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Laser DCR
Laser DCR
Laser-Assisted Dacryocystorhinostomy
S. Mirza and N. Jones
7
The type of laser appropriate for a DCR would allow Close cooperation with ophthalmalogical colleagues
delivery via flexible optic fibers, achieve effective is essential to ensure a correct diagnosis. Although
bone ablation and provide good hemostasis with a the ELDCR is mainly an ENT-oriented procedure
relatively shallow depth of penetration; therefore, the with most of the surgery being intranasal, it is ideal if
Laser-Assisted Dacryocystorhinostomy Chapter 7 75
Table 7.2. Lasers used for endonasal laser DCR Table 7.3. The advantages and disadvantages of the laser endo-
nasal DCR over non-laser endonasal DCR
KTP
Holmium:YAG Advantages Disadvantages
Diode Can be performed Lower success rate
Neodymium:YAG under local anesthetic
Argon Can be performed Expensive equipment
CO2 on anticoagulated patients
Shorter operative time Laser precautions required
More effective hemostasis
and low hemorrhage rates
76 S. Mirza, N. Jones
an otorhinolaryngologist and ophthalmologist un- tively with the laser, removing the scarred tissue
dertake the procedure jointly. Assistance from the bloodlessly, although the outcome cannot be reliably
ophthalmologist to pass a vitreo-retinal light pipe to predicted on account of excessive scarring which may
transilluminate the site of the operation is useful involve the canaliculi and the common canaliculus. It
(Fig. 7.1), and some patients may have additional pa- is important that during the procedure the laser power
7 thology such as a stenosed punctum, which requires setting be high enough to effect vaporization, rather
concurrent management by way of a three-snip pro- than charring, since the latter will mean that further
cedure. laser energy and heat may be dissipated to surround-
ing tissue and produce more scar tissue.
7.4 Patient Assessment: Case History nation of the punctum may show it to be ex-
tremely small. If the lower canaliculus is ste-
Syringing and probing of the lacrimal system is used nosed, a DCR is of little value as 90% of tears
to diagnose the site of any nasolacrimal duct obstruc- drain via this route. Probing the lacrimal path-
tion. Nasendoscopy prior to ELDCR is advisable to way with a smooth double-ended Bowman’s
ensure adequate access and rule out co-existing probe often has a “soft stop” as the probe passes
pathology. through the common canaliculus (Fig. 7.2). In
Patients with epiphora may have one or more sites some cases, probing and dilatation may be suc-
of obstruction along the lacrimal drainage pathway. cessful in re-establishing the patency of the
Proximal obstruction needs to be excluded before system or with a stenosed punctum the oph-
listing a patient for ELDCR and this can be performed thalmologist may do a “three-snip procedure”
without the need for complex investigations in the to enlarge the opening.
majority of cases. It is also important to exclude ma- 3. Regurgitation of fluid on syringing through
lignancy, which may present with blood stained the upper punctum = distal blockage
epiphora, or a progressively enlarging mass within
the lacrimal sac with or without tethering of the skin.
A thorough ophthalmic and nasal examination usu- If saline regurgitates through the lower punctum
ally fails to show any obvious etiological factor in the after a slight delay, then it must have entered the lac-
majority of cases. rimal sac, encountered a distal obstruction, and re-
A history of trauma to the nasoethmoid complex, turned through the upper canaliculus. The positive
such as a LeFort type-II or type-III fracture, may re- regurgitation test thus confirms an obstruction in the
sult in an unfavorable outcome from EDCR. Such nasolacrimal duct. Rarely, a minor degree of blockage
cases are best dealt with via an external DCR where of the nasolacrimal duct may resolve with flushing.
wide excision of bone and mucosa can be undertaken Some cases present with both proximal as well as
under direct vision. distal obstruction. When the proximal obstruction is
A visible and palpable swelling, infero-lateral to
the medial canthus, may indicate the presence of a
lacrimal mucocele or pyocele. Massaging of the lacri-
mal sac may express discharge or frank pus from the
puncti, indicating a diagnosis of mucoid or purulent
dacryocystitis.
The patency of the system is tested by flushing
with saline solution. Flushing should be undertaken
gently since it can cause damage to the delicate cana-
liculi and produce false passages. Syringing and prob-
ing is done via the upper canaliculus with one of the
following results:
7.6.3.1 Preparation ing the upper canaliculus also obviates injuring the
functionally more important inferior canaliculus.
The patient is placed in the supine position at 15° re- The light is then held in the most dependent position
verse Trendelenburg. Appropriate laser-safety pre- where its position can be seen intranasally. It must be
cautions for the patient and operating team are taken kept in the same position while the rhinostomy is be-
to avoid ocular injury. Wet eyepads are placed over ing made to avoid firing the laser in several positions
the patient’s eyes. when the light has moved.
nostomy results in a sump syndrome, predisposing to in situ by a Watzke sleeve or they are gently tied so
recurrent infections of the sac and the duct. A Dun- that a small loop remains at the inner canthus
das Grant attic seeker can be used to palpate the sac (Fig. 7.6). It is best to avoid excessive tightening of the
through the rhinostomy opening to ensure that there loop as this may eventually cause “cheese wiring” at
is no pocketing of mucus or pus, or fibrous strands, the medial canthus. Stents are removed by cutting the
within the sac. loop at the inner canthus and pulling the sleeve with
stents from the nostril.
A silicone tubed stent is used by a number of surgeons 7.7.2 Poor Surgical Access
to maintain the patency of the rhinostomy (Woog et
al. 1993; Reifler 1993; Szubin et al. 1999; Mirza et al. To obtain adequate access for the operation anatomi-
2002). One end of the tubing is inserted and fed cal obstruction, such as a deviated nasal septum,
through the upper canaliculus, and the other through prominent anterior lacrimal crest, or a large anterior
the lower canaliculus, so that the ends come out of the end of the middle turbinate, may need initial surgical
new opening into the nasal cavity. The ends are held intervention.
After 3 months, the fistula cannot always be de- to define the patency of the system. The most com-
tected as a distinct opening, and the operation site mon cause of failure is stenoses of the rhinostomy. In
may show a slight dimple, or may even appear com- common with surgically created stomas in other parts
pletely normal. of the body, the dacryocystorhinostomy also shrinks.
The purpose of creating a large rhinostomy is to allow
for the shrinkage but even so the nasal mucosa may
7.10 Results grow over the bony opening and heal completely
without any visible scarring. Other causes of obstruc-
Most failures occur in the first 18 months due to ste- tion of the internal nasal opening include granula-
nosis at the rhinostomy site, although late stenosis tions, adhesions, and synechia. Revision laser DCR
can occur up to 3 years after surgery. Subjective scor- surgery may be indicated and is easily performed with
ing by the patient is usually used to measure the out- good success rates (Kong et al. 1994; Mirza et al. 2002).
come. In unilateral cases, it is common for the patient Some patients may ultimately require an external
to compare the results of the operation with the DCR.
“good” eye. In bilateral cases, the patient compares
improvement with the severity of watering prior to
the operation. In the immediate post-operative peri- 7.12 Post-operative Complications
od, particularly when a stent is not inserted, the im-
provement is both immediate and dramatic. As the In the majority of patients, there are very few post-
healing proceeds, the symptoms may return, but less operative complications, and the procedure is associ-
so in both severity and frequency. Where the im- ated with very low morbidity. A list of complications
provement is partial, it is usual for the patient to com- is given in Table 7.5 and the following is a brief sum-
plain of eye watering in cold winds, or in the smoky mary of the more common ones.
atmosphere of bars and restaurants. In cases with no
improvement whatsoever, however short-lived, there Table 7.5. Complications of laser DCR
may be other reasons for failure such as atony of the
Stenosis
lacrimal pump.
Endoscopic examination may show no patent rhi- Granulation tissue
nostomy, but in a number of cases, the patient remains Synechia
symptom-free. It is likely that a minute opening, not Stent migration
easily visible to the naked eye, may remain patent and Sump syndrome
continue to drain. An alternative explanation for the
Cutaneous fistula (rare)
improvement of symptoms when no patent stoma is
seen, is that the pathology responsible for the distal Hemorrhage (rare)
obstruction has resolved.
A physiological and objective method to assess the
patency of the stoma consists of the dye disappearing
test where, for example, fluorescein is placed into the 7.12.1 Hemorrhage
conjunctiva without any syringing of the puncti and
canaliculi. A nasal endoscope then confirms the pas- Significant hemorrhage is rare in laser DCR, and only
sage of the fluorescein into the nasal fossa signifying occasionally is nasal packing necessary, whereas with
a patent system. the external DCR it has been reported as occurring in
5–10% of patients.
if it rubs the rhinostomy site. Stent removal usually 7.13.1 Avoidance of Stenting
results in a satisfactory resolution. Antibiotic nasal
and eye drops may help reduce the incidence of gran- Most series have utilized stenting, and premature
ulations. stent removal may be associated with failure (Boush
et al. 1994; Sadiq 1997; Mirza et al. 2002); however,
stenting may lead to complications such as the forma-
7.12.3 Synechia tion of granuloma, infection, or scarring of the lacri-
mal puncta, and therefore some authors advise avoid-
Synechia are adhesions that form between two dam- ing routine stenting (Allen and Berlin 1989). Stenting
aged apposing mucosal surfaces and are not uncom- may be particularly useful where there is considerable
mon after nasal surgery. The damage may result from scarring from previous operations, and in revision
instrumentation or from the spread of laser thermal endonasal surgery. The stent should be secured with a
energy to surrounding non-target structures. Syn- loose knot or a Watzke sleeve rather than metal clip in
echia usually form between the lateral surface of the order to avoid a foreign body reaction and subsequent
middle turbinate and the medial surface of the lateral granuloma formation leading to fibrosis.
wall of the nose and may obstruct the rhinostomy re-
7 sulting in failure of the procedure. Synechia occur
more commonly in cases with narrow nasal fossa, 7.13.2 Combined Laser
large concha bullosas, and chronic pathological con- and “Cold” Instrument Surgery
ditions of the nasal mucosa. If the synechae are symp-
tomatic, then revision surgery may be required. Concomitant use of instruments such as the otodrill
Covering the lateral surface of the middle turbi- and microrongeur may be more effective in removing
nate with wet ribbon gauze during the procedure may thick bone and less painful for the patient (Kong et al.
prevent adhesions. 1994). In addition, using endoscopic instruments
instead of laser vaporization to open the lacrimal sac
may reduce scarring and improve patency rates
7.12.4 Stent Migration (Szubin et al. 1999).
tervention. Laser endonasal DCR can readily be done Mirza S, Al-Barmani A, Douglas SA, Bearn MA, Robson AK.
under local anesthetic as an outpatient procedure, but A retrospective comparison of endonasal KTP laser dac-
ryocystorhinostomy versus external dacryocystorhinos-
the incidence of restenosis is approximately 10% more tomy. Clin Otolaryngol 2002;27:347<351
than if conventional instruments are used. In revision Moore WM, Bentley CR, Olver JM. Functional and anatomic
DCR, a laser DCR can be done very easily as it usually results after two types of endoscopic endonasal dacryocys-
only requires ablation of scar tissue that has formed at torhinostomy: surgical and holmium laser. Ophthalmol-
the rhinostomy site. ogy 2002;109:1575<1582
Morgan S, Austin M, Whittet H. The treatment of acute dac-
ryocystitis using laser assisted endonasal dacryocystorhi-
nostomy. Br J Ophthalmol 2004;88:139<141
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