1. Revision Dacrocystorhinostomy Babak Saedi MD Imam Khomeini Hospital

2. 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%

3. Failure of DCR Inadequate rhinostomy, excessive scar tissue production, Anatomic anomalies paranasal sinus Septal déviation

4. Physical Examiation Probing of the naso- lacrimal duct is the first line of treatment.

5. SURGICAL ANATOMY

6. Physiology of tear drainage

7. Anatomy of lacrimal drainage system

8. Canalicular obstruction 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%.

9. Functional blockage 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.

10. 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 American Journal of Rhinology & Allergy

11. INVESTIGATIONS Identification of the site of blockage requires one or more of the following tests:

12. PATIENT’S EVALUATION Irrigation of lacrimal passages(diagnostic/therapeutic). PNS CT Dacryocystography Scintography General and Systemic examination

13. Dye tests 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.

14. Dye tests 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.

15. Syringing and probing 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.

16. Macro dacryocystography (MDCG) and scintigraphy 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.

17. Dacryocystogram

18. How to Treat

19. 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.) !?

20. Probing

21. Punctum dilation

22. Probing

24. Video monitoring for localization of laser fibre optic (location of nasal opening)

27. DCR tube (silicone stent)

29. Enonasal DCR 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

30. Endonasal DCR 6) technical facility due to the anterior removal of the lacrimal bone, 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 8) direct visualization of the site and amplitude of the nasolacrimal