43 Revision Endoscopic Dacryocystorhinostomy Revision endoscopic dacryocystorhinostomy (DCR) has proved to be an excellent treatment modality for the patient who develops recurrent epiphora or dacryocystitis after primary DCR.1,2 Endoscopic instrumentation allows the surgeon to identify and correct the most common causes of DCR failure, which include intranasal adhesions, an obstructing middle turbinate, and occult disease of the ethmoid sinus. In contrast to most surgical procedures, for endoscopic DCR, revision surgery is actually easier to perform than a primary procedure. The most technically challenging portion of lacrimal surgery is usually removal of thick bone along the lateral nasal wall overlying the lacrimal sac. Because this bone has already been removed in patients who have undergone previous DCR, revision endoscopic DCR is quite suitable for the surgeon who wishes to learn the technique of endoscopic DCR. Revision endoscopic DCR may be performed under general or local anesthesia, depending on the patient’s medical condition and the surgeon’s preference. The patient is placed in the supine position with a slight reverse Trendelenburg position to decrease venous pressure at the operative site. Nasal packing strips soaked in 4% cocaine hydrochloride (HCL) solution are placed along the lateral nasal wall to provide decongestion. The nose and affected eye are draped in the operative field. A 4 mm diameter, 0-degree nasal endoscope is used for visualization for the majority of the procedure. A solution of 1% lidocaine HCL with epinephrine 1:100,000 is injected into the submucosa of the middle turbinate and the lateral nasal wall anterior to the attachment of the middle turbinate (Fig. 43.1). The assistant surgeon passes a lacrimal probe through a canaliculus into the obstructed lacrimal sac. The tip of the probe can be observed with the endoscope as it tents the mucosa of the lateral nasal wall (Fig. 43.2). The surgeon then uses a sickle knife to make a crescent-shaped curvilinear incision ~1 cm anterior to the tip of the probe. There is occasionally extensive submucosal fibrosis from the primary surgery, which may need to be sharply elevated with the sickle knife. The resulting posterior mucosal flap is then grasped with a straight Blakesley forceps and removed with a twisting motion to avoid avulsing the mucosa of the lateral nasal wall (Fig. 43.3). The mucosa adjacent to the opening created may need to be resected with similar bites with the Blakesley forceps to provide an opening of at least 10 mm. If the sac has been entered after removal of the mucosa, the tip of the lacrimal probe will be visible. However, frequently there is additional scar tissue that needs removal before the sac can be entered. The intranasal opening is deepened with an angled Blakesley forceps directly laterally toward the sac (Fig. 43.4). Because scarring from previous surgery may obscure sac anatomy, it is important to use the probe that lies within the sac as a guide for tissue removal. Care is taken to remove only tissue surrounding the probe to remain within the confines of the lacrimal sac and to avoid inadvertent entry into the orbit with exposure of periorbital fat. Once the intranasal opening has been sufficiently enlarged, the interior of the sac and internal common punctum are usually visible with a 30-degree endoscope. Occasionally, two separate internal puncta are visible in the sac interior. At this point, lacrimal probes should pass freely into the nose from the superior and inferior canaliculi. The lacrimal probe is then replaced by Silastic tubing that has its ends threaded over a rigid wire (Guibor Canaliculus Intubation Set, Medtronic ENT, Jacksonville, Florida). This tubing may be used instead of a lacrimal probe at the start of the case. The rigid ends of the tubing are passed through the superior and inferior canaliculi into the nose via the opening created in the lacrimal sac. The rigid ends protruding into the nasal cavity are then grasped individually with the Blakesley forceps (Fig. 43.5
Surgical Technique
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