Types of DCR (Dacryocystorhinostomy) Surgeries: A Comprehensive Overview

Having delved into the intricacies of nerve blocks around the lacrimal sac, let’s now explore the steps and types of DCR (dacryocystorhinostomy) surgeries. DCR is a surgical procedure designed to address obstructions in the nasolacrimal apparatus, allowing tears to flow directly from the lacrimal sac into the nasal cavity. This is achieved by creating a new opening or ostium in the lacrimal sac area, bypassing the blocked nasolacrimal duct.

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WHAT IS DACRYOCYSTORHINOSTOMY ( DCR)?

By now we all know how tears reach from the puncta to the nasal cavity. We discusses that in detail in our video on lacrimal pump mechanism.

In cases where the nasolacrimal duct is obstructed, tears can flow back into the eye, resulting in symptoms like watering or epiphora. Dacryocystorhinostomy involves creating an ostium in the lacrimal sac area, extending into the lateral wall of the nose, specifically the middle meatus. This allows tears to bypass the blocked nasolacrimal duct, facilitating a direct flow into the nasal cavity.

TYPES OF DCR SURGERIES

Let us discuss about the various types of DCR surgeries. in each of these we create an ostium, but the approach to creating the ostium is different. we shall discuss about the external DCR, endonasal DCR, endocanalicular laser DCR and Conjunctivo-DCR ( Lester-Jones procedure). Let us understand one by one.

External DCR (Conventional DCR)

Approach: An external skin incision is made to access the lacrimal sac.
Procedure: The ostium is created through an external approach.
Key Points: This traditional method is effective, but it may result in scarring.
For detailed information on steps of the External DCR, clink on the link.

Endonasal DCR

Approach: The ostium is created through the nose using an endoscope.
Procedure: An endoscope is inserted into the nose, and an illuminating lead pipe is introduced into the lacrimal sac via the puncta.
Key Points: Endonasal DCR offers a less invasive alternative to external DCR, reducing scarring.

Endocanalicular Laser DCR

Approach: Laser is used to create an opening through the lacrimal sac into the nasal cavity.
Procedure: A laser, often holmium YAG or diode laser, is employed for precision.
Key Points: This bloodless procedure is fast, scar-free, and suitable for elderly individuals.Also pateints on anticoagulant medications , who may not be able to stop the medication, canalso undergo this procedure. However, it comes with a lower success rate (70%) compared to external and endonasal DCR. Patients with failed endocanalicular DCR may need revision external or endonasal DCR surgery.

Conjunctivo DCR (Lester Jones Procedure):

Indication: Sometimes along with the nasolacrimal duct blockage, Canaliculi may also be blocked. Especially if the canalicular blockage is less than 8 mm then this procedure can be done
Procedure: First initial steps of the DCR surgery are done dealing with the NLD blockage( distal obstruction). then to deal with the canalicular obstruction(proximal obstruction) a pathways needs to be created for tears to flow from the conjunctiva to the lacrimal sac and then to the created ostium .To achieve this a portion of the caruncle is excised using the GRAEFE’S knife (CARUNCULECTOMY) .A Lester Jones tube is inserted into the newly formed tract, providing a permanent bypass for tears.
Key Points: This procedure addresses both proximal and distal canalicular obstructions, ensuring tear flow into the nasal cavity. However there are problems associated with the tube and it needs repeated cleaning .

Considerations for Successful DCR:

Lacrimal Pump Function: For a successful DCR, it’s crucial that the lacrimal pump operates normally. The Jones dye test can provide insights into the pump’s functionality.
Puncta and Canaliculi Patency: The puncta, responsible for tear transport to the sac, and the canaliculi should be patent for successful tear drainage.

In the next post, we will delve into the detailed steps of the External DCR, providing a comprehensive guide to this traditional approach. Stay tuned for more insights into the world of dacryocystorhinostomy surgeries!