Dacryocystorhinostomy

Indications

Chronic epiphora secondary to acquired stenosis of the nasolacrimal duct.

Select cases of recurrent or chronic dacryocystitis.

Select cases of congenital dacryostenosis that are unresponsive to more conservative medical and surgical interventions.

In cases of nasolacrimal duct obstruction without canal-icular abnormality, the dacryocystorhinostomy (DCR) may be performed intranasally under endoscopic or direct visualization (this procedure is not discussed).

Note: the location of obstruction to tear drainage will dictate particular variations in the procedure to be performed. For example, cases with obstruction of the canaliculi will require a procedure to bypass the entire lacrimal drainage system. An in-depth discussion of each variation lies beyond the scope of this book. Instead, this chapter will describe a basic DCR with silicone intubation of the lacrimal system.

Preoperative Procedure

See Chapter 3.

Rule out other causes of epiphora.

1. Ocular irritation secondary to blepharitis.

2. Reflex tearing in response to dry eye.

a. Perform Schirmer test.

b. Measure tear break-up time.

3. Eyelid malposition or dysfunction.

a. Lid laxity.

b. Ectropion.

c. Punctal ectropion.

4. Punctal stenosis.

5. Canaliculitis.

6. Perform medical evaluation of lacrimal system anatomy to locate the site of obstruction to tear drainage.

a. Jones primary and secondary dye tests.

b. Probing and irrigation.

c. Dacryocystography if indicated.

d. Evaluation of nasal anatomy.

e. Orbital imaging if mass lesion is suspected.

7. Control any active infection with appropriate antibiotic therapy before proceeding with surgery.

8. If possible, discontinue aspirin and nonsteroidal anti-inflammatory agents for 10 days before surgery. Discontinue warfarin preoperatively, if medically possible.