The elevator is used to lift the periosteum posteriorly to expose the anterior lacrimal crest. There is often a small vessel in a bony groove just anterior to the crest that is cauterized. The periosteum is lifted in the lacrimal sac fossa, and down as far as possible in the nasolacrimal canal (Fig. 14.2).

At this point, local anesthetic is infiltrated in the lacrimal sac. A small cottonoid with adrenaline or cocaine is placed in the space between the lacrimal sac and the fossa, and the intranasal cottonoids are removed to avoid damage to these mucosal tissues during the next step of bone removal.

The Agricola retractor is replaced with a Goldstein retractor, which has longer teeth to provide better exposure. A 4 mm burr on a high speed drill is used to remove an oval window of bone anterior to the lacrimal crest, taking care not to damage the nasal mucosa. The nasal mucosa is infiltrated with local anesthetic, and a dental burnisher is passed through the bony window to separate the nasal mucoperiosteum from the underside of the bone (Fig. 14.3).

A 45° Kerrison rongeur is used to enlarge the bony opening to include removal of the anterior lacrimal crest, and the entire lacrimal sac fossa from the level of the medial canthal tendon superiorly and including the superior aspect of the nasolacrimal canal inferiorly. The medial canthal tendon is left intact, with care taken to remove enough bone in this area to provide at least a 5 mm distance from the level of the common canaliculus. Occasionally during this process there will be an anteriorly placed ethmoid air cell that is removed.

The lacrimal sac is then vertically incised along its entire length with a #11 blade, and anterior and posterior flaps are created. A corresponding vertical incision is made through the nasal mucosa, with creation of anterior and posterior flaps. Both posterior flaps are then excised.

Attention is then directed to the caruncle. If it is prominent, it is conservatively debulked with a scissors. A sharp Stevens scissors is inserted in the area of the caruncle and gently advanced in a slightly downward trajectory into the previously created opening into the nose, taking care to angle anterior to the middle turbinate. If the middle turbinate interferes, the anterior tip can be judiciously resected. The scissors are slightly opened, and a Bowman probe with the appropriate length Jones Tube in place is passed immediately anterior to the scissors. The scissors are slowly removed, with the blades still slightly open, as the Jones Tube (Gunther Weiss Scientific Glass Blowing Company, Portland, Oregon) is pressed forward using a forceps (Fig. 14.4). The tip of the tube of the tube is inspected, and must rest halfway between the lateral wall of the nose and the septum, or should be replaced with a tube of a different length. The anterior mucosal flaps are then sutured together anterior to the Jones Tube using 5–0 polyglactin on a small curved needle. The orbicularis is closed with a running 6–0 polyglactin suture, followed by closure of the skin with a running 6–0 fast absorbing gut suture. A 6–0 polyglactin suture is secured to the medial canthal tissue and wrapped around the collar of the tube to prevent migration of the tube in the early postoperative period. A 4 mm collar is typically placed initially to prevent inward migration of the tube, and can be replaced at a postoperative visit if the collar is causing irritation of the ocular surface or if the appearance is cosmetically objectionable to the patient.