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DACRYOCYSTORHINOSTOMY EXTERNAL VS ENDOCANALICULAR DCR (ECL-DCR)

DACRYOCYSTORHINOSTOMY EXTERNAL VS ENDOCANALICULAR DCR (ECL-DCR). Introduction. Epiphora is a relatively frequent problem in ophthalmology . Standard surgery is Dacryocystorhinostomy. Recent advent of laser technology. Inclusion Criteria.

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DACRYOCYSTORHINOSTOMY EXTERNAL VS ENDOCANALICULAR DCR (ECL-DCR)

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  1. DACRYOCYSTORHINOSTOMY EXTERNAL VS ENDOCANALICULAR DCR(ECL-DCR)

  2. Introduction • Epiphora is a relatively frequent problem in ophthalmology . • Standard surgery is Dacryocystorhinostomy. • Recent advent of laser technology.

  3. Inclusion Criteria • Primary acquired nasolacrimal duct obstruction with / without chronic dacryocystitis • Patent canaliculi • Normal eyelid function • Patients age less than 40 years

  4. Exclusion Criteria • Sac pathology • History of previous sac surgery • Lacrimal fistula • Turbinate hypertrophy • Gross deviated nasal septum • Nasal Pathology(Atrophic Rhinitis,Polyp)

  5. Pre-Operative Evaluation • History • Clinical evaluation • Examination of lids • Assessment of punctum • Examination of sac area • Nasal examination • Diagnostic Tests • Flourescein Dye Disappearance Test • Lacrimal syringing

  6. Follow up • At 10th day, one and six months post surgery • Results were graded as : Full Success – NO TEARS NO INFECTION NO REFLUX Partial Success - LESS TEARING THAN BEFORE PARTIAL REFLUX Surgical Failure - PERSISTENT TEARING CLOSED OSTIUM

  7. Steps Of External DCR 1. Skin incision 2. Bone osteotomy 3. Dissection of sac flap 4. Anastomosis of flap

  8. Steps of External DCR

  9. Procedure for ECL-DCR • Anesthetise the nasal cavity with 10% Xylocaine spray • Dilate the punctum • Probing. • Feel the bone.

  10. 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.

  11. 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,

  12. Steps of ECL-DCR

  13. Operative Complication

  14. Success

  15. Major Postoperative Complication External DCR – Scar Related

  16. ECL DCR– Osteotomy Related Major Postoperative Complication

  17. Results

  18. Results • The Success in the External DCR : -Immediate mucosa lined fistula via the closure of the mucosal flaps.

  19. Results • The failure in the laser DCR group : - Anatomic variations - Post-operative inflammation and fibrosis. • Inability to create an adequate opening. • Wrong selection of patients.

  20. External DCR - The Gold Standard • Large bony osteotomy. • Lacrimal sac is exposed -canalicular DCR. • Success rate of 95%

  21. Limitations of External DCR • Per-operative haemorrhage • Surgery is lengthy (variable). • Risk of sump syndrome. • Re-do surgery -fibrous tissue. • The cutaneous scar.

  22. Laser Procedures in DCR • Advantage over Surgical Approach- - Cutaneous Scarring is eliminated. - Minimal tissue disruption. - Minimal bleeding. • CSF leaks unlikely. • Can be used in deabilitated patients.

  23. Definitive edge of Endocanalicular DCR • Laser energy is directed away from eye • Ophthalmologist friendly. • Nasal endoscopy and Instrumentation unneccesary.

  24. Conclusions Which procedure to choose????

  25. Conclusions PATIENT SELECTION -Right procedure for right patient

  26. Conclusions • DISCUSSION WITH PATIENT • Viable option treatment. • Discuss the advantages and disadvantages with patients.

  27. Conclusions FOLLOW UP… More frequent and regular follow-up for ECL-DCR patients

  28. 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 .

  29. Thank You

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