Presentation on theme: "DACRYOCYSTORHINOSTOMY EXTERNAL VS ENDOCANALICULAR DCR (ECL-DCR)"— Presentation transcript:
DACRYOCYSTORHINOSTOMY EXTERNAL VS ENDOCANALICULAR DCR (ECL-DCR)
Introduction Epiphora is a relatively frequent problem in ophthalmology. Epiphora is a relatively frequent problem in ophthalmology. Standard surgery is Dacryocystorhinostomy. Standard surgery is Dacryocystorhinostomy. Recent advent of laser technology. Recent advent of laser technology.
Inclusion Criteria Primary acquired nasolacrimal duct obstruction with / without chronic dacryocystitis Primary acquired nasolacrimal duct obstruction with / without chronic dacryocystitis Patent canaliculi Patent canaliculi Normal eyelid function Normal eyelid function Patients age less than 40 years Patients age less than 40 years
Exclusion Criteria Sac pathology Sac pathology History of previous sac surgery History of previous sac surgery Lacrimal fistula Lacrimal fistula Turbinate hypertrophy Turbinate hypertrophy Gross deviated nasal septum Gross deviated nasal septum Nasal Pathology(Atrophic Rhinitis,Polyp) Nasal Pathology(Atrophic Rhinitis,Polyp)
Pre-Operative Evaluation History History Clinical evaluation Clinical evaluation –Examination of lids –Assessment of punctum –Examination of sac area Nasal examination Nasal examination Diagnostic Tests Diagnostic Tests –Flourescein Dye Disappearance Test –Lacrimal syringing
Follow up At 10th day, one and six months post surgery At 10th day, one and six months post surgery Results were graded as : Results were graded as : Full Success –NO TEARS NO INFECTION NO INFECTION NO REFLUX NO REFLUX Partial Success -LESS TEARING THAN BEFORE PARTIAL REFLUX Surgical Failure - PERSISTENT TEARING CLOSED OSTIUM
1. Skin incision 2. Bone osteotomy 3. Dissection of sac flap 4. Anastomosis of flap Steps Of External DCR
Steps of External DCR
Procedure for ECL-DCR Procedure for ECL-DCR Anesthetise the nasal cavity with 10% Xylocaine spray Dilate the punctum Probing. Feel the bone. Wavelength980nm Optical power 10 Watt Aiming Beam 635nm, 4mW; brightness adjustable Operating Mode cw, pulsed Dimensions (H x W x D) 12 X 26 X 30 Weight5Kg
Procedure Procedure Keep the initial power at 7 watt. Insert the 600µ fiber into the cannaliculus upto the lacrimal bone. Focus endoscope in a way that the middle turbinate remains in central vision when the red aiming beam is seen above or in front of the anterior end of middle turbinate Press the laser footswitch maintaining moderate pressure against bone with the DCR cannula.
Procedure Fire the laser. On any resistance from the bone or sac, increase the power. Manipulate the cannula and keep firing the laser to increase the size of the opening (4-5mm). Syringing at the end of the surgery with normal saline water, then with dilute povidone iodine solution or Betadine,
Steps of ECL-DCR
Operative Complication Operative Complication Operative complications EXTERNALDCRECL-DCRBleeding7(28%)2(8%) Hard bone 2(8%)1(4%) None16(64%)22(88%)
Success Success Full succes s Partial succe ss Failure EXTERNALDCR23(92%)2(8%)0 ENDOLASERDC R 21(84%)1(4%) 3(12% )
Major Postoperative Complication External DCR – Scar Related Post operative complications External DCR Prominent scar 80% Faint scar 20% 20%
ECL DCR– Osteotomy Related Major Postoperative Complication ECL-DCR Closure of osteotomy 12% Patent osteotomy 88%
Results External DCR Endocanalicula r DCR Full Success 92%84% Partial Success 8%4% FailureNil12%
Results The Success in the External DCR : The Success in the External DCR : - Immediate mucosa lined fistula via the closure of the mucosal flaps.
Results The failure in the laser DCR group : The failure in the laser DCR group : - Anatomic variations - Post-operative inflammation and fibrosis. - Inability to create an adequate opening. - Wrong selection of patients.
External DCR - The Gold Standard Large bony osteotomy. Large bony osteotomy. Lacrimal sac is exposed -canalicular DCR. Lacrimal sac is exposed -canalicular DCR. Success rate of 95% Success rate of 95%
Limitations of External DCR Per-operative haemorrhage Per-operative haemorrhage Surgery is lengthy (variable). Surgery is lengthy (variable). Risk of sump syndrome. Risk of sump syndrome. Re-do surgery -fibrous tissue. Re-do surgery -fibrous tissue. The cutaneous scar. The cutaneous scar.
Laser Procedures in DCR Advantage over Surgical Approach- Advantage over Surgical Approach- -Cutaneous Scarring is eliminated. - Minimal tissue disruption. -Minimal bleeding. - CSF leaks unlikely. - Can be used in deabilitated patients.
Definitive edge of Endo canalicular DCR Laser energy is directed away from eye Laser energy is directed away from eye Ophthalmologist friendly. Ophthalmologist friendly. Nasal endoscopy and Instrumentation unneccesary. Nasal endoscopy and Instrumentation unneccesary.
Conclusions Which procedure to choose???? Which procedure to choose????
Conclusions PATIENT SELECTION -Right procedure for right patient
Conclusions DISCUSSION WITH PATIENT Viable option treatment. Discuss the advantages and disadvantages with patients.
Conclusions FOLLOW UP… More frequent and regular follow-up for ECL-DCR patients
If two different techniques give the same result, use the one that is easier and faster But if a more difficult and longer operation yields a superior result, use it.