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Post Graduate Section

Step-by-step dacryocystorhinostomy for beginners: An expert’s view

Shrikant Deshpande, Anjaneya Agashe, Abhinav Loomba, Neha Dhiware

Chronic dacryocystitis occurs usually due to obstruction of lacrimal passage at the junction of the lacrimal sac Access this article online
and the nasolacrimal duct or within the bony nasolacrimal duct. Reconstruction of the lacrimal passages in such Website:
cases can be achieved by several surgical techniques, although external dacryocystorhinostomy (DCR), proposed www.jcor.in
by Ohm and by Dupuy-Dutemps and Bourguet in 1921, is still the most successful operation. Despite ease and DOI:
decreased morbidity of endonasal DCR, external DCR is procedure of choice as it is more successful. Several 10.4103/2320-3897.138865
ophthalmologists fear performing DCR because of bleeding and unfamiliarity of structure. This article tries to Quick Response Code:
provide few tips to make DCR easy and stress-free. Proper case selection, pre-operative workup and adequate
exposure go a long way in making DCR stress-free and successful. Excessive bleeding, a common hindrance
in DCR surgery can be successfully tackled by proper positioning of patient, use of adrenaline, suction, and
adjustment of nasal pack.

Key words: Chronic dacryocystitis, dacryocystorhinostomy, nasolacrimal duct obstructions

Chronic dacryocystitis occurs usually due to obstruction of lacrimal
passage at the junction of the lacrimal sac and the nasolacrimal
duct or within the bony nasolacrimal duct. Reconstruction of the
lacrimal passages in such cases can be achieved by several surgical
techniques, although external dacryocystorhinostomy (DCR),
proposed by Ohm and by Dupuy-Dutemps and Bourguet in 1921,
is still the most successful operation.[1] The external approach is
performed through a cutaneous incision to access the lacrimal sac.
The procedure gained popularity due to its efficacy and relatively
low complication rates. Endoscopic endonasal DCR has recently
gathered momentum with direct visualization under endoscopic
guidance. Caldwell first introduced the endonasal approach for
lacrimal surgery in 1893. However, endoscopic endonasal DCR has
only recently been employed with new endoscopy instruments
and technique. This approach avoids an external scar and
neurovascular disruption along the tract exposing the lacrimal
sac. The reported success rates of both procedures range from 63%
to 97%.[2] Despite ease and decreased morbidity of endonasal DCR,
external DCR is the procedure of choice as it is more successful. A
lot of ophthalmologists fear performing DCR because of bleeding
and unfamiliarity of structure. This article tries to provide few
tips to make DCR easy and stress-free.
Basic Evaluation
Case selection
Case selection is very important for beginners attempting
to do DCR. Best sac for doing DCR is the one with mucocele
because sac is bigger and flaps are easily made. While the
best patient for doing DCR is a thin, frail, elderly patient
with roomy nostril due to ease of bone punching and less
bleeding, any well-evaluated patient without any ear, nose
and throat (ENT) abnormality, may be taken up. Patients
with positive regurgitation test are ideal candidates.
Patients with common canalicular block usually require
complicated procedure, which may require stenting and
intubation.
Pre-operative workup
Blood pressure control is very important to decrease the
risk of bleeding. The ENT evaluation should be done to
rule out atrophic rhinitis and other nasal abnormalities.
Blood thinners and anti-coagulants should be withheld in
consultation with the treating physician to further decrease
bleeding.
Pre-operative medications
Ethamsylate is a hemostatic drug, which not only promotes
platelet adhesion but also inhibits platelet disaggregation. It
should be started at a dose of 250 mg twice one day prior to
the surgery. Nasal decongestant such as otrivin drops should
be given twice a day to reduce nasal congestion. Patient is
kept nil by mouth for ease of sedation. There should always
be a standby anesthesiologist to provide sedation and to deal
with systemic complications.
Intraoperative Tips
Position

Department of Ophthalmology, Mahatma Gandhi Mission Medical

College, Navi Mumbai, Maharashtra, India
Address for correspondence: Dr Anjaneya Agashe, Department
of Ophthalmology, Mahatma Gandhi Mission Medical College,
Kamothe, Navi Mumbai - 410 206, Maharashtra, India.
E-mail: kant123@rediffmail.com
Manuscript received: 03.06.2014; Revision accepted: 28.06.2014
Patient should be comfortably supine with head high 10-20
degree. Surgeon should be at the head-end, as it provides easy
access to both sides of the head. The table height should be
adjusted depending upon whether the surgeon is operating
in standing or sitting position. The light in operating room
should be an overhead, shadowless light, which must reach
the depth of surgical field (usually between surgeon’s and

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Deshpande, et al.: Step-by-step dacryocystorhinostomy for beginners: an expert’s view

assistant’s head). Light should have adequate illumination important step in DCR surgery [Figures 4 and 5]. Once MPL is
because of small field of illumination. exposed, the orbicularis fibers are separated along the entire
Instruments length of the incision. Dis-insertion (not dividing) of MPL is
Apart from DCR set, there should be plenty of tightly wound done at the anterior lacrimal crest by cutting on the bone at
peanut-shaped swabs soaked in lignocaine-adrenaline. The insertion with 11 number blade.
following should also be kept ready: Exposure of bone
a. Gauze pieces.
Dis-insertion of MPL automatically opens up the periosteum,
b. Few cotton buds.
which is now separated along the entire length of the incision
c. Roller gauze for nasal packing.
d. Suction machine with thin catheter or infant feeding tube
ready.
e. Viscoelastic for sac inflation OR chloro applicabs (chloramphenicol
ointment).
Nasal packing
Proper nasal packing is very important to reduce the bleeding.
It is done to keep the mucosa taut and reduce bleeding. Nasal
packing should be explained to the patient. Few drops of 4%
topical lignocaine should be instilled first in the ipsilateral
nostril, then nasal pack (roller gauze soaked in 2% lignocaine-
adrenaline jelly) inserted in the ipsilateral nostril with the
help of nasal packing forceps in the direction of medial
palpebral ligament (MPL), insinuated and negotiated as deep
as possible The direction of nasal packing is superior, then Figure 1: Site of incision for external dacryocystorhinostomy
posterior, then inferior.
Anesthesia
Local anesthesia with sedation is preferred as it reduces stress,
which in turn decreases bleeding. Lignocaine with adrenaline
is used which decreases bleeding unless systemically
contraindicated. With anesthetist’s permission, full 12 cc of
1:1,00,000 lignocaine-adrenaline is loaded in 10 cc syringe; of
this, 4-5 cc is sprinkled on the nasal pack (roller gauze) and
7-8 cc is used for infiltration.
Local infiltration
We prefer a single point block in DCR surgery. The preferred
site of infiltration is upper inner angle of orbit just medial
to medial canthus, where the MPL is situated. At the MPL
insertion, the bone is hit with the 26-gauge needle and 2-3 cc
injected, then the bevel of the 26-numberneedle rotated Figure 2: J shaped curvilinear incision

superiorly and 2-3 cc injected and then rotated inferiorly

while injecting the remaining 2-3 cc. Firm pressure is applied
for 5-10 min for the anesthetic to act. Cleaning is done with
spirit and betadine right up to the upper lip.

Surgical Steps
Incision
A J-shaped groove is created with back-end of BP handle
medial to the medial canthus. In the groove, created by firm
pressure, J shaped curvilinear incision is taken (skin deep and
not bone thick) 3-4 mm from medial canthus, starting 2-3 mm
above MPL, about 1.5-2 cm in length [Figure 1 and 2]. MPL
insertion is reached by blunt dissection of orbicularis fibers
[Figure 3] with artery forceps in the region of MPL (medial to
medial canthus). Identification and exposure of MPL is a very Figure 3: Skin excised and orbicularis fibres exposed

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Deshpande, et al.: Step-by-step dacryocystorhinostomy for beginners: an expert’s view
with sharp dissector or periosteum elevator. Lacrimal sac is
retracted with periosteum elevator. Baring of periosteum is
done to decrease pain and to aid bone punching. Periosteum
is elevated posteriorly till the lamina papyracea. Lamina
papyracea is a thin bone with consistency and color different
from lacrimal bone. Periosteum also elevated anteriorly,
inferiorly and superiorly as much as reasonably possible
[Figures 6 and 7]. With a sharp dissector, the lamina is
punctured breaking it outwards and removing the pieces
with forceps.
Bone punching
Bone removal is started with a small punch and then with
a big punch. The correct method of using bone punch is as
follows: insinuate, engage the bone with the punch, support
with left thumb, hitch back, crush properly and then gentle
rocking movement to remove the bone. Bone punch should
always be perpendicular to the punching surface. Clear the
punch of bone pieces with 20G needle. Osteotomy should be
as large as possible and should be of size of thumbnail. Extent
of osteotomy should be as follows:
Figure 4: Skin excised. Orbicularis oculi fibres separated to expose
thick, white Medial Palpebral Ligament (MPL)
Figure 6: MPL dissected (held in forceps); periosteum elevated to
expose shiny ivory white bone. 1. Anterior lacrimal crest in continuation
with inferior orbital rim (thick dotted line). 2. Deep inside the cavity,
papery thin pinkish Lamina Papyracea (Lacrimal Bone)
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Posteriorly: Till lamina papyracea.
Superiorly: At or slightly above level of MPL.
Anteriorly and inferiorly: As much as possible. [Figure 8]
Adjustment of the nasal pack during bone punching may
be required to reduce bleeding. Suction with infant feeding
tube or Ryle’s tube should be used to aid exposure in case
of bleeding.
Sac flaps
Dilate the upper punctum with punctum dilator. Inflate the
sac with viscoelastic or chloro ointment in a 2-cc syringe with
a 26 number cannula. Long vertical top to bottom incision is
taken with 11 number blade and spring scissors on the medial
sac wall to create largeranterior and smaller posterior flaps
[Figure 9, and 10]. Vertical long top to bottom incision with a
11 number blade should be made on nasal mucosa such that
posterior flaps can appose well and anterior flap is large.
Small horizontal cuts may be required on the posterior nasal
mucosal flap to help it revert and appose well with posterior
lacrimal sac flap. Anterior horizontal cuts are made later, after
suturing the posterior flaps.
Figure 5: MPL exposed
Figure 7: Bone exposed
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Deshpande, et al.: Step-by-step dacryocystorhinostomy for beginners: an expert’s view
Figure 8: Large osteotomy (as indicated by thin dotted line) extending
superiorly slightly above level of MPL, inferiorly till the level of inferior
orbital margin, posteriorly from lamina papyracea as much as required
and anteriorly for good nasal flap
Figure 10: Fashioning the anterior and posterior nasal mucosal flaps.
1. Straight vertical incision 2. Small horizontal cuts to create posterior
flap. 3. Large horizontal cuts to create anterior flap
Figure 12: Anterior nasal flap created and sutured with two stutches
to the anterior nasal flap. Suture passed through thick stem of MPL
for reattachment to periosteum on nasal side
Closure
Posterior flaps are sutured so that the posterior sac flap
does not block common canalicular ostium in sac. The 6-0
vicryl needle is slightly bent in the middle of its shaft for
easy suturing of the posterior flaps in the depths. One suture
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Figure 9: Lacrimal sac inflated with viscoelastic or chloramphenicol
eye ointment with 26 no. cannula through upper punctum. 1. Inflated
buldging lacrimal sac. 2. Site of incision on lacrimal sac for creating
anterior and posterior flap
Figure 11: Posterior flaps sutured with one or two sutures. Incision 3
not yet made. Inferior flap not yet created. Shaded portion in between:
Nasal cavity with nasal pack visible
usually is sufficient for posterior flap. Care should be taken
to avoid nasal pack in the suture [Figure 11]. Anterior nasal
flap is now opened with 11 number blade and sutured to
the anterior sac flap with minimum two 6-0 vicryls sutures
(sometimes three) [Figure 12]. Inserting lacrimal probe helps
to confirm proper flap suturing. MPL re-attachment is done
with periosteum using deep down to the bone bite of 6-0
vicryl on the medial incision edge at MPL level. Movement
of the head when suture is pulled confirms the firm suture
attachment to periosteum. Additional 3-4 orbicularis closure
stitches are taken. Skin closure can be achieved with either
interrupted or continuous sub-cuticular sutures. Before
closures, conjunctival sac should be irrigated to remove any
bone pieces. Chloramphenicol ointment should be applied
on the wound and in the eye. Quarter folded pad on the
wound and half-folded pad on the eye should be applied. Full
pad can be put over this. Minimum 4-5 micropore tapes in a
criss-cross fashion with one tape to secure the nasal pack in
position should be applied.
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Deshpande, et al.: Step-by-step dacryocystorhinostomy for beginners: an expert’s view

Post-operative care Conclusion

Complete bed rest in propped up position and chin extension
is recommended for 24 hours. Patients should be told to
avoid blowing of nose. Oral antibiotics, non-steroidal anti-
inflammatory drug (NSAID) — Serratiopeptidase combination
and ethamsylate should be given routinely for five days.
Dressing and nasal pack removal to be done after 24 hours.
Local treatment includes otrivin-P nasal drops twice daily,
chloramphenicol ointment on the wound twice daily and
antibiotic with steroid eye drop four times daily.
Sac syringing should be done gently once in 2-3 days for the
first week or 10 days to remove blood clots. Suture removal
to be done after 1 week.
Results
We have operated 250 cases in the past 2 years with 95%
success rate.
Proper case selection, pre-operative workup and adequate
exposure go a long way in making DCR stress-free and successful.
Excessive bleeding, a common hindrance in DCR surgery can
be successfully tackled by proper positioning of patient, use of
adrenaline, suction, and adjustment of nasal pack.
References
1. Baldeschi L, Nardi M, Hintschich CR, Koornneef L.
Anterior suspended flaps: A modified approach for external
dacryocystorhinostomy. Br J Ophthalmol 1998;82:790-2.
2. Karim R, Ghabrial R, Lynch T, Tang B. A comparison of external
and endoscopic endonasal dacryocystorhinostomy for acquired
nasolacrimal duct obstruction. Clin Ophthalmol 2011;5:979-89.
Cite this article as: Deshpande S, Agashe A, Loomba A, Dhiware N. Step-by-
step dacryocystorhinostomy for beginners: An expert’s view. J Clin Ophthalmol
Res 2014;2:161-5.
Source of Support: Nil. Conflict of Interest: None declared.

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