Opthalmology · Otorhinolaryingology

Dacryocystorhinostomy (DCR)

  1. Dacryocystorhinostomy (DCR) surgery is a procedure that aims to eliminate fluid and mucus retention within the lacrimal sac,increase tear drainage for relief of epiphora.
  2.  removal of bone adjacent to the nasolacrimal sac and incorporating the lacrimal sac with the lateral nasal mucosa in order to bypass the nasolacrimal duct obstruction.
  3. Nasolacrimal duct obstruction (NLDO) can result in a watery eye, due to obstruction of the outflow of tears.
  4. congenital or acquired disease
  5.  obstruction of the nasolacrimal excretory system may occur in the proximal puncta, canaliculi, common canaliculus, or more distally within the lacrimal sac or nasolacrimal duct.
  6. ETIOLOGY: secondary to facial trauma, chronic environmental allergies, toxicity from chemotherapeutic drugs or topical medications, neoplasms, long-standing sinus disease, or following sinonasal surgery.
  7. Symptoms

    • Tearing (Epiphora)
    • Mucopurulent discharge
    • Mattering of lashes and lids, crusting in the morning
    • Pain
    • Blurred vision from tears
    • Bloody tears
  8. Dacryocystitis (abscess infection of the lacrimal sac in the inner corner of eye area
  9. Diagnostic procedures

  10. Tear meniscus height measurement

    Elevated tear meniscus using slit-lamp biomicroscopy.

    • Dye disappearance test
    • Jones test I and II
    • Probing and irrigation: Gold standard of nasolacrimal outflow testing. A drop of topical anesthetic is placed on the ocular surface, and a punctal dilator is used to dilate the punctum. A 0-0 Bowman probe can be used to assess the canaliculus for any diffuse stenosis or focal strictures. If present, the distance of the stricture from the punctum is recorded to determine if a conjunctivodacrycystorhinostomy (CDCR) is indicated. A 21 or 23 gauge lacrimal cannula on a 3cc syringe is advanced through each canaliculus, and saline is injected. Reflux of saline through the same canaliculus indicates obstruction of the canaliculus, whereas reflux from the opposite punctum indicates obstruction in the nasolacrimal sac or duct. Passage of saline into the nose and throat with ease and no reflux signifies an anatomically patent nasolacrimal excretory system. A partial obstruction can also exist if there is some flow into the nose but with increased resistance to irrigation and/or some degree of reflux.
    • DCG: A contract dye is injected actively into the punctum and canaliculus during simultaneous CT or MRI imaging to determine if an anatomic obstruction exists within the outflow system, and where the obstruction occurs. Excellent anatomic detail can be achieved.3
    • DSG: A radioactive agent, technetium-99m pertechnetate or technetium-99m-labeled sulfur colloid, is placed on the ocular surface.4,5 The patient is seated and immediately imaged using a gamma camera to take rapid pictures of the lacrimal outflow system as the tracer flows passively through the lacrimal pump system. The canaliculi and sac should be visualized within 10-12 seconds following injection, with passage into the nasal cavity occurring within 10-30 minutes. The disadvantages of DSG include the low resolution and lack of anatomic detail.

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