1. Endoscopic DCR Evaluation, Anatomy and Physiology
Gary Kroukamp

2. Causes of Epiphora by Age
Children
Congenital nasolacrimal duct obstruction
Young Adults
Trauma
Post herpetic canalicular disease
Middle-aged adults
Dacryolith
Older Adults
Primary acquired nasolacrimal duct obstruction

3. At 5 – 6 weeks tissue develops along the cleft between lateral nasal and maxillary processes.
Within this tissue Two solid rods form .A proximal one at the medial canthus and a inferior one at the site of nasal opening.They elongate towards each other
At 12 weeks segmental disintyegration takes place
At 24 weeks this is complete except for the junction between the two processes which remain incomplete for some time.This junction is called the valve of Hassner.At birth this membrane may still be present.

4. Lacrimal drainage system anatomy – puncta located 5 mm from medial canthus no lashes medial, lower lid needs to be everted to view

5. Puncta 5mm from medial canthus On lacrimal papillae No lashes medial
Evert lower lid

6. Canaliculi 2mm vertically oriented Ampulla 8mm horizontally oriented
Variable common canaliculus
Enters sac at common internal punctum
Valve of Rosenmuller

8. Lacrimal sac Lacrimal fossa 2mm wide (semi-collapsed) 10-15mm long
Narrows to meet the nasolacrimal duct

9. Lacrimal pump Medial canthal ligament limbs surround sac
Compress sac with blinking
Pumps tears

10. Nasolacrimal Duct 15mm long Valve of Hassner – near exit
Exits into inf meatus

11. Let us have a look at the anatomy for a moment to familiarise ourselves with the territory
The Lacrimal sac rests in a shallow osseus groove nl.lacrimal fossa
It’s front edge is the anterior lacrimal crest
Post it’s border is the post lacrimal crest

12. A more lat view clearly demonstrates that the sac is protected by the thick frontal process of the maxillary bone.
Posterior to this isn the lacrimal bone which is very thin and can literally be egshelled out of the way.

13. On this Axial view one gets a better impression of its relationship regarding the middle turbinate.However,the anterior limit of the Mt can very and the uncinate process is a more reliable landmark.

16. This is the real life view. Bleeding is your greatest enemy
This is the real life view.Bleeding is your greatest enemy.I prepare the nose with a 5% Cocaine and adrenalin solution on ribbon gause and then infiltrate submucoperichondrialy with 2% lignocaine with adrenalin.
The incision is made over here.The rongeur is slid in submucosally and a bite of bone (frontal process maxillary bone) removed .Exposing the sac.Which is then incised.
It is essential to do all this atraumatically so as not to create adhesions.These patients do not allow you to examine them post –op to perform nasal toilette.
Good luck if you think they’l be indulging in nasal lavage.
The Crawfords tube is left in for anything up to a year.Removal requires a GA

18. Congenital Anomalies Atresia Amniotocele Absence of valves
Canalicular atresia
Punctal Atresia
Supernumerary Puncta & Canaliculi
Facial Anomalies
Atresia accounts for 95%
Dacryocele rare
Pneumatocele

19. Evaluation of Epiphora
Eyelid and eyelash deformities
Entropion, extropion, pump, punctum
Exclude dacryocystitis
Inflammation, pus, mucocoele
Slit lamp examination
Lacrimal system
Dye disappearance test, Palpation of canaliculus, Lacrimal irrigation
Nasal examination