
 Fire the laser.
 On any resistance from the bone or sac,
increase the power.
 Manipulate the cannula and keep firing
the laser to increase the size of the
opening (4-5mm).
 Syringing at the end of the surgery with
normal saline water, then with dilute
povidone iodine solution or Betadine,
Steps of ECL-DCR
Operative Complication
OPERATIVE COMPLICATIONS
Operative
complications
EXTERNAL
DCR
ECLDCR
Bleeding
7(28%)
2(8%)
2(8%)
1(4%)
16(64%)
22(88%)
Hard bone
25
None
22
CASES
20
15
16
Series1
10
7
Series2
2
5
1
2
S2
0
Bleeding
S1
Hard bone
None
COMPLICATIONS
Success
Success
SUCCESS
Full
succes
s
0
2
100%
3
90%
1
Partial
succe
ss
Failure
2(8%)
0
1(4%)
3(12%
)
80%
70%
EXTERNALDCR
60%
50%
23
40%
21
30%
ENDOLASERDC
R
20%
10%
0%
EXTERNAL DCR
ENDOLASER DCR
Full success
Partial success
Surgical failure
23(92%)
21(84%)
Major Postoperative
Complication
Post operative complications
External DCR
Prominent scar
External DCR – Scar Related
Faint scar
5
20
Prominent scar
Faint scar
80%
20%
Major Postoperative
Complication
ECL-DCR
ECL DCR– Osteotomy Related
3
22
Closure of osteotomy
Patent osteotomy
Closure of osteotomy
12%
Patent osteotomy
88%
Results
Full Success
External DCR
Endocanalicula
r DCR
92%
84%
Partial Success 8%
4%
Failure
12%
Nil
Results

The Success in the External DCR :
-Immediate mucosa lined fistula via
the closure of the mucosal flaps.
Results

The failure in the laser DCR group :
- Anatomic variations
- Post-operative inflammation and fibrosis.
-
Inability to create an adequate opening.
-
Wrong selection of patients.
External DCR - The Gold
Standard

Large bony osteotomy.

Lacrimal sac is exposed -canalicular
DCR.

Success rate of 95%
Limitations of External
DCR

Per-operative haemorrhage

Surgery is lengthy (variable).

Risk of sump syndrome.

Re-do surgery -fibrous tissue.

The cutaneous scar.
Laser Procedures in DCR

Advantage over Surgical Approach-
- Cutaneous Scarring is eliminated.
- Minimal tissue disruption.
- Minimal bleeding.
-
CSF leaks unlikely.
-
Can be used in deabilitated patients.
Definitive edge of Endo
canalicular DCR



Laser energy is directed away from
eye
Ophthalmologist friendly.
Nasal endoscopy and
Instrumentation unneccesary.
Conclusions
Which procedure to
choose????
Conclusions
PATIENT SELECTION
-Right procedure for
right patient
Conclusions
DISCUSSION WITH PATIENT
•Viable option treatment.
•Discuss the advantages and disadvantages with patients.
Conclusions
FOLLOW UP…
More frequent and regular
follow-up for ECL-DCR patients
If two different techniques give
the same result, use the one
that is easier and faster
But if a more difficult and longer
operation yields a superior
result, use it .