Elsevier

Survey of Ophthalmology

Volume 48, Issue 1, January–February 2003, Pages 73-84
Survey of Ophthalmology

Diagnostic and surgical techniques
The Evolution of Endonasal Dacryocystorhinostomy

https://doi.org/10.1016/S0039-6257(02)00397-1Get rights and content

Abstract

Dacryocystorhinostomy is an important treatment in the relief of tearing. Through the years, there have been several advances in this procedure. Once performed only from an external approach, the advent of rigid endoscopes and endoscopic instrumentation has made the endonasal approach a reality. Advantages of the endonasal approach include lack of a cutaneous incision and excellent visualization of intranasal pathology, which is often the cause of dacryocystorhinostomy failure. Preoperative evaluation including a detailed medical history, physical examination with office endoscopy, and imaging, as well as postoperative care are important. Surgical technique with detailed knowledge of intranasal anatomy and meticulous attention to hemostasis are critical. Endonasal laser-assisted dacryocystorhinostomy is also performed today, and special preoperative considerations and key features of the lasers available are important in the selection of a laser for tissue or bone ablation during the procedure. Endoscopic conjunctivodacryocystorhinostomy is performed today, and given the critical nature of proper length and placement of the Jones tube intranasally, provides the significant advantage of intranasal visualization. Endoscopic dacryocystorhinostomy in children is also performed today; however, challenges such as small nasal anatomy and maintenance of the intranasal osteomy postoperatively in a child are significant issues.

Section snippets

External dcr

The function of DCR is to divert lacrimal drainage into the nose through an osteomy at the level of the lacrimal bone. This procedure is performed either through an external or endonasal approach. The external approach is the most commonly used. External DCR, as originally described in 1904 by Toti,84 consisted of resecting the lacrimal sac mucosa, bone, and nasal mucosa through an external skin incision. This technique was modified by Dupuy-Dutemps and Bourguet,18 who introduced the concept of

Anatomy

Knowledge of the anatomy of the lacrimal drainage system is important prior to performing any lacrimal surgery procedure. The anatomical relationship between the lacrimal drainage system and the lateral nasal wall highlights the advantages of the endonasal procedure (Fig. 1). The lateral nasal wall is formed by turbinates, which are bony projections that are lined by mucus membrane. The meatus is the opening beneath and lateral to the corresponding turbinate. The important structures of the

Medical history

Endonasal DCR is successful only if important preparative techniques are employed. Careful history with special attention to bleeding disorders or diseases that may require anticoagulation are important. A detailed medication history may elicit anticoagulants, and these drugs are discontinued if possible upon consultation with the patient's primary care physician. Coumadin should be discontinued 3 to 4 days prior to surgery, with heparinization stopped 6 hours prior to surgery. Aspirin and

Hemostasis

Attention to meticulous hemostasis is critically important in performing endonasal DCR. Minimal amounts of bleeding obscure visualization through the endoscope and increase the difficulty of this procedure. Hemostasis of the nasal mucosa can be achieved with placement of nasal packing soaked with decongestants such as 0.04% oxymetazoline hydrochloride or 4% cocaine and is important in maintaining excellent visibility throughout the surgical procedure. Oxymetazoline hydrochloride is effective as

Postoperative Care

Postoperative care is important to maximize success rate of these surgical procedures (Table 1).50 If nasal packing is placed intraoperatively, it should be removed at the post-operative day-one visit.8 Systemic antibiotics are recommended for 7–10 days.8, 46, 81 Irrigation of the fistula with saline nasal spray and antibiotic-steroid eye drops are important. Some patients are given intranasal steroid spray after the first postoperative visit. Each postoperative visit may include debridement of

Complications

Complications secondary to endoscopic DCR include bleeding from the nasal mucosa, ethmoid air cells, or nutrient vessels of the anterior lacrimal crest. Nasal packing, anesthetic injection with epinephrine, and gelfoam placement are helpful in resolution of bleeding. Orbital injury from posterior bone removal is also possible. CSF leak can occur with fractures of the ethmoid bone extending superiorly to the cribiform plate. This can occur secondary to bone removal by rongeurs in a torsion

Endoscopic versus External DCR

Several reports have compared endoscopic and external DCR.5, 26 Most show that external DCR has a higher primary success rate. Hartikainen found that secondary success rate of both procedures was the same.26 Success rates with secondary revision have been reported as 80–95%.7, 43 Advantages of endoscopic DCR include lack of a cutaneous incision, direct access and visualization of the osteotomy site, and avoidance of disruption of the medial canthus and lacrimal pump function. Disadvantages

Endoscopic Revision of Failed DCR

Endoscopic DCR has been shown to be a valuable tool in the revision of external and endoscopic DCR. This idea was initially reported by Jones, in which the procedure consisted of mucosal elevation and tissue excision.40 Allen et al described using the nasal endoscope to visualize intranasal anatomy and evaluate the etiology of DCR failure.16 Primary failure rates of external DCR have been shown to be less than 10%.2, 35, 36, 90 Primary failure rates of endoscopic DCR range from 10–33%.26, 99

Endoscopic Conjunctivodacryocystorhinostomy

Endoscopic Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement has been described. Most reports of CDCR have described the external approach, whereby a medial canthal incision is utilized to create the bony osteotomy and position the pyrex tube. CDCR is performed as a primary procedure after failed DCR for canalicular stenosis or obstruction16, 40, 90 or to alleviate severe lacrimal pump dysfunction.16 Placement of a Jones tube bypasses the lacrimal system and creates a new

Endoscopic DCR in Children

Endoscopic DCR has been reported in small series in children. Although congenital nasolacrimal duct obstruction occurs in 6%–20% of all infants,51, 68 the rate of spontaneous resolution is 85–96% within the first year.76, 78 Ninety-five percent of children who do not resolve spontaneously improve with nasolacrimal duct probing.88 However, the success of probing decreases with increasing age of the child. This small percentage of patients (usually older than 12 months) who are unresponsive to

Conclusion

The evolution of endonasal DCR continues. As economic constraints increase and patient expectations remain high, this procedure must constantly be refined to approach the safety and efficacy of external DCR. Physician preference, patient selection, availability of equipment, and monetary constraints will determine the choice as to whether or not to perform surgery to relieve outflow obstruction externally or endoscopically, with or without lasers, in adults or children. Consultation with

Method of Literature Search

The database used in this search was Medline. The years searched were from 1970 until 2001. A few select articles published before 1970 were included for historical purposes, but the review is based mainly on articles published in the last three decades. The search words used included dacryocystorhinostomy, endoscopic dacryocystorhinostomy, lacrimal, tearing, laser-assisted dacryocystorhinostomy, endoscopic conjunctivodacryocystorhinostomy, pediatric dacryocystorhinostomy, congenital

Acknowledgements

The authors would like to thank Scott Turley for his help in preparing the manuscript and Bob Galla for his illustrations. The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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