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.
Wavelength
980nm
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
Weight
5Kg

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
Operative complications
EXTERNAL
DCR
ECL-
Bleeding
7(28%)
2(8%)
Hard bone
1(4%)
None
16(64%)
22(88%)

14. Success Full success Partial success Failure EXTERNALDCR 23(92%) 2(8%)
ENDOLASERDCR
21(84%)
1(4%)
3(12%)

15. Major Postoperative Complication
Post operative complications
External DCR
Prominent scar
80%
Faint scar
20%
External DCR – Scar Related

16. Major Postoperative Complication
ECL-DCR
Closure of osteotomy
12%
Patent osteotomy
88%
ECL DCR– Osteotomy Related

17. Results External DCR Endocanalicular DCR Full Success 92% 84%
Partial Success 8% 4%
Failure
Nil
12%

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 Endo canalicular DCR
Laser energy is directed away from eye
Ophthalmologist friendly.
Nasal endoscopy and Instrumentation unneccesary.

24. Which procedure to choose????
Conclusions
Which procedure to choose????

25. -Right procedure for right patient
Conclusions
PATIENT SELECTION
-Right procedure for right patient

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

27. follow-up for ECL-DCR patients
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