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Endoscopic Dacryocystorhinostomy
Endoscopic Dacryocystorhinostomy Tabitha Galloway, MD David Chang, MD March 6, 2013 Outline • Anatomy and physiology • Epiphora • Obstruction • Evolution of DCR • Surgical techniques Outline • Anatomy and physiology • Epiphora • Obstruction • Evolution of DCR • Surgical techniques http://www.ajmc.com/publications/supplement/2008/2008-04-vol14-n3Suppl/Apr08-3141pS079-S087/1 http://mydryeyes.com/why_is_it_important.cfm http://drugline.org http://www.ajmc.com/publications/supplement/2008/2008-04-vol14-n3Suppl/Apr08-3141pS079-S087/1 1 1 1 Outline • Anatomy and physiology • Epiphora • Obstruction • Evolution of DCR • Surgical techniques Epiphora • Excessive tearing – Hyper secretion • irritants, infection, allergy, trauma – Reduced outflow • lid malposition, duct obstruction • More common with advancing age – Progressive fibrosis with chronic inflammation • 4:1 women to men • 9-10% prevalence at 40 years of age • 35-40% prevalence at 90 years of age Teary Terry • 82 year old female – Referred to you from her ophthalmologist with diagnosis of nasolacrimal duct obstruction http://painttheceilingbeige.blogspot.com/2013/01/saucy-at-80.html Key History Elements • • • • • • • • • Unilateral or bilateral? Continuous or intermittent? Seasonality? Medial or lateral? Nasal symptoms? Previous surgery? Previous trauma? Systemic disease history? Ocular symptoms? 6 Outline • Anatomy and physiology • Epiphora • Obstruction • Evolution of DCR • Surgical techniques Obstruction Anatomic • Determine level – Probe the canalliculi Functional • Failure to identify a blockage in a symptomatic patient – Irrigate the duct • “Pump” failure – Imaging studies • Dacryocystogram • CT scan – Scintilligraphy 2 2 Rheeman CH, Meyer DR. Enlargement of the nasolacrimal canal in the absence of neoplasia. Ophthalmology. Aug 1998. Vol 105. Issue 8. 1498-1503. Obstruction Congenital • Children < 2 yrs old • 20% children have epiphora – 96% of these resolve spontaneously in <12 mo • Underdeveloped sinuses, small meatus, close proximity to anterior cranial fossa http://www.barrywasserman.com/princeton_lasik_new_jersey/pediatric_ne w_jersey/pediatric-ophthalmologist-new-jersey.htm Outline • Anatomy and physiology • Epiphora • Obstruction • Evolution of DCR • Surgical techniques 1 Evolution of DCR • Function of the DCR has not changed – “divert the lacrimal drainage into the nose through an osteotomy in the lacrimal bone” • Changes in technique – External – Endonasal 1 Evolution of DCR • External procedure – Originally described in 1904 by Toti • Described resecting lacrimal bone, lacrimal sac and nasal mucosa – 1920’s - Dupuy-Dutemps and Bourguet • Described using flaps of nasal and lacrimal mucosa to create an epithelial-lined fistula – This still remains the gold standard for acquired naso-lacrimal duct obstruction 1 Evolution of DCR • Endonasal procedure – 1893 – first proposed by Caldwell • Using a metal probe and an electric burr – 1914- bone window osteotomy • Difficulty with nasal visualization, adequate lighting, endonasal bleeding – 1970-80’s –endoscope popularization – 1989- first publication of endoscopic DCR by McDonough and Meiring 1 Evolution of DCR • Advances/changes in endoscopic technique – Laser assistance • 1982 discovered that the ostium created, when healed was still functional but only 2% of it’s original size • 1990 led to advent of laser assistance – Mitomycin C – “Powered” procedure – Mucosal flaps Outline • Anatomy and physiology • Epiphora • Obstruction • Evolution of DCR • Surgical techniques External DCR http://oculoplastics.info/video/lacrimal/dcr/ http://www.digplanet.com/wiki/Dacryocystorhinostomy Endonasal Endoscopic DCR 3 1 Endonasal Endoscopic DCR 3 1 Endonasal Endoscopic DCR 3 1 Endonasal Endoscopic DCR 3 3 Endonasal Endoscopic DCR 3 3 Endonasal Endoscopic DCR http://rhinologyarchive.com/Sacks3.html Postoperative Care 1 Success • Resolution of symptoms • Patient intranasal ostium • Flow of flourescin • External & endonasal – 90-95% • Secondary revisions – 80-95% • Functional – 50-60% 4 5 5 Outline • Anatomy and physiology • Epiphora • Obstruction • Evolution of DCR • Surgical techniques QUESTIONS References 1 3 2 4 References 5 6 7 8