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ARTICLES
Year : 1972  |  Volume : 20  |  Issue : 3  |  Page : 127-129

Modified dacryo-cysto-rhinostomy


Department of Ophthalmology, Himachal Pradesh Medical College, Simla-1, India

Correspondence Address:
G C Sood
Department of Ophthalmology, Himachal Pradesh Medical College, Simla-1
India
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Source of Support: None, Conflict of Interest: None


PMID: 4587597

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How to cite this article:
Sood G C, Sofat B K, Mehrotra S K, Chandel R D. Modified dacryo-cysto-rhinostomy. Indian J Ophthalmol 1972;20:127-9

How to cite this URL:
Sood G C, Sofat B K, Mehrotra S K, Chandel R D. Modified dacryo-cysto-rhinostomy. Indian J Ophthalmol [serial online] 1972 [cited 2019 Dec 9];20:127-9. Available from: http://www.ijo.in/text.asp?1972/20/3/127/34660

From the time TOTI [10] described ex­ternal Dacryo - cysto-rhinostomy (D.C.R.) operation, several modifica­tions have been suggested either to improve the results or to facilitate and simplyfy the otherwise hazardous tech­nique. We carried out a modified method in our cases with very grati­fying results; the same is being pre­sented here.


  Method Top


The cases of chronic dacryocystitis were investigated and only those with obstruction in nasolacrimal duct (N.L.D.) or at the junction of lac­rimal sac and N.L.D. were selected. Before undertaking the operation, any pathology of the nasal passages was excluded and if present was duly recti­fied. The operations were carried out under general anaesthesia, however, this surgery can be safely performed under local anaesthesia in co-operative patients. The nasal cavity on the side of the operation was packed with gauze strip soaked in 2% xylocaine with adrenaline.

The lacrimal sac and fossa are ex­posed by the usual incision and dissec­tion. Lacrimal sac is retracted lateral­ly and periorbita removed from lacri­mal fossa and adjoining region. A circular osteotomy hole about 1.8 to 20 mm is made in the medial wall of the orbit, such that its lower end cor­responds with the junction of lacrimal sac and nasolacrimal duct. The nasal mucosa opposite the osteotomy hole is deliberately removed. Now a trans­verse cut is made in the middle of me­dial wall of sac and its anterior and posterior limits are extended both up­wards and downwards, thus fashioning an upper and lower flap. [Figure - 1].[Figure - 2]. The upper flap is sutured to the periorbita and soft tissues around the upper margin of bony opening with 3 x 0 plain catgut. Similarly the low­er flap is sutured to the periorbita and soft tissues near the lower margin of the opening. Thus the interior of the sac forms a well epithelialized surface opposite the osteotomy opening and no cul-de-sac is left in the dependent portion of the sac. Medial palpebral ligament is sutured by plain catgut and skin incision closed with inter­rupted or subcuticular 3 x 0 silk sutures. Nasal pack is removed and pressure bandage given. Dressing is removed on the next day, conjunctival sac cleaned with normal saline and an antibiotic cream applied. Nasal cavity is examined by anterior rhinoscopy and any blood clot or crust if present is removed gently by swabing. Syring­ing of the sac with crystalline penicil­lin lotion in normal saline (10.000 units/ml) is started on the fourth post­operative day and repeated once or twice a week for about two months. While syringing, the tip of the lacrimal cannula is pushed beyond the osteo­tomy hole and gently moved from side to side with the object of dislodging any blood clot if present and prevent the formation of fibrous membrance Ephedrine saline drops 1 % are given 2 to 3 times a day as a routine mea­sure to prevent nasal congestion and oedema. Skin stitches are generally removed on the seventh day.


  Observations Top


So far we have operated upon six patients by this method. The age ranged from 16 to 55 years. In all the cases post-operative recovery was uneventful, epiphora disappeared and on syringing, fluid readily passed into the nasal cavity indicating patency of lacrimo-nasal passage.


  Discussion Top


TOTI's [10] original technique of ex­ternal dacryo-cysto-rhinostomy was improved upon by MOSHER [2] who re­commended removal of medical wall of lacrimal sac and nasal mucosa from the osteotomy hole, without putting sutures. As the results were not very satisfactory and frequently the opening was blocked, DEPUY DUTEMPS [1] made anterior and posterior flaps in the medial wall of lacrimal sac and nasal mucosa and sutured them sepa­rately. WRIGHT [13] also preferred the two-flap method. Frequent injury of friable nasal mucosa during osteotomy and suturing, made these operations extremely difficult. TRAQUIR, [11] PRASAD AND BAJPEYI (1966) sutured anterior flaps only. GILL [2] inserted a rubber catheter in the lacrimal sac and brought the other end from the nostril. This method besides being cumbersome and unpleasant for the patient is likely to produce chronic nasal discharge. SUMMERSKILL [8],[9] suggested two me­thods of D.C. R. by intubation. The results again were not satisfactory and in many cases progressive cicatrization pushed the tube into the lacrimal sac. Moreover polyethelene tube tends to produce foreign body reaction, chronic inflammation, sloughing of medial wall of sac, excessive cicatrization and closure of the opening. Drill dacryo­cysto-rhinostomy through transcanali­cular approach of NAGPAL, MATHUR AND BALDHA [4] has been described, but has the disadvantage of being a blind procedure, produces a small opening with possibility of injury to the can­naliculus and nasal septum and early closure. WEST'S [12] method of perform­ing D.C.R. though nose really never became popular with ophthalmologists because of limited field for surgery and difficulty in establishing anasto­mosis. In most of the procedures, the greatest difficulty arises in preserving the nasal mucosa and placing sutures through the flaps and often it be­comes impossible to achieve this. The chief advantage of the present proce­dure is that it obviates the necessity of preserving and suturing the friable nasal mucosa. Upper and lower flaps of lacrimal sac are easy to suture. Be­sides it prevents the formation of a cul-de-sac in the dependent portion, where accumulation of tears can other­wise be a constant source of recurrent infection. Drainage is facilitated by the action of gravity.


  Summary Top


A modified technique of dacryo­cysto-rhinostomy is described in which the nasal mucosa opposite the osteo­tomy hole is deliberately removed. Upper and lower flaps are fashioned in the medial wall of lacrimal sac and are sutured to the periorbita and soft tissues near the upper and lower mar­gins of the opening. The advantages of such a procedure are (1) Cul-de-Sac does not remain, (2) application of the sutures is easier.

In six patients who were operated by this method epiphora ceased and the ostrum remained patent during the follow-up period.

 
  References Top

1.
Dupui-Dutemps; cited by Stallard in 6, p. 327 (1933).  Back to cited text no. 1
    
2.
Gill, W. D.: Dacryocystorhinostomy, Simplified Technique. Amer. J. Ophth., 30, 198, (1947).  Back to cited text no. 2
    
3.
Mosher: cited by Speath in 7, p. 114, (1921).  Back to cited text no. 3
    
4.
Nagpal, P. N.; Mathur, R. N. and Baldha, C. R.: Drill Dacryocystor­histostomy J. All India Ophth. Soc., 17, 226, (1969).  Back to cited text no. 4
    
5.
Prasad, P. N. and Bajpeyi, S. P.: One flap Dacryocystorhinostomy. J. All. India Ophth. Soc. 14. 176, (1966).  Back to cited text no. 5
    
6.
Speath, E. A.: The principles and Practice of Ophthalmic Surgery, 3rd edit., Lea & Febiger, Philadelphia (1944).  Back to cited text no. 6
    
7.
Stallard, H. B.: Eye surgery, 3rd edit. John Wright & Sons, Bristol, (1958).  Back to cited text no. 7
    
8.
Summerskill, W. H.: Dacryocysto­rhinostomy. Trans. Ophth. Soc. U.K., 69, 494, (1949).  Back to cited text no. 8
    
9.
Summerskill, W. H.; Dacryocysto­rhinostomy by intubation. Brit. J. Ophth., 36, 240, (1952).  Back to cited text no. 9
    
10.
Toti, A.: Clin. Med. Firenze, 10, 385, cited by Summerskill in 9.  Back to cited text no. 10
    
11.
Traquair, H. M.: External Dacryo­cystorhincstomy. Trans. Ophth. Soc. U.K., 52, 149, (1932).  Back to cited text no. 11
    
12.
West, P.: cited by Speath in 6, p. 117, (1932).  Back to cited text no. 12
    
13.
Wright, R. E.: Dacryocystorhinosto­my. Loncet, ii, 250, July (1937).  Back to cited text no. 13
    


    Figures

  [Figure - 1], [Figure - 2]



 

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