Transcript DCR
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 .