1/23/2017 Dacryocystorhinostomy

DACRYOCYSTORHINOSTOMY(DCR)
VijayRamakrishnan,MD
ToddKingdom,MD

INTRODUCTION
Dacryocystorhinostomy(DCR)isaprocedureperformedforthetreatmentoftearing(epiphora)dueto
blockageofthenasolacrimalduct.Tearsoriginateinthelacrimalgland,locatedattheupperoutermarginof
theeye.Astearscrosstheeyewitheachblink,theyaredirectedintosmallopeningsintheeyelidscalled
puncta.Fromthispoint,tearstravelthroughapathwayknownasthecanalicularsystemintothelacrimalsac.
Thelacrimalsacislocatedbetweentheeyeandthenose,andfunnelstearsintothenasalcavitythroughthe
nasolacrimalduct(Figure1).Asthisisquitealongpathfortearstotravel,therecanbemanycausesof
excessivetearing.Blockageofthenasolacrimalductisonecommoncause,andcanbetreatedbycreatinga
directopeningfromthelacrimalsacintothenasalcavityinaprocedureknownasDCR.Theevaluationand
managementoftearingmayinvolvebothanophthalmologistandanotolaryngologist.

Fig1.Tearsoriginatingfromthelacrimalglandcrossovertheeyeintothecanalicularsystemontheirwaytothenasalcavity.

INDICATIONS
DCRisindicatedinthetreatmentoftearingduetonasolacrimalductobstruction.Blockageofthisductcan
beduetotrauma,priorsurgery,tumor,orinflammatorymedicalconditions,butmostcommonlyoccurs
withoutanidentifiablecause.Todetermineifthisistrulytheproblemareainapatientwithtearing,anumber
oftestsmaybeperformed.Aphysicalexaminationisperformedbythephysician,andisoftenfollowedby
probingandirrigationofthecanalicularsystem(Figure2).Placementofdyeinthetearsmaybeobserved
andtimedforclearance.Thisevaluationiseasilydoneandwelltoleratedintheofficesetting.

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Fig2.Probingandirrigationiscommonlyperformedintheevaluationoftearing.

PROCEDURE
Surgeryisoftenperformedundergeneralanesthesia,butmaybeperformedunderlocalanesthesia
accordingtopatientorsurgeonpreference.DCRcanbeachievedfromanexternal(throughafacialincision)
approachorfromanendoscopic(usingasmalltelescopeandinstrumentsthroughthenose)approach.The
goaloftheprocedureistobypasstheobstructednasolacrimalductandallowforteardrainageintothenose
directlyfromthelacrimalsac.ExternalDCRapproachesthelacrimalsacthroughasmallincisionbetween
theeyeandthenose.Thelacrimalsacisidentifiedandopenedintothenasalcavity.Tomaintainthe
opening,thesurgeonmayusesuturesorstents(Figure3).

Fig3.Ifused,astentisplacedthroughthepunctaintothenose.

EndoscopicDCRaccomplishesthesamegoal,butisperformedthroughthenosewiththeuseoftelescopes
andsmallinstruments.ThisapproachtoDCRisnowcommonlyperformedbecauseitavoidsafacialscar,
andisgenerallyassociatedwithlesspain.Thelocationofthelacrimalsacisknownbasedonextensive
anatomicstudy.Boneisremovedfromtheareaoverthelacrimalsacandthesacisopenedintothenose
(Figure4).Somesurgeonsprefertousestentsforsometimepostoperativelytomaintaintheopening.

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Fig4.Intraoperativeendoscopicviewoftheopeningcreatedfromthelacrimalsacintothenose(circled),afterirrigationwith
fluoresceindye.Thecommoninternalpunctumislocatedattheasterisk.

RISKS
Intheendoscopicapproach,painisminimalandcanbecontrolledwithacetaminophenormildprescription
painmedications.Infectionisuncommon,butmanysurgeonsprefertoadministerantibioticsaftersurgery.
Bleedingshouldbeminimal,butrarelycanbesignificant.Scarringwithinthenosemayoccur,leadingto
blockageoftheopeningandrecurrenceoftearing.Althoughextremelyrare,themajorriskoftheprocedure
isbleedingwithintheorbitalcavity(orbitalhematoma)orinjurytoaneyemuscle,whichmaycausedouble
visionorvisionloss.Scarandtemporarybruisingwilloccurwithexternalprocedures,althoughtheseshould
berelativelyminor.Ifyoursurgeonpreferstokeepastentinplaceafterwards,prolapse(movementoutofthe
noseorupintotheeye)mayoccur,whichrequiresstentadjustmentorremoval.

BENEFITS
DCRisafairlysimpleoutpatientprocedure.Overallsuccessratesexceed90%,althoughinparticularcases
thelikelihoodofsuccessmaybelower.Therisksandsideeffectsoftheprocedurearerelativelylow,andcan
potentiallyleadtoalonglastingreliefofbothersometearing.

SUMMARY
Althoughtherearemanycausesoftearing,somepatientsareexcellentcandidatesforDCR.Aproper
evaluationmusttakeplacetodeterminethelikelihoodofsuccesswiththissurgery.Asanoutpatient
procedure,DCRpresentsaniceoptionforpatientswithbothersometearingduetoobstructionofthe
nasolacrimalduct.Surgeonswillhavetheirownpreferencesinparticularaspectsoftheprocedureexternal
orendoscopic,useofstents,sizeofopeningcreated,postoperativevisitschedulebuttheultimategoals
andsuccessratesarequitesimilar.

Revised01/20/2015
AmericanRhinologicSociety

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