Trans canalicular D'C'R with Endonasal Endoscopic Intubation

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Trans canalicular D.C.R with Endonasal
Endoscopic Intubation
Laser Assisted
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DR QAZI M. WASIQ
M.C.P.S.,F.I.C.S EYE
SURGEON
SPENCER EYE HOSPITAL CDGK
KARACHI
DR FASIHULLAH MIR
M.C.P.S.,F.I.C.S,D.L.O.(LONDON)
ENT SURGEON
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INTRODUCTION

• EPIPHORA OR ABNORMAL TEARING occurs due to
  blockage in the lacrimal drainage system.
• Causes of lacrimal obstruction includes,failed
  canalization at birth,recurrent infections,growth
  and aging factors.

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INTRODUCTION

• DCR surgery provides fistulization of lacrimal
  sac in to nasal cavity
• Operative approach may be external,endonasal
  endoscopic or transcanalicular.
• Our approach Transcanalicular combined with
  endonasal endoscopic.

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MATERIALS

• Nettleship punctum dilator,malleable probes
• Diomed diode laser,with power settings maximum15w
• Fibreoptic cable,flexible laser fibre,with
  diameter of 400micro meter core with outer
  cladding,total diameter 800micro meter.

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MATERIALS

• Endoscope with mounted video camera connected to
  TV monitor.
• DCR silicone tube.(stent).

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PATIENTS EVALUATION

• History
• Examination,by ENT,EYE and Anaesthetist.
• Regurgitation (rough method of assesment of
  blockage )
• Florescin dye test

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PATIENTS EVALUATION

• Irrigation of lacrimal passages(diagnostic/therape
  utic).
• PNS,X-rays
• Dacryocystography
• General and Systemic examination(to exclude
  diabetes,hypertension,bleeding disorders)

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ADVANTAGES

• Provides effective safe procedure without skin
  incision
• Less tissue injury and bleeding
• Can be done in narrow nasal fossae
• Pumping action of orbicularis is preserved
• No nasal packings required usually
• Faster patient recovery.
• Procedure can be repeated if required

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Anatomy of lacrimal drainage system
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Physiology of tear drainage
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Dacryocystogram
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Probing
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D.C.R surgery steps
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ENDOSCOPIC CAMERA
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DIOMED LASER WITH CAMERA
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Protective Laser shield goggles for surgery team
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Patients preparation
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Instruments trolley
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Punctum dilation
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Probing
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Probing
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Laser fibre opticswith red aiming beam
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Video monitoring for localization of laser fibre
optic (location of nasal opening)
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SURGICAL ANATOMY
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Transcanalicular and Endonasalcombined approach
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Probing and insertion of laser fibre optic
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Transcanalicular entry into the nose
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Endoscopic nasal entry withvideo camera
attachment
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Endonasal widening of opening
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DCR tube (silicone stent)
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Metallic tip of DCR tube in the nose localized
with endoscope
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Introduction of DCR tube into lacrimal passages
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Placement of bicanalicular silicone stent
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Nasal ends tied in the nose
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Recovery,Post op patient on the table
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POST OP
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Complications

• Operative Damage to punctum and
  canaliculus.
• False passage.
• Encounter thick bone.
• Inadvertent damage to
  lacrimal and nasal tissues.

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Complications

• Immediate post operative
• Pain and swelling.
• Bleeding and infection
• Expulsion of silicone tube.
• Nasal mucus plugs and crusts.

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Complications

• Late post operative
• Infection.
• Fibrosis.and
• Stenosis of
  the Rhinostomy
  opening.
• Cheese
  wiring of puncta and
• canaliculii.

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TABLE 1LIST OF PATIENTS
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TABLE 2
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Results

• 8/12 had good satisfactory out come,with absence
  of epiphora.(66.6).
• 3/12 had mild epiphora with morning sticky
  discharge.(25).
• 1/12 had totally failed outcome after 5
  months,repeat surgery done,1 month back,with
  satisfactory outcome.(8.4).
• Two patients had infection ,treated
  conservatively with success.

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CONCLUSION

• Different techniques are proposed for relief of
  NLD obstruction.
• External DCR
• Transcanalicular approach
• Endonasal technique
• Conjunctivo-dacryocystorhinostomy
• Combined technique of TCL-DCR and ENL-DCR offers
  added advantages.

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Key words

• In our experience combined technique appears to
  be quick,efficient,less traumatic,reliable and
  repeatable.

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Post op patient
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Post op patient 2nd day
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Post op patients
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Pre op patient with scarred lacrimal area
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Post op patientwith silicone tube in place