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Endonasal Dacryocystorhinostomy
Surgery, Capture and Editing - Martyn Barnes, UK
Supervision - Salil Nair, New Zealand
Editing, Illustration, Script and Narration - Pavol Surda, UK
An instructional video on the surgical technique of an endonasal dacryocystorhinostomy (DCR).
This relatively new development on the traditional technique of external DCR represents an increasingly common skill-set in rhinologic practice.
1. Peer Review is pending
None so far...
1. Endonasal vs. External
In short, both techniques are highly successful.
The main argument for an endonasal approach is the lack of a scar.
In good hands however, the scar is very inconspicuous. Also, these patients tend to be of an older age group that are not conscious of a small scar by the side of the eye.

The main argument against the endonasal approach has been a lower rate of success.
Recent studies however, very much suggest that the differences have resolved with increasing experience of the technique or possibly general advances in rhinologic equipment.

2. The use of ‘tubes’ (O'Donoghue silicone stents)
Nobody yet seems to have a definitive answer to the question of whether or not to leave these stents in place at the end of the procedure (as we did in this case).

3. Others? - Peer Review is pending
Welcome to our dacryocystorhinostomy video or DCR. DCR has become an established technique for the treatment of lacrimal duct obstruction. In this video, we mainly focus on the surgical technique, but is very important that the patient is properly selected and indicated for the procedure. After nasal decongestion with Moffat’s solution soaked neuropatties, we infiltrate the mucosa with adrenaline and lidocaine. It is crucial to place correctly the initial incisions as shown on this diagram. They are very important as they form the borders of the subsequent bone removal and sac exposure.

The number 15 blade is used for initial incisions. The first incision is made horizontally 8-10mm above the axilla of the middle turbinate and then coming forward onto the frontal process of the maxilla. The blade is then turned vertically, and the vertical incision is made to about 2/3 of the middle turbinate. Using the suction Freer’s elevator, the flap is elevated and the tip should always maintain the contact with the bone. Perioperatively it is useful to use blunt dissection with adrenaline-soaked neuropatties to reduce the bleeding. At this point, the bone should be palpated so the junction of the lacrimal bone and the hard bone of the frontal process can be identified. This is the key landmark. A round knife is used to flake the soft lacrimal bone away from the posterior inferior region the sac to prevent the damage. Now, we use the Hajek-Koffler punch forceps to remove the first portion of the front proc. Tip of the punch is used to push lacrimal sac away before the bone is engaged and removed. Bone removal continues ant sup so the Hajek-Koffler punch forceps can no longer be seated on the bone. Now we see how the lacrimal sac is slowly exposed. For the residual portion of the bone, we often use the drill. We recommend the diamond burr as the contact of burr and sac does not cause the damage. The level of exposure of the lacrimal sac should be such, that when the probe is directed horizontally from the eye, it can tent the lacrimal sac mucosa with a good clearance of bone around it. Moreover, now we will slowly start to see fully exposed lacrimal sac.

Now the inferior punctum is dilated with the dilator. This is usually performed by the ophthalmologist. Bowman lacrimal probe is then passed into the sac and with gentle downward and medial movement is inserted inside. At this point, the movement of the probe should visible in the nasal cavity. One should never cut the sac if the tip is not obviously present as this can cause the damage of the common canaliculus.
You have just seen the typical H-shaped incision. For this purpose, we use Keratoma knife, DCR spear, sickle knife. Firstly we place this vertical incision which is followed by two horizontal incision in order to create anterior a posterior flap. For this purpose, the soft tissue scissors are often helpful but in this case we have not used it. It is important never to place the entire blade into the sac to prevent the unnecessary damage.
Now, the superior punctum is dilated which is followed by placement of O’Donoghue lacrimal tubes. Subsequently they are retrieved endonasally. To avoid the collateral damage of the tissue inside the nose, we grasp the tip of the sharp probe and retrieve it out from the nasal cavity. Subsequently the other end of the O’Donoghue lacrimal tube is placed in the inferior punctum and again retrieved endonasally. Now, a square of gelfoam is slit over the tubes into the nasal vestibule. Silastic spacer is used to push the gelfoam into the nasal cavity and support/stabilize the mucosal flap. Before placing the clips make sure that the loop tubing is not pulled too tight so it will not be uncomfortable for the patient.

In the next sequence, we will shorten the mucoperichondrial flap with scissors or microdebrider so it will meet the posterior flap created out of lacrimal sac. There should be no overlap. With regards to the postoperative recommendation, the patient are discharged the same day with analgesia and sinus rinse bottle. Postoperatively, we recommend using saline douching 3x day broad spectrum of antibiotics for 5 days and antibiotic eye drops for 3 weeks. The O’Donoghue lacrimal tubes are removed 4 weeks after surgery and patency of nasolacrimal system is checked with fluorescein test. Thank you for watching our video. We always emphasize that is our own technique which will almost certainly change with the time. If you feel that you have got any interesting tips or contributions, please get in touch with us through
If you have references that you think we should add, or any other recommendations for this page,
just let us know!
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Thanks to our
peer reviewers

Kim Ah-See
Martyn Barnes
Jochen Bretschneider
Mike Davison
Prof. Richard Douglas
Prof. Wytske Fokkens
Quentin Gardiner
Iain Hathorn
Claire Hopkins
Christopher McCann
Gerald McGarry
Dirk Jan Menger
Mohammed Miah
Salil Nair
Peter Ross
Anshul Sama
Pavol Surda
Nolst Trenité
May Yaneza
Hadé Vuyk

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