Endoscopy and Microendoscopy of The Lacrimal Drainage System

®
ENDOSCOPY AND
MICROENDOSCOPY OF THE
LACRIMAL DRAINAGE SYSTEM
Reynaldo M. JAVATE
Ferdinand G. PAMINTUAN
Susan Irene E. LAPID-LIM
Raul T. CRUZ, Jr.
Reynaldo M. Javate, M.D., F.I.C.S Ferdinad. G. Pamintuan, MD, Susan Irene E. Lapid-Lim, M.D., Raul T. Cruz, Jr., M.D.
FPSO-HNS D.PBO, F.PAO
Reynaldo M. Javate is Professor and Chairman, Department of He is a Fellow of the Philippine Society of Otolaryngology Head and Neck
Ophthalmology, and Chief of Lacrimal, Orbital and Oculofacial Plastic Surgery Inc., Associative Board Examiner for the Philippine Board of
Surgery, University of Santo Tomas Hospital, University of Santo Tomas, Otolaryngology, and the current President of the Philippine Academy of
Manila, Philippines. He has pioneered minimally invasive surgical techniques CranioMaxillofacial Surgery.
in ophthalmic plastic and reconstructive surgery including: Endoscopic Susan Irene Lapid-Lim is Visiting Consultant with the Department of
Radiofrequency-Assisted Dacryocystorhinostomy (ERA-DCR); Mini-Incision Ophthalmology of the University of Santo Tomas Hospital, University of Santo
DCR using a Radiosurgery Unit; Endoscopic Lacrimal Duct Recanalization Tomas, Manila, Philippines. She completed her ophthalmology residency
(ELDR) using Microendoscope. In the course of his surgical innovations, he training in the same hospital as Chief Resident. She is a Diplomate of the
has designed instruments like the JAVATE Endoscopic DCR Electrodes, the Philippine Board of Ophthalmology and Fellow of the Philippine Academy of
JAVATE-PAMINTUAN dacryoplasty electrode, and the JAVATE-KHAN endo Ophthalmology.
suction set, which are manufactured and distributed by ELLMAN International,
Inc. (3333 Royal Avenue, Oceanside, NY, USA), the JAVATE lacrimal trephine, Dr. Lapid-Lim has shown continued interests in research and publication on
and the newly-designed JAVATE microendoscope manufactured by KARL ophthalmic plastic and reconstructive surgery. She has co-authored winning
STORZ Tuttlingen, Germany. research papers and other papers presented in national and international
meetings including “Peg and Prosthesis Coupling with the Porous Biphasic
Dr. Javate has published numerous articles and book chapters on lacrimal, Calcium Phosphate Sphere: A Philippine-Manufactured Integrated Orbital
orbital and oculofacial plastic surgeries and has given lectures/presentations, Implant” (Jesus Eusebio, Sr. Research Paper Contest, 1999); “Endoscopic
cadaveric and live surgical demonstrations worldwide. Guided Repair of Canalicular Laceration, Case Report” (PAO free paper
As Professorial Chair Holder in Ophthalmology at the University of Santo session).
Tomas from (1998–2004) he worked extensively on the subject of surgery She has co-authored published articles and book chapters including:
of the lacrimal system. For this, he has gained awards and citations such “Refinements in Surgical Technique of External Dacryocystorhinostomy”,
as Gold Series Awards, Faculty of Medicine and Surgery, University of and “Sutureless Dacryocystorhinostomy Surgery” (Operative Techniques in
Santo Tomas, Best Faculty Research Award for four consecutive 2-year Oculoplastic, Orbital, and Reconstructive Surgery, 1998); “Radiofrequency
terms (1994-2002), Dangal ng UST Awards (1998, 1999, 2001, 2003), Hall for Use in Dacryocystorhinostomy” (New Waves in Dacryocystorhinostomy,
of Fame Award 2004, The Outstanding Thomasian Alumni (TOTAL) for Health- Oculoplastic Surgery With Radiofrequency, Aimino G. et al, 1999);
Medicine 2005, Philippine Academy of Ophthalmology Award of Distinction “Radiofrequency Dacryocystorhinostomy” (The Lacrimal System Diagnosis,
for the PAO Geminiano De Ocampo Outstanding Researcher in Ophthalmology Management and Surgery, Springer, 2006).
Award, and the PAO Outstanding Ophthalmic Educator Award.
Raul T. Cruz Jr. is a Consultant at the Department of Ophthalmology,
He is a fellow of the American Society of Ophthalmic Plastic and Reconstruc- University of Santo Tomas Hospital, University of Santo Tomas, Manila,
tive Surgery, a Life fellow of the Philippine Academy of Ophthalmology (PAO) Philippines where he has done all his medical activity and completed his
and a Board Examiner of the Philippine Board of Ophthalmology (PBO), Past training as Chief Resident. He is also an Active Consultant at the St. Anthony
President of the Philippine Society of Ophthalmic Plastic and Reconstructive Medical Center, Marikina City, Philippines, Alfonso Specialist Hospital, Pasig
Surgery, Congress President of the 10th World Congress of the International City, Philippines and Family Clinic Inc., Manila, Philippines. He has been the
Society of Dacryology and Dry Eye, and President of the 11th World Congress CEO/active consultant of Centro Estetico Rejuvenation Center, Quezon City,
of the International Society of Dacryology and Dry Eye. Philippines since 2008.
Ferdinand G. Pamintuan is a Consultant of the Department of He has co-authored several lectures in lacrimal, orbital, and oculofacial
Otolaryngology Head and Neck Surgery, and Chief of Section for Maxillofacial, plastic surgery.
Plastic and Reconstructive Surgery, and member of the Residency Training He has been fully dedicated since its beginning to the development and
Committee at the University of Santo Tomas Hospital, University of Santo advancement of microendoscopy of the lacrimal system research studies
Tomas, Manila, Philippines. and the publication of its article.
He has co-authored with Dr. Javate papers on Endoscopic Radiofrequency He has deeply involved in Radiofrequency Technology in aesthetic research
– Assisted Dacryocystorhinostomy (ERA-DCR) and Endoscopic Lacrimal Duct studies, publication of its article and its inclusion in Aesthetic Oculofacial
Recanalization (ELDR) published in both the Journal of Surgical Technique in Rejuvenation by W.B. Saunders (2010).
Ophthalmic Plastic and Journal of Reconstructive Surgery and Ophthalmic
Plastic Reconstructive Surgery. He, likewise has published several articles Armida L. Suller, who contributed to this silver booklet as academic
and book chapters on lacrimal surgery and has delivered lectures and collaborator, is Resident at the Department of Ophthalmology, University of
workshops in this field. Santo Tomas Hospital, University of Santo Tomas, Manila, Philippines.
He belongs to the regional faculty for Asia in the AO-Association for the Study
of Internal Fixation (ASIF). In line with this, he has given lectures about facial
trauma in various Asian countries.
®
ENDOSCOPY AND
MICROENDOSCOPY OF THE
LACRIMAL DRAINAGE SYSTEM
Reynaldo M. JAVATE, M.D.
Ferdinand G. PAMINTUAN, M.D.
Susan Irene E. LAPID-LIM, M.D.
Raul T. CRUZ, Jr., M.D.
Department of Ophthalmology, University of Santo Tomas Hospital
University of Santo Tomas, Manila, Philippines
Department of Otorhinolaryngology, University of Santo Tomas Hospital
Academic collaborator:
Armida L. SULLER, M.D.

Resident, Department of Ophthalmology
University of Santo Tomas Hospital
4 Endoscopy and Microendoscopy of the Lacrimal Drainage System
Important notes: Endoscopy and Microendoscopy of the Lacrimal Drainage System

Medical knowledge is ever changing. As new research Reynaldo M. Javate, M.D., Ferdinand G. Pamintuan, M.D.,
and clinical experience broaden our knowledge, Susan Irene E. Lapid-Lim, M.D. and Raul T. Cruz, Jr., M.D.
changes in treatment and therapy may be required.
The authors and editors of the material herein have Department of Ophthalmology, University of Santo Tomas Hospital,
consulted sources believed to be reliable in their efforts University of Santo Tomas, Manila, Philippines
to provide information that is complete and in accord Department of Otorhinolaryngology, University of Santo Tomas Hospital,
with the standards accepted at the time of publication. University of Santo Tomas, Manila, Philippines
However, in view of the possibility of human error by
the authors, editors, or publisher, or changes in medical Academic Collaborator: Armida L. Suller, M.D.
knowledge, neither the authors, editors, publisher, nor Resident, Department of Ophthalmology, University of Santo Tomas Hospital,
any other party who has been involved in the preparation University of Santo Tomas, Manila, Philippines
of this booklet, warrants that the information contained
herein is in every respect accurate or complete, and they
are not responsible for any errors or omissions or for Correspondence address of the author:
the results obtained from use of such information. The
information contained within this booklet is intended for Prof. R.M. Javate, M.D.,
use by doctors and other health care professionals. This 48 Tirad Pass, corner Sultan Kudarat Sts.,
material is not intended for use as a basis for treatment Ayala Heights Village, Quezon City, Philippines
decisions, and is not a substitute for professional Fax: +63 (2) 732-7481
consultation and/or use of peer-reviewed medical E-mail: rmjavate@pacific.net.ph
literature.
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Endoscopy and Microendoscopy of the Lacrimal Drainage System 5
Table of Contents
1.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.0 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Nasal Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2 Nasolacrimal Sac and Duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3 Anatomical Variations in the Lacrimal System by Race and Gender . . . . . . . . . . 9
2.4 Dimensions of the Nasolacrimal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.5 Thickness of the Lacrimal Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6 Soft Tissue Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.0 Evaluation of Patients with Epiphora. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.1 Schirmer Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.2 Rose Bengal Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.3 Tear Breakup Time (BUT)
Fluorescein Breakup Time (FBUT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.4 Fluorescein Dye Disappearance Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.5 Jones I Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.6 Jones II Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
3.7 Canalicular Probing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4.0 Basic Principles for Surgical Application
of Radiofrequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
4.1 Definition of Radiofrequency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Radiofrequency Waveforms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Electrodes in Radiosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5.0 Lacrimal Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
5.1 Endoscopic Radiofrequency-Assisted Dacryocystorhinostomy (ERA-DCR) . . . . . 15
5.1.1 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
5.1.2 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5.1.3 Discussion: ERA-DCR versus External DCR . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
5.2 Mini-Incision Dacryocystorhinotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
5.2.1 The Surgical Techniques involved in Mini-Incision DCR . . . . . . . . . . . . . . . . . 22
Preoperative Preparation and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . 22
Skin Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Lacrimal Sac Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Nasal Mucosal Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Anastomosis of the Posterior Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Silicone Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Anastomosis of the Anterior Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Skin Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5.2.2 Postoperative Care in Mini-Incision DCR . . . . . . . . . . . . . . . . . . . . . . . . . 26
5.2.3 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5.2.4 Endoscopic Follow-up Documentation after Mini-Incision DCR . . . . . . . . . . . 27
5.3 Endoscopic Lacrimal Duct Recanalization (ELDR) . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.3.1 Proper Selection of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.3.2 Anatomic Consideration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5.3.3 Operating Room Set Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5.3.4 Step by Step Approach to ELDR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5.3.5 Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5.3.6 Advantages and Learning Curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.3.7 Tips and Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.3.8 Management of Obstructions Proximal to the Lacrimal Sac . . . . . . . . . . . 37
Microendoscopic Canalicular Trephination with
Silicone Intubation for Canalicular Obstructions . . . . . . . . . . . . . . . . . . . . 38
5.3.9 Videoendoscopic Images of the Lacrimal Excretory System . . . . . . . . . . . 39
Normal Lacrimal Drainage System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Sac and Lacrimal Duct before and after ELDR . . . . . . . . . . . . . . . . . . . . . 39
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.0 Introduction
Epiphora, or excessive tearing, is a manifestation of obstruction within the lacrimal
system in segments or its entirety. A partial or complete hindrance to lacrimal flow
can result in stagnation of fluid and debris that predisposes to purulent infections.
This gives rise to signs and symptoms like epiphora, mucus discharge, excessive
mattering, conjunctivitis, visual fluctuations in varying degrees, periocular swelling,
dermatitis, or cellulitis. The inconvenience to patients can range from benign to
severe.
In 1893, G.W. Caldwell performed the very first surgery directed at the lacrimal
system. His dacryocystorhinostomy through an endonasal approach evaded popularity
because of poor intra-operative visualization from bleeding at the surgical site. In
1904, Addeo Toti introduced the external dacryocystorhinostomy (DCR) technique for
the surgical correction of teary eye. The Toti DCR has been the gold standard against
which adaptations in surgical strategies for nasolacrimal duct obstruction (NLDO) are
compared.
Since its inception, DCR has undergone a multi-faceted evolution. In recent decades,
management shifted again to endonasal applications, then external methods, and
back. Only one aspect in the surgical correction of medically refractory NLDO stays
constant: its dynamism. The emergence of operative modifications continues with the
goal of establishing a paradigm in the standards of NLDO management.
Toti’s external dacryocystorhinostomy is the prototype for operative correction of
NLD obstruction. Success rate for symptom correction after external DCR has been
reported at 80–95%. Despite this favourable outcome, the external approach is
accompanied by considerable trauma and hemorrhage risk. Likewise, the cosmetic
effect of incisional scarring is a deterrent that makes this procedure unacceptable to
some patients. Technically, the complexity of this relatively lengthy method primarily
disregards the the anato-physiology of the natural tear drainage system.
The transnasal DCR has matured through the years since Caldwell’s initial attempts.
Parallels by West (1910) and Mosher (1921) have since been followed by more
modifications. Proponents attribute to the endonasal approach minimal operative
bleed, shortened operative time, less patient discomfort and downtime, as well as
avoidance of a cutaneous scar. More recently, lasers and radiofrequency have
emerged as endonasal adjunctive techniques. Initial outcomes with endonasal laser-
or Radiofrequency-Assisted DCR, however, have failed to approximate the highly
acceptable rates of standard external approach. Many ophthalmologists remained
critical of what they regarded as disadvantages of these methods: the need for
re-familiarization with the intricacies of intranasal anatomy, the need for collaboration
with ENT colleagues, the technical challenge in the use of new equipment, and the
relatively steep learning curve.
Eventually, another minimally invasive technique surfaced. Microendoscopes for the
direct visualization of the lacrimal system were developed. This made possible the
microendoscopic transcanalicular approach to diagnosis and treatment of lacrimal
system pathology, such as obstruction, neoplasm, fistula, foreign bodies, dacryoliths,
or mucosal inflammation. With a microendoscope, any obstruction and pathologies
in the lacrimal system can be visualized directly. Obstructions can be surgically
removed precisely, greatly limiting injury to surrounding normal tissues resulting in

less hemorrhage. The method leaves no facial scar, requires a shorter operative time,
and results in less postoperative pain. The technique preserves the pumping function
of the orbicularis oculi muscle and can be performed even in the presence of active
infection of the lacrimal system. The microendoscopic transcanalicular approach has
comparable anatomic and functional success rate to the external approach, making it
an acceptable alternative to external dacryocystorhinostomy.
This compilation of surgical techniques will cater to experienced or beginning
ophthalmologists interested in acquiring newer or in relearning older approaches
to lacrimal surgery. It presents technical innovations and procedural variations that
may be adapted into personal surgical protocols. More importantly, it may serve as a
springboard to further brainstorming and experimentation that may offer even better
techniques to resolve lacrimal system disorders.
The silver booklet lays down the following:
general indications for and operative approaches to the obstructed nasolacrimal
system;
variations in dacryocystorhinostomy surgery that have been tried and tested
by the authors to address problematic situations involving the obstructed
nasolacrimal system; and,
innovations in the repair of canalicular obstruction.
Its goal is to provide a comprehensive understanding of current lacrimal system

surgical techniques that will benefit ophthalmologists and other surgeons.
2.0 Anatomy
2.1 Nasal Cavity

The nasal cavity, an air-filled fossa occupying the space above and behind the nose,
is divided into internal and external parts. The internal part is much larger than the
external portion. The external nose, which projects from the face, has supporting
structures composed of nasal bones, lateral nasal wall, greater alar and lesser alar
cartilages, and fibrofatty tissues. The entire nasal cavity extends from the nostrils
anteriorly to the choanae posteriorly.
The nasal cavity is divided by a septum that forms the medial wall for the right and
left halves. Each half is further bounded by a roof, a floor and a lateral wall. The floor
of the nasal cavity consists of the palatine process of the maxilla and the horizontal
plate of the palatine bone. The narrow roof is formed by several bones and cartilages:
the bridge of the nose, anteriorly; the ethmoidal cribriform plate, intermediately; and
the floor of the sphenoid sinus, posteriorly. The nasal cavity is divided by the nasal
septum which is partly osseous and partly cartilagenous. Each lateral wall is marked
by three projections (called turbinates or conchae): the superior, middle and inferior
conchae. The area below each concha is referred to as meatus.
The inferior turbinate is an infolding of the lateral nasal wall, about 60 mm in size
from anterior to posterior direction (Fig. 1). It forms part of the nasal valve and is
embryologically related to the maxilloturbinal ridge. The middle turbinate lies medial
to the anterior ethmoidal air cells, the maxillary sinus ostium. It has a length of around
40 mm and height of 14 mm superiorly and 7 mm inferiorly, and develops from the
ethmoturbinals. The uncinate process, which is a sickle-shaped fold projecting into
the middle meatus, covers the opening to the maxillary sinus. The nasofrontal duct
or frontal recess, the highest part of the medial meatus along its anterior portion,
receives drainage from the frontal sinus (Fig. 2). Both the nasofrontal duct and the
uncinate process are important anatomic landmarks for endoscopic sinus surgery
and endonasal DCR.
The superior turbinate is present in 30% of the population and drainage is from the
nasofrontal duct and anterior ethmoids.
The nasal cavity functions as the superior part of the respiratory tract where the organ
of olfaction is located. It also serves as an air passageway to the lungs that filters
impurities, especially dust, from the inspired air and warms and humidifies the air that
we breathe. It aids in phonation and receives secretions from the paranasal sinuses
and the nasolacrimal canal.
2.2 Nasolacrimal Sac and Duct

The egress of tears from the external eye occurs via the lacrimal apparatus, starting
at the lacrimal puncta found near the medial aspects of the upper and lower lid
margins. Each punctum, with an orifice measuring 0.3 mm in diameter, is found at
the summit of the lacrimal papilla, a fibrous mound of avascular tissue, thus giving
the punctum a relatively pale appearance. Tears entering each punctum pass on
into a canaliculus which continues 2 mm vertically before taking a 90-degree turn
medially into horizontal segments that run a distance of 8 mm through the substance
of the orbicularis muscle. The superior and inferior canaliculi coalesce into a common
canaliculus in 90 to 94% of individuals before empyting into the lacrimal sac at an
acute angle. The valve of Rosenmuller, found at the medial aspect of the common
canaliculus, helps prevent tear reflux.
Both the common canaliculus and lacrimal sac are situated between the anterior
and posterior limbs of the medial canthal ligament. The lacrimal sac, averaging 12 to
15 mm in height, has a rounded, closed, superior border extending 3 to 5 mm superior
to the medial canthal ligament. This oval tear sac lies immediately external to the
orbit, lodged within the lacrimal fossa, a hollow indentation bounded anteriorly by
1 Endoscopic view of the inferior turbinate. 2 Sagittal section. Right lateral wall of the nasal cavity in an
anatomical specimen presenting the inferior turbinate (it), middle
turbinate (mt), superior turbinate (st) and supreme turbinate (sut).
the bony junction of the frontal process of the maxilla and posteriorly by the thinner
lacrimal bone (Fig. 3). Intranasally, the lacrimal sac lies an average of 8.8 mm above
the insertion of the middle turbinate. Its narrow lower end continues inferiorly into
the nasolacrimal duct (NLD). The NLD or tear duct initially travels in a posterolateral
direction within a bony nasolacrimal canal of the maxillary bone (a 12 mm long,
superior, intraosseus portion) before continuing 2 to 5 mm intranasally within the nasal
mucosa (inferior, membranous portion). The NLD opens up beneath the inferior nasal
turbinate into the inferior meatus, located approximately 15 mm above the nasal floor
and 4 to 6 mm posterior to the head of the inferior turbinate (Fig. 4). Inferiorly, the NLD
follows a posterior and slightly lateral course. A mucosal fold, the valve of Hasner, is
usually present at the nasal opening.
2.3 Anatomical Variations in the Lacrimal System

by Race and Gender
Nasolacrimal surgery demands knowledge on the variations in the bony and soft
tissue anatomy of the nasolacrimal system that arise from race and gender. Carter
and Gausas (2006) acknowledged differences in nasolacrimal canals of patients as
to dimensions, thickness of bones, and proximity to the surrounding ethmoidal air
cells. Accordingly, they emphasized the need for surgeons to give due consideration
to soft tissue inter-individual differences among patients. Furthermore, they noted
anatomical dissimilarities of the lacrimal system between men and women, and
among Caucasians, Asians, and black patients that are pertinent when discussing
endoscopic lacrimal surgery.
2.4 Dimensions of the Nasolacrimal Canal

Several studies have demonstrated a tendency for narrower and longer nasolacrimal
ducts in females, supporting higher incidences of involutional stenosis and making
them susceptible to nasolacrimal duct obstruction. Carter and Gausas also pointed
out this gender disparity with respect to the width and length of the nasolacrimal
canal containing the membranous nasolacrimal duct.
Racial variations were cited to explain the higher percentage of NLD obstruction
occuring among Caucasian patients opposed to patients of the Asian and black
races. The rationale behind such thinking being that Asian and black individuals have
shorter and wider nasolacrimal ducts that have lower tendencies to occlude.
3 Sagittal section. Maxillary bone (mb) and lacrimal sac (ls). 4 Endoscopic view of the nasolacrimal duct opening.
2.5 Thickness of the Lacrimal Bone

Asians and blacks clinically appear to possess lacrimal bones that are thicker
than those of white patients. During dacryocystorhinostomy on Finnish patients,
Hartikainen et al. measured a mean lacrimal bone thickness of 106 microns.
Taiwanese patients, however, were found by Lui et al. to have an average lacrimal
bone thickness of 5.8 mm ± 0.9 mm in males and 4.2 ± 0.8 mm in females. Though
more clinical studies are needed to substantiate these observations, the fact remains
that surgeons need to address such differences in order to anticipate necessary
variations in their surgical technique.
Carter and Gausas maintained that the adequacy of the body opening in lacrimal
surgery cannot be overemphasized. Routine instrumentation may suffice in order
to create large osteotomies in the papery lacrimal bones of white patients. The use
of adjunctive instruments such as drills must be anticipated, on the other hand, if
ample-sized osteotomies are to be achieved in the thicker bones of Asian and black
patients. The surgeon’s preference towards an external or endoscopic approach to
DCR will, likewise, be largely influenced by his/her awareness of such gender and
racial deviances in lacrimal bone anatomy.
Race and gender are not the only factors affecting the thickness of lacrimal bones.
Systemic conditions may contribute to bone alterations. The thickness and density of
the lacrimal bone correlated well with those of systemic bones, in a study by Hinton
et| al. Osteoporosis has been shown to be associated with thinner, low-density
lacrimal bones. Since the prevalence of osteoporosis leans more to women than to
men, then it follows that clinical studies have concluded that adequate osteotomies
are easier to create in women who are more prone to osteoporosis.
2.6 Soft Tissue Disparities

Several studies discuss that dissimilarities in skin thickness, presence or absence
of epicanthal folds, disparities in nasal projection, and other variations in external
soft tissues all figure in the selection of DCR technique. An endoscopic, intranasal
approach can do away with the external soft tissue scarring problems of external
DCR, but may be more difficult or even impossible to perform in the face of the thicker
lacrimal bone structure of Asian and black individuals.
2.7 Summary
The challenge to a lacrimal surgeon is not so much the perfection of technique, but
the conscious effort to anticipate possible variations in the patient’s lacrimal system.
Sufficient knowledge in racial, gender, and anatomical differences can determine the
course of a surgeon’s technique during a DCR surgery.
3.0 Evaluation of Patients with Epiphora

The management of patients with “wet eye” or epiphora cannot begin without an
initial, complete assessment of the external eye and eyelid. Careful inspection
should distinguish the cause of excessive tearing as either lacrimal hypersecretion
or mechanical occlusions to the drainage system and, thus, eliminate unnecessary
surgery or result in erroneous surgical procedures.
Dutton and White presented an excellent summary of external ocular signs that may
point to tear hypersecretion or reflex lacrimation as the primary reason for epiphora
including: medial canthal swelling, discharge, and erythema (acute dacryocystitis);
entropion and trichiasis (corneal irritation); ectropion with punctal eversion and/or
exposure keratitis (lid laxity of aging or seventh nerve palsy); and corneal pathologies
(erosions, ulceration, infections, retained foreign bodies) are possible reasons for
excess tearing.
Findings that support partial or complete occlusion at some point along the lacrimal
drainage include: punctal occlusion, punctal opposition, mass lesions near the medial
canthal area, mucopurulent reflux, nasal polyps, among others.
3.1 Schirmer Testing

Fundamental to the evaluation of dry eye or excessive tearing are the tests introduced
by Schirmer in 1903.
Schirmer I pays particular attention to the aqueous component of the tear film.
It is a gross measure of tear production at best, without indicating how much of
this is basic or reflex lacrimation. Before testing, effort is taken to ensure that the
patient’s eyes are dry by wiping away excess tears from the lid margins and palpebral
cul-de-sac. Filter paper strips measuring 50 mm x 5 mm (#41 Whatman strips), one for
each eye, are folded 5 mm from one end. The lower lid margin is pulled downwards
as the patient gazes upward. The folded end of the filter strip is positioned gently
into the exposed cul-de-sac at the junction of the middle and lateral thirds of the
lower lid margins taking care to avoid stimulating the cornea. After the filter paper
is positioned, the lower lid is released, and the patient is made to gaze forward and
blink at a normal rate. Exact techniques may vary (dim room or in ambient light; total
length of filter paper strip used; eyes gazing forward while blinking normally or eyes
closed). What remains consistent with all techniques is that the test is carried out for
5 minutes and on both eyes simultaneously. Results are interpreted as negative if
the filter paper strips show at least 10 mm of wetting, indicating a normal production
of tears. Schirmer I is the more commonly used test for dry eye syndrome, but the
inconsistencies in manner and time performed and persons doing the evaluation limit
its value to diagnosing severe cases of dry eye.
Disputes continue as to the use of topical anesthesia when performing Schirmer I
test. There are advocates who claim that Schirmer I test without topical anesthesia
measures both basic and reflex tearing, while adding a topical anesthetic drop will
limit the measure to just reflex lacrimation. Others contend that with or without topical
anesthetic, end results are too similar. Hence, Schirmer II test was devised to measure
reflex secretion of tears.
When Schirmer I test is positive (showing less than 10 mm of wetting), evaluation
can proceed to Schirmer II testing in a dimly illuminated room and topical anesthetic
(proparacaine 1%) drops instilled in both eyes. The patient keeps both eyes shut
for one minute, while the nasal mucosa is mechanically irritated with a cotton-tip
applicator or chemically with ammonium chloride. The steps for Schirmer I test are
then repeated. The difference in wetting between Schirmer I and II determines the
amount of reflex tear secretion under stress. Equal wetting in both tests point to
lack of reflex tearing. If Schirmer II results exceed Schirmer I wetting, then this may
indicate a total block in conjunctival efferent nerves (Dutton and White).
3.2 Rose Bengal Test

One percent Rose Bengal stain is a chloride-substituted iodinated fluorescein dye.
Not only does it stain dead and devitalized epithelial cells and keratin, it is capable of
staining epithelial cells that are insufficiently covered by tear film and mucin. Staining
can be seen even in early or mild conditions of dry eye, thus easily indicating
inadequate tear physiology in syndromes like keratoconjunctivitis sicca.
3.3 Tear Breakup Time (BUT)

Fluorescein Breakup Time (FBUT)
A normal tear film is continuously formed over the ocular surface, and maintained by
blinking. Tear breakup times vary depending on the integrity of the mucin layer. This
can be tested after touching a slightly moist flourescein strip to the lower palpebral
conjunctiva to stain the tear film. Utilizing the diffuse cobalt blue setting of the slit
lamp illumination, the patient is instructed to blink and keep the eyes open in primary
gaze. The length of time between the last blink and the appearance of the first dry
spot on the cornea is measured. Fluorescein Breakup Time (FBUT) is between 15
and 30 seconds. An underlying mucin deficiency and inadequate tear film stability is
consistent with BUT’s of 10 seconds and below. Such dry eye conditions may trigger
reflex hypersecretion of the aqueous component of the tear film resulting in epiphora.
3.4 Fluorescein Dye Disappearance Test

This is a simple way to qualitatively estimate the rate at which tears flow out of the
conjunctival sac. The tear films of both eyes are stained with fluorescein dye and
initially examined under slit lamp microscopy with cobalt blue light. The tear meniscus
in each eye is again examined in similar manner after 5 minutes and graded using a
scale from 0 to 4+ in terms of dye retention. A clear tear film or Grade 0 or a positive
test due to absence of any remaining dye is attributed to normal outflow in the lacrimal
system. Grade 4+ is given to eyes where all dye remains. This negative test can
indicate either an anatomical blockage (lacrimal outflow obstruction) or a functional
blockage (pump failure), but unfortunately cannot discriminate between the two.
3.5 Jones I Test

The anatomical and physiologic patency of the lacrimal drainage system may be
evaluated by confirming the actual passage of a vital dye through its length. This is
the principle behind the commonly used Jones tests (primary and secondary) in the
evaluation of patients presenting with epiphora.
The primary Jones (Jones I) test for physiologic patency must be carried out under
conditions that approximate the normal. The patient is seated upright during the test,
blinking at a normal rate, and does not receive surface ocular anesthesia. The nasal
mucosa, however, may be topically anesthesized to keep the patient comfortable
(Dutton and White). Fluorescein vital dye (2% solution) is instilled into the inferior
palpebral conjunctival fornices near the punctum and the patient is advised to
avoid rubbing the eye. After five minutes, the patient is made to occlude the nostril
opposite the eye being tested and to blow into white tissue. If fluorescein dye is not
grossly visible with this maneuver, repeat the test. This time, however, a cotton-tipped
applicator is inserted about 10 mm into the nose against the inferior turbinate, at the
level of the nasolacrimal duct ostium that opens 5 to 10 mm below the vault of the
anterior end of the nasal meatus. The applicator insertion is done at 2 and 5 minutes.
A positive Jones I test, where vital dye is recovered from the nose, indicates the
system’s anatomic patency and its probable normal function. Partial obstruction or
abnormal physiology, however, is not ruled out. Non-retrieval of the fluorescein dye, or
a negative Jones I test, may point to anatomic obstruction, physiologic dysfunction,
or a false negative test where lacrimal anatomy and physiology are still normal. Jones
I test is unable to single out the particular pathology involved.
3.6 Jones II Test

The secondary Jones test is done if the primary Jones test yields a negative result.
With the patient leaning forward, clear saline is irrigated into the nasolacrimal system
using a lacrimal cannula through the inferior punctum. The patient then expectorates
into a basin or blows his/her nose into white tissue. If clear irrigating fluid passes into
the nose, the nasolacrimal system is patent but may have functional blockage at the
level of the punctum or canaliculus since the vital dye failed to enter the nasolacrimal
system. Recovery of dye at the nose supports a functional blockage, usually distal to
the lacrimal sac, since the dye was able to enter the nasolacrimal system up to that
point.
Complete nasolacrimal duct obstruction results in reflux of irrigating saline with dye
through the upper punctum. The absence of dye in the fluid that backflows through
the upper punctum, however, is highly indicative of complete occlusion of the
common canaliculus.
3.7 Canalicular Probing

Probing of the puncta, canaliculi, and lacrimal sac is done to confirm the level of
obstruction. Topical anesthesia is instilled into the eye and a small probe is inserted
into the canaliculus. If blockage or stenosis is present, the probe is clamped at the
punctum to measure the distance of the obstruction in millimeters before withdrawal.
4.0 Basic Principles for Surgical Application

of Radiofrequency
4.1 Definition of Radiofrequency

A radiofrequency (RF) unit has become an indispensable tool for both primary care
and subspecialty physicians. Compared to traditional scalpel surgery, radiofrequency
or modern electrosurgery, as it is sometimes called, is increasingly gaining acceptance
in procedures and techniques employed in general surgery, otorhinolaryngology,
dermatology and gynecology. In the same way, it continues to gain a foothold as a
therapeutic tool in ophthalmic plastic and orbital surgeries (Pfenninger, 2003).
Drs. Harvey Cushing and William T. Bovie pioneered in the use of RF current in medical
practice as early as the 1920s, in that they used an electrosurgical device for tissue
incision and coagulation for surgery (Sung, 2000). Dr. Bovie, an eccentric physicist
and plant physiologist, developed a unique electrosurgical machine that was able to
pass alternating current of high frequencies through a human body in order to cut or
coagulate tissues. He collaborated with Dr. Cushing, the pioneer of neurosurgery in
America, thus introducing the Bovie electrosurgical unit for use in delicate surgical
procedures (O’Connor, 1996).
A typical RF unit usually comprises a transformer, an electrode and a ground plate.
Radiofrequency energy, modified by the transformer, essentially, travels from the
active electrode to the body tissues of a patient, then back to the machine via the
ground plate. Radiofrequency energy is a very high-frequency alternating current
(AC) that differs from either alternating current of low frequency or direct current.
The high-frequency radio waves flow from the conductor or active electrode into
the immediate surrounding space as electromagnetic waves. These radiofrequency
waves exert a “skin effect”. The AC energy is distributed close to the surface of an
active conductor. Application of RF energy to tissues at the target site of surgery
essentially induces superficial tissue alterations, with only minor spread of heat
in deeper levels or adjacent areas, thus limiting collateral thermal damage. The
current then travels back to the RF generator by way of dispersive electrodes in the
ground plate applied to the patient’s body. The heat generated in the tissues rises to
temperatures ranging from 60 to 1000º C, enough to induce cellular death resulting in
precise incisions, excisions, and/or tissue coagulation (Gupta, 2005).
In principle, radiosurgery is the passage of high-frequency radio waves ranging from
500 KHz to 4 MHz, from an “active electrode” (a thin tungsten wire) in a hand piece
through soft tissues, focused by a “passive electrode” (an insulated ground plate /
antenna plate) close to, but not necessarily in contact with, the patient (Aimino, 1999).
RF surgery differs from conventional electrosurgery with galvanic energy where
currents are delivered to the operative tissues using the patient’s body as a
conductor. Conversely, RF makes use of electrical energy, the generation of which is
based on a transmitter-receiver principle. Electrical energy, emitted by a flat antenna,
is concentrated at the apex of an electrical field, and then converged onto the tip
of a delivery electrode. From here, the current is distributed through the tissues at
the operative field without requiring an electrical conductor. There is an inverse
relationship between the intensity of the current applied and the distance between
the RF energy source and the tissues being surgically treated. When the tip of the RF
electrode is placed closer to the surgical field, then less electrical power is necessary
to produce a change in the tissues being treated (Vogt, 2007).
Radiofrequency Waveforms
Radiofrequency waves can be modified to either cut (excise), cut and coagulate
(blend), coagulate (produce hemostasis), or fulgurate (ablate) soft tissues by setting
a
the radiofrequency unit to deliver current at certain waveforms or intensities (Aimino,
1999).
An RF generator has a transformer that modifies the main voltage input into a
high-frequency, high-voltage alternating current. Four possible output waveforms are
produced by further filtering and rectification (Javate, 2006).
b
The first is a continuous high-frequency waveform dissipating the smallest amount
of lateral heat and effecting a micro-smooth pure cut (Fig. 5a). This fully-filtered,
fully-rectified, 90% cut + 10% coagulation waveform is preferred when the goal is to
produce tissue incisions with the least collateral tissue damage from spreading heat.
This waveform is used when cuts are made and bleeding is expected to be minimal
c (e.g. initial skin incisions, excision biopsies, tissue grafting, etc.) (Javate et al., 2006).
The continuous waveform is delivered from a fine-wire electrode to produce smooth
incisions similar to those created by cold-knife surgery (Older, 2002). Electrosection
refers to this cutting effect that avoids crushing pressure on surrounding tissues since
the passing radio waves generate enough heat in water molecules along its path,
d enough to volatize the cells along the way. What results is a precise split through soft
tissues (Javate, et al. 2006).
A fully rectified, modulated waveform is emitted with minute wave pulsation, resulting
in a less-effective electrosection or cut (Fig. 5b). Unlike the continuous waveform,
lateral heat is generated to a degree that is useful to promote hemostasis. This
waveform, when delivered with an electrode shaped like a large-diameter needle, is
e
appropriate for dissecting through subcutaneous tissues (Aimino, 1999). This blended
5 The various radiosurgery waveforms: (fully rectified 50% cut/ 50% coagulation) cut/coagulation waveform is ideal for
Fully Filtered (Cut) (a). Fully Rectified
(Cut/Coag) (b). Partially Rectified (Hemo) (c).
excising lesions or subcutaneous tissue dissection, since it blends the minimal tissue
Fulguration (d). Bipolar (e). injury of a pure cut with the coagulation needed for hemostasis. For instance, this
waveform can address the slight bleeding expected when working with lesions like
verrucae, nevi, papillomas, keratoses, skin tags, or keloids. It is especially helpful in
transconjunctival blepharoplasty (Javate et al., 2006).
When working with vascular soft tissue structures, hemostasis becomes a priority.
The surgery will require the partially rectified, modulated waveform (Fig. 5c). The
delivery of intermittent, high frequency waves with increased transmission of
lateral-spreading heat, affords the surgeon excellent hemostasis (Aimino, 1999). The
a b c d generation of coagulation currents is based on the principle of molecular oscillations
producing heat. This results in tissue dehydration and coagulation without volatizing
6 The various radiosurgery electrodes:
Round loop electrode (a). Fine wire cells (Javate et al., 2006). This direct/indirect, spot coagulation with minimal lateral
electrode (b). Vari-tip™ wire electrode (c). heat spread requires a partially rectified (10% cut/90% coagulation) waveform
Empire® electrode (d). to adequately control bleeding vessels up to 2 mm in diameter. This waveform is
appropriate when resecting orbicularis muscle and orbital fat in procedures such as
blepharoplasty, ptosis repair, correction of lid retractions, and lesion excisions (e.g.,
telangiectasias and spider veins). This is also used in external, Mini-Incision, and
endonasal DCR (Javate et al., 2006).
The fulguration or spark-gap waveform allows for rapid dessication and destruction
of tissues that the active electrode comes in contact with (Fig. 5d). The modified
electrical current causes limited tissue destruction through the insulating effect of
carbonized tissues and a space or air gap the spark must leap across. The spark-gap
waveform is most appropriate for fulguration purposes since it produces significant
lateral heat. It is useful when destruction and superficial hemostasis is required, e.g.,
when excising small lesions of basal cell carcinomas or cysts. This mechanism is
similar to unipolar diathermy using a Hyfrecator.
A 1.7 MHz bipolar waveform is preferred for wet-field cauterization, when precision
hemostasis is required, or when control of individual, microsurgical bleeders is critical
(Fig. 5e). The waveform specifically avoids adherence of tissues to the tip of forceps.
Electrodes in Radiosurgery
Radiofrequency procedures typically involve that the surgeon is faced with decisions
not only as to which waveform, but also which electrode type to use. The choice
of the appropriate electrode depends on the various lesions to be treated, surgical
procedures to be performed, degree of hemostasis needed, or the cosmetic
results desired. The selective use of a fine needle electrode, a wire-loop electrode,
a scalpel blade electrode or other types of electrodes will help deliver the correct
current while resulting in minimal tissue lateral damage, minimal scarring, and a faster,
cosmetically-acceptable healing (Fig. 6) (Javate et al., 2006).
When minimal scarring from a very fine skin incision is desired, for example, an
extra-fine Empire® electrode may be utilized. Excision of small lesions (as occuring
in eyelid areas) or excision biopsy for collecting specimens from bigger neoplasm
may call for the use of round-loop electrodes. Skin lesions raised above the base,
a
or pedunculated lesions may be excised using triangular or oval-loop electrodes.
Coagulation may necessitate the use of ball-type electrodes (Javate et al., 2006).
In Endoscopic Radiofrequency-Assisted Forehead (ERAF) lift procedures, Javate|et|al.
make use of the endoscopic forehead lift electrode. For endonasal DCR, Mini-Incision
DCR and standard external DCR procedures, the authors prefer the use of the Ellman
JAVATE DCR electrode (Javate et al., 1995).
5.0 Lacrimal Surgical Techniques
5.1 Endoscopic Radiofrequency-Assisted b
Dacryocystorhinostomy (ERA-DCR) 8 Endoscopic laser-assisted DCR using a

CO2 laser (a). Endoscopic laser-assisted
Standard external dacryocystorhinostomy (SE-DCR) has been the traditional mainstay DCR using a Potassium titanyl phosphate
among surgical approaches to nasolacrimal obstruction management for the past (KTP) laser (b).
millenium. This gold standard, however, is not without its disadvantages (Table| 1)
including cutaneous incisional scarring, potential injury to medial canthal structures,
cerebrospinal fluid rhinorrhea, functional interference with lacrimal pump physiology,
Table 1 Disadvantages of External DCR
postoperative morbidity including periorbital bruising, risk of copious hemorrhage,
and late DCR failure. Presence of a cutaneous scar.
®
Rigid 0º and 30º-HOPKINS rod-lens nasal endoscopes (Fig. 7) made endoscopic Potential for injury to medial canthal
DCR possible with direct visualization of the intranasal cavity (Shun-Shin and structures.
Thurairajan, 1997). Lasers later came into use for the endonasal approach (Hehar Cerebrospinal fluid rhinorrhea.
et al., 1997). Functional interference with the
Carbon dioxide (CO2) or Potassium titanyl phosphate (KTP) lasers for endoscopic physiological action of the lacrimal pump.
laser-assisted DCR have been described by Gonnering, Lyon and Fisher (Figs. 8a–b). Postoperative morbidity including
The limitations with laser-assisted procedures are primarily economic as they can periorbital bruising, risk of copious
make operative costs for lacrimal surgery prohibitive (Tables 2–3). hemorrhage and late DCR failure.
Table 2 Disadvantages of Laser-

Assisted DCR
Argon, KTP laser not designed for bone
removal
CO2 laser cumbersome, lack of a
fiberoptic delivery system
Ho:YAG laser requires adjunctive use of
0° a drill
Table 3 Disadvantages of External DCR

30°
Extensive technical support required
45° Cost of purchasing and maintaining the

laser has been prohibitive
®
7 KARL STORZ IMAGE1 Camera Control Unit (top), HOPKINS rod-lens nasal endoscope
(middle), available in various angles of view, 0°, 30° and 45° (left).
In 2005, Javate and Pamintuan described the Endoscopic Radiofrequency-Assisted

DCR (ERA-DCR) as an alternative to laser-assisted DCR (Fig. 9). This innovation
required commonly cost-effective instrumentation like curette, KERRISON punch,
FREER periosteal elevator, HOPKINS® endoscope, Ellman Surgitron Dual Frequency
Unit (Ellman International, Inc., 3333 Royal Avenue, Oceanside, NY, USA), and the
JAVATE DCR electrodes designed for the procedure (Figs. 10a–c) (Table 4).
In 1995, Javate, Campomanes et al. first reported use of a radiofrequency adjunct for
endonasal DCR yielding a surgical success rate of 90%. Since then, the original ERA-
DCR technique with the addition of double stenting using a Griffiths collar button
(Javate and Pamintuan, 2005) (Fig. 11a). The Griffiths collar button is a nasolacrimal
catheter designed to fit within the lacrimal fossa, while extending through the nasal
mucosa. The collar button has a 5-mm interflange distance and a 3-mm lumen.
The silicone tubes are made to run through the lumen of the catheter that is kept in
place for 5–6 months to ensure patency of the nasal ostium (Fig. 11b). The anterior
9 Endoscopic Radiofrequency-Assisted and posterior flanges have flat top configurations measuring 8 mm in diameter by
DCR (ERA-DCR). 0.5 mm in thickness that allow flexibility during the catheter placement and removal.
The flange virtually eliminates migration of the catheter either distally into the nasal
cavity or retrograde into the lacrimal sac (Javate and Pamintuan, 2005).
Table 4 Instrument Set for Endoscopic Radiofrequency-Assisted Dacryocystorhinostomy (ERA-DCR)

Headlight (KARL STORZ Tuttlingen, HOPKINS® Rhinoscopes 0° and 30° Bone curette
Germany) (KARL STORZ Tuttlingen, Germany) KERRISON punch
Bayonet forceps BLAKESLEY nasal forceps Crawford Bicanaliculus Intubation Set
Nasal speculum Aquagel (Parker Laboratories, Fairfield, NJ, (S1-1270u, FCI, 20–22 rue Louis Armand,
USA) 75015 Paris, France)
Cotton pledgets
Retinal light pipe Mitomycin (2 mg/mL solution)
Oxymetazoline HCl 0.05%
Ellman Surgitron Dual Frequency Unit Corneal eyeshields
Spinal anesthesia needle (Ellman International, Inc., 3333 Royal Griffiths collar button (Griffiths Nasal
Lidocaine solution 2% with 1:100,000 Avenue, Oceanside, NY, USA) Catheter No. 5206; Visitec)
epinephrine, lidocaine 4%, bupivacaine JAVATE DCR Ellman electrodes Collagen absorbable haemostat
0.75% Suction unit (KARL STORZ Tuttlingen, Suction cannula
Wydase®, (Hyaluronidase) Germany) with tip Endoscope lens anti-fogging agent
a b a b
c c
10 JAVATE DCR electrodes (a). Ellman Surgitron Dual RF S5 (Ellman 11 Griffiths collar button (a). Griffiths collar button with silicone tubes
International, Inc., 3333 Royal Avenue, Oceanside, NY, USA) (b). (b). Preoperative nasal packing (c).
JAVATE-PAMINTUAN ERA-DCR recommended instrument set (c).
5.1.1 Surgical Technique

The following is a detailed description of the JAVATE-PAMINTUAN surgical approach
for ERA-DCR. The nasal mucosa is initially sprayed with lidocaine 4% for surface
anesthesia and nasal packing with oxymetazoline HCl 0.05% soaked cotton pledgets
is done for vasoconstriction (Fig. 11c). A solution of 2% lidocaine with epinephrine
1:100,000 and 0.75% bupivacaine HCl is infiltrated into the nasal mucosa to achieve
regional nerve block (Figs. 12a–b).
The superior canaliculus is lubricated with antibiotic ointment, then dilated and
intubated with a 20-Gauge retinal light pipe (Fig. 13a). A rigid 0º- and/or 30º-
HOPKINS® endoscope (KARL STORZ Tuttlingen, Germany) is inserted through the
nose until the area anterior to the nasal turbinate is visualized through the video
camera. (Fig. 13b). When the tip of the light pipe is at the postero-inferior wall of the
lacrimal sac, it is fixed in place using sterile tape.
Endoscopic visualization is more precise when the illumination from the retinal light
pipe is regulated at minimum levels, just enough to focus a discrete area of light on
the point along the lateral nasal wall that is intended for rhinostomy. A malpositioned
light pipe casts a diffuse glow indicating that the light pipe is inadequately apposed
to the lacrimal bone.
b b
a a
12 Anesthetic infiltration under endoscopic guidance (a). Intranasal 13 Retinal light pipe insertion (a). Transillumination from the retinal light
endoscopic view (b). pipe (b).
The nasal mucosa at the endoscopically visualized rhinostomy area is anesthesized

with a lidocaine-bupivacaine-epinephrine mixture. Utilizing the Ellman JAVATE
electrode connected to an Ellman Surgitron unit, a mucosal incision measuring
20 mm is created (Figs. 14, 15a–b).
a b
14 JAVATE DCR electrode connected to an 15 Incising the nasal mucosa using a JAVATE DCR electrode (a–b).
Ellman Surgitron unit.
A FREER periosteal elevator is used to

lift the incised nasal mucosa off from the
underlying bone, followed by initial punc-
ture at the rhinostomy target area using a
curette (Figs. 16a–b).
a b
16 A FREER periosteal elevator is used to lift the incised nasal mucosa off (a) from the
underlying bone (b).
A KERRISON punch is used to place an

initial puncture in the target area of rhino-
stomy and to enlarge the ostium to a size
of 10 to 15 mm, making sure that the
rhinostomy includes part of the frontal
process of the maxilla (anterior lacrimal
crest) (Figs. 17a–b).
a b
17 A KERRISON punch is used to enlarge the osteotomy to a 10–15 mm sized ostium (a–b).
Indenting the sac wall using the retinal

light pipe facilitates the procedure to
ensure an incisional opening measuring
between 5 mm to 10 mm (Figs. 18a–b).
a b
18 Indenting the sac wall using the retinal light pipe (a–b).
Once the lacrimal sac is visualized, its

postero-inferior and antero-inferior walls
are incised with Ellman JAVATE DCR
electrodes (Figs. 19a–b). Occasions
arise when cicatrization may prevent
adequate identification and visualization
of the lacrimal sac. In these cases,
Aquagel (Parker Laboratories, Inc.,
Fairfield, NJ) may be injected through the
canaliculus in order to dilate the sac. This
is a precaution against accidental injury a b
to the common canaliculus when incising 19 Incision of postero-inferior and antero-inferior walls using JAVATE DCR electrodes (a–b).
through the sac walls.
The authors recommend shorter electrodes to incise through normal-sized or

enlarged lacrimal sacs. The longer electrodes are preferred for scarred, malformed
sacs. Should there be excess marginal lacrimal sac tissues, these may be excised
using BLAKESLEY nasal forceps (Fig. 20). The authors have found that the use of
Ellman JAVATE DCR electrodes and the BLAKESLEY nasal forceps in endoscopic
DCR gives the surgeon an option what laser DCR cannot: direct visualization and
biopsy of the lacrimal sac.
a b
20 Excision of excess marginal lacrimal sac 21 Mitomycin-C 2 mg/vial (a). Cotton balls soaked in mitomycin-C (0.5 mg/mL) are applied
tissues using BLAKESLEY nasal forceps. over the underlying mucosa for 3 minutes (b).
a b c
22 Crawford Bicanaliculus Intubation Set (S1-1270u, Bicanalicular silicone intubation through the The guidewire tip has been passed through the
FCI, 20–22 rue Louis Armand, 75015 Paris, France). superior and inferior canaliculi. intranasal ostium.
a b
23 Probes of the bicanalicular tubes are The positioned Griffiths collar button with 24 Lacrimal irrigation around the silicone
inserted through the central lumen of the silicone tubes in place. stent.
Griffiths collar button.
Once the surgeon decides that the nasal mucosa, rhinostomy and lacrimal sac
incisions are of ample measure, cotton balls soaked in mitomycin (0.5 mg/mL) are
applied over the underlying mucosa for 3 minutes with the goal of preventing scarring
from overactive fibroblastic proliferation (Figs. 21a–b). Measures must then be taken
to aggressively wash off all mitomycin from the operative site with generous irrigation
using sterile saline solution.
A Crawford Bicanaliculus Intubation Set (S1-1270u, FCI, 20–22 rue Louis Armand,
75015 Paris, France) is utilized for bicanalicular silicone intubation of the nasolacrimal
fistula (Figs. 22a–c).
The probes of the canalicular tubes are inserted through the central lumen of the
Griffiths collar button (Griffiths Nasal Catheter No. 5206; Visitec) after which the
catheter is pushed superiorly through the nostril and positioned with alligator forceps
or a curette to ensure that its flanges straddle the bony ostium (Figs. 23a–b). The
tubes are finally secured with two square knots, fixed by a 5-0 silk suture, and cut to
appropriate lengths within the nose.
Lacrimal irrigation around the silicone stent is done under endoscopic view to ensure
intra-operative patency of the fistula (Fig. 24).
The average length for the ERA-DCR cases that the authors performed ranged from
35 to 40 minutes.
5.1.2 Postoperative Care

Operative and postoperative bleeding can be controlled by positioning oxidized
regenerated cellulose at the tip of the middle turbinate using bayonet forceps. The
cellulose absorbs spontaneously (Fig. 25).
The authors’ medical postoperative regimen comprises the following: ofloxacin
ophthalmic solution (Inoflox, Santen Pharmaceutical Co. Ltd, Osaka, Japan), applied
four times daily; thrice daily nasal irrigation with saline; finally, fluticasone proprionate
nasal spraying beginning on the first day following surgery.
Patient follow-up is scheduled on the first postoperative day and on the first, second,
and third postoperative weeks. For each follow-up visit, the patient undergoes
lacrimal irrigation and removal of any residual nasal debris. Likewise, the intranasal
ostium is examined endoscopically (Figs. 26a–b).
The Griffiths collar button is removed on the second or third month following surgery
or until the scarring process around the catheter is endoscopically confirmed to be
complete (Fig. 27). Removal of this catheter is a relatively easy office-procedure.
The lacrimal stent must be kept in place for 6 months postoperatively (Fig. 28).
Premature removal of the stent might spell DCR failure caused by canalicular system
closure.
For their series of patients, the authors reported a postoperative follow-up length
ranging 12 to 80 months. Success rates were reported at 98% (110 out of 112
Table 5 An operation is defined as
patients).
success if:
Preoperative epiphora has resolved. 5.1.3 Discussion: ERA-DCR versus External DCR
Nasolacrimal patency as confirmed by
lacrimal irrigation. The ERA-DCR is deemed successful when the following are confirmed during
patient follow-up: resolution of preoperative epiphora, restored nasolacrimal
Endoscopic observation of fluorescein
patency confirmed by lacrimal irrigation under endoscopic observation at one-year
dye flowing through the surgical ostium
postoperative visit; and endoscopic visualization of fluorescein dye flow from the tear
on lacrimal irrigation.
meniscus into the nose (Fig. 29) (Table 5).
a b
®
25 Oxidized regenerated cellulose 26 Postoperative follow-up using a rigid HOPKINS endoscope to 27 The Griffiths collar button is
placed at the tip of the middle visualize the intranasal ostium (a). Endoscopic view one week removed on the second or third
turbinate using bayonet forceps. postoperatively (b). month following surgery.
Tear Lacrimal Nasal Tear Dilated Nose

lake sac space lake lacrimal sac
1st 2nd 2nd
3rd
Backwash Small
of debris rhinostomy
28 Intranasal ostium after stent 29 Patency of the intranasal 30 The lacrimal paradox. 31 Backwash of fluid debris
removal. ostium is confirmed with from the residual second
irrigation of fluorescein dye under compartment – the lacrimal sac.
endoscopic visualization at one
year postsurgery.
Advocates of endoscopic DCR give value to the absence of external cutaneous

Table 6 Advantages of Endonasal DCR
scarring. An added plus is the greater ability to curb injury to the nasolacrimal fistula
(Table|6). On the other hand, some surgeons remain skeptical about the long-term Avoidance of a cutaneous incision and
patency following endonasal DCR since it does not emphasize the need for formal scar.
mucosal flaps and it results in smaller rhinostomies. Limitation of tissue injury to the site of
In standard external DCR, the nasal mucosa is sutured to the lacrimal sac mucosa the nasolacrimal duct.
to encourage healing by primary intention. These sutured mucosal flaps serve as Decreased intraoperative hemorrhage.
scaffolds upon which a new epithelium-lined passage forms for the smooth egress Decreased postoperative morbidity and
of tears. enhanced recovery.
As opposed to this, endonasal DCR has been found to encourage greater
postoperative fibrosis due to tissue healing by secondary intention. Reported lower
success rates in endonasal DCR may have resulted from such reasoning. For instance,
healing around the osteotomy site has been associated with endoscopic evidence
of fibrous tissue scarring and granulation. These same healing characteristics may
encourage adhesion of the osteotomy to the turbinates and septum. Common
canalicular obstruction is also a possibility.
Dr. Geoffrey Rose elucidated on the “lacrimal paradox” to clarify the drawbacks from
a smaller rhinostomy following endonasal DCR (Fig. 30). Creating a smaller-diameter
fistula to connect the lacrimals to the nasal space produces persistent volume
symptoms explained by the backwash of fluid debris from the residual second
compartment – the lacrimal sac (Fig. 31).
Therefore, for endonasal DCR to achieve better results, it requires a wider channel
from the lacrimal sac to the nasal cavity by eliminating the sac and eliminating volume
signs and symptoms. The original anatomy described as a three-compartment
hydraulic system is essentially rearranged into a two-compartment system (Fig. 32). Table 7 Griffiths collar button prevents
In such cases, wide soft tissue anastomosis can be assured when a large osteotomy, Progressive cicatricial closure of the
anterior ethmoidectomy, and sutured mucosal flaps are incorporated into dacryo- ostium
cystorhinostomy. Development of adhesions between the
The complications of ERA-DCR with Griffiths collar button were reported as: tissue ostium and the middle turbinate
granulation (sometimes visualized at the intranasal ostium, but not necessarily Formation of synechiae between the
indicating occlusion of the ostium) (Fig. 33) ; and, nasal mucosa that migrates to ostium and the nasal septum
cover the distal flange of the Griffiths collar button (Fig. 34).
The Griffiths collar button has been shown to improve the success rate of ERA-
DCR to 98% (Javate and Pamintuan, 2005). This catheter appears to function as
an impediment to: progressive ostium occlusion by cicatrization, ostium adhesion
to the middle turbinate; synechiae formation between the ostium and nasal septum
(Table|7). In DCR procedures where mucosal flaps are not fashioned, a Griffiths collar
button straddling the rhinostomy site for a few months postoperatively replaces the
absent mucosal flaps to serve as the scaffold upon the new epithelium-lined channel
is formed.
Tear Nasal space

lake and former lacrimal sac
1st
3rd
32 The original anatomy, 33 Granulation tissue at the 34 Migration of the nasal

described as a three- edge of the Griffiths collar mucosa over the distal
compartment hydraulic system button (arrow). flange of the Griffiths collar
is rearranged into a two- button.
compartment system.
The postoperative care after standared external DCR is relatively routine: 3 to 4

Table 8 The increased success rate of
follow-up visits that require removal of the skin sutures, and eventually, the silicone
ERA-DCR can be attributed to
tubes on the last visit. Endonasal DCR, in comparison, needs a more demanding
Additional modification in the surgical postoperative regimen: frequent follow-up visits during which mucus and debris at
technique. the rhinostomy are cleansed when indicated. Besides endonasal debridement, the
Proper instrumentation. edges of the distal flange of the Griffiths collar button must be mobilized to disallow
Mastery of surgical details. nasal mucosal migration over the flange. Again, for each follow-up visit, endoscopic
visualization is required.
Careful postoperative follow-up.
Mitomycin-C as adjunct in endonasal DCR to ensure rhinostomy patency was
described by Bousch et al. in 1994. Mitomycin-C has been reported to push
endonasal DCR success rates up to 99.2% in a study done by Camara|et |al. The
same was used in earlier reports on ERA-DCR to modify healing at the rhinostomy
by inhibiting fibroblastic proliferation and scarring that would otherwise result in
rhinostomy occlusion.
It is generally agreed that smaller rhinostomies created during DCR result in a smaller
healed ostium, making the “sump” syndrome likely due to poorly draining remnants
of the lacrimal sac. Interest has recently surfaced, however, in “inferior” or “terminal”
endonasal DCR. This creates a relatively small ostium at the point where the lacrimal
sac meets with the nasolacrimal duct, thereby decreasing the occurrence of lacrimal
sump syndrome. With a KERRISON punch, an area of underlying bone and frontal
maxillary process measuring 8 to 10 mm in diameter, is removed, creating a bony
opening sufficient in size for the proximal flange of the Griffiths collar button to be
inserted.
5.2 Mini-Incision Dacryocystorhinotomy

Standard external DCR usually begins with a cutaneous incision made along the
lateral nasal wall. The incision is a relatively vertical, straight cut that usually leaves
insignificant deformity or scarring in older patients. More overt blemishes can result in
the thicker nasal skin of younger patients with vigorous healing mechanisms that may
explain more visible scarring (Figs. 35a–b).
Harris, Sakol and Beatty, in 1989, introduced their modification to the cutaneous
incision. They incised through the lower eyelid crease incision creating a cut 12 to
15 mm long, positioned about 4 mm below the lid margin, and extending to the nasal
end of the eyelid. As this incision runs along the periorbital relaxed skin tension lines,
a
the cutaneous scarring was reported to be relatively inconspicuous.
In 2001, however, Javate et al. presented their modification to the Harris, Sakol
and Beatty incisional technique which resulted in better cosmetic results. This
modification involves the use of the Ellman-JAVATE DCR electrode attached to the
Ellman Surgitron® Dual RF S5 Unit (Ellman International, Inc., 3333 Royal Avenue,
Oceanside, NY, USA) set in cut mode, and a skin incision is defined measuring
b 8–10 mm in length, positioned about 7–8 mm below the lower lid margin. The
authors reported less incisional scarring with this incision as compared to one set at
35 Visible scars 6 months after standard 3–4 mm beneath the lower lid margin, the latter being prone to ectropion from wound
external DCR.
contracture. More scarring is noted also from orbital fat prolapse seen in incisions
made just above the orbital septum. The radiofrequency electrode used for skin
incision has an added purpose of controlling hemorrhage, preventing obscuration of
tissue anatomy or poor healing incisions postoperatively. The Mini-Incision offers less
postoperative painful inflammation, ease with spectacle wear, and less downtime.
5.2.1 The Surgical Techniques involved in Mini-Incision DCR
Preoperative Preparation and Anesthesia

Mini-Incision DCR may be performed under local or general anesthesia, based on
patient age, medical condition, or personal preference. The authors perform anterior
ethmoidal and infraorbital nerve blocks with a local anesthetic concoction of lidocaine
HCl 2% + bupivacaine 0.75% + epinephrine 1:200,000 solution. Additional anesthesia
is infiltrated subcutaneously at the skin incision.
The cornea is protected with a contact lens. Cotton pledgets soaked in a mixture of
oxymetazoline HCl 0.05% and lidocaine HCl 4% are applied to the nasal mucosa
anterior to the middle turbinate to induce vasoconstriction.
Skin Incision
The cutaneous incision in Mini-Incision DCR measures 8 to 10 mm long, located 7 to
8 mm below the margin of the lower eyelid (Fig. 36). It starts at the level of the anterior
lacrimal crest slightly below the medial canthal tendon and continues in a lateral-
horizontal fashion in a slight downward slope to merge into the first lower lid crease
(Fig. 37). The incision essentially follows the periorbital relaxed skin tension lines to
help reduce the chances for bowstringing and postoperative scarring (Fig.|38). The
wound position is ideal for postoperative, comfortable wear of eyeglasses, if required.
Prior to actual cutting, lidocaine HCl 2% with epinephrine 1:200,000 dilution is
injected subcutaneously with a 30-Gauge needle for anesthesia and hemostasis
(Fig.|39). The skin is incised with an RF electrode and the underlying fiber bundles of
36 Skin marking 7–8 mm below the lower lid
the orbicularis muscle are separated with blunt-tipped scissors until the anterior bony margin.
lacrimal crest is reached. Careful effort should be taken to identify the angular vessels
and gently pull them aside with a rake retractor. In case the angular vessels have been
traumatized, rapid hemostasis may be achieved by touching the RF electrodes to
the fine forceps holding the bleeding points (Fig. 40). Postoperative ecchymosis and
bruising can be avoided.
The DCR electrode is next used to incise the periosteum along the anterior lacrimal
crest. The incision should start in close proximity to the insertion of the medial canthal
tendon which must be preserved to maintain the surgeon’s bearing on structure and
anatomy of the tendon (Fig. 41). This will prevent otherwise unavoidable manipulation
beyond the necessary boundaries, thus reducing the risk of causing iatrogenic
cerebrospinal fluid leakage. With a FREER periosteal elevator (KARL STORZ
Tuttlingen, Germany) the periosteum is reflected off the crest down to the lacrimal
fossa in order to maximize exposure of the lacrimal sac (Fig. 42). The periosteum
anterior to the incision line should be kept intact; accidental excision of this portion
during bone removal can be avoided by elevating this portion a few millimeters, again,
37 Skin incision using finewire Ellman
with the FREER elevator. electrode in the cut mode.
38 Periorbital relaxed skin tension lines 39 Lidocaine HCl 2% with epinephrine 40 Hemostasis is achieved by touching the
(RSTL). 1:200,000 dilution, is injected fine forceps holding the bleeding points
subcutaneously with a 30-Gauge needle with the RF electrode.
for anesthesia and hemostasis.
41 The periosteum is incised with the RF 42 The periosteum is reflected off the
electrode. anterior lacrimal crest down to the
lacrimal fossa with a FREER periosteal
elevator to maximize exposure of the
lacrimal sac.
Osteotomy
The osteotomy is started with the FREER periosteal elevator after exposing the nasal
mucosa overlying the area of the lacrimal bone lying beneath the lacrimal maxillary
suture. A blunt instrument like the FREER elevator is sufficient to puncture this
papery-thin area of bone with. It is a simple, painless technique minus the noise from
drills, saws or trephines that can be daunting to a conscious patient undergoing DCR
with local anesthesia. Following the initial puncture, a KERRISON punch inserted
between the nasal mucosa and the maxillary frontal process is utilized to create a
15 mm x 15 mm osteotomy (Fig. 43). The osteotomy is positioned making certain that
the common internal punctum lies within the central portion (at least 5 mm from the
edge) of the bony window instead of near the edge. The boundaries of the osteotomy
43 A KERRISON punch, inserted between are: anteriorly, 5 mm anterior to the anterior lacrimal crest; posteriorly, to the posterior
the nasal mucosa and the maxillary
frontal process, is utilized to create a lacrimal crest; inferiorly, to the curve of the crest where it merges with the inferior
15 mm x 15 mm osteotomy. orbital margin; and superiorly, to the sac fundus or the level below the reflected part
of the medial canthal tendon.
It is important that the osteotomy dimensions be 15 mm x 15 mm, even if the
remaining intranasal septum heals to a small size. The osteotomy should be large
enough to allow easy mobilization and approximation of the mucosal flaps.
Bleeding may be controlled by application of oxymetazoline HCl 0.05% with cotton
pledgets, or by infiltration anesthesia to cause nasal mucosal blanching.
Lacrimal Sac Flaps

Lacrimal sac flaps must be created before attempting to fashion the flaps on the side
of the nasal mucosa. The size and shape of the resulting sac flaps are needed to help
decide on how the flaps on the side of the nasal mucosa should be made.
44 Tenting of the sac with a Bowman probe

The following steps describe the creation of lacrimal sac flaps. A Bowman probe
(No. 00). (No.|00) is passed through the superior canaliculus until its tip indents the lacrimal sac
(Fig. 44). The indentation indicates the point of where a stab incision is made into the
sac using a sickle knife (No. 12 blade) or Beaver knife (No. 15 blade) (Fig. 45). Then, a
Jameson muscle hook is inserted into the cavity of the sac, its end guided toward the
point where the sac and nasolacrimal duct join (Fig. 46). The muscle hook lifts both
the inner mucosa and loose outer covering of the lacrimal sac, and guides the incising
blade from the fundus of the sac to the nasolacrimal duct (Fig. 47). Using the muscle
hook is a technique the authors found to be helpful in guiding the sickle or beaver
blade from the sac fundus to the nasolacrimal duct junction. This ensures that the sac
incision is full thickness and follows a proper orientation.
After the initial longitudinal incision has been completed, H-shaped lacrimal sac flaps
are created using vertical incisions on either end of the first cut.
When the lacrimal sacs are cicatrized or difficult to delineate, it is dilated with
viscoelastic substance in order to facilitate incising through its wall without damaging
the nearby common canaliculus.
45 A stab incision is made into the sac using
a sickle knife.
46 A Jameson muscle hook is inserted into 47 The muscle hook lifts both the inner 48 Infiltration of anesthetic solution into the
the lumen of the sac. mucosa and loose outer covering of the nasal mucosa.
lacrimal sac, and guides the incising blade
from the fundus of the sac to the nasolacrimal
duct.
Nasal Mucosal Flaps

Elaborate fashioning of the resultant lacrimal sac flaps, as described in the preceding
step, will help the surgeon determine the best dimension and configuration for the
flaps to be created on the nasal mucosa. The lacrimal sac, should ideally contribute
to both anterior and posterior flaps, that should anastomose to corresponding flaps
from the nasal mucosa. If, however, the lacrimal sac is inadequate in size, cicatrized
or friable from chronic inflammation, or damaged during the course of surgery, then
this may not be possible. The nasal mucosa, should provide adequately-sized flaps
to make up for the sacs’ limitations. This explains why nasal mucosal flaps are dealt
with only after sac flaps have been fashioned.
The Ellman radiofrequency unit is set to cut and coagulation mode to make nasal
49 Using the electrode the nasal mucosa is
mucosal incisions more precise and to minimize hemorrhaging during flap creation. incisesd to create H-shaped flaps that
Prior infiltration of anesthetic solution into the mucosa helps improve hemostasis mimic and complement the lacrimal sac flaps.
(Fig.| 48). The electrode incises the nasal mucosa to produce H-shaped flaps that
mimic and complement the lacrimal sac flaps (Fig. 49). When lacrimal sacs are
scarred or damaged, the surgeon may opt to enlarge the osteotomy anteriorly to
provide greater access to the nasal mucosa to form adequately-sized flaps.
When the lacrimal sac flaps (both anterior and posterior) are adequate in size, then
standard H-shaped nasal mucosal flaps are made. If, however there is an ample
anterior sac flap, but insufficient posterior flap from the sac, then the nasal mucosa is
incised to create an inverted U-shaped nasal flap resulting in a larger posterior mucosal
flap. On the other hand, a smaller anterior sac flap should be complemented by a
larger anterior flap from the nasal side which is accomplished by using a U-shaped
incision through the nasal mucosa. All incisions are created using the Ellman-JAVATE
DCR electrode attached to an Ellman Surgitron unit.
Once the nasal flaps are completed, the nasal packing is retrieved from the nostril
with a bayonet forceps. 50 The posterior flaps of the lacrimal sac and
nasal mucosa are apposed with one or
two interrupted sutures using 6-0 polyglactin
Anastomosis of the Posterior Flaps sutures (Vicryl).
The posterior flaps of the sac and nasal mucosa are apposed with one or two
interrupted sutures using 6-0 polyglactin sutures (Vicryl) (Fig. 50). The suture is set
in place with a backhand throw from the lacrimal sac to the nasal mucosal posterior
flap.
Silicone Intubation
Once the posterior flap is prepared, a bicanalicular silicone tube (Crawford
Bicanaliculus Intubation Set, S1-1270u, FCI, 20–22 rue Louis Armand, 75015 Paris,
France) is needed to intubate the nasolacrimal fistulae (Figs. 51a–d). The ends of the
tube are secured in place by a series of two square knots followed by silk 5-0 sutures;
after which, the ends are trimmed to appropriate length without extending beyond the
nose orifices.
a b c d
51 Bicanalicular intubation (Crawford Bicanaliculus Intubation Set, Stent retrieval using a Crawford Silicone tubes emerging from the
S1-1270u, FCI, 20–22 rue Louis Armand, 75015 Paris, France) (a–b). hook. common internal punctum.
Anastomosis of the Anterior Flaps

Anastomosis of the anterior flaps created from the nasal mucosa and the lacrimal sac
is performed using 5-0 polygalactin sutures (Vicryl) (Fig. 52). A continuous running
suture is placed, running from the inferior end of the flap up to its superior end, then on
to the overlying orbicularis oculi muscle fibers that are intended to anchor the anterior
flaps as this layer is closed. This way, the newly fashioned lacrimal drainage conduit
is prevented from collapsing. Local hemostasis in the muscular and subcutaneous
layers is again achieved using the Ellman Surgitron unit to control postoperative
periorbital ecchymosis, while carefully sparing the skin.
Skin Closure
52 Anastomosis of the anterior flaps created
from the nasal mucosa and the lacrimal A 6-0 nylon suture is used for closure of the skin incision using either continuous
sac, is performed using 5-0 polyglactin running or subcuticular suturing (Fig. 53). Since the sutured skin incision follows the
sutures (Vicryl). relaxed skin tension lines, patients of all ages are less prone to develop cosmetically
unattractive surface scars. Eyeglass wearers are not bothered by scars when the
frames touch the skin.
The radiosurgery unit is highly effective at providing good hemostasis, optimal
visualization, and helps to reduce recovery periods for the patients.
5.2.2 Postoperative Care in Mini-Incision DCR

The patient’s incisional wound is covered with a light, sterile patch for 24 hours. An ice
compress is applied continuously over the operative site for 48 hours post-surgery.
Debris and blood from the nose are collected by light nasal gauze packs positioned
at the floor of the nose, away from the osteotomy, for 24 hours. Oral antibiotics and
topical ophthalmic antibiotic solutions are prescribed for 7 to 14 days. On the 3rd to
12th postoperative month, silicone tubes are removed on a case-to-case basis.
5.2.3 Discussion
In order to assess functional and aesthetic outcomes of Mini-Incision DCR, the
authors conducted an efficiency review which included the patients’ subjective
perceptions in terms of relief of preoperative symptoms of NLD obstruction, and
involved videoendescopic evaluation of anatomic patency of the lacrimal drainage
system. A videoendescopic unit was used prior to and after removal of the silicone
tubes at either 3 or 6 months following DCR surgery. Postoperative drainage function
of the lacrimal duct system was assessed by irrigation under endoscopic vision
confirming its anatomic patency.
Operative outcome is assessed using a videoendoscopic unit before and after removal
of the silicone tubes (at 3 to 6 months postoperatively). When the preoperative signs
and symptoms from nasolacrimal obstruction are alleviated following the surgery,
then the procedure is considered successful. Anatomic patency of the tear drainage
systems is confirmed by lacrimal irrigation viewed endoscopically.
a b c
53 A 6-0 prolene suture is used for skin 54 Postoperative Two months post-surgery (b–c).
closure either in continuous running or photograph one day
subcuticular fashion. after Mini-Incision DCR.
Using these criteria, the authors’ surgeries were successful in 98% of cases, bringing
long-term relief from watery eye. Such rates are comparable with the 80% to 99%
success rate attributed to standard external dacryocystorhinostomy (SE-DCR).
Aside from the very high success rates, the Mini-Incision DCR technique significantly
diminishes bowstringing and postoprerative scarring. Residual scarring at the incisional
wound site was minimal and hardly noticeable following the procedure (Figs. 54 a–c).
5.2.4 Endoscopic Follow-up Documentation after Mini-Incision DCR

Postoperative healing of the intranasal ostium following Mini-Incision DCR can be
properly documented with endoscopic imaging during postoperative follow-up of
patients. An unpublished study by Drs. Subhyakto, Javate, et al. was conducted
on 21 patients who underwent Mini-Incision DCR from 2003 to 2006 for complete
NLD obstruction. Osteotomy healing in all patients was documented by endoscopic
videography and imaging. The observations showed that wound healing in the
osteotomy is most rapid during the first 4 weeks post-operation, then gradually
becomes stable.
The following is a collection of still images captured during videoendoscopic
Mini-Incision DCR and on different postoperative days.
th
55 Intra-operative view: note large 56 36 postoperative day. 57 Two months and 13 days 58 Three months postoperatively:
flaps measuring 10 x 15 mm postoperatively. ostium with a 2-mm cross-
and the bicanalicular silicone tubes sectional diameter; wound appears
coming from the common internal healed; no evidence of infection.
punctum.
59 Four months and 2 days 60 Four months and 2 days 61 Five months postoperatively. 62 Five months postoperatively.
postoperatively. postoperatively.
63 Six months postoperatively. 64 Seven months postoperatively. 65 One year and 6 months 66 Eleven years postoperatively.
postoperatively.
5.3 Endoscopic Lacrimal Duct Recanalization (ELDR)

The success of any surgical procedure is considerably improved when the surgeon
is able to directly visualize structures within the operative field. Before technological
advances in surgery surfaced, the surgeon’s operative perspective was limited to
gross anatomy. However, with the emergence of endoscopes, video signal display
and recording devices, operative magnifying lenses, and similar instrumentation,
surgeons are empowered to better visualize anatomical areas in greater detail and
to perform surgical maneuvers that cause minimal trauma to surrounding tissues,
targeting only those structures that need to be included in operative treatment.
These innovative developments have given birth to procedures such as balloon
angioplasty, and now even lacrimal duct recanalization procedures. The level of
difficulty inherent in these two procedures may be significantly different, and the
gravity of their medical indications may be worlds apart. Yet, these seemingly
unrelated procedures are similar in their goals to relieve obstructions or to create
passages that reroute or bypass obstructions.
Endoscopic dacryoplasty (ELDR using a microendoscope), a minimally invasive
approach to lacrimal system outflow problems, is now possible. Lacrimal surgery
that addresses the occluded ducts with minimal trauma to surrounding tissues can
be performed using miniature telescopes (microendoscopes). The lacrimal duct is
directly visualized by lacrimal endoscopy or dacryoendoscopy, proceeding from the
upper lacrimal punctum to the point where the nasolacrimal duct exits in the inferior
nasal meatus.
The first applied research in lacrimal system endoscopy was performed by Ebran,
Maigret and Bechetoille in 1989. A one-millimeter diameter metal tube catheter
was placed within the inferior canaliculus allowing soft fiberoptic endoscopes to
be introduced directly into the tubes. Hard and soft endoscopes were tried in both
cadavers and then in live DCR patients. Microendoscopy was also described by
Kuchar, Novak and colleagues in 1997. They successfully recanalized presaccal
stenoses using a flexible endoscope and an Erbium:YAG laser to address upper,
lower and common canalicular stenoses. Emmerich, Luchtenberg and colleagues
also performed studies in therapeutic dacryoendoscopy. It was Piffaretti, however,
who had a key impact on the development of endoscopic instrumentation for
diagnostic and therapeutic applications in lacrimal system problems as early as 1993.
In more recent years, Valazzi|et al. have stepped up the development of dedicated
endoscopic equipment to further refine lacrimal microendoscopy. More and more
surgeons have taken interest in perfecting the technique.
Described, hereafter, is the technique adapted by Javate et al. in endoscopic
dacryoplasty for restoration of lacrimal outflow system patency.
5.3.1 Proper Selection of Patients

The endoscopic dacryoplasty procedure detailed below is recommended for
recanalizing lacrimal canaliculi or nasolacrimal ducts in:
Complete or partial primary acquired nasolacrimal duct obstruction (PANDO);
and
Canalicular stenoses.
However, patients with the following conditions are not considered good candidates
for the endoscopic technique:
Presence of bony alteration, such as post-traumatic bony deformity or previous
fractures, which can inhibit the recanalization of the nasolacrimal duct;
Mucocele of the lacrimal sac, because plastic surgery of the sac wall cannot be
performed via an endoscopic approach;
History of acute dacryocystitis or conditions that result in a dilated sac, which
has lost its fibroelastic resiliency.
5.3.2 Anatomic Consideration

A prime advantage of microendoscopy is precise localization of obstructions within
the lacrimal drainage system and its mucous membranes. This affords the surgeon’s
direct visualization of conditions along the lacrimal tract, and aids in the subsequent
planning of surgical treatment.
Observing the color and consistency of the mucosal lining along the system, for a b
example, can help the surgeon to determine the status of a canal and possible
67 Unobstructed lumen of the canaliculus
causes of its obstruction. A normal canal and tract lumen should be lined by smooth, (a–b).
light pink healthy mucosa (Figs. 67a–b). A partially stenotic tract is characterized
by a narrow lumen that enlarges with irrigation and presents with whitish-grey,
inelastic membranes in the lacrimal sac and duct. Endoscopy can precisely locate
the obstructed site, which commonly occurs in the nasolacrimal duct (Figs. 68a–b).
Submucosal folds at this area are thick, grey strictures. Endoscopy helps the surgeon
to determine on the spot whether an obstruction is caused by stenosis along the
tract or by debris and mucosal secretions. The latter are easily removed in the same
a b
session. Complete stenosis of the tract is supported by the presence of fibrotic
plaques and whitish-grey inelastic membranes (Figs. 69a–b). 68 Partial obstruction, sac-duct junction
(a–b).
5.3.3 Operating Room Set-Up

The authors use a microendoscope (0°-Miniature Straight Forward Telescope with
incorporated high-resolution fiberoptic bundle (10,000 pixels), 110°-field of view and
0.65 to 0.85 mm outside diameter; KARL STORZ Tuttlingen, Germany). The micro-
endoscope, which is coupled to a 10-cc syringe and an extension suction tube
(Fig.|70), is connected to a xenon cold light source (XENON NOVA® 175) 175 Watt, a b
emitting white light with a constant color temperature of 6000 K (Fig.|71) and to a
69 Complete obstruction, sac-duct junction
KARL STORZ IMAGE1™ H3, three-Chip HD Camera Head (Fig. 72, 햲). The camera (a–b).
head is connected to an IMAGE1™ HD hub Camera Control Unit (CCU) (Fig.|72,|햳).
As an alternative option, obviating the use of the 10-cc syringe, a flow-regulated roller
pump (ENDOMAT® LC) may be connected to the silicone tubing for irrigation (Fig. 73)
(Table|9, parts A–C).
70 The microendoscope is connected to a

10-cc syringe and an extension suction
tube.
® ™
71 Xenon cold light source (XENON NOVA 72 IMAGE1 H3, three-Chip HD Camera 73 ENDOMAT LC (KARL STORZ Tuttlingen,
175 watt) emitting white light with a Head|햲, and IMAGE1™ HD hub Camera Germany).
constant color temperature of 6000 K. Control Unit 햳, (KARL STORZ Tuttlingen,
Germany).
The JAVATE Lacrimal Trephine, (KARL STORZ Tuttlingen, Germany) presented in this
procedure has been designed with a conical tip, thus, allowing it to be maneuvered
within the nasolacrimal lumen without causing iatrogenic injury to the mucosal lining
of the system (Fig. 74).
Once recanalization has been completed, a Ritleng Lacrimal Intubation Set (S1-1450,
FCI, 20–22 rue Louis Armand, 75015 Paris, France) should be inserted to prevent
adhesions from forming along the mucosal lining post-ELDR (Fig. 75).
For data storage the authors prefer the use of an AIDA™ DVD-M with Smartscreen™
(KARL STORZ Tuttlingen, Germany), which allows digital still images, video sequences
and audo files to be collected during ELDR surgery (Fig. 76).
A radiofrequency unit, the Ellman Surgitron Dual RF S5 (Ellman International Inc.,
74 JAVATE Lacrimal Trephine, 58001 KA, 3333 Royal Avenue, Oceanside, N.Y., U.S.A.) is set up with JAVATE-PAMINTUAN
(KARL STORZ Tuttlingen, Germany).
Dacryoplasty (JPD) Electrodes for coagulation of raw bleeding areas of the
nasolacrimal duct mucosa (Fig.|77).
5.3.4 Step by Step Approach to ELDR
Table 9 Instrument Set for Endoscopic Lacrimal Duct Recanalization (ELDR)

Part A: Instruments and Endoscopes Alligator forceps
JAVATE Lacrimal Trephine (KARL STORZ Suction tips

Tuttlingen, Germany)
JAVATE Lacrimal Dilating Cannula FREER elevator
JAVATE-PAMINTUAN Dacryoplasty (JPD)
0.3 mm forceps with tip
Electrode (Ellman International, Inc., 3333
Royal Avenue, Oceanside, NY, USA) Westcott scissors
75 Ritleng Lacrimal Bicanaliculus Intubation Ellman Surgitron Dual RF S5 Unit (Ellman
Set (FCI, 20–22 Rue Louis Armand, International, Inc., Oceanside, NY, USA) Punctum dilator (small and large size)
75015|Paris , France).
Ritleng Lacrimal Bicanaliculus Intubation Suction and irrigation cannula
Set (FCI, 20–22 rue Louis Armand,
75015|Paris, France) Nasal speculum
Sharp-tipped stylet
Bayonet forceps
HOPKINS® Rhinoscopes 0° and 30°
(KARL STORZ Tuttlingen, Germany) Operating loupe
Part B: Supplies Gauze
Oxymetazoline hydrochloride (Drixine Suction tubing

nasal drop 0.05%) 10 cc-syringe
Lidocaine (Xylocaine 10 % pump spray)
Combination antibiotic-steroid eyedrops
Dye-impregnated fluorescein strips (Haag- (tobramycin-dexamethasone eye drop
™ ™ Streit AG, CH-3098 Köniz, Switzerland) solution)
76 AIDA DVD-M with Smartscreen .
Distilled H2O and medicine cup Surgical hand antiseptic liquid (Sterillium
Cotton balls Rub®; Bode Chemie Hamburg, Germany)
Part C: Videoendoscopic Equipment and Accessories for Documention

IMAGE1™ HD hub Camera-Control Unit (CCU) with integrated SDI-Module,
integrated KARL|STORZ Communication Bus,
and keyboard with US-English character set
IMAGE1™ H3-Z 3-Chip HD Camera Head with 2 freely programmable
camera head buttons, color systems PAL/NTSC
AIDA™ DVD-M AIDA™ DVD-M with Smartscreen, compact image and
™
with Smartscreen data storage system with integrated DVD/CD writer and
integrated Smartscreen™, color systems PAL/NTSC
XENON NOVA® 175 SCB Xenon cold light source, 174 Watt, with integrated
KARL|STORZ Communication Bus
HOPKINS® Straight Semirigid, with remote eyepiece, with integrated working
77 Ellman Surgitron Dual RF S5 (Ellman
International, Inc., 3333 Royal Avenue, Forward Telescope 0° channels and protection tube, with fiber optic light
Oceanside, NY, USA). transmission incorporated.
ELDR can be performed under local or general anesthesia, depending on patient’s

medical status and/or personal preference.
The ipsilateral nostril is packed with cotton pledgets soaked in 0.05% oxymetazoline
hydrochloride and sprayed with 10% lidocaine. This induces vasoconstriction of the
nasal mucosa (Fig.|78).
Regional nerve-block anesthesia is used. For this purpose, a mixture of lidocaine 2%,
epinephrine 1:200,000, and bupivacaine hydrochloride 0.75% solution is prepared
and infiltrated in the medial canthal, anterior ethmoid, and infraorbital areas, as well
as in the inferior turbinate (Fig.|79).
Based on the authors’ experience, access to the area where the nasolacrimal duct
empties into the inferior meatus is facilitated by infracturing the inferior turbinate
medially (Figs.|80a–d) with a FREER elevator under endoscopic visualization with a 78 Nasal packing with cotton pledgets
soaked in 0.05% oxymetazoline
30º-HOPKINS® rhinoscope, diameter 4 mm (Fig.|81). hydrochloride.
Proparacaine hydrochloride 0.5% solution is instilled into the conjunctival cul-de-sac
for ocular surface anesthesia (Fig.|82). The superior lacrimal punctum and canaliculus
are expanded using two punctum dilators of increasing calibre (Figs. 83a–b)
79 Regional nerve-block anesthesia.
a b c d
80 Once the rhinoscope has been Endoscopic view of the inferior During infracture. After infracture.
inserted in the left nostril, meatus prior to medial infracture
the FREER elevator is introduced. of the inferior turbinate using a
FREER elevator.
a b
®
81 30º-HOPKINS rhinoscope, diameter 82 Proparacaine hydrochloride 0.5% solution 83 Punctum dilatation using a small-caliber
4 mm (KARL STORZ Tuttlingen, Germany). is instilled into the conjunctival cul-de-sac dilator (a) and a large-caliber dilator (b).
for ocular surface anesthesia.
84 Insertion of JAVATE lacrimal 85 The microendoscope is 86 The trephine and

trephine. introduced through the lumen microendoscope are advanced
of the trephine. horizontally.
a b a b
87 Endoscopic view of the lumen of the common canaliculus (a–b). 88 Medial wall of the lacrimal sac. Lumen of the lacrimal sac.
89 The index finger is used to 90 Whitish fibrous tissue 91 Whitish fibrous tissue 92 Whitish fibrous tissue
palpate externally the frontal obstruction along the common obstruction within the lumen obstruction within the lumen
maxillary process. canaliculus. of the sac. at the sac-duct junction.
a b
93 Endoscopic view through 94 Recanalized lumen of the nasolacrimal duct (a–b).
the 4-mm HOPKINS®
rhinoscope showing the lacrimal
trephine below the vault of the
anterior end of the inferior nasal
meatus. Whitish fibrous plaque
emanates from the lumen of the
nasolacrimal duct.
a b a b
95 JAVATE-PAMINTUAN lacrimal electrode (a). Once the JAVATE-PAMINTUAN lacrimal 96 Insertion of Ritleng probe (a). Insertion of
electrode has been connected to the radiofrequency unit (Surgitron Dual RF S5; Ellman Ritleng silicone tubes (b).
International, Inc., 3333 Royal Avenue, Oceanside, NY, USA), it is inserted into the lumen of
the trephine to control bleeding points using the coagulation mode (b).
in preparation for insertion of the trephine (Fig. 84). The microendoscope is

slowly introduced into the trephine lumen (Fig. 85) and images of the canaliculus are
obtained that may be stored on the AIDA™ DVD-M system (Fig. 76). The trephine and
microendoscope are advanced horizontally (Fig. 86) toward the common canaliculus
(Figs. 87a–b) and the medial wall of the lacrimal sac (Fig. 88a). The trephine is then
rotated to assume a vertical position, allowing the microendoscope to capture images
of the lacrimal sac lumen (Fig. 88b). As the trephine, with the microendoscope,
passes along the isthmus of the lacrimal sac, the surgeon may use the index finger
to gently palpate from the external surface of the sac-duct junction for the trephine
(Fig.|89). This is usually the point at which the trephine enters the osseus nasolacrimal
canal. Throughout the entire downward movement of the trephine-microendoscope, a
the lumina of the canaliculus, sac and duct are kept dilated by positive pressure
from continuous or intermittent fluid infusion from the 10-cc syringe. A line drawn
externally, connecting the tear sac and the ala nasi, can serve to guide the surgeon
during the course of the trephine’s lateral descent through the nasolacrimal duct until
the inferior nasal meatus is reached. Viewing the video images of the microendo-
scope as it traverses from punctum to inferior meatus, the surgeon is able to localize
any fibrous obstruction along the excretory system (Figs. 90–92). At the same time,
the trephine may be utilized to perforate through points of stenoses.
The rigid 4-mm HOPKINS® rhinoscope can be utilized to view the lacrimal trephine
below the vault of the anterior end of the inferior nasal meatus (Fig. 93). Next, the
microendoscope is gradually withdrawn to visualize the recanalized nasolacrimal c b
duct (Figs. 94a–b). 97 Silicone tubes retrieved using a Ritleng
The JAVATE-PAMINTUAN lacrimal electrode is connected to the radiofrequency unit hook (a). Removal of the Ritleng probe (b).
Silicone tubes in place (c).
(Surgitron Dual RF S5; Ellman International, Inc., 3333 Royal Avenue, Oceanside,
NY, USA) which is then inserted into the lumen of the trephine to control bleeding
points in coagulation mode (Figs. 95a–b). The micoendoscope is reinserted to
assess the outcome of hemostasis and to confirm that patency of the duct has been
reestablished.
A bicanalicular silicone intubation [Ritleng lacrimal intubation set (S1-1450), Ritleng
probe (S1-1460), Ritleng endonasal forceps (S1-1470), Ritleng hook (S1-1480);
FCI, 20–22 rue Louis Armand, 75015 Paris, France] is inserted to prevent mucosal
adhesions from forming (Figs. 96a–b). The ends of the silicone stent are retrieved at
the inferior meatus of the nose using the Ritleng hook (Figs. 97a–c). The ends of the
silicone tubes are secured with a retinal buckle to prevent the tubes from slipping into
the nasolacrimal duct. The tubes stay in place for at least 6 to 12 months.
Steroid eye drops are used to flush the nasolacrimal duct mucosa (Fig. 98).
Postoperative photographs one day after ELDR with silicone stent (Figs. 99a–e).
98 Steroid eye drops are administrated to
flush the nasolacrimal duct mucosa.
5.3.5 Postoperative Care

Post-ELDR medications include topical antibiotic steroid eye drops instilled every
3| hours and a topical antibiotic ointment applied at bedtime. Debris and blood
clots in the lacrimal system are flushed out by irrigating the canaliculus on the
first postoperative week (Figs. 99a–e). Canalicular irrigation is repeated once a
month following surgery to help maintain patency of the tear excretory system. In
cases where simple canalicular irrigation results in reflux, the JAVATE lacrimal dilating
cannula (Eagle Labs Company, Rancho Cucamonga, CA, U.S.A.) is passed from
the superior punctum to the nasolacrimal duct followed by irrigation to help improve
patency (assisted patency) (Fig. 100). Mobilization of the Ritleng stent is also done to
dislodge debris and blood clot and to prevent mucosal adhesions from forming.
100 Lacrimal dilating cannulas (Eagle Labs
Company, Rancho Cucamonga, CA, The following parameters are monitored on a monthly basis to assess the outcome
U.S.A.). of surgery: subjective relief from preoperative epiphora, positive primary Jones test,
patency on irrigation (confirmation of restored anatomical patency of the lacrimal
excretory system), and absence of reflux on pressure at the lacrimal sac fossa.
This post-ELDR regimen differs from that used for patients who undergo SE-DCR.
For the latter patients, continuous application of ice packs over the surgical site for
48 hours; topical antibiotic eye drops are instilled to the ipsilateral eye 4 times a day
for 2 months; and the silicone tubes are removed between 3 and 12 months after the
operation.
a b c
d e
99 Postoperative photographs one day after ELDR with silicone stents (a–e).
5.3.6 Advantages and Learning Curve

Until recently, the diagnosis of disorders of the lacrimal system has been based on
digital dacryocystography and on clinical examinations such as fluorescein dye test,
lacrimal probing, and irrigation.
Now, direct viewing of the lacrimal system’s lumen and mucosal linings is possible
through lacrimal microendoscopes. Microendoscopy is a relatively new, minimally-
invasive method that allows direct localization and precise treatment of lacrimal
outflow obstructions. It helps pinpoint the causes (inflammation, tumors, etc) and
degree (partial or complete) of stenoses.
Lacrimal endoscopy or dacryoendoscopy represents a new way of examining the
lacrimal drainage system, passing from the upper lacrimal punctum to the exit of the
nasolacrimal duct in the inferior meatus. It provides direct visualization of the lacrimal
excretory system morphology and direct information about the condition of the
mucosa and the degree and function of stenosis. It can be valuable in subsequent
planning of surgical options for the patient.
Recanalization of the obstructed NLD using a microendoscope is a highly suitable

treatment modality in that:
it restores the integrity of the natural lacrimal drainage system;
it avoids the necessity of making new openings through the medial lacrimal sac
wall, lacrimal fossa, and lateral nasal wall;
it eliminates the need for anterior middle turbinectomy; all of which may be
required in endoscopic DCR procedures.
Recanalization of the NLD therefore should be the least invasive of all these
techniques.
The authors have found Endoscopic Lacrimal Duct Recanalization (ELDR) using the
microendoscopic technique to be highly effective, safe, simple, and easy to perform.
Currently, lacrimal microendoscopic surgery can be used effectively to identify and
open a stenotic tract, however, its inherent limitations make it feasible for a limited
range of applications, only. As with any other innovation, there is a learning curve
that must be dealt with. With practice, the surgeon should be able to recognize
anatomical landmarks, disease markers, and thus, avoid creating false passages
during recanalization.
In summary, the following are the benefits of Endoscopic Lacrimal Duct Recanali-
zation using a microendoscope:
It has high success rates for anatomic patency (93.02%), comparable to SE-DCR
rates (93.75%).
It is safe, associated with minimal bleeding, short recovery, less postoperative
discomfort, and without major complication.
It is simple, less invasive technique, without skin incision and can be performed
under local anesthesia.
It is easy, straightforward, quick and performed under direct endoscopic
visualization.
With continued improvements in technique and endoscopic technology, ELDR will

definitely play a significant future role in the treatment of acquired nasolacrimal duct
obstruction.
5.3.7 Tips and Pitfalls

Lacrimal endoscopy permits surgeons to manage obstructive diseases of the lacrimal
drainage system with precision while preserving integrity and normality of surrounding
tissues. Precision, however, is not synonymous with ease. Surgeons adept at the
procedure will make it look seamless, but the difficulties attributed to this surgery
should not be underestimated.
Initial attempts at dacryoendoscopy may be hampered by unclear video images
and disorientation on the part of surgeons and their surgical assistants. Fine tuning
of instrument-handling and full awareness of the direction to which the endoscope
is advancing, takes time to master. With practice, surgeons eventually learn how
to preadjust the microendoscope to correctly display video images on the screen
101 Correct preadjustment of the
microendoscope. (orientation and focusing) (Fig.|101). Presetting of white balance should provide video
images of greater contrast and clarity (Fig. 102).
The major technical difficulty for beginners is how to keep the probe of the
microendoscope coaxial to the lumen of the canaliculus and sac, otherwise the
image disappears from the monitor. Initial difficulties in handling the instruments,
evaluation of the mucous membranes, and diagnosis of pathological changes should
decrease with experience as the surgeon becomes more adept at recognizing certain
landmarks.
The surgeon also have to be careful to ascertain that he performs all maneuvers with
caution and lightness of hand, so as not to create false passages.
To avoid false passage or false route, the lateral descent of the nasolacrimal duct
can serve as a guide. Clinically, the lateral divergence of the descending course of
the nasolacrimal duct can be estimated by drawing a line between the tear sac and
the ala nasi. Individuals with narrow interorbital distances and wide noses will show
102 Presetting of white balance should the greatest lateral divergence along the descending course of the nasolacrimal duct
provide video images of greater contrast
and clarity. (Fig.|103) while those with wide interorbital distances and narrow noses will exhibit a
more vertical divergence of the descending course of the nasolacrimal duct (Fig.|104).
During the procedure, it is also very important to keep in mind that the nasolacrimal
duct is angled at approximately 15 degrees in posterior direction, and at 10|degrees
in medial direction as the canal descends from the lacrimal fossa to the nose. The
latter angle can be clinically estimated by a line drawn between the lacrimal fossa and
the first molar tooth.
In some cases, the lacrimal aspect of the nasolacrimal canal is almost completely
composed of the maxilla and, in turn, correlated with a decrease in the lacrimal
bone and inferior turbinate bone contribution, resulting in a narrowed lumen of the
nasolacrimal canal.
In 2007, Shigeta, Takegoshi and Kikuchi published a retrospective study based on
the results of standard axial sinus CT scans in 314 patients to determine variations in
103 Narrow interorbital distances and wide the bony structure of nasolacrimal canals as to sex and age. Their conclusion pointed
noses demonstrate the greatest lateral to a tendency for chronic inflammation along the nasolacrimal drainage system
divergence along the descending course of predominantly observed in females. In this context, females were found to have
the nasolacrimal duct.
narrower bony lacrimal canals as well as more acute angles between the bony canal
and the nasal floor. In females, narrowness of the bony nasolacrimal canal and the
acute angle between the bony canal and the nasal floor makes them prone to chronic
inflammation of the nasolacrimal drainage system. Their quantitative anatomical
study may very well explain the more frequent occurrence of primary acquired NLD
obstruction in young female patients as opposed to their male counterparts.
It is possible that increased prevalence of PANDO in female subjects is, at least in
part, caused by the smaller diameter of the bony nasolacrimal canal. This smaller
lumen could explain higher incidences of tear fluid stasis and infections extending
from the nasal cavity in females who tend to have flatter bony nasolacrimal canals.
This could be attributed to smaller midfacial structures in females.
The lacrimal diaphragm consists of the extension of the orbital periosteum covering
104 Wide interorbital distances and narrow the lacrimal fossa to which the lateral wall of the tear sac is firmly attached. Into it are
noses exhibit a more parallel, vertical
alignment of the descending course of the inserted the fibers of both the inferior and superior preseptal orbicularis oculi muscle.
nasolacrimal duct. Once the diaphragm is pulled laterally, a negative pressure is created in the tear sac.
When the pull is released, a positive pressure forms due to the fibroelastic resilience
of its wall. In patients with dilated sac, the lacrimal pump mechanism is already
impaired because the sac has lost its fibroelastic resiliency.
Based on the authors’ experience, in order to avoid false passage, the inferior
turbinate is gently mobilized medially for better visualization of the opening of the
nasolacrimal duct prior to endoscopic recanalization. It is very important to keep
the examined cavities open throughout the procedure by positive pressure from
continuous or intermittent fluid infusion using a 10-cc syringe. Care should be taken
to always align the miniature endoscope coaxial to the canaliculus, sac, and sac-duct
junction. It is also very important to visualize the lumen of the canaliculus and the
movement of the walls of the lacrimal sac during recanalization. The brightness level
of the light source is adjusted throughout the procedure to give better contrast and
visualization of the digital images. Follow the lateral descent of the nose externally
through the nasolacrimal duct until the inferior nasal meatus is reached. The surgeon
should palpate externally for the lacrimal trephine at the sac-duct junction. This is
usually the point at which the trephine enters the osseous nasolacrimal canal.
Only minor problems were seen by the authors during the first 10 cases (hematoma
or edema of surrounding soft tissues after creating false passages, usually in patients
with histories of acute dacryocystitis; due to extravasation of fluid during irrigation or
continuous fluid injection) which resolved by the fourth postoperative day. No major
complications were noted.
5.3.8 Management of Obstructions Proximal to the Lacrimal Sac

Problems related to tear flow are generally attributed to the most common type
of lacrimal outflow obstructions which are usually found at the junction between
lacrimal sac and nasolacrimal duct. Next in order of frequency are stenoses within
the canalicular segments of the drainage system. Accurate localization is considered
a critical factor in the successful treatment of canalicular system blockage. Hurwitz
et al. reported on technically more demanding surgeries in patients with obstructions
found at less than 8 mm distal to the punctum, compared to stenosis located in the
common canaliculus (Figs. 105a–b).
Combined Jones tube-canalicular intubation with conjunctivodacryocystorhinostomy
(CDCR) is still the most utilized surgical approach to surgically manage canalicular
a b
obstructions. Tube migration and obstruction, however, has been reported to be as
high as 85.4% following CDCR with Jones tube placement (Sekhar, 1991). Alternative 105 Microendoscopic view of canalicular
surgical options to this procedure include trephination, dilatation with balloon catheter, stenosis (a–b).
and laser recanalization. Sisler and Allarakhia reported removal of core obstructive
tissues within canaliculi using a mini-trephine followed by stenting. Their results
showed patients claiming relief from tearing, either complete or relative, in 83.3% of
cases studied.
The use of microendoscopes has made recanalization of canalicular obstruction at
this site more manageable. Microendoscopy is even more valuable when a surgeon is
faced with obstructions proximal to the sac. While simple trephination may on the one
hand be applied effectively in the majority of surgically treated cases, complications
related to false passages may occur in some patients following trephination, that
is essentially carried out “blindly”. According to the treatment protocol adopted at
the author’s institution, the microendoscope is used as an adjunct to canalicular
trephination and silicone stent intubation to treat obstructions within the canalicular
system. The author and his team conducted a restrospective review of medical
records including patients presenting with epiphora between November 2003 and
June 2010 at the University of Santo Tomas Hospital Eye Center, University of Santo
Tomas, Manila, Philippines. Patients were labeled as having complete canalicular
obstruction if, under local anesthesia, a lacrimal probe (4-0 Bowman probe) failed to
be advanced beyond a soft-stop within the canaliculus, or when irrigation past the
obtruction was impossible.
Qualifying patients underwent microendoscope-aided canalicular trephination with
silicone stent intubation (under local anesthesia) (Fig. 106), with or without subsequent
Endoscopic Lacrimal Duct Recanalization or external dacryocystorhinostomy when
concurrent nasolacrimal duct obstruction was eventually established (under general
106 Office-based procedure performed under
anesthesia). local anesthesia in a patient treated for
canalicular stenosis with microendoscopy of
the lacrimal drainage system involving
bicanaliculus intubation with autostable,
self-retaining silicone stents.
Microendoscopic Canalicular Trephination with

Silicone Intubation for Canalicular Obstructions
Surgical Procedure
b In their continuous effort to facilitate trephination of stenotic canaliculi by use of
microendoscopes, Javate and his colleagues perform surgeries consistent with the
technique briefly described in the following. The surgical procedures were performed
on a total of fourteen eyes in ten patients.
The upper and lower puncta of the eye ipsilateral to the obstructed canaliculus are
a enlarged with a punctum dilator. A 4-0 Bowman probe is advanced into the canaliculus
107 The autostable self-retaining bicanaliculus until a point of “soft-stop” is encountered, setting an approximate localization for the
stent (a). The heads of the stent are fitted obstruction that should be visualized. The probe is removed and replaced with the
with flexible winglets and guides giving rigidity JAVATE lacrimal trephine (KARL STORZ Tuttlingen, Germany), the tip of which is
to the tube and facilitating intubation (b).
advanced to reach the medial wall of the lacrimal sac. A fiberoptic microendoscope
(KARL STORZ Tuttlingen, Germany) with a 0.65 mm-external diameter is inserted into
the 0.7 mm-diameter lumen of the trephine, and carefully advanced to the stenotic
tissues. Once the tissues are actually visualized, trephination is initiated by gently
rotating the instrument. Real-time video images of the trephination have proved to be
very helpful in preventing creation of false passages that would otherwise occur with
blind instrumentation. Irrigation is then performed to confirm restoration of patency of
the trephined canalicular lumen and to assess the condition of the nasolacrimal duct
after the point of obstruction. In the presence of stenosis extending beyond the point
initially treated by trephination, the surgeon proceeds either with ELDR or external
DCR using silicone intubation. A bicanalicular silicone intubation (Ritleng lacrimal
intubation set S1-1450) is passed through both the upper and lower punctum into the
corresponding canaliculi and are retrieved beneath the inferior turbinate. The ends of
108 Once trephination is complete, the size of the silicone tubes are secured with a retinal buckle to prevent the tubes from slipping
the stent suitable for intubation needs to
be determined by inserting a measuring device
into the NLD.
into the recanalized canaliculus. Three out of fourteen patients had purely canalicular obstructions. Intubation in these
patients required a self-retaining stent, such as the autostable bicanaliculus intubation
set with disposable dilator SRS (FCI, 20–22 rue Louis Armand, 75015 Paris, France)
with flexible winglets and guides that facilitate placement and anchorage within the
canaliculi (Figs. 107a–b). Once trephination is complete, the size of the stent suitable
for intubation needs to be determined by inserting a measuring device into the
recanalized canaliculus (Fig. 108). Following dilatation of the upper and lower puncta,
the ends of the stent are inserted and advanced on-axis with the canaliculus as far as
the medial wall of the sac (Fig. 109).
Each head of the stent possesses two flexible winglets that are folded against the
tube as the tubes are inserted through the puncta (Fig. 110). The winglets then spread
back out when the tube end passes the junction between common canaliculus and
lacrimal sac, thus helping to keep the stent in place (Figs. 111a–b).
109 Dilation of the punctum.
a b
110 Insertion of the stent in the upper and in 111 Each head of the self-retaining stent is Patient with autostable self-retaining
the lower puncta along the axis of the fitted with two flexible winglets that fold bicanaliculus stent after the procedure (b).
canaliculus up to the medial wall of the sac. inwards during insertion through the punctum
and spread back out after passage through
the junction of the common canaliculus and
lacrimal sac, thus securing the stent’s fixation (a).
Follow-up and Results

Stents were removed after 3 to 14 (average of 8.7) months. Relief from epiphora was
assessed in each patient based on the guidelines set forth by the Royal College of
Ophthalmologists. The manifestation of epiphora symptoms is categorized in three
levels: absence, improvement, or no change. In their series, Javate et al. noted a
93% complete remission of epiphora (13 out of 14 eyes). Only one patient claimed no
change in his tearing symptoms. These success rates are comparable to those of the
time-tested approach to canalicular obstructions, CDCR, which has been reported to
succeed in 57 to 100% of surgical cases.
The authors hold the opinion that microendoscopy-aided trephination of canalicular
obstructions is a procedure that must be highly considered as an alternative to
112 Endoscopic images captured in different
standard CDCR or simple blind trephination. They also mentioned that self-retaining segments of the normal lacrimal excretory
bicanalicular stenting is adequate for intubation in cases where obstruction is system.
confined to the canalicular system. It facilitates microendoscopic trephination as an
outpatient surgical procedure for purely canalicular stenoses under local anesthesia.
5.3.9 Videoendoscopic Images of the Lacrimal Excretory System

Microendoscopy performed during lacrimal system surgery furnishes the surgeon
with actual images of the tissue morphology, lumen patency, and mucosal conditions.
The surgeon, thus, has direct knowledge on the presence or absence of anatomical
obstruction, as well as degree and function of any stenosis.
Normal Lacrimal Drainage System

The following endoscopic photos exemplify a normal, unobstructed lacrimal
excretory system. The widely patent lumina of the canaliculus, common canaliculus,
lacrimal sac, and nasolacrimal duct are evident. The entire system demonstrates 113 Partial Obstruction: before and after
the characteristics of a healthy mucosa: smooth, light pink, mobile during irrigation ELDR.
(Fig. 112).
Sac and Lacrimal Duct before and after ELDR
Partial Obstruction
Partial stenosis along the lacrimal drainage tract presents with narrowed lumina
that enlarge with irrigation. The lining mucosa usually show whitish-grey inelastic
membranes. The photographs on the right show dramatic changes in the pre-and
post-ELDR conditions of the tract in patients treated with ELDR for partial obstructions
in the lacrimal sac and NLD (Fig. 113). Following surgery, the recanalized sac and
NLD again present with wide, patent lumina.
Microendoscopy allows for visual intra-operative evidence of pathologic change such
as mucosal strictures and scarring. Mucosal inflammatory changes, like mucosal
folds, are easily visualized and differentiated from partial obstructions. Stenoses 114 Complete Obstruction: before and after
ELDR.
are, likewise, differentiated form debris and mucosal secretions which can be easily
removed.
Complete Obstruction
Complete stenosis presents with fibrotic plaques and whitish-grey, ineslastic
membranes (Fig. 114). With microendoscopy, the precise location of stenosis is
identified, commonly in the nasolacrimal duct. Stenoses, heralded by whitish-grey,
inelastic membranes, whether in the canaliculus, lacrimal sac or nasolacrimal duct,
are treated surgically. These are differentiated from mucosal folds that present as
thick, grey strictures.
The images also show the widely patent lumen of a recanalized NLD following ELDR.
References
1. AIMINO G, DAVI G.|Principles of 11. GROESSL SA, SIRES BS, LEMKE BN.|
Radiofrequency in Oculoplastics. Oculoplast An anatomical basis for primary acquired
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Arch Ophthalmol 1997; 115:71–74
2. BALDESCHI L, NOLST TRENITÉ GJ, 12. GUPTA PJ.|Radiofrequency surgery: offering
HINTSCHICH C et al.|The intranasal ostium a novel approach to ano-rectal diseases.
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5. CALDWELL GW.|A new operation for the 15. ILGIT ET, YÜKSEL D, ÜNAL M,|et al.
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Cohen AJ, Mercandetti M, Brazzo BG, et al. The endoscope and the radiofrequency
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Efficacy of Endoscopic Lacrimal Duct
9. EBRAN JM, MAIGRET Y, BECHETOILLE A.|
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Radiofrequency dacryocystorhinostomy. dacryocystorhinostomy – an end of an era?
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Refinements in surgical technique of
34. SNELL RS.|Clinical Anatomy by Regions
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Sutureless Dacryocystorhinostomy Surgery.
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Oper Techn Oculoplastic Orbital Reconstr
stents. Radiology 1993;186:372–376
Surg 1998;1(2):93–97
24. KUCHAR A, NOVAK P, PIEH S et al.| 36. SUNG RJ, LAUER MR.|Fundamental
Endoscopic laser recanalisation of Approaches to the Management of cardiac
presaccal canalicular obstruction. arrhythmias. Kluwer Academic Publishers,
Br J Ophthalmol 1999; 83:443–447 2000
25. MAIER M, SCHMIDT T, SCHMIDT M.| 37. TOTI A.|Nuovo metodo conservatore di cura
Endoscopically controlled surgery with the radicale delle suppuratzioni croniche del
micro–drill and intubation of the lacrimal sacco lacrimale (dacriocistorhinostomia).
ducts. Ophthalmologe 2000;97:870–873 Clin Mod 1904;10:33–34
26. O’CONNOR JL, BLOOM DA. WILLIAM T. 38. TSIRBAS A, DAVIS G, WORMALD PJ.|
Bovie and electrosurgery. Surgery Mechanical endonasal dacryocystorhinos-
1996;119(4):390–396 tomy versus external dacryocystorhinostomy.
Ophthal Plast Reconstr Surg 2004;20:50–56
27. OLDER JJ. The value of radiosurgery in
oculoplastics.Ophthalmic Plast Reconstr Surg 39. VOGT K|. Radiofrequency Surgery in
2002;18(3):214–218 Otorhinolaryngology. Endo-Press®, Tuttlingen,
Germany, 2009
28. PFENNINGER JL, DEWITT DE. Radiofrequency
Surgery (Modern Electrosurgery). In: 40. WOBIG JL, DAILEY RA.|Anatomy of the
Pfenniger JL, Fowler GC, eds. Pfenninger and Lacrimal System. In: Wobig JL, Dailey RA,
Fowler’s Procedures for Primary Care, 2nd ed. eds. Oculofacial Plastic Surgery: Face,
Philadelphia, PA: Mosby, 2003:213–224 Lacrimal System, and Orbit. New York, NY:
Thieme, 2004:129 –137
29. ROSE GE. The lacrimal paradox: toward a
greater success in lacrimal surgery. Ophthal 41. XIANG N, HU W, YUAN J et al.|Diagnosis
Plast Reconstr Surg 2004:20(4):262-265 and therapy of lacrimal system diseases by
micro lacrimal endoscope. Front Med China
30. SEKHAR GC, DORTZBACH RK, GONNERING RS 2009;3(1):113–117
et al.|Problems associated with
conjunctivodacryocystorhinostomy. 42. YAZICI B, YAZICI Z.|Final nasolacrimal ostium
Am J Ophthalmol 1991;112:502–6 after external dacryocystorhinostomy.
Arch Ophthalmol 2003;121:76–80
31. SHIGETA K, TAKEGOSHI H, KIKUCHI S.|Sex
and age differences in the boy nasolacrimal
canal: an anatomical study. Arch Ophthalmol
Dec 2007; 125 (12): 1677–1681
Miniature Straight Forward Telescope for Nasolacrimal Duct Endoscopy
58001
58001 Miniature Straight Forward Telescope 0°,

diameter 0.6 mm, working length 10 cm,
semirigid, working channel 0.15 mm,
remote eyepiece with fiber optic light transmission incorporated
Examination Sheath
58001 KA
58001 KA Examination Sheath,

1.1 mm, length 10 cm, LUER-Lock, with obturator,
for use with Telescope 58001
It is recommended to check the suitability of the product for the intended procedure prior to use.
Metal Tray for Sterilization and Storage
11580 B Metal Tray,

for sterilization and storage of Miniature Straight
Forward Telescopes 11575 A, 11581 A, 11582 A,
11583 A, 11578A or 58001 perforated,
lid with silicone bridges,
with irrigation connector for irrigation connector,
external dimensions (w x d x h): 275 x 178 x 35 mm
n
Unique benefits of the KARL STORZ TELE PACK X LED at a glance
Crystal clear image Easy control combined with highest safety

## 15" LCD monitor with LED backlight ## Membrane keyboard approved for wipe
## Rotatable image display disinfection
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Bit color intensity for natural color
rendition ## Arrow keys for intuitive control
## DVI video input for pristine picture quality ## Pedal control available
## DVI video output for connecting HD monitors
Flexible storage possibilities Additional information

## SD ## Sturdy, portable casing
card-slot allows high storage capacity
## USB-slot ## Ergonomic design allows comfortable transport
for external HDDs and flash drives
## Universal power supply unit: 100 – 240 VAC,
## Picture gallery for records
50/60 Hz
## Playback of saved videos
## Measurement (H x W x D):
## Print-ready patient report documentation 450 mm x 350 mm x 150 mm
## Weight: 7 kg
Natural illumination Ordering Information

## LED high-performance light source TP100 EN TELE PACK X LED, endoscopic video
unit for use with all KARL STORZ
## Naturalcolour rendition close to sunlight with a TELECAM one-chip camera heads
colour temperature of 6400 K and video endoscopes, incl. LED-light
## Up to 30,000 hours lamp operating time source on a similar niveau as the
Power LED 175, with integrated digital
Image Processing Module,
15" LCD monitor with LED backlight,
USB/SD memory module,
color systems PAL/NTSC,
power supply 100 - 240 VAC, 50/60 Hz,
including:
USB Silicone Keyboard
with Touchpad, with US character set
20 2120 40 PAL TELECAM

20 2121 40 NTSC One-Chip Camera Head
color system PAL, autoclavable, soakable, gas-sterilizable,
with integrated Parfocal Zoom Lens, f = 14 – 28 mm (2x),
2 freely programmable camera head buttons,
20 2120 40 / 20 2121 40
including plastic container 39301 ACT for sterilization
IMAGE1 S Camera System n

Economical and future-proof
## Modular concept for flexible, rigid and ## Sustainable investment
3D endoscopy as well as new technologies ## Compatible with all light sources
## Forward and backward compatibility with video
endoscopes and FULL HD camera heads
Innovative Design
## Dashboard: Complete overview with intuitive ## Automatic light source control
menu guidance ## Side-by-side view: Parallel display of standard
## Live menu: User-friendly and customizable image and the Visualization mode
## Intelligent icons: Graphic representation changes ## Multiple source control: IMAGE1 S a llows
when settings of connected devices or the entire the simultaneous display, processing and
system are adjusted documentation of image information from
two c onnected image sources, e.g., for hybrid
operations
Dashboard Live menu
Intelligent icons Side-by-side view: Parallel display of standard image and

Visualization mode

Brillant Imaging
## Clear and razor-sharp endoscopic images in ## Reflection is minimized
FULL HD ## Multiple IMAGE1 S technologies for homogeneous
## Natural color rendition illumination, contrast enhancement and color
shifting
FULL HD image CLARA
FULL HD image CHROMA
FULL HD image SPECTRA A *
FULL HD image SPECTRA B **
* SPECTRA A : Not for sale in the U.S.

** SPECTRA B : Not for sale in the U.S.
TC 200EN
TC 200EN* IMAGE1 S CONNECT, connect module, for use with up to

3 link modules, resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz
including:
Mains Cord, length 300 cm
DVI-D Connecting Cable, length 300 cm
SCB Connecting Cable, length 100 cm
USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU
Specifications:
HD video outputs - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1 kg
SCB interface 2x 6-pin mini-DIN
For use with IMAGE1 S

IMAGE1 S CONNECT Module TC 200EN
TC 300
TC 300 IMAGE1 S H3-LINK, link module, for use with

IMAGE1 FULL HD three-chip camera heads,
power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz,
for use with IMAGE1 S CONNECT TC 200EN
including:
Link Cable, length 20 cm
Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH 103, TH 104, TH 106
(fully compatible with IMAGE1 S)
22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without IMAGE1 S technologies CLARA, CHROMA, SPECTRA*)
LINK video outputs 1x
Power supply 100 – 120 VAC/200 – 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg
* SPECTRA A : Not for sale in the U.S.

** SPECTRA B : Not for sale in the U.S.
IMAGE1 S Camera Heads n

For use with IMAGE1 S Camera System
IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300
and with all IMAGE 1 HUB™ HD Camera Control Units
TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated
Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x),
2 freely programmable camera head buttons,
TH 100 for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD
Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head,

50/60 Hz, IMAGE1 S compatible, autoclavable,
progressive scan, soakable, gas- and plasma-sterilizable,
with integrated Parfocal Zoom Lens, focal length
f = 15 – 31 mm (2x), 2 freely programmable camera head
TH 104 buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD
Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
Monitors
9619 NB 19" HD Monitor,
color systems PAL/NTSC, max. screen
resolution 1280 x 1024, image format 4:3,
power supply 100 – 240 VAC, 50/60 Hz,
wall-mounted with VESA 100 adaption,
including:
External 24 VDC Power Supply
Mains Cord
9619 NB
9826 NB 26" FULL HD Monitor,

wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image fomat 16:9,
power supply 100 – 240 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord
9826 NB
Monitors
KARL STORZ HD and FULL HD Monitors 19" 26"

Wall-mounted with VESA 100 adaption 9619 NB 9826 NB
Inputs:
DVI-D l l
Fibre Optic – –
3G-SDI – l
RGBS (VGA) l l
S-Video l l
Composite/FBAS l l
Outputs:
DVI-D l l
S-Video l –
Composite/FBAS l l
RGBS (VGA) l –
3G-SDI – l
Signal Format Display:
4:3 l l
5:4 l l
16:9 l l
Picture-in-Picture l l
PAL/NTSC compatible l l
Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for monitor 9619 NB
Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26"
Desktop with pedestal optional optional
Product no. 9619 NB 9826 NB
Brightness 200 cd/m2 (typ) 500 cd/m2 (typ)
Max. viewing angle 178° vertical 178° vertical
Pixel distance 0.29 mm 0.3 mm
Reaction time 5 ms 8 ms
Contrast ratio 700:1 1400:1
Mount 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg
Rated power 28 W 72 W
Operating conditions 0 – 40°C 5 – 35°C
Storage -20 – 60°C -20 – 60°C
Rel. humidity max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm
Power supply 100 – 240 VAC 100 – 240 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC,
protection class IPX2
Cold Light Fountains and Accessories
495 NL Fiber Optic Light Cable,

with straight connector, diameter 3.5 mm,
length 180 cm
495 NA Same, length 230 cm
Cold Light Fountain Power LED 175 SCB
20 1614 01-1 Cold Light Fountain Power LED 175 SCB,

with integrated SCB, high-performance LED
and one KARL STORZ light outlet,
power supply 110–240 VAC, 50/60 Hz
including:
Cold Light Fountain Power LED
Mains Cord
20 1320 26 Xenon-Spare-Lamp, 175 watt, 15 volt
Cold Light Fountain HALOGEN 250 twin
20 1133 01 Cold Light Fountain HALOGEN 250 twin,

power supply:
100/120/230/240 VAC, 50/60 Hz,
including:
Mains Cord
Cold Light Fountain XENON 300 SCB
20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated
KARL STORZ Communication Bus System SCB
power supply:
100 –125 VAC/220 –240 VAC, 50/60 Hz
including:
Mains Cord
20133027 Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028 XENON Spare Lamp, only,
300 watt, 15 volt
Data Management and Documentation

KARL STORZ AIDA® – Exceptional documentation
The name AIDA stands for the comprehensive implementation

of all documentation requirements arising in surgical procedures:
A tailored solution that flexibly adapts to the needs of every
specialty and thereby allows for the greatest degree of
customization.
This customization is achieved in accordance with existing
clinical standards to guarantee a reliable and safe solution.
Proven functionalities merge with the latest trends and
developments in medicine to create a fully new documentation
experience – AIDA.
AIDA seamlessly integrates into existing infrastructures and
exchanges data with other systems using common standard
interfaces.
WD 200-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL HD, 2D/3D,
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
WD 250-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL HD, 2D/3D,
including SMARTSCREEN® (touch screen),
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
*XX Please indicate the relevant country code

(DE, EN, ES, FR, IT, PT, RU) when placing your order.
Workflow-oriented use
Patient
Entering patient data has never been this easy. AIDA seamlessly
integrates into the existing infrastructure such as HIS and PACS.
Data can be entered manually or via a DICOM worklist.
ll important patient information is just a click away.
Checklist
Central administration and documentation of time-out. The checklist
simplifies the documentation of all critical steps in accordance with
clinical standards. All checklists can be adapted to individual needs
for sustainably increasing patient safety.
Record
High-quality documentation, with still images and videos being
recorded in FULL HD and 3D. The Dual Capture function allows for
the parallel (synchronous or independent) recording of two sources.
All recorded media can be marked for further processing with just
one click.
Edit
With the Edit module, simple adjustments to recorded still images
and videos can be very rapidly completed. Recordings can be quickly
optimized and then directly placed in the report.
In addition, freeze frames can be cut out of videos and edited and
saved. Existing markings from the Record module can be used for
quick selection.
Complete
Completing a procedure has never been easier. AIDA offers a large
selection of storage locations. The data exported to each storage
location can be defined. The Intelligent Export Manager (IEM) then
carries out the export in the background. To prevent data loss,
the system keeps the data until they have been successfully exported.
Reference
All important patient information is always available and easy to access.
Completed procedures including all information, still images, videos,
and the checklist report can be easily retrieved from the Reference module.
Equipment Cart
UG 220 Equipment Cart

wide, high, rides on 4 antistatic dual wheels
equipped with locking brakes 3 shelves,
mains switch on top cover,
central beam with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable winding
on the outside,
Dimensions:
Equipment cart: 830 x 1474 x 730 mm (w x h x d),
shelf: 630 x 510 mm (w x d),
caster diameter: 150 mm
inluding:
Base module equipment cart, wide
Cover equipment, equipment cart wide
Beam package equipment, equipment cart high
3x Shelf, wide
Drawer unit with lock, wide
2x Equipment rail, long
Camera holder
UG 220
UG 540 Monitor Swifel Arm,

height and side adjustable,
can be turned to the left or the right side,
swivel range 180°, overhang 780 mm,
overhang from centre 1170 mm,
load capacity max. 15 kg,
with monitor fixation VESA 5/100,
for usage with equipment carts UG xxx
UG 540
Recommended Accessories for Equipment Cart
UG 310 Isolation Transformer,

200 V – 240 V; 2000 VA with 3 special mains socket,
expulsion fuses, 3 grounding plugs,
dimensions: 330 x 90 x 495 mm (w x h x d),
UG 310
UG 410 Earth Leakage Monitor,

200 V – 240 V, for mounting at equipment cart,
control panel dimensions: 44 x 80 x 29 mm (w x h x d),
for usage with isolation transformer UG 310
UG 410
UG 510 Monitor Holding Arm,

height adjustable, inclinable,
mountable on left or right,
turning radius approx. 320°, overhang 530 mm,
load capacity max. 15 kg,
monitor fixation VESA 75/100,
UG 510
Headlight KS60
with Cold Light Illumination
Special features:
## Luminous field can be focused – adjustable from ## Sterilizablehandle allows adjustment under sterile
20 to 80 mm at a working distance of 40 cm – conditions, moveable and height adjustable
resulting in brightness of over 175,000 lux ## Light cable is divided in the head area, ensuring
## Double lens system provides outstanding even distribution of weight
illumination in the depths of the operating field ## Extremely robust and flexible light cable due to
## Precise delineation and no luminous field color special protective casing
margins ## Convenient light cable length of 290 cm provides
## Homogeneous illumination of the luminous field greater freedom of movement
without shadows
## Newly designed, lightweight headband provides
improved comfort, also suitable for a small head
size, can be adjusted both horizontally and
vertically
310060 / 310061
310060 Headlight KS60, with double lens system and Y-fiber optic light cable,
>175,000 lux, illuminated area adjustable from 20 – 80 mm in diameter
with 40 cm working distance
including:
Headlight KS60, with removeable and sterilizable Focus Handle 310065
Headband, fully adjustable, with Forehead Cushion 078511,
with cross band, including holder for Headlight 310060/310063
Y
-Fiber Optic Light Cable, with special protective casing for
Headlight 310063, length 290 cm
C
lip with Band, for attaching the fiber optic light cable to OR c
lothing
Same, including:
310061
Headlight KS60
Headband
Y-Fiber Optic Light Cable, with special protective casing for
Headlight 310063, with 90º deflection to the light source, length 290 cm
Clip with Band
Notes:
Notes:
with the compliments of
KARL STORZ — ENDOSKOPE

Endoscopy and Microendoscopy of The Lacrimal Drainage System

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Endoscopy and Microendoscopy of The Lacrimal Drainage System

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Armida L. SULLER, M.D.

Important notes: Endoscopy and Microendoscopy of the Lacrimal Drainage System

removed precisely, greatly limiting injury to surrounding normal tissues resulting in

Its goal is to provide a comprehensive understanding of current lacrimal system

2.1 Nasal Cavity

2.2 Nasolacrimal Sac and Duct

2.3 Anatomical Variations in the Lacrimal System

2.4 Dimensions of the Nasolacrimal Canal

2.5 Thickness of the Lacrimal Bone

2.6 Soft Tissue Disparities

3.0 Evaluation of Patients with Epiphora

3.1 Schirmer Testing

3.2 Rose Bengal Test

3.3 Tear Breakup Time (BUT)

3.4 Fluorescein Dye Disappearance Test

3.5 Jones I Test

3.6 Jones II Test

3.7 Canalicular Probing

4.0 Basic Principles for Surgical Application

4.1 Definition of Radiofrequency

5.0 Lacrimal Surgical Techniques

5.1 Endoscopic Radiofrequency-Assisted b

Dacryocystorhinostomy (ERA-DCR) 8 Endoscopic laser-assisted DCR using a

Table 2 Disadvantages of Laser-

Table 3 Disadvantages of External DCR

45° Cost of purchasing and maintaining the

In 2005, Javate and Pamintuan described the Endoscopic Radiofrequency-Assisted

Table 4 Instrument Set for Endoscopic Radiofrequency-Assisted Dacryocystorhinostomy (ERA-DCR)

5.1.1 Surgical Technique

The nasal mucosa at the endoscopically visualized rhinostomy area is anesthesized

A FREER periosteal elevator is used to

A KERRISON punch is used to place an

Indenting the sac wall using the retinal

Once the lacrimal sac is visualized, its

The authors recommend shorter electrodes to incise through normal-sized or

5.1.2 Postoperative Care

Tear Lacrimal Nasal Tear Dilated Nose

Advocates of endoscopic DCR give value to the absence of external cutaneous

Tear Nasal space

32 The original anatomy, 33 Granulation tissue at the 34 Migration of the nasal

The postoperative care after standared external DCR is relatively routine: 3 to 4

5.2 Mini-Incision Dacryocystorhinotomy

5.2.1 The Surgical Techniques involved in Mini-Incision DCR

Preoperative Preparation and Anesthesia

Lacrimal Sac Flaps

44 Tenting of the sac with a Bowman probe

Nasal Mucosal Flaps

Anastomosis of the Anterior Flaps

5.2.2 Postoperative Care in Mini-Incision DCR

5.2.4 Endoscopic Follow-up Documentation after Mini-Incision DCR

5.3 Endoscopic Lacrimal Duct Recanalization (ELDR)

5.3.1 Proper Selection of Patients

5.3.2 Anatomic Consideration

5.3.3 Operating Room Set-Up

70 The microendoscope is connected to a

5.3.4 Step by Step Approach to ELDR

Table 9 Instrument Set for Endoscopic Lacrimal Duct Recanalization (ELDR)

JAVATE Lacrimal Trephine (KARL STORZ Suction tips

Part B: Supplies Gauze

Oxymetazoline hydrochloride (Drixine Suction tubing

Part C: Videoendoscopic Equipment and Accessories for Documention

ELDR can be performed under local or general anesthesia, depending on patient’s

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head,

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head,

WD 200-XX* AIDA Documentation System,

WD 250-XX* AIDA Documentation System,

*XX Please indicate the relevant country code

UG 510 Monitor Holding Arm,