Download Failure of DCR

Revision Dacrocystorhinostomy
Babak Saedi MD
Imam Khomeini Hospital
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Dacryocystorhinostomy (DCR) has a
very high success rate.
Many centers have described success rates
of 90–95%
revision DCR surgery is not quite as high,
varying from 80 to 90%
Failure of DCR
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Inadequate
rhinostomy,
excessive scar tissue
production,
Anatomic anomalies
paranasal sinus
Septal déviation
Physical Examiation
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Probing of the nasolacrimal duct is the first
line of treatment.
SURGICAL ANATOMY
Physiology of tear drainage
Anatomy of lacrimal drainage
system
Canalicular obstruction
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a) Canalicular blockage
More complex surgical procedures are necessary if
intubation is not successful. The micro-surgical repair of
canaliculi has been proposed with a canaliculo-DCR
being reserved for distal canalicular blockage. Retrograde
intubation of the canaliculi combined with DCR is used
for proximal canalicular obstruction and punctal agenesis,
with a success rate of 60-70%.
Functional blockage
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Functional blockage due to preductal or ductal
narrowing, identified by delayed MDCG or
scintigraphy can be treated by DCR and a silicone
stent. Many cases of functional blockage have
also been successfully treated using lid shortening
and punctal snip procedures.
It seems that in such cases other underlying
causes have been responsible such as punctal
phimosis. Functional blockage due to pump
failure (facial nerve palsy) might require by-pass
lacrimal surgery. Treatment remains
controversial.
How to prevent
A small bony ostium has been identified
as one of the most important causes of the failure of
DCR surgery.
 Mucosal Flap!
 resection of the uncinate process
 Mitomycin C
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American Journal of Rhinology & Allergy
INVESTIGATIONS
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Identification of the site of blockage
requires one or more of the following tests:
PATIENT’S EVALUATION
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Irrigation of lacrimal
passages(diagnostic/therapeutic).
PNS CT
Dacryocystography
Scintography
General and Systemic examination
Dye tests
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Two or three drops of sodium fluorescein are instilled into
the lateral fornix. Dye may drain completely (dye
disappearance) and be collected by a swab at the inferior
meatus (Jones I).
The ocular surface is examined simultaneously.
Conjunctival and corneal staining should be noted to rule
out ocular surface disease. On the whole dye tests are
objective and not reliable.
Dye tests
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The secondary dye test (Jones II) is performed by
irrigating the inferior canaliculus with saline and
collecting the used solution in a small basin. The
patient holds the basin in front of the appropriate
nostril, with the head tilted forward
This finding confirms the presence of a functional
block.
Syringing and probing
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The lower puncti are gently dilated under topical
anaesthesia. If it enters the sac without my
resistance, the site of blockage is most probably
NLD.
The exposed end is measured to identify
accurately the site of the blockage. Syringing of
the NLD then follows.
Macro dacryocystography
(MDCG) and scintigraphy
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MDCG is particularly useful to reveal details of lacrimal
sac anatomy and the site of nasolacrimal duct
obstruction.MDCG with a delayed erect film 5 minutes
after injection of contrast medium can detect functional.
Scintigraphy is mainly used to confirm a diagnosis of
functional blockage when there is delayed or no out- flow
of radioactive media in the presence of a normal DCG.
Dacryocystogram
How to Treat
Endonasal D.C.R :
- Lower incidence of restenosis and better cosmetic result
Surgicalsteps :
1. Remove
uncinate process.
2. Remove mucosa above the frontal recess and lacrinal bone.
3. Drill away bone above lacrimal sac (until 270 of its medial
circumference is exposed).
4. Probe lacrimal sac .
5. Incise lacrimal sac above the probe.
6. Remove entire medial circumfer ence of the sac.
7. Insert
a silicose tube (for 6 mon.) !?
Probing
Punctum dilation
Probing
Probing
Video monitoring for localization of
laser fibre optic
(location of nasal opening)
DCR tube (silicone stent)
Enonasal DCR
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1) absence of external scars,
2)maintenance of the mechanisms of lacrimal pumping of the
orbicular muscle,
3) reduction of the lesion to structures of the medial eye canthus,
4) less bleeding,
5) shorter hospitalization, fistula.1
Endonasal DCR
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6) technical facility due to the anterior removal of the lacrimal bone,
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7) possibility to correct during the same surgical act nasosinusal
comorbidities that may potentially lead to surgical failure such as
septal deviations, synechiae, granulation tissues, rhinosinusitis, nasal
polyposis, incomplete bone removal, etc, and
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8) direct visualization of the site and amplitude of the nasolacrimal