Download Wipe your tears thro` the nose DR . M. DEEPTHI

Wipe your tears thro’ the nose
DCR
DR . M. DEEPTHI
ASST . PROFESSOR
DEPARTMENT OF ENT & HEAD AND
NECK SURGERY
Lacrimal pathway
NLD opens into inferir meatus 10-15 mm behind anterior end of inferior turbinte
And 16 mm above floor of nasal cavity - HASNER’S VALVE
Applied anatomy
• lacrimal fossa -Lacrimal bone & frontal process of
maxilla
- 15 x 4-8 x 2 mm
- houses lacrimal sac
• Lacrimal sac - 2/3rd of sac lies above insertion
of middle turbinate and 1/3rd below
• 8% 0f cases - Anterior ethmoid air cell ,Lacrimal
cell lies medial to lacrimal bone
EPIPHORA (Watering Eyes)
CAUSES
•Excess Tear Production(Hyper
Lacrimation)
•Lid Malposition(Punctal Ectropion)
•Ocular surface irritation(Dry
eye,Blepheritis)
•Canalicular stenosis and obstruction
•NLD Obstruction—Associated with
inflammation
NLD OBSTRUCTION – Atresia
Congenital
Acquired - functional block / mechanical block
1.PRIMARY : IDIOPATHIC –increasing age –
Involutional
2. SECONDARY :
•
•
•
•
•
Mucocoele, pyocoele or recurrent dacrocystitis
Surgical trauma- MMA
Mid face fractures
Malignancy – ethmoid sinus, antrum extending into
inferior meatus
Granulomatous conditions of nose –cicatricial
CLINICAL DIAGNOSIS – Epiphora
• Secretory defect – Hyper secretion
• Excretory pathway defect
SECRETORY defect : Hypersecretion
Schirmir test -Wetting of filter paper strip
after 5 minutes
I – Basal tear secretion
II – Tears secreted following nasal stimulation
Normal values : 15 mm > 40 years
10mm < 40 years
Excretory pathway defect
a. Massaging the sac – regurgitation from puncti
b. Fluorescein Retention Test - 2% Fluorescein
c.
dye is instilled into eye ,Prolonged retention (more
than 5 mints) – Cobalt blue light
Probing with `0’ Bowman’s probe – Hard stop /soft
stop
d.Syringing – Reflux of saline through other punctum
e. Jones Dye Test I & II
PROBING
a)HARD STOP
–No
mechanical
Obstruction
b)SOFT STOP –
Mechanical
Obstruction +,
at level of stop
Jones Dye Testing
I. PRIMARY TEST (a)
Differentiates restricted
drainage from hyper secretion
Positive - Dye recovered
Negative -No dye recovered
-
partial obstruction or pump failure
II .SECONDARY TEST(b)
After washing eye from any residual
Fluorescein , irrigation is done
Positive - Stained saline
recovered – partial obstruction
Negative - Unstained saline
recovered- pump failure
Other tests
• Nasal endoscopy
• Dacrocystogram-diverticuli,stenosis,stricture,
dacroliths,or tumors
• Dacroscintigraphy - 99M Tc
• CT Scanning – Malignancy/ facial fracture
(bloody discharge from punctum)
• Fine rigid Dacrocystoscopes -0.7 mm diameter
• Ultrasound , MRI, MR Dacrocystography, CT
Dacrocystography
TREATEMENT OPTIONS
• Medical –antibiotics ,anti inflammatory drugs
• Massaging and periodical syringing
• Surgical management
Congenital NLD obstruction
• membraneous block of the valve of Hasner 50% of newborn
• spontaneously resolved 4-6 weeks after birth
• conservative treatment with topical antibiotic
• Crigler massage upto 1 year ; syringing &
probing.
• DCR & stenting after 3-4 yrs
DCR Methods
• External DCR – Low Howarth’s incision
• Endonasal DCR with conventional
instruments
• Endonasal Laser assisted DCR
• Balloon DCR
• Transcanalicular laser DCR
HISTORY
• 1893 - Cald well - ENDO NASAL DCR •
•
•
•
rhinostomy after removing part of inferior
turbinate , followed NLD to sac
1904 - Toti - EXTERNAL DCR
Dupy – Dutemps and Bourget –Sutured mucosal
flaps in ext DCR
1980’s – Steadman, Mc Donagh, Mayring –
resurgence of ENDONASAL DCR
1990 – Massaro et al – laser endonasal DCR –
argon blue – green laser
- Gonnering et al – CO2 and KTP
EXTERNAL DCR
• GA / LA
• Howarth incision
• Medial canthal ligament cut, sac incised
and retracted,lacrimal bone exposed,and
punched out suture lacrimal sac mucosa to
nasal mucosa
• Stenting
Disadvantages of Ext.DCR
• External scar
• Injury to the medial canthus
• Pumping mechanism of Orbicularis oculi
lost
• Periorbital haemorrhage,injury to angular
vein
• Epistaxis
• CSF leak
ENDO NASAL DCR Indications
• Chronic
•
•
•
•
dacryocystitis – not
relieved by probing
and syringing
Lacrimal abscess
Cosmetic reasons
Acquired intra saccal
or post saccal
stenosis
NLD obstruction
INSTRUMENTS
ENDO NASAL DCR - procedure
• Local / General Anesthesia
• Pre medication and Nasal packing
• 0 deg /70 deg scope or operating microscope
•
•
•
•
(300 mm ) lens
Infiltration
Incision
Exposure of lacrimal bone ,punch it ,expose sac
, incise it
Syringing - patency
Post op care
• Analgesics
• Antibiotics
• Topical eye drops
• Periodic syringing and follow -up
Endoscopic DCR
Advantages
Avoiding skin incision and scar
Thorough inspection
Avoiding injury to the medial canthus
Preserving the pumping mechanism
of Orbicularis oculi
Avoiding periorbital haemorrage
Advantages(cont...)
Paranasal disorders that may contribute to
nasolacrimal obstruction - simultaneous
treatment in one sitting
Short day care procedure
Hospital stay minimised
Bilateral - performed simultaneously
Endoscopic DCR
Disadvantages
 Sophisticated equipments
 Bleeding
 Injury to the vestibule if drill is used
 Synechia
 Granulations
Endoscopic DCR
Causes of failure
 Persistent nasosinus infection
Dns
Inadequate follow up and
post op syringing
Reasons for earlier failure – Endo DCR
• Relative inaccessibility
• Poor visibility of operating area
• bleeding
ENDONASAL LASER ASSISTED
DCR- Ho-YAG; KTP/532 ; Diode laser
Superior Punctum and canaliculus is dilated for
passage of VITREO RETINAL LIGHT PROBE
• This light can be seen endoscopically –
guide for site of sac for laser
• Light is dimmed –lacrimal cell,thick walled
mucocoele
• Optimal power –tissues are charredperiodically removed
• On exposing sac,vitreoretinal probe is
removed, lacrimal probe is used to tent
sac medially
• Rhinostomy of 5-8 mm diameter .
• Silicone stent can be louped around
medial canthus and both canaliculi to nose
ENDONASAL LASER DCR
ADVANTAGES
• No ext scar
• Out patient procedure
• Those not fit for GA and
on Warfarin
• Minimal bleeding
• Less disruption of medial
canthus and pump
• Short operating time
DISADVANTAGES
• Laser precautions
• Expensive
• High failure rates-stenosis
and scarring
Balloon DCR
• LA
• Angioplasty
balloon catheter
over protected
guide wire
• Inflation- dilates
the stenosis
• Re- stenosis
TRANS CANALICULAR LASER
DCR-1992
600 mm laser
Probe- through
Canaliculus
Canalicular damage
Due to leakage
May enter orbit -post.
Medial wall of sac
COMPLICATIONS
• FAILURE- granuloma,scarring
• Adhessions
• Migration of stents
• Sump syndrome- rhinostomy is high and
mucous collects within sac
• Haemorrhage
TAKE HOME MESSAGE
• DCR – distal NLD obstruction
× proximal obs
× Functional problem
× wagener’s / sarcoidosis ,etc
• Endo L DCR – revision DCR
• Post op follow-up and syringing – prevents
stenosis
Thank u