Fig. 10.1
Incision of the nasal mucosa with a crescent knife
Fig. 10.2
Inferior incision with scissors. The superior incision has been done
Fig. 10.3
Osteotomy of the frontal process of the maxilla
Fig. 10.4
Lacrimal sac exposed after completion of osteotomy with light probe in the superior portion
The lacrimal sac is then filled with a viscous solution of methylcellulose. The transillumination probe can be used to tent up the lacrimal sac. A straightened crescent knife is used to create a vertical incision in the anterior portion of the lacrimal cylinder. The incision is directed posteriorly at the superior and inferior end allowing the large lacrimal mucosal flap to be hinged posteriorly (Fig. 10.5). Massage of the sac at the inner canthus allows for visualization of the fundus of the sac and removal of any dacryolith that may have caused obstruction. The lacrimal mucosa can also be biopsied and sent for histopathologic examination if it is felt to be abnormal.
Fig. 10.5
Incision of sac with light probe showing through in upper portion of the sac
A Freer elevator is used to mobilize the nasal mucosal flap laterally to come in contact with the posteriorly directed lacrimal sac flap (Fig. 10.6). Having the flap edges in close apposition on the lateral nasal wall allows for fusion of the mucosal flaps when healing creating a mucosal lined fistula from the sac to the nose [12]. This resembles flap creation in external DCR. At the end of surgery, bicanalicular intubation is done with silicone tubes and the ends are retrieved from the nose with straight microethmoid forceps. Lastly, a small piece of Gelfoam soaked in methylprednisolone 40 mg/cm3 is slipped over the tubes down on the mucosal flaps to stabilize them and encourage stabilization of the flaps in contact with each other (Fig. 10.7).
Fig. 10.6
Lacrimal sac and duct opened with lacrimal mucosal flap reflected posteriorly. The nasal mucosal flap is seen medially and will be brought back to make contact with the lacrimal mucosa
Fig. 10.7
Apposition of lacrimal and nasal mucosal flaps with silicone tubing going through the internal punctum in the lumen of the sac and duct
Postoperative Care
Patients are instructed to avoid nose blowing for 10 days. Prophylactic systemic antibiotics are used only if significant infection is present. Washing of the nostril with saline sprayed in the nose is done for 1 week, three or four times daily. An antibiotic–steroid combination eye drop is used for a week in the operated eye. The lacrimal system is irrigated at 1 week and at 1 month. The tube is removed at 1 month. Endoscopy can be performed at 1 week if cleaning of the nostril is felt to be necessary and at 1 month to confirm adequate healing of the surgical site (Fig. 10.8). A final follow-up is done at 3 months to confirm the patency of the lacrimal passage and rehabilitation of the nasal anatomy (Fig. 10.9).
Fig. 10.8
Gelfoam packing soaked in steroid solution and slip over lacrimal silicone tubes and being positioned over the mucosal flps with the tip of a Freer elevator
Fig. 10.9
At 3 months, the dye test is frankly positive at 1 min and the mucosa now is back to a normal appearance with good continuity of the mucosal flaps
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