In defense of endonasal DCR

Toronto-Endonasal dacryocystorhinostomy (DCR) is quickly becoming an attractive procedure among ophthalmologists, according to Nancy Tucker, MD.

The interest in endonasal DCR has been increasing due to the procedure:

·      Avoiding a visible incision and wound-related complications

·      Having no postoperative bruising or swelling

·      Offering minimal to no patient discomfort

·      Providing more rapid recovery postoperatively.

The procedure is also safe-even in cases of acute dacryocystitis-and it can be used for DCR with Jones tubes, said Dr. Tucker, Department of Ophthalmology and Vision Sciences, University of Toronto.

The procedure is contraindicated in patients with a suspected lacrimal gland malignancy, she said.

When Dr. Tucker performs endonasal DCR, she said she injects 1% lidocaine with epinephrine into the lateral nasal wall followed by creation of an incision with a modified crescent blade.

When the lacrimal sac is visualized after the overlying bone is removed, a modified crescent blade is used to open the sac.

A retinal transillumination light is passed into the nasal cavity and tissue can be removed for biopsy. After the retinal transillumination light is removed, silicone intubation tubes can be passed through the superior and inferior canaliculus and DCR site and secured together in the nose, Dr. Tucker said.

Variations of the procedure exist primarily regarding bone removal.

A variety of lasers-argon, homium-YAG, CO², potassium titanyl phosphate, neodynium-YAG, and diode-have been used through endonasal and transcanalicular approaches. However, the success rates are poor and likely related to charring and scarring associated with the lasers.

Balloon endolaser DCR involves a smaller opening through which a catheter with an attached balloon is passed and the balloon is inflated two to three times. After the balloon is removed, tubes are inserted.

This minor surgery, however, has not withstood the test of time and the long-term results are poor, Dr. Tucker said.

An ENT shaver-which is a drill-can be used to remove bone in difficult cases, but an ultrasonic probe is a more elegant device to remove bone.

This procedure, she said, protects the soft tissue beneath such as the lacrimal sac.

Compared with an external DCR, Dr. Tucker said the position of the osteotomy tends to be more inferior and more posterior, but the sizes are comparable between the two techniques.

“The success rate of endonasal DCR has been considered poor compared with external DCR,” she said. “Interestingly, recent reports that included 100 or more patients found that the actual success rates seem to be quite good and the success rates between the endonasal and external approaches are comparable.”

Despite the number of advantages associated with endonasal DCR, there has been a slow transition away from external DCR. This is likely because of the learning curve associated with the technique, Dr. Tucker said.

However, Dr. Tucker said she believes interest in the procedure will increase with training during fellowship programs and patient education about the procedure.

“Although external DCR is by far the more commonly performed procedure, the many advantages of endonasal DCR make it an attractive alternative to external DCR in cases of uncomplicated primary acquired nasolacrimal duct obstruction,” she said.

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